Sensory Recovery in Finger Tip Injuries

[Pages:6]Original Article

Amer et al.: Sensory recovery in finger tip injuries

Sensory Recovery in Finger Tip Injuries

Tarek A. Amer 1, Ashraf A. Enab 2, Sameh A. El-Nomani 1, Neveen M. El-Fayoumy 3

Departments of Surgery, Cairo University1, Beni Suef University2; Clinical Neurophysiology3, Cairo University; Egypt

ABSTRACT

Background: Traumatic amputation of the tip of the finger is a common injury both in domestic and industrial settings and it is the most common injury seen in upper extremity. Several options for the management of this type of injury are available. These options include surgical and conservative management. The main aim of these options is coverage and retaining sensation of the finger tip. Objective: The aim of this study is to compare sensory recovery using two point discrimination test and sensory nerve conductions following conservative management versus local flaps in finger tip injuries without bone exposure. Methods: Sixty-four fingers in 58 patients are included in this study. Thirty-three finger tips were allocated to group 1 (conservative management) and 31 to group 2 (local non sensate flaps). Two point discrimination test and sensory nerve conductions were done after one year. The incidence of infection, joint stiffness, cold intolerance and hypersensitivity was also noted. Results: There was a highly statistically significant difference between the two groups as regards the two point discrimination test, and peak latency, amplitude and conduction velocity of sensory nerves (p0.001) with better values in group 1. Conclusion: sensory recovery presented by two point discrimination test and sensory nerve conductions in patients under conservative management is much better than that achieved with local flaps and there is no statistical difference in the incidence of cold intolerance or hypersensitivity between the two methods of treatment after one year. (Egypt J Neurol Psychiat Neurosurg. 2010; 47(2): 325-330)

Key words: Fingertip injuries- two point discrimination - sensory nerve conductions-conservative management- local flaps.

INTRODUCTION

Traumatic amputation of the tip of the finger is a common injury both in domestic and industrial settings (1). Finger tip amputation is the most common type of amputation injury in the upper extremity (2). The finger tip is defined as the portion of the finger distal to the plane of the major dorsal and volar skin creases at the distal interphalyngeal joint (3).

The two-point discrimination test is the most frequently used test for the assessment of the sensory outcome after nerve repair (4). For dermatomal regions of the arm and forearm, mean values ranged from 30.7 mm to 45.4 mm. In the hand, the skin overlying the first dorsal interosseous muscle demonstrated discrimination values of 21.0 mm while that covering the volar surface of the tips of the thumb and long and little fingers showed values of 2.6 mm. (5)

Sensory nerve conduction studies can add much as evidence of diffuse sensory fiber involvement, localized lesions involving a cutaneous nerve or disorders that preferentially damage the sensory fibers in a mixed nerve, so they are a necessary part of any electrophysiologic evaluation of peripheral disorder(6).

Correspondence to Neveen Mohammed El-Fayoumy, clinical neurophysiology unit, Cairo University; Egypt. TEL.: +20123714317. Email:neveenfayomy@.

The treatment of finger tip amputations is controversial and so, many treatment options are available. These treatment options are either conservative management or surgical treatment. The main aim of these treatment options is to keep functional impairment to a minimum. Of course regaining sensation at the finger tip is the most important aspect of maintaining function in finger tip injury3.

Aim of work: This study was conducted to compare sensory

recovery using sensory nerve conductions and two point discrimination test following conservative management versus local flaps in finger tip injuries without bone exposure.

PATIENTS AND METHODS

Study design and population: This study included Sixty four finger tip injuries

in 58 patients. All patients were recruited from the department of surgery, Kasr El-Eini hospital, Cairo University, Egypt, and department of surgery BeniSuef University, Egypt.

Patients were allocated according to treatment policy into: a- Group 1: Thirty three finger tips received

conservative management. b- Group 2: Thirty one finger tips were treated

using local non-sensate flaps.

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Amer et al.: Sensory recovery in finger tip injuries

Exclusion criteria: Smokers, patients with peripheral neuropathy

(using nerve conductions) and diabetics were excluded from the study. Patients with carpal tunnel syndrome were also excluded by doing mid palm ?wrist segment sensory nerve conduction and sensory nerve conductions from the other digits supplied by the median nerve. Moreover, patients with bone exposure or other associate hand injury were excluded.

On admission, adequate history taking, thorough physical examination and X-rays were taken to exclude associated