a method for closing a traumatic defect of a finger tip

A METHOD FOR CLOSING A TRAUMATIC

DEFECT OF A FINGER TIP

ROBERT A. JONES, M.D.

Chief of SurgicaI Service, U. S. Marine HospitaI

SAN FRANCISCO, CALIFORNIA

T HE hand is injured in one-third of all industrial a&dents,1

the fingers being involved in many of this group. Loss of a

finger tip is not an infrequent injury and in many individuals

it is a seriousIy disabling one. A typist, musician, eIectrica1 worker or skiIIed mechanic is greatIy handicapped by the Ioss of a finger tip and further disabIed by the thin, easiIy uIcerating, painfu1 scar which often resuIts after the heaIing of these wounds. A method of surgical treatment which wiI1 lessen the disabiIity in these injuries, restore the

part to a nearIy norma condition and reduce the time of healing is worthy of consideration. In this paper there is presented a method of restoring a defect of a finger caused by accident. OnIy the early cases

are reported, the secondary ones presenting scars of heaIed wounds for excision and grafting are not incIuded.

We first used this method on ApriI 28, 1921. A kitchen empIoyee of the hospita1 had the tip of the left midfinger shaved off when he put his hand in a moving coffee grinder. Figure I iIIustrates the nature of the injury. A Aap was sutured to the tip of the finger from the palm of the hand in the manner shown in Figure 2. The fina resuIt showed a finger with no disability, norma sensation in the grafted area, and scars that were scarceIy visibIe at the tip of the finger and in the paIm of the hand. Figure 3, a photograph taken in 1939 eighteen years after the accident, shows the result of operation.

Later, in 1923, one of the stenographers of the hospita1 sIammed a door on her Ieft midfinger. The tip of the finger was pinched off. She reported to the hospita1 the foIIowing morning and a graft from the paIm of the hand was sutured to the defect in the finger. Again the resuIt was good. November 6, 1926, she wrote, “The scars on both the finger and the hand are so faint now that it is hard to teI1 any- thing has been done to the finger. No one ever notices it unIess I shouId happen to caII their attention to it. I type with it a11 the time now and it never bothers me in the Ieast.” Figure 4, a photograph taken in 1926, shows appearance of finger two years after operation.

326

JONES-DEFECT OF FINGER TIP 32;

The method was not again used until a few years ago. Now nearly all our finger tip defects are treated by this method.

In 1926, Gatewood reported a similar method which he used to

FIG. I. FIG. 2.

FIG. I. A, traumatic defect at tip of index finger; B, flap raised from thenar eminenw.

FIG. 2. Flap sutured to tip of index finger.

cover a defect in the palmar surface of the distal third of the finger. He mentioned the fact that at that time the Thiersch graft was the

most popular method of closing these defects of the lingers and hand, but thought that the graft was not serviceable because it remained thin and adherent. He believed that full thickness grafts had too few takes except in the hands of a few surgeons. Figure 3 shows a diagram taken from Gatewood’s article.

In looking through the Iiterature for the past decade we find that these wounds are still closed by free grafts such as the Thiersch, Thiersch-Ollier (spht grafts), and full thickness grafts, by tube grafts from the skin of the chest or abdomen or by, sIeeve or pocket grafts from the abdomen, hip or some other area. GiIcreest3 has described an amputation of the tip of the distaI phalanx in which the remaining two-thirds of the nail are preser\,ed and all the soft parts remaining after the injury are sutured to the nail Lauten” placed the finger in a pocket graft over the crest of the ilium and used a graft from the crest to restore the lost bone. With the exception of Gatewood’s article, we did not find any mention of using the skin of the palm of hand as a source of the skin Ilap.

It has been our experience that Thiersch, split grafts and full thickness grafts do not fiII the defects as adequately as the flap from the palm of the hand which carries the underlying fat. The flaps from

328 JONES-DEFECT OF FINGER TIP

other parts of the body whiIe exceIIent for the dorsum of the hand and fingers are of a different texture and coIor than the paImar skin, are more easiIy traumatized and do not give a good cosmetic resuIt.

FIG. 3. E. R. Photograph taken October 27.

‘939. eighteen years after accident shows result at tip of midfinger and on thenar

eminence.

The objection which might be offered to taking a graft from the paIm of the hand is that there is no skin to spare in this region and that the resuIting scar in the paIm is in itseIf disabIing. Another objection is that in some of the oIder individuals, keeping the finger immobiIized to the palm of the hand for two or more weeks is IiabIe to cause contracture of the joints of the finger. Although we have not a Iarge number of cases to report, we beIieve we can state fairIy that if one pays attention to detai1 in the operation and after treatment, these compIications wiI1 not occur or be serious enough to offset the good features of the method.

