Edited by Christina Liu and CJ Nessralla - 7/1/2021
Indications/Contraindications
Nailbed lacerations, open distal phalanx/tuft fractures
Materials/positioning
Positioning
Supine on stretcher, arm out to the side Additional table to side as operating platform
Irrigation Materials
Bucket for irrigation
Chux
500cc saline bottle with squirt top vs syringe for irrigation
Hematoma block
10cc syringe
18 gauge needle (draw lidocaine)
25 gauge needle (digital block)
Lidocaine without epinephrine
Repair/amp Materials
Betadine prep
IV tourniquet vs cut out strip of smallest glove finger (finger tourniquet)
Lac repair kit vs OR hand kit (better needle drivers and pickups, freer)
4-0/5-0 chromics (usually grab 2-4 depending on size of lac)
Sterile gloves
Sterile gauze (4x4)
Dressing Materials
Adaptic or xeroform, Bacitracin ointment Splinting supplies depending on type of splint (webril, plaster, ace, tape)
Technique - Digital Block
Lidocaine (no epi) - 5-8cc lidocaine per finger
Inject lateral & medial finger web near MCP on dorsal surface (2-3cc each)
Inject A1 pulley (at MC head) along tendon sheath like a trigger finger injection (2-5cc)
Technique - Nailbed Repair
Nail removal: Use Freer to lift up nail and remove from bed, can also spread scissors underneath nail
I&D nailbed with saline +/- betadine
Repair as needed
Clean lacs repaired with interrupted chromic sutures Complex lacs can be covered with dermabond Incise both edges of the nail fold to flip back and repair any eponychial injury
Can replace nail to stent the nail fold open. If nail is destroyed, cut a piece of xeroform or chromic wrapper to size. Place two 4.0 chromic stitches into base to hold in place.
Cut xeroform dressing to place over digit tip - no circumferential wrapping.
Set aside gauze/kerlex for final dressing
Dressing: adaptic vs xeroform, bacitracin, gauze, volar splint intrinsics plus with splint going to tips of finger to prevent any flexion/extension
Technique - Revision Amputation
Revision amputation: commonly done for complete amputations distal to DIP or PIP
Distal to DIP: preserve FDP insertion if able.
Distal to PIP: debulk FDP since no longer inserted onto distal phalanx and useless. Make sure FDS still inserted to allow for PIP flexion
Maintain as much length as possible when shortening and smoothing out bone cut or soft tissue closure.
Proximal phalanx of IF can get in the way of pinch between thumb and LF/RF, but proximal phalanx of LF/RF important to prevent things from falling through between IF/SF. If repairing laceration/soft tissues, avoid placing lots of sutures or deep sutures because risk ischemia with sutures, if possible only approximate skin/outermost soft tissue