3. Primary survey
›A : talk cleary ,no tender at C-spine
›B : no dyspnea,RR20
›C : pulse full ,BP 97/53
›D : E4V5M6 ,pupil 3mm RTLBE
›E : Avulsion wound 1.5 cm at 1st big
toe, exposed bone
4. Secondary survey
A : no drug allergy
M : no current medication
P : no underlying disease
L : last meal 5 hr PTA
E : ขี่จักรยาน เท้าขวาเข้าไปเกี่ยวในล้อจักรยาน มีแผลฉีกขาดที่ปลาย
นิ้วโป้ งเท้าขวา ปวดบริเวณแผล กระดิกนิ้วเท้าได้ ไม่ชา ไม่มีบาดแผล
บริเวณอื่น ศีรษะไม่กระแทกพื้น ไม่สลบ
5. Avulsion wound 1.5 cm
at 1st big toe exposed bone
with active bleeding
Nail bed laceration
capillary refill <2 sec
EHL grade V
intact sensation at tip of 1st
toe
6. Avulsion wound 1.5 cm
at 1st big toe exposed bone
with active bleeding
Nail bed lacerattion
capillary refill <2 sec
EHL grade V
intact sensation at tip of 1st
toe
10. •Injury to the finger with variable involvement of soft
tissue, bone, and tendon
•Goals of treatment
• sensate tip
• durable tip
• bone support for nail growth
•Prognosis
• improper treatment may result
in stiffness and long-term functional loss
Finger tip injury
11. •History
mechanism
• avulsion
• laceration
• crush
•Physical exam
inspection
• often, characteristics of laceration will
guide management
• presence or absence of exposed bone
range of motion
• flexor and extensor tendon involvement
13. Allen's classification
Type 1 Injuries
These injuries involve only the pulp
Type 2 Injuries
Type 2 fingertip injuries involve the pulp and nail bed.
Type 3 Injuries
Type 3 injuries of the fingertip include partial loss of
the distal phalanx.
Type 4 Injuries
Type 4 injuries are proximal to the lunula.
• Type 1 injuries may heal quite well by secondary intention.
Type 3 and 4 often require some type of flap coverage.
14. Fingertip
injuries
เด็กเล็ก Composite flap ถ้าไม่รอด gangrene
เด็กโตหรือผู้ใหญ่
Bone not
exposed
1 cm2 Dressing wound
>1 cm2 STSG, FTSG
Bone exposed
Dorsal slant or
transverse cut
V-Y
advancement
flap
Volar slant
Cross finger
flap
15. Fingertip
injuries
เด็กเล็ก Composite flap ถ้าไม่รอด gangrene
เด็กโตหรือผู้ใหญ่
Bone not
exposed
1 cm2 Dressing wound
>1 cm2 STSG, FTSG
Bone exposed
Dorsal slant or
transverse cut
V-Y
advancement
flap
Volar slant
Cross finger
flap
16. Fingertip
injuries
เด็กเล็ก Composite flap ถ้าไม่รอด gangrene
เด็กโตหรือผู้ใหญ่
Bone not
exposed
1 cm2 Dressing wound
>1 cm2 STSG, FTSG
Bone exposed
Dorsal slant or
transverse cut
V-Y
advancement
flap
Volar slant
Cross finger
flap
17. Fingertip
injuries
เด็กเล็ก Composite flap ถ้าไม่รอด gangrene
เด็กโตหรือผู้ใหญ่
Bone not
exposed
1 cm2 Dressing wound
>1 cm2 STSG, FTSG
Bone exposed
Dorsal slant or
transverse cut
V-Y
advancement
flap
Volar slant
Cross finger
flap
18. •Nonoperative
healing by secondary intention
• indications
adults and children with no bone or
tendon exposed with < 2cm of skin loss
children with exposed bone
Operative
primary closure (revision amputation)
full thickness skin grafting from hypothenar
region
flap reconstruction
Treatment
19. •Secondary intention technique
• initial treatment with irrigation and soft
dressing
• after 7-10 days, soaks in water-peroxide
solution daily followed by application of
soft dressing and fingertip protector
• complete healing takes 3-5 weeks
21. Plan of Management
›Admit
›NPO, IV fluid
›NSS irrigation
›Set OR : for Excisional debridement with repair nail bed
›Pain control : Pethidine 20 mg iv prn q 6 hr,
Paracetamol syr (250mg/5ml) 1 tsp po prn q 6 hr
›Antibiotic : Cefazolin 500mg iv q6hr with stat
(Gustillo Classification type 2)
›Wet dressing