As a working ruIe it is considered that these wounds are con- taminated up to tweIve hours and that after that time infection has

JONES-DEFECT OF FINGER TIP 329

already taken pIace. Therefore, we do not usually accept these cases for reconstructive and pIastic operations after the twelve-hour period.

FIG. 4. E. C. C. Three years before this photograph

was taken patient slammed door on tip of left

midtinger. Graft from thenar eminence was sutured to tip of finger. Note faint scar on thenar

cmmence.

Most of these injuries to the finger tips occur in men who are working at the time of the accident. The fingers and hand are often covered with grease or other material with which the patient has been working. We have found that equa1 parts of chloride of lime and sodium bicarbonate mixed into a soft paste with water makes an exceIIent cleaning agent. The wound is kept covered with sterile gauze and the remaining fingers and hand are gentIy massaged with the mixture, after which the hand is washed with steriIe water poured from a pitcher. After the hand has been dried with a sterile towe1, ether and then aIcoho1 are used, folIowed by tincture of iodine and alcoho1, equa1 parts. This preparation is not allowed to enter the wound but comes up to the edges of same.


The finger is anesthetized with a 2 per cent solution of procain, the digita nerves being blocked in the proxima1 third of the finger.

Next the wound is gently washed with pure soap and water, foIIowed

Fteps in operation.

FIG. 5. Diagram shown in Gatewood’s articIe. (From Gatewood, J. A. hf. A., 87: 1479, 1926.)

by steriIe norma saIt solution. A dbbridement is then done with a sharp scaIpe1. A11 foreign materia1 is removed with the tissue to which it is cIinging and a11 devitahzed and mangIed tissue is excised so that onIy heaIthy, viabIe tissue remains. If the nai1 is missing and the nai1 bed badly damaged, it is compIeteIy excised. If there is a fracture at the tip of the terminal phaIanx, the Ioose fragments are excised and the tip of the phaIanx rounded off smoothIy. If the digita arteries continue to bIeed after the application of fine hemostats, they are Iigated with tripIe No. ooo plain catgut with onIy two knots, the Iigature being cut close to knot. However, we avoid as far as possibIe putting any catgut into the wound. During the operation the wound is bathed in a I per cent solution of chloramine-T. We do

JONES-DEFECT OF FINGER TIP 33’

not use mercury compounds because the lime and soda and tincture of iocline preparation followed by mercury antiseptics have caused skin rashes.

FIG. 6. 1, PcdicIe IateraIIy; 2, pedicle FIG. 7. Shows the graft sutured to dr-

proximally. This iIIustration shows feet. in linger tip. There must be no

the Ran raised from the thenar and tension on sutures and no kinking in .I

h! pothcnar eminences. The flap graft whcrc this runs from graft onto

avoids the creases and the mobiIv

clisr:ll half of the palm.

finger.

The finger tip is flexed against the palm and a pattern of the defect is thus made on the skin of the thenar or hypothenar eminences. This area is next anesthetized with 2 per cent procain and the flap raised with the pedicIe proximally or IateralIy, whichever is more con\,enient. (,Fig. 6.) Skin flaps should not be taken in the palm of the hand distal to the thenar and hypothenar eminences. Here the skin is mobiIe and moves with the fingers. AIso, there are important creases which incisions should not cross. The flap must be wide enough to cover the defect without tension and when raised as long as the defect. As much fat as necessaq- is raised with the skin. Figure 6 shows the Asp raised from the paIm. The finger is no\3 approximated to the palm and the distal end of the graft is sutured to t.he skin between the defect and the nail, to the nail itself, or to theskin


of the dorsum of the finger depending on the nature of the wound. (Fig. 7.) The sides of the graft are sutured to the sides of the defect as far proximaIIy as possibIe without tension or kinking of

FIG. 8. Shows the suturing of graft to defect completed. The wound in paIm caused by raising flap has been sutured. Adhesive tape which has been passed through the A ame of an aIcoho1 lamp has been applied as iIIustrated. A dressing of vaseIine gauze is passed between finger and palm to cover wounds. A Iight Iayer of gauze is pIaced over finger and the hand bandaged. A padded board spIint is applied to dorsum of hand and forearm and extremity kept eIevated in an arm sIing.

the graft. An assistant keeps the finger approximated to the paIm until the end of the operation. Care must be taken that there is no tension on the sutures and no kink in the graft where this runs from the paIm of hand onto the finger. We use horsehair sutures for most of the suturing, but an occasiona fine silkworm gut suture is used where added strength is necessary. Next, the defect in the paIm caused by raising the graft is sutured with Iight silkworm gut. These sutures must not come too cIose to the base or pedicIe of the graft because of the danger of constriction or pressure. (Fig. 8.) A Iight gauze


dressing is placed over the wound. Figure 8 shows the suturing of the graft to the finger tip completed.

