1. IN THE NAME OF GOD

2. INTRODUCTION Management of injuries to the nail bed is based on the integrity of the nail plate and nail margin.

3. Anatomy

4. Perionychium nail plate nail fold eponychium nail bed hyponychium paronychium

6. at least 4 mm of dorsal skin proximal to the nail plate is needed for adequate venous anastomosis.

7. Nail Bed Injuries nail bed lacerations requiring repair occurred in 60% of patients when the subungual hematoma was >50% of the nail plate 95%of patients when there was an associated fracture of the distal phalanx.

8. in patients with an intact nail plate and injuries to the nail bed managed with trephination alone or trephination with nail removal and laceration repair,regardless of hematoma size or the presence of fracture. However,trephination alone is associated with substantially lower costs.

9. Classic repair of the nail bed consists of approximation of the lacerated edges with small-caliber (6.0 to 7.0) chromic or other absorbable suture

10. In a randomized controlled trial, Strauss et al compared the efficacy of the adhesive 2-octylcyanoacrylate (Dermabond, Ethicon) with that of suture repair no difference in the results of both treatment groups, but the adhesive group required less time for repair than did the suture group.

11. Management of Partial Fingertip Amputations Primary closure or healing by secondary intention are preferable for partial fingertip amputations when no bone is exposed and when adequate soft tissue coverage is available volarly.

12. significant soft tissue loss on the volar aspect of the distal finger completion amputation(ie, shortening and closure) The most important parts of this procedure are full ablation of the nail bed to prevent hook nail deformity and identification and transection of the digital nerves as far proximal to the level of amputation as possible to prevent formation of painful neuroma

13. Autogenous skin grafts a well-vascularized recipient bed dorsal skin more amenable to skin grafting cannot be placed directly on bone or tendon One advantage of full-thickness grafts is that they prevent wound contracture more than do split thickness grafts.

14. Injuries with exposed bone and a lack of available soft tissue for coverage often require flap reconstruction Local flap Atasoy-Kleinert V-Y flap Kutler lateral V-Y flap Moberg flap Regional flap

15. Atasoy-Kleinert V-Y Flap

16. best used for transverse or dorsal oblique amputations for all digits contraindicated in patients with volar oblique amputations and more tissue loss volarly Damage to the neurovascular bundles should be avoided

18. Kutler Lateral V-Y Flap Better suited for volar oblique amputations that have more tissue loss volarly than dorsally, but it can also be used for transverse amputations. Provides only 3 to 4 mm of advancement

20. Moberg Flap for soft-tissue defects of the thumb

21. Regional Flaps types cross-finger flap Thenar flap thenar-H flap second operation to detach the fingertip from the donor site 3 to 4 weeks after the initial procedure prolonged period of immobilization

22. cross-finger flap a reverse cross-finger flap can be used to cover dorsal soft-tissue defect

24. Thenar and Thenar-H Flaps

25. Island Flaps with a neurovascular pedicle provide sensation to the finger tip may avoid the prolonged period of immobilization required for a cross-finger or thenar flap

26. Other Treatment Options Distant flaps Groin, chest, and cross-arm acellular dermal regeneration templates Placed directly on exposed bone or tendon those with vascular disease poor donor-site tissue

28. Replantation Complete distal fingertip amputations are one of the best indications for replantation. The most common complications of replantation were nail deformity (23%) and pulp atrophy (14%).

29. failure of the replanted digit : crush-type injuries improper treatment of the amputated digit Smoking high platelet counts

30. Tamai classification Allen classification