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206
13 Reconstruction ofFinger Joint Defects
preserve the necessary blood supplying artery and soft tissue
that would prevent the ischemia of the nger. Measure the
length of the bone and joint defect, joint position, and
required length of the tendons, blood vessels, and nerves.
13.3.2 The Cutting oftheToe
Design the proximal interphalangeal joint of the second toe
according to the length of the bone joint needed for the
defect. Mark the level of dissociation on the skin surface, and
the second toe is cut in the same way as the conventional
method. When dissociating the dorsal and plantar digitorum
arteries of one side of the toe, attention should be paid to the
protection of the joint capsule branch entering the interphalangeal joint, and the condylar branch and metaphyseal
branch supplying the proximal phalangeal bone, middle phalangeal bone, and epiphysis.
13.3.3 Transplantation
Cross wire internal xation or Kirschner wire xation can be
used for osteoarticular operation. Then suture the tendons.
Then, under the microscope, the dorsal and plantar digitorum arteries and nerves are anastomosed with the corresponding digital arteries and nerves, respectively, and the
dorsal digitorum vein is anastomosed with the dorsal digital
vein.
13.3.4 Postoperative Treatment
(a) Intensive nursing and heat preservation should be performed routinely after the operation; (b) “three anti” therapy
should be performed after the operation; (c) the blood supply
of the ap should be observed regularly after the operation.
If there is vascular crisis, timely treatment or exploration
should be conducted.
13.5 Announcements
(a) Bone xation should not only be rm and reliable, but
also conducive to early functional exercise after the operation. Cross wire xation is recommended; (b) Since the condylar and metaphyseal branches that supply the proximal
phalanges and the distal phalanges are all distributed within
the distance of 0.5cm from the joint, the distance of 0.5cm
from the donor joint should be avoided when the joint is
removed, so as to avoid damaging these branches; (c) When
bone defect in the recipient site is relatively larger and longer
phalangeal bone is needed, special attention should be paid
to prevent the separation of skin and bone joints during the
operation to avoid affecting the blood supply; (d)
Intraoperative movements should be gentle and delicate to
prevent vascular pulling and damage; (e) The peripheral
blood supply of the transplanted tissue and the affected nger should be observed while the occurrence of vascular crisis should be dealt within time after the operation; (f) Pay
attention to early rehabilitation exercise which is helpful for
improving joint function.
13.6 Case Description
Case 1 A 45-year-old male patient was admitted to hospital
for more than 7 months due to bone exposure of the right
index nger with movement limitation. Physical examination: He was in good general condition, with stable vital
signs, about 1.0 × 0.8cm soft tissue defect on the dorsal side
of the proximal interphalangeal joint of the index nger with
bone exposure. The proximal interphalangeal joint was
reconstructed by the interphalangeal joint of the second toe
of the left foot combined with composite ap under general
anesthesia selectively, and the donor site was sutured directly.
The operation was successful, and he returned to the ward
safely. Routine reconstruction treatment was given after the
operation, and the reconstructed joint survived successfully
and the donor site healed in the rst stage. The efcacy was
satisfactory (Fig.13.1).
13.4 Operation Characteristics
(a) To repair the interphalangeal joint of the ngers by the
interphalangeal joint of the toes transplantation; (b) the cutting of the toe did not involve the metatarsophalangeal joint
and the transverse ligament as far as possible; (c) the blood
supply of the nger should be carefully evaluated before
operation, and the blood supply of the distal part of the nger
must be retained intraoperatively to prevent the distal
necrosis.
Case 2 A 22-year-old female patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the left
index nger defect caused by punch injury. Physical examination: She was in good general condition, with stable vital
signs, composite tissue defect of the index nger, irregular
skin of the stump, exposed bone, and active bleeding. And
the other ngers were normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete
debridement, the index nger was reconstructed by the inter-
13.6 Case Description
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a b c
207
d
Fig. 13.1 Reconstruction of the interphalangeal joint defect of the
right index nger by the interphalangeal joint of the second toe transplantation. (a) Preoperative condition of the defect. (b) Exposure of the
interphalangeal joint of the nger. (c) Dissociation of the interphalan-
e
phalangeal joint of the second toe of the right foot combined
with composite tissue ap and bular ap of the great toe
under general anesthesia in emergency, and the donor site
was covered by transposition of the lateral tarsal ap. The
operation was successful. After the tourniquet was relaxed,
the reconstructed ngers were ruddy with moderate tension,
wrapped with the sterile cotton, bulked and stuffed with the
broken cotton gauze around, and she returned to the ward
safely. Routine reconstruction treatment was given after the
operation. Fourteen days after the operation, the reconstructed nger survived successfully. Regular follow-up was
conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory. The
donor site healed in the rst stage, and the patient was satised with the appearance and function (Fig.13.2).
