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- Eponychium - aka cuticle. Small amount of thin skin over lunula
- Paronychium - sides of nail
- Hyponychium - tip of finger below nail
- Lunula - corresponds to distal end of germinal matrix
- Germinal Matrix
- Sterile Matrix - nail ned
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- 1 - finger tip
- 2 - involve nail bed but not bone
- 3 - involve bone; distal to lunula
- 4 = proximal to lunula, distal to DIPJ
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- Favourable = more palmar skin
- Neutral
- Unfavourable = less palmar skin
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- > 25 % remaining = keep length.
- If < 25% remaining = revision amputation
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- No bone exposed
- < 1cm2 = dressings
- > 1cm2 = full thickness graft from forearm or flap
- Bone exposed = need flap
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- If Volar favorable
- If pulp length > 75% ➔ VY plasty
- If pulp length < 75% ➔ Local Neurovascular island flap
- If Volar Unfavorable
- IF, MF = Thenar flap
- MF = Reverse Vascular Island Flap
- RF, LF = Cross Finger Flap
- Free flap options - radial forearm, toe pulp, groin flap
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- Flap harvested from the dorsal side of adjacent finger
- Donor site covered with full thickness skin graft
- Divided after 2-3 weeks
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- “Based on the reverse flow from contralateral communicating artery to digital artery”
- Skin flap harvested proximally along finger
- Rotated with digital artery to cover defect
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- Flap derived from thenar eminence, post op immobilise in splint; flap division in 2 weeks.
- (+) provides glabrous skin unlike cross finger flap/ grafts
- (-) flexion contractures and unsightly donor site scars [Brian Rinker 2006 retrospective analysis found no significant flexion contractures and no problematic donor sites]
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- Skin island raised just proximal to skin defect with its NVB
- Island advanced into wound
- Donor site covered with graft
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- Midlateral incision, dorsal to neurovascular bundles
- Flap dissected off flexor tendon sheath
- Advanced with the NV bundles, helped by flexion of IPJ
- If flap too much tension, can make a proximal transverse incision with FTSG coverage over secondary defect
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