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EDWARD A. JACKSON, M.D., Michigan State University College of Human Medicine, East Lansing, Michigan

Am Fam Physician. 2001 Aug 1;64(3):455-459.

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Fingertip amputations are injuries commonly seen by family physicians. The classification of fingertip injuries corresponds with the normal anatomy of the tip of the digit. There are three zones of injury; the V-Y plasty technique is used to repair zone II injuries. The plane of the injury can be described as dorsal, transverse or volar. The dorsal và transverse planes lover themselves to lớn the use of the V-Y plasty technique. In carefully selected injuries, the family physician can use this technique to repair the injured digit. The use of a single V-Y plasty has replaced the original technique that repaired the digit and restored the contour of the fingertip. Good cosmetic và functional results can be obtained. Complications may include flap sloughing, infection và sensory changes.


Fingertip amputation is a common injury.1 Multiple repair techniques have sầu been described in the literature, including skin grafts, local or distant flap procedures, & partial toe transplantation. Many of these techniques are complex and can only be performed by specially trained physicians. The V-Y plasty repair is an easy technique khổng lồ learn và can be valuable khổng lồ the family physician. Although it is not a routine procedure, family physicians may choose to lớn persize it in certain settings & circumstances.

The V-Y plasty technique is an island pedicle flap procedure. While most local flaps rotate inkhổng lồ a wound from nearby tissues, bringing the blood supply with the intact portion of the flap, island pedicle flaps receive sầu the blood supply from below, in the capillaries immediately beneath the dermis. This capillary supply must not be disrupted by undermining the tissue when creating an isl& pedicle flap.2


Many fingertip amputations can be classified consistent with the normal functional anatomy of the tip và perionychium.3 Injuries can be classified according lớn where the amputation has occurred or whether the injury primarily involves the pulp (soft tissue) or nail bed. These classification systems refer lớn the zone and the plane of injury3,4(Figures 1 and 2).


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FIGURE 1.

Zonal classification of amputations involving the nail bed và fingertip: Zone I is distal lớn the phalanx; Zone II is distal to lớn the lunula; Zone III is proximal to the lunula.


FIGURE 1.

Zonal classification of amputations involving the nail bed và fingertip: Zone I is distal khổng lồ the phalanx; Zone II is distal to lớn the lunula; Zone III is proximal khổng lồ the lunula.


An injury classified as zone I occurs distal to lớn the bony structures of the digit và the distal phalanx is preserved. Most of the nail bed and the integrity of the matrix is intact, allowing for normal nail contours following healing. Treatment of zone I injuries is usually conservative sầu, such as leaving the wound open for secondary healing.3 Meticulous wound care và conservative sầu debridement of these injuries are essential. Wound healing is facilitated by the use of topical antibiotic ointments và by monitoring of the injury to lớn avoid the development of excessive granulation tissue.


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FIGURE 2.

Planes of injury in fingertip amputations. The plane influences the technique used lớn repair the amputation. Both the plane & the zone of injury must be kept in mind when considering the strategy of reconstruction.


FIGURE 2.

Planes of injury in fingertip amputations. The plane influences the technique used to repair the amputation. Both the plane & the zone of injury must be kept in mind when considering the strategy of reconstruction.


Injuries classified as zone II are located distal khổng lồ the lunula of the nail bed & are complicated by the bony exposure of the distal phalanx. These injuries require local or distant pedicle flap reconstruction.3 The plane of zone II injuries helps determine what type of repair technique should be used.

Injuries classified as zone III involve the nail matrix and result in the loss of the entire nail bed. Most patients with injuries in zone III are not candidates for elaborate reconstruction. The most effective sầu management of these injuries is amputation of the distal phalanx.

Amputation injuries are also classified as dorsal, transverse or volar, according lớn the plane of the amputation (Figure 2). The plane of the amputation and the condition of the tissue at the injury site help determine the best repair technique for these injuries. The V-Y plasty technique can be used khổng lồ repair amputations with dorsal or transverse planes.4

In a recent article,5 researchers proposed a new classification system for fingertip injuries. This system classifies a fingertip injury into lớn three areas: pulp, the nail and the bone, or PNB (pulp, nail, bone).5 This classification system may have sầu merit but, because it has not been widely used, it requires further study to be useful for classification of fingertip injuries, including amputations.