Case 3 A 41-year-old male patient was admitted to hospital
in emergency for 1.5 h due to pain and bleeding of the right
rst to third ngers caused by punch injury. Physical examination: He was in good general condition, with stable vital
signs, soft tissue defect on the dorsal side of the rst and
second nger webs, metacarpophalangeal joint of the index
nger defect, exposed bone, irregular skin of the stump, and
seriously polluted. After admission, routine preoperative
preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement,
the index nger and soft tissue defect of the thumb were
f
geal joint of the second toe. (d) X-ray after the operation. (e) Appearance
of the reconstructed joint 8 months after the operation. (f) Function of
the reconstructed joint 8 months after the operation
reconstructed by the metacarpophalangeal joint of the second toe of the right foot combined with composite tissue ap
and dorsal metatarsal ap under general anesthesia in emergency, and the donor site was covered by free skin graft. The
operation was successful. After the tourniquet was relaxed,
the reconstructed ngers were ruddy with moderate tension,
wrapped with the sterile cotton, bulked and stuffed with the
broken cotton gauze around, and he returned to the ward
safely. Routine reconstruction treatment was given after the
operation, and the reconstructed nger survived successfully.
The efcacy was satisfactory (Fig.13.3).
Case 4 A 47-year-old male patient was admitted to hospital
in emergency for 1.5 h due to pain and bleeding of the left
thumb defect caused by milling machine injury. Physical
examination: He was in good general condition, with stable
vital signs, soft tissue and interphalangeal joint defect of the
thumb, exposed bone and articular surface, irregular wound,
and seriously polluted. After admission, routine preoperative
preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement,
the thumb was reconstructed by the interphalangeal joint of
the great toe of the right foot combined with composite tissue ap under general anesthesia in emergency, and the
donor site was shortened and closed. The operation was successful. After the tourniquet was relaxed, the reconstructed
ngers were ruddy with moderate tension, wrapped with the
208
kl
13 Reconstruction ofFinger Joint Defects
abc
def
gh i
j
m
Fig. 13.2 Reconstruction of joint defect of the left index nger by the
interphalangeal joint of the second toe and composite tissue ap transplantation. (a) Preoperative palmar condition of the defect. (b)
Preoperative dorsal condition of the defect. (c) Preoperative X-ray. (d)
Preoperative design. (e) Dissociation of the toe. (f) Dissociation of the
ap. (g) Situation of the donor site after the operation. (h) Dorsal situa-
tion of the reconstructed nger after operation. (i) Palmar situation of
the reconstructed nger after operation. (j) Postoperative X-ray. (k)
Donor and recipient site 14 days after the operation. (l) Dorsal appearance of the reconstructed nger 14 months after the operation. (m)
Palmar appearance of the reconstructed nger 14 months after the
operation
13.6 Case Description
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abc
209
d
g
j
e
h i
k
f
l
mn
Fig. 13.3 Reconstruction of the joint defect of the index nger by the
metatarsophalangeal joint of the second toe and composite tissue ap
transplantation. (a) Preoperative dorsal condition of the hand defect. (b)
Preoperative palmar condition of the hand defect. (c) Preoperative
X-ray. (d) Preoperative design. (e) Remove the metatarsophalangeal
joint. (f) Dissociation of the ap. (g) Reconstructed nger after the
operation. (h) First nger web after the operation. (i) X-ray of the
reconstructed nger after the operation. (j) X-ray of the donor site after
the operation. (k) Extensor function of the reconstructed nger 30
months after the operation. (l) Flexor function of the reconstructed nger 30 months after the operation. (m) Comparison of the left index
nger and the reconstructed nger 30 months after the operation. (n)
Appearance of the donor site 30 months after the operation
210
abc
d e f
ghi
13 Reconstruction ofFinger Joint Defects
j k l
Fig. 13.4 Reconstruction of the joint defect of the thumb by the interphalangeal joint of the great toe combined with composite tissue ap
transplantation. (a) Preoperative dorsal condition of the nger defect.