The finger is held in position with adhesive tape which has been

FIG. 9. T. N., age forty-three, a fisherman. About IO P.M., October 19, 1939, Ieft IittIe finger was struck by a cIosing window, the end of finger being cut off. He entered the hospita1 at I A.M. October 20, 1939. X-ray fiIms showed a crush- ing fracture of dista1 extremity of third phalanx, nail missing. On October 20, a first stage auto- plasty was performed and on November 16, the second stage was done. On November 16, 1939, the patient was discharged to out-patient department, San Pedro, California.

run through the flame of an alcohol Iamp. One strip of tape starts on the back of the hand and runs over finger and down onto the palm and lower forearm. A pad of gauze is pIaced over the knuckles where the adhesive tape passes over them in order to prevent pressure sores. The hnger is further immobilized by adhesive tape running transversely across the dista1 third of finger and also across the first longitudinal strip. (Fig. 8.) A light pad is apphed and the finger


bandaged to the hand. It is necessary to remove onIy the outer dressing in order to inspect the graft. Thus the graft, finger and hand may be inspected at any time without any disturbance to the opera-

A B

FIG. IO. A and B, photographs of same hand seen in Figure g taken November 6, 1941. Note scar on hypothenar eminence.

tive fieId. A basswood splint is pIaced over the dorsum of the hand and forearm and the extremity is kept eIevated on a pilIow whiIe the patient is in bed and in an arm sIing when the patient is up and about. The spIint and eIevation of the Iimb are very important in the after-treatment.

The sutures are removed about the tenth to tweIfth day, the wounds carefuIly cleaned with ether and aIcoho1 and the adhesive tape reappIied to the finger. In two weeks to eighteen days after the operation the graft is detached from the paIm. LocaI anesthesia may be used again, but gas inhaIation anesthesia or pentotha1 intravenousIy are frequently given. The granuIation tissue at the tip of the finger and on the undersurface of the graft is excised. The skin


edges are slightly undermined and a slight amount of skin is excised around the margin of the wound. The wound in the palm of the hand is cIosed in a similar manner. The graft is now sutured to the remaining portion of the defect with horsehair sutures. Sometimes a rubber

band drain is placed in an angle of the wound. The joints of the linger are manipulated and the linger completely extended. A light dressing is applied and the linger bandaged with the joints in slight flexion. The basswood splint is again applied and the arm kept elevated. Sometimes a moist dressing of aqueous azochloramide or chlo- ramide-T solution is applied to the wound. Two or three days later

E,lO\\.i T,,E NlhlBEK OF CASES, TIIE KESL’LTS ,A’i\;D “I KY,10X 0,: T,<,:.4T\ll~.2I’

TOTAL NUMBER OF CASES - 18.

Duration of Treatment: Average number of days = 43 Maximum number of doys = 80 Minimum number of days = 28

the wound is dressed. It is seIdom infected, but occasionahy there is a collection of serum between the wound and the graft. This is irrigated away with a medicine dropper Wed with aqueous azochloramide, and a few drops of a solution of azochloramide in triacetin r-500 injected under the flap. In a few days the wound becomes dry. The same treatment may be used in the wound in the palm of the hand. In a week to ten days the joints of the finger may gradually be extended. The sutures are removed after the tenth day. After the fourteenth day the hand is cleaned and washed with soap and water. A day or two Iater there is a desquamation of the outer Iayer of the skin over the graft and a pink healthy looking skin remains. If there should be any delay in the complete extension of the joints of the


finger, this may be corrected by appIying a board spIint to the dorsum of the hand and forearm and pIacing a wide rubber band over the termina1 phaIanx of the finger. It is we11 to pIace a pad

between the finger and the rubber band. We have not yet had any serious or disabIing contractures of the joints even in our older

patients.

In a few weeks sensation appears in the graft. With use of the finger irreguIarities in the graft and the scar tend to smooth out and Iater disappear, so that in many cases it is difhcult to see where the graft was pIaced. We have not yet had any painfu1 scars or neuromas

develop. TabIe I shows the number of cases, the resuIts of treatment,

compIications and duration of treatment.

SUMMARY

A method of cIosing a traumatic defect of a finger tip is described. This method more nearIy restores the covering of the finger tip to a norma condition than any other procedure because paImar skin and

subcutaneous tissue are used. As in a11 plastic methods attention to detai1 is necessary, but the

technic is not difKcuIt.