At first glance, the performance of pedicle flaps may seem daunting, but a simple V-Y plasty pedicle flap easily can be advanced to cover the defect left by fingertip injury.4,6–10 The V-Y plasty advancement flap technique should be used when the injury leaves more pulp than nail bed. Attempts lớn use this technique when the opposite situation occurs results in undue tension on the flap & failure of the procedure. Physicians must consider their experience level when deciding lớn persize this procedure. The technique is not difficult lớn learn but, at centers with readily available hvà và plastic surgeons, referral may be considered.

The V-Y plasty technique preserves the normal contours of the dorsal finger, helps pad the fingertip & preserves normal sensation.6,7,9 The original technique, which used a double lateral V-Y pedicle advancement to cthua trận a fingertip amputation, has been largely replaced by the single V-Y plasty technique4 described below.6–10 Use of loupe magnification may assist the performance of this technique. The 12 steps of the single V-Y plasty technique follow:

Step 1. Persize a digital bloông xã using 1 percent lidocaine (Xylocaine) without epinephrine administered on both sides of the proximal finger lớn achieve adequate anesthesia. If more extensive sầu debridement is needed, consider using conscious sedation with an agent such as midazolam (Versed).

Step 2. Drain blood from the finger & apply a tourniquet using a rubber bvà or a small Penrose drain at the base of the affected digit.

Step 3. Clean the wound thoroughly using saline or water.

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Step 4. Debride any devitalized tissue.

Step 5. If there is a portion of the bone protruding from the distal phalanx, smooth or trim it using a rongeur to lớn allow for the advancement of the flap.

Step 6. Create a triangular-shaped flap with the base of the flap at the cut edge of the skin where the amputation occurred. It should be as wide as the greakiểm tra width of the amputation10,11(Figure 3a).


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FIGURE 3.

Illustration of the V-Y plasty technique. DIPhường = distal interphalangeal


FIGURE 3.

Illustration of the V-Y plasty technique. DIP = distal interphalangeal


Step 7. Skin incisions are made through the full thickness of the skin. Do not undermine the flap itself, because the blood supply for this islvà pedicle flap comes from beneath. The flap usually has enough mobility to lớn allow for closure of the defect.

Step 8. Advance the flap over the defected area và suture it to the nail bed with either 5-0 or 6-0 nylon sutures (Figure 3b).

Step 9. Place corner stitches to avoid interference with the blood supply khổng lồ the corners.2 Convert the V-shaped defect into lớn a final Y-shaped wound (Figure 3c). A more complete discussion of the use of the corner stitch has been published elsewhere.212–15

Step 10. Remove sầu the tourniquet. Observe sầu the flap for good capillary refill và color. Please note that there may be a delay in filling for five sầu to 10 minutes khổng lồ access the blood flow.

Step 11. If capillary refill is slow, kiểm tra the distal sutures to make certain that they were not placed too snugly.

Step 12. The wound is cared for with moist wound healing by applying an antibiotic ointment lớn the area. A protective sầu splint is often beneficial.

The V-Y pedicle plasty technique allows most patients to regain sensation & two-point discrimination in the fingertip.10 The cosmetic results are usually excellent, with good contour và fingertip padding preserved. Figure 4 shows an example of a fingertip that has undergone the V-Y plasty technique, showing the minimal scar.


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FIGURE 4.

Successful repair of a fingertip amputation showing the well-healed scar và well-preserved fingertip contour.


FIGURE 4.

Successful repair of a fingertip amputation showing the well-healed soto và well-preserved fingertip contour.


Tissue sloughing can occur if excess tension is applied or if the blood supply is disrupted by undermining the flap. Permanent sensory changes may be noted, including paresthesias, hyperesthesia or a sensation of coldness.6,7,16 Sensory changes are experienced by more than 50 percent of patients with fingertip amputations but often subside with time.16 Infection rarely occurs at this highly vascular location.

While not all fingertip amputations are amenable to the use of the V-Y plasty wounds closed with this technique usually have favorable outcomes. Physicians who perform care in the office, emergency department or urgent care center can readily master this technique.

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