(b) Preoperative palmar condition of the nger defect. (c) Preoperative
X-ray. (d) Preoperative design. (e) Dissociation of the blood vessels and
nerves. (f) Dissociation of the composite tissue ap. (g) Dorsal view of
sterile cotton, bulked and stuffed with the broken cotton
gauze around, and he returned to the ward safely. Routine
reconstruction treatment was given after the operation, and
the reconstructed nger survived successfully. The efcacy
was satisfactory (Fig.13.4).
the reconstructed nger. (h) Palmar view of the reconstructed nger. (i)
Palmar view of the reconstructed nger 3 months after the operation. (j)
Nail appearance and extensor function of the reconstructed nger 15
months after the operation. (k) Flexor function of the reconstructed nger 15 months after the operation. (l) Situation of the donor site 15
months after the operation
and little ngers defect caused by punch injury. Physical
examination: He was in good general condition, with stable
vital signs, the ring nger defect from the middle plane of the
proximal segment, exposed bone and articular surface, transverse wound at the proximal palmar print of the little nger,
straight deformity, irregular wound, and seriously polluted.
Case 5 A 35-year-old male patient was admitted to hospital
in emergency for 2 h due to pain and bleeding of the left ring
After admission, routine preoperative preparation for recon-
struction was given, and surgical contraindications were
13.6 Case Description
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211
a
d
b
e
c
f
gh
Fig. 13.5 Reconstruction of joint defect of the ring nger by the metatarsophalangeal joint of the second toe combined with composite tissue
ap transplantation. (a) Preoperative condition of the nger defect. (b)
Preoperative design. (c) Dissociation of the toe. (d) Palmar view of the
reconstructed joint 1 week after the operation. (e) Dorsal view of the
excluded. After complete debridement, the ring nger was
reconstructed by the metatarsophalangeal joint of the second
toe of the right foot combined with composite tissue ap
under general anesthesia in emergency, and the donor site
was closed by stump repair. The operation was successful.
After the tourniquet was relaxed, the reconstructed ngers
were ruddy with moderate tension, wrapped with the sterile
cotton, bulked and stuffed with the broken cotton gauze
around, and he returned to the ward safely. Routine reconstruction treatment was given after the operation, and the
reconstructed nger survived successfully. The efcacy was
satisfactory (Fig.13.5).
Case 6 A 27-year-old male patient was admitted to hospital in emergency for 2.5 h due to composite tissue defect,
pain and bleeding of the right middle nger caused by
punch injury. Physical examination: He was in good gen-
reconstructed joint 1 week after the operation. (f) Palmar view of the
reconstructed joint 40 months after the operation. (g) Dorsal view of the
reconstructed joint 40 months after the operation. (h) Dorsal view of the
reconstructed joint 40 months after the operation
eral condition, with stable vital signs, composite tissue
defect of the middle nger, exposed bone and articular sur-
face, irregular wound, and seriously polluted. After admis-
sion, routine preoperative preparation for reconstruction
was given, and surgical contraindications were excluded.
After complete debridement, the middle nger was recon-
structed by the interphalangeal joint of the second toe of
the right foot combined with composite tissue ap under
general anesthesia in emergency, and the donor site was
closed by stump repair. The operation was successful. After
the tourniquet was relaxed, the reconstructed ngers were
ruddy with moderate tension, wrapped with the sterile cot-
ton, bulked and stuffed with the broken cotton gauze
around, and he returned to the ward safely. Routine recon-
struction treatment was given after the operation, and the
reconstructed nger survived successfully. The efcacy
was satisfactory (Fig.13.6).
