The Use of Composite Bone and Nail Bed Graft Combined With Cutaneous Flaps for Reconstruction of Finger Tip Amputations

Fingertip injuries are among the most common hand injuries regardless of age, as the fingertip is a prominent and frequently used part of the hand. However, no consensus yet exists regarding the ideal reconstruction of fingertip injuries with nail bed defects, and its reconstructive methods are limited.

Allen has classified fingertip amputations into four types. Type I injuries involve only the pulp of the finger. Type II includes pulp and nail loss. Type III has partial terminal phalanx loss and corresponding pulp and nail loss. Finally, type IV involves the lunule of the nail, pulp, nail, and partial loss of the terminal phalanx.

Fingertip amputations through the proximal half of the nail-bed are challenging as the remaining nail-bed has inadequate length for satisfactory nail growth. Replantation at this level gives a good functional and cosmetic results but is technically demanding, requires microsurgical skills and adequate facilities and is not always possible.When replantation is not possible, the use of a local advancement palmar flap preserves digital length and the remaining nail bed.

However, when the amputation is through the proximal third of the nail, this technique leaves very little nail bed and nail deformities are common.To avoid these deformities, complete ablation of the nail bed and germinal matrix with closure by a palmar advancement flap, or by shortening, are usually carried out. Unfortunately, these treatments often fail to satisfy the patient's desire to retain his or her nail.

When replantation is not feasible, the technique of advancing a palmar V-Y flap and applying the nail bed retrieved from the amputated part to the dorsum of the flap provides an alternative means of restoring nail bed length. So the technique of using composite bone and nail bed graft from the amputated part with a local or regional cutaneous flaps may be an option for treatment of fresh fingertip amputation to restore the shape and preserve the length of the fingertip especially in circumstances when microsurgical replantation is not feasible.