Lehigh County Health & Medicine Spring 2021 - 24

FEATURE

fashion to enhance the chance that when a new
nailplate grows back from the regenerating cells
found in the lunula [the crescent moon shaped
area next to the nailfold], that the nail will still
be able to attach once again to the nailbed and
not split or not adhere about a scar as it grows
toward the end of the finger (1). This process
is very slow, and in an adult may take up to 6
months to be completed.
As an important aside, whenever a nailplate
has been torn off the nailbed or removed by
the physician, make sure that it is found and
never discarded until absolutely sure that it is
not needed. The nail itself, since it conforms
perfectly to that individual's finger from which it
came, is the best splint to hold any minor distal
phalanx fragments together while protecting
the traumatized nailbed while it heals. The
nailplate should also always be put under the
nailfold when reinserted so that the latter does
not heal to the lunula and block protrusion as
the new nail tries to grow out. A simple way
to affix the nailplate is to put medical grade
superglue around its edges, although sutures
can be a substitute but are more difficult to
place since the nailplate usually is very hard (2).
More significant injuries with soft tissue
loss resulting in bone or tendon exposure or
even amputation may require a flap [a piece
of tissue having its own blood supply] for
coverage so that further shortening of the digit
can be avoided. This would best be done by
a surgeon with hand expertise, as sometimes
not so simple to accomplish. Take for example
partial amputation of a thumb. The thumb
provides 50% of overall hand function, so
extreme measures to preserve length to allow
adequate prehensile capabilities is justifiable.
Depending on culture and expectations, this
can realistically be accomplished by the transfer of part or all of a great or second toe for
replacement of missing parts (3). Nailplate,
bone, flexor and extensor tendons, and/or
glabrous skin can be moved using microsurgical
techniques to connect nerves, arteries, and
veins of the toe to corresponding structures
of the thumb to reestablish blood flow. The
result can be a strong, mobile, and sensate digit
with restoration of normal function, although
form and appearance can be satisfactory also
[Figure 2.]-the same goals for the treatment
24 Lehigh County Health & Medicine | SPRING 2021

Donor toe: A to C-great toe, D to F-2nd toe. In the center is the appearance of the donor foot when the great toe was used
[left], or second toe [right]. Note when compared to the contralateral foot, most people will not even notice a missing 2nd
toe, just as in the comic strips where hands & fingers have only 4 digits! In all cases, none of these patients had any problems
walking even with their toe missing!

of any fingertip injury no matter how difficult
or how simple.
Dressings after any fingertip repair are
chosen to minimize bloody ooze and swelling,
immobilization as indicated, and for comfort.
For a small avulsion, pressing an absorbable
gelatin sponge on the wound [every ER has
this] will initiate clotting to stop bleeding, then
covered with a bandaid. A splint will prevent
stretching soft tissues apart, while perhaps even
more important protect the fingertip as a shield
to deflect any unexpected impacts that always
will be very painful, since a disproportionate
number of sensory nerves endings may be found
in the pulp as that is our tactile connection to the
world. Keep the entire hand elevated afterwards
to facilitate by gravity reduction of the expected
edema. Dressing changes, suture removal and
further wound management should be at the
discretion of your treating physician. Difficulties
in joint mobilization, scarring, edema, and
sometimes discomfort can often be overcome
with an occupational therapy consultation for

help as needed. The take home message for all
this is that as sure at the snowflakes will disappear
in Spring, someone will unexpectantly injure
their fingertip. Be prepared and be careful!

REFERENCES

1.Brown, RE, Zook, EG, Russell, RC, Fingertip
Reconstruction with Flaps and Nail Bed Grafts,
J Hand Surg. 1999;24(A):345-351.
2.Hallock, GG, Lutz, DA, Octyl-2-Cyanoacrylate
Adhesive for Rapid Nail Plate Restoration, J Hand Surg,
2000;25(A):979-981.
3.Woo, SH, Lee, GJ, Kim, KC, Ha, SH, Kim, JS, I
mmediate Partial Great Toe Transfer for the
Reconstruction of Composite Defects of the Distal T
humb,Plast Reconstr Surg, 2006;117(6):1906-1915.



Lehigh County Health & Medicine Spring 2021

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https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Spring21
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMFall_Winter20
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LehighCountyHealthMedicineSummer2020
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Spring20
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Winter19
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Fall19
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Summer19
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Spring19
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Winter18
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHM_Fall18
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMSummer18
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMSpring18
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMWinter2018
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMWinter18
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/Fall2017
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMSummer2017
https://www.nxtbook.com/hoffmann/LehighCountyHealth_Medicine/LCHMSpring2017
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