212
abc
def
ghi
13 Reconstruction ofFinger Joint Defects
Fig. 13.6 Reconstruction of interphalangeal joint defect of the middle
nger by the interphalangeal joint of the second toe combined with
composite tissue ap transplantation. (a) Preoperative palmar condition
of the nger defect. (b) Preoperative dorsal condition of the nger
defect. (c) Preoperative design (dorsal side). (d) Preoperative design
(plantar side). (e) Dissociation of the blood vessels and nerves. (f)
Palmar view of the reconstructed joint after the operation. (g) Dorsal
view of the reconstructed joint after the operation. (h) Palmar view of
the reconstructed joint 3 weeks after the operation. (i) Dorsal view of
the reconstructed joint 3 weeks after the operation
Reconstruction ofNail Defects
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14
Abstract
The tip of the nger is exposed to the farthest end of the
limb, which is the most vulnerable to injury in labor and
life. The traditional method is nger amputation, which
often results in type I or type II defect; Such as the use of
local ap, the length of nger body is retained, but the
nger end is dry, the ap has no feeling, the dorsum of the
nger is without ngernails that would cause a certain
degree of disability. Because the function of the hand is
special, in addition to labor and life, it is also an important
organ of social activities and mutual communication just
like the face. Therefore, the standard of the repair and
reconstruction of thumb and nger defects should be
improved correspondingly. Instead of simply repairing
the wound surface, anatomical and physiological repair
with consistent function and appearance should be pursued. In 1980, Morrison etal rst applied the great toenail
ap graft to repair the skin sleeve avulsion of the thumb
successfully, and it has been widely used because it reappears the complete shape of the thumb.
Traditionally, ngernail defect has no obvious effect
on nger function that doesn’t need to be reconstructed.
However, with the development of microsurgical technology, there is no problem with the technique of toenail
transplantation to reconstruct the ngernail, and its surgical method and difculty are similar to that of the ngertip reconstruction. Therefore, nail reconstruction is
feasible for nail defect patients with high demand for nger aesthetics. The commonly used methods for nail
defect reconstruction include: great toenail ap transplantation, half great toenail ap transplantation, second toenail ap transplantation, and other toenail ap
transplantation. Generally speaking, great toenail ap is
large, which has a great inuence on great toe; The second toenail ap is small and the shape is poor after reconstruction. Half great toenail ap has relatively high
technical requirements, better shape, and less injury.
Specic plan should be selected according to the size of
ngernail bed, soft tissue defect, and bone defect.
Keywords
Finger reconstruction · Nail defect
14.1 Reconstruction ofNail Defect by
Split-Thickness Toenail Bed
Transplantation
The ngernail bed defect is very common in clinic, and the
reasons are various. The types and defect sizes caused by
different causes are different, so it is necessary to select the
appropriate surgical method according to the actual conditions of the injuries. In the past, due to the limitations of
medical conditions, the nail bed defect was often repaired by
shortening the phalanx or scarring. The former caused the
incomplete end of the nger, which had a great impact on the
function and appearance of the nger. The latter is prone to
wound infection and residual nail deformity due to the longtime of dressing change after the operation. Later, skin ap
transplantation was also used to treat nail bed defects, and
the length of the nger body was effectively preserved, but
the problem of missing nails still failed to be solved. With the
development of microsurgical technology, nail reconstruction was realized.
Before the toenail ap was used to repair the nail bed
defect, some scholars proposed to directly transplant the nail
bed to repair the damaged nail bed, but the regenerated nails
were not smooth and had growth deformity after the operation. On this basis, Shepard proposed to remove the full thick
nail bed and then transplant the nails, postoperative follow up showed good growth and no deformity. Subsequently,
some scholars used the split-thickness nail bed transplantation for the treatment of post-traumatic nail deformity, which
also achieved good clinical effects. After that, the fullthickness nail bed transplantation was gradually eliminated
in clinical practice, and the split-thickness nail bed transplantation has become a common surgical method to repair
the ngernail bed defect.
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_14
213
214
14 Reconstruction ofNail Defects
14.1.1 Indications
(a) Patients who are with partial nail defect; (b) The germinal
layer of the nail root is not damaged; (c) Patients who have a
strong desire for reconstruction; (d) Patients who don’t have
dermatophytosis or other nail-related disease.
14.1.2 Surgical Design
The recipient site: according to the patient’s ngernail condition, the wound is circularly cut to the normal nail bed margin (Fig.14.1).
The donor site: the incision should be designed according
to the defect of nail bed after debridement.
