Microsurgical management of complex fingertip injuries: comparison to conventional skin grafting

In selected cases of severe fingertip injuries, an aggressive approach using microvascular and microneural techniques can yield functional results equal or superior to conventional methods of treatment in less severe injuries. A series of 20 patients were treated microsurgically from 1983 to 1986 for severe acute distal finger injuries or their early sequelae--five distal replantations, eight neurovascular free tissue transfers, and nine distal neurorrhaphies/nerve grafts with or without vascular conduit. Concurrently, 33 simpler tip avulsions were treated with full-thickness skin grafts for comparison. In the microsurgical series, one replant and the distal 1 cm of a free toe flap necrosed. Replants averaged two-point discrimination of 9.8 mm and pulp pinch 65 percent of normal; free toe transfers, two-point of 6 mm, pulp pinch 58 percent; distal nerve reconstruction, two-point 6 mm. Operating time per digit averaged 5.0 hours for replants, 4.3 hours for toe flaps, and 1.5 hours for nerve repair/grafts. All patients returned to full pre-injury employment within six months. None required revisional surgery for dysesthetic fingertips. In the conventional skin graft series, greater than six months follow-up is available in 17 patients. Average two-point was 7 mm (range: 3 to greater than 15 mm) and pulp pinch 83 percent of normal. There were seven poor results with cold intolerance, numbness, and paresthesias, three of which required revisional surgery. The data suggest that microsurgical management of fingertip injuries achieves results comparable to skin grafts, despite the greater complexity of the initial injury. This approach has resulted in fewer secondary tip revisions. Operative times are acceptable. Parameters of sensory return are similar, although pulp pinch is slightly less. Disability times are comparable to the average in major pulp losses. Of importance, final permanent partial factors of disability are diminished in rating, due to retained digital length, improved esthetic appearance, and less dysesthesia/cold intolerance.