The duration of treatment, much of which may be done in the out-patient department, is as short in the average case as most other methods of treating these injuries except amputation. About thirty to thirty-five days are necessary in the average case.

REFERENCES

I. Accident Facts. Page 19. Chicago, 193% The National Safety Council, Inc. 2. GATEWOOD. A pIastic repair of finger defects without hospitabation. J. A. M. A., 87:

1479, I 926. 3. GILCREEST, EDGAR L. PIastic operation for repair of traumatic amputation of end of

finger. Surg. Clin. North America, 6: 539-554, 1926. 4. LAUTEN, W. F. Finger tip reconstruction, a new operation. Indust. Med., 8: 99-100,

1939.

DISCUSSION

EDGAR L. GILCREEST (San Francisco, CaIif.): Dr. Jones’ paper is a very worth whiIe contribution to the surgery of trauma even though it concerns itseIf with nothing more than the restoration of the tip of a finger. This, however, to a person who has Iost it, is exceedingIy important.

His method recommends itseIf because of its simpIicity and further because it can he used so frequentIy. This accident occurs often in industry


but perhaps more often in the home. The Aap of skin from the paIm which

Dr. Jones uses makes an idea1 fuI1 thickness graft for the finger. In 1926, I described in the SurgicaI Clinics of North America a restora-

tion of the tip of a finger in which one-third had been Iost by traumatic

amputation. With rongeur forceps I bit off the bone unti1 a flap of tissue

on the palmar surface could be brought up, covering the bone. With a smaII, curved cutting needIe threaded with silkworm-gut sutures, this

flap of skin was brought up over the bone and the needIe was passed through the remnant of the nail. Five sutures made a satisfactory approxi-

mation. I had never sewed a fIap of skin to nail before and did not know that it would adhere below. I was dehghted, therefore, at the end of a

week, to see that this ffap of skin had grown beneath the nai1 and after

remova of the sutures there was no separation. I have not been able to find any case in the Iiterature in which soft tissues had been sewed to the

base of the nail. Six weeks after the operation she was abIe to pIay a piano,

using the stump of the amputated hnger just as we11 as the other fingers.

The end of the finger, which at first had a bIunt, fan-shaped appearance,

rounded off Iike a norma finger. The length was exactIy the same as her

ring finger. The nail, of course, while only half-length, made an incon- spicuous deformity.

I have seen severa of Dr. Jones’ patients on whom he had performed this operation and the resuIts obtained were indeed spIendid. I am inclinecl

to believe that in most instances I wouId prefer his method to the one I

used. His success is due to his careful and meticulous attention to every detail.

CARLETON MATHEWSON, JR. (San Francisco, CaIif.): I feel unqualilied

to discuss this paper, because I have not had an opportunity to use the operation Dr. Jones describes. I have had the opportunity, however, of

seeing one of Dr. Jones’ patients, a typist who had an excehent functional and cosmetic result.

There are a few minor points which I think are important. Dr. Jones

suggest the use of IocaI bIock anesthesia in carrying out the operation. I

might say that if you do use 1ocaI anesthesia for bIocking off the Iinger,

you should avoid the use of adrenalin. We have seen gangrene of the tip

of the tinger which we attributed to interference in circuIation caused by

the use of adrenaIin and novocaine. I think one cannot overemphasize

the importance of thorough cIeansing of the hand. We have found it very

difhcult to cIeanse the hand thoroughIy in any acute injury. Most of these

injuries occur to peopIe who, because of the t.ype of their empIoyment, have extremeIy greasy or dirty hands. I have lvatched nurses attempting

to hoId an extremity with one hand and cIean it with the other. The resuIts are not efficient, so that in the end one is dependent upon antiseptics rather than thorough cIeansing for asepsis.


It has been my habit in these small injuries of the hand to block off the

linger with Iocal anesthesia, then to take the patient into the scrub room

with me and show him how to scrub up for an operation, instructing him

to scrub his hands at the same time. He rather enjoys it and you get the

hand thoroughIy cleansed.

Many patients think that we can perform miracles, which is often fortunate in this type of injury. Very often persons who have Iost a portion

of a Iinger or the whoIe finger, bring it in in a handkerchief. They usually

pick up the abolated part, pIace it in a handkerchief, then run for the

emergency hospital. If they do bring in the tip of the finger, very often

you can cleanse it and suture it in place. Occasionally; it will take as a

free graft and will give you a good functional result.

We have aIso found it useful in acute injuries that are still bloody to cleanse an area of skin on the forearm and then place the bloody tip of

the finger on this area. In this manner one can outline accurately the size

of a full thickness graft.

a method for closing a traumatic defect of a finger tip

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