14.1.3 Surgical Method
The anesthesia methods are brachial plexus block combined
with epidural anesthesia or general anesthesia. The tourniquet of the affected limb is raised to stop the bleeding. The
wound is debrided completely according to the injury of the
affected nger, and then the nail bed area of the donor site
should be designed and cut according to the defect area of
the nail bed after debridement (Fig.14.2).
The lower limb is lift to inate the, the nail plate should be
removed, and the toenail bed is cut according to the defect area
and shape of the nail bed and the thickness is about 0.6–0.8mm
(about 1/2–1/3 of the full thickness of the nail bed (Fig.14.3).
Loosen the tourniquet, transplant the free toenail bed to
the recipient site, adjust the position, and prune appropriately according to the size of the wound in the recipient site,
then suture it without tension (Fig.14.4).
Fig. 14.1 Patial defect of the nail
Fig. 14.2 The design for the donor nail
Fig. 14.3 The dissection of the nail bed
14.2 Reconstruction ofNail Defect by Supercial Dermal Fascia Composite Tissue Transplantation
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14.1.6 Announcements
(a) During debridement, the periosteum of the exposed
bone should be kept as far as possible to ensure the blood
supply to the base of the transplanted nail bed, so as to
improve the survival rate.
(b) If the distal edge of the nail bed defect is the lower edge
of the nail, the distal edge of the nail plate should be
slightly higher than the lateral edge of the lower nail skin
when suturing to avoid pain symptoms during future nail
plate growth.
(c) The operation should be performed under a magnifying
glass or microscope to reduce suture tension in the nail
bed and avoid rupture.
(d) Choose the right donor toe and the range of removed
toe nail should be accurate. The most commonly used
donor toe is the great toe. The thickness of the nail bed
is generally about 2.0 mm, and the thickness of the
transplanted nail bed is 0.6–0.8mm (1/2 of the thickness of the nail bed in the donor site). The size of the
donor nail should be slightly larger than the edge of
the defect area by 1.0 mm to facilitate tension-free
suture.
(e) For patients combined with phalanx fracture, the frac-
ture can be reduced and xed rst, and then to repair the
nail bed. In patients with bone defects and deformities,
Fig. 14.4 Transplantation and suture
bone grafts are used to support the nail bed.
215
14.1.4 Postoperative Treatment
(a) Intensive nursing, heat preservation should be performed
routinely after the operation; (b) Three-anti therapy should
be performed after the operation; (c) The blood supply of the
ap should be observed regularly after the operation. If there
is vascular crisis, timely treatment or exploration should be
conducted.
14.1.5 Operation Characteristics
(a) Free toenail bed transplantation which is without anasto-
mosis of blood vessels and nerves, simple operation,
with less postoperative complications.
(b) The survival rate is high. Compared with full-thickness
nail bed transplantation, it is thinner and easier to survive.
(c) The injury of the donor site is small, because only the
split-thickness nail bed is taken, and the whole toenail
can still grow after the operation, which does not affect
the donor site.
(d) The appearance of the nail is not as good as that of toe-
nail ap transplantation.
(e) The thickness is different from the original nail bed
which would affect the adhesion of the new nail.
14.2 Reconstruction ofNail Defect by
Supercial Dermal Fascia Composite
Tissue Transplantation
Nail (also known as the nail plate) belongs to the attached
tissue of the nger and has the barrier function, which can
defend the nger from trauma damage, protect and maintain the stability of the nger pulp, enhance the tactile sensitivity of the nger pulp, and help the nger to do grasping,
pinching, pressing and other actions. The nailbed is rich in
nutrient blood supply, which can regulate the body temperature, the blood supply to the extremities, and the function of the nutrient nail plate. Once the nail bed is
traumatized, the function and appearance of the nger may
be seriously affected. With the great improvement of material life, people pay more and more attention to their own
external beauty and have higher and higher requirements
for the repair effect of nail defects. Clinically, we have
been looking for a ngernail reconstruction method that
can not only cover the wound and grow the nail, but also
reduce the damage to the donor site and do not increase the
burden of the patient. Reverse-free transplantation of
supercial dermal fascia composite tissue for ngernail
reconstruction has a satisfactory effect and has been widely
used.
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