Orthopedic Teaching Cases 2023, Jan, 17 | 12:00 am

Hand CASE 36

CASE                               36                               

A 26-year-old, right-hand-dominant woman presents to the emergency department 1 hour after sustaining an injury to the tip of her left middle finger (Fig. 4–19A and B). She works as an executive assistant and smokes 1 pack of cigarettes daily but is otherwise healthy. She reports that she sustained the injury when her car door accidentally closed on the tip of the finger, and she sustained a volar oblique amputation of her fingertip. The injury measures 1.8 cm2 in area, and there is visible exposed bone at the base of the wound. The patient has brought the amputated fingertip into the emergency department, which has been wrapped in moist gauze and placed on ice.

 

 

Figure 4–19 A–B

Which of the following is the most appropriate diagnostic test to order/perform at the time of presentation?

  1. CBC with differential

  2. INR/PT and PTT

  3. ESR

  4. Plain films of the affected digit

  5. CT scan of the hand and wrist

 

Discussion

The correct answer is (D). Radiographs are important to determine the presence or absence of associated distal phalangeal and other fractures, which can help guide management. The majority of distal phalanx fractures can be treated nonoperatively, but significant displacement often warrants fixation, usually via percutaneous pinning. None of the other diagnostic tests are routinely indicated for this injury in an otherwise healthy young woman.

Which is the most important factor in determining the appropriate treatment for this injury?

  1. Presence of exposed bone within the wound

  2. Area of the wound >1.5 cm2

  3. Female gender

  4. B and C

  5. A and B

 

Discussion

The correct answer is (E). The management of fingertip injuries varies between surgeons and patients, but it is generally accepted that injuries with exposed bone and those with larger defects (generally >1.5 cm2) require additional intervention to achieve optimal wound closure and soft tissue coverage. The injury geometry is relevant and helps guide treatment options; a variety of surgical procedures exist for volar oblique injuries depending on the digit involved. Female gender by itself does not dictate the optimal treatment.

 

Which of the following is NOT appropriate initial management of this injury?

  1. Irrigation of the wound, closure of available tissue, and application of a moist dressing with prompt clinic follow-up

  2. Wound debridement and reverse homodigital neurovascular island flap

  3. Immediate shortening of the finger with debridement of the FDP and extensor mechanism proximal to the DIP joint with primary closure

  4. Wound debridement and V–Y flap reconstruction

  5. Wound debridement and thenar flap reconstruction

 

Discussion

The correct answer is (C). A variety of surgical options exist for the treatment of fingertip injuries, including homo- and heterodigital island flaps, V–Y flaps, thenar flaps, cross-finger flaps, as well as bony shortening with healing by secondary intention. These can often be performed in semi-elective fashion within the first 1 to 2 weeks post-injury. Immediate shortening of the finger with debridement of the FDP and distal extensor insertion would not be appropriate in this patient, and would render the finger significantly less functional. Each of the other options constitutes more appropriate treatment of this deformity.

Which deformity may result from proximal retraction of the FDP tendon in management of an injury to the distal part of the finger?

  1. Claw finger

  2. Lumbrical plus deformity

  3. Quadriga

  4. Flexion contracture

  5. Intrinsic tightness

 

Discussion

The correct answer is (B). In the lumbrical plus deformity, the finger paradoxically extends at the interphalangeal joints with attempted flexion. This occurs when the proximal end of the FDP tendon retracts proximally, drawing the attached lumbrical. Mechanically, this causes increased tension on the radial lateral band resulting in paradoxical PIP joint extension known as the “lumbrical plus” deformity. Conversely, quadriga occurs when there is tethering of the FDP tendon distally; this results in weak grasp and loss of flexion power in the other digits. Claw finger, flexion contracture, and intrinsic tightness do not result from proximal migration of the FDP tendon.

Objectives: Did you learn...?

 

Describe the treatment algorithm for distal phalanx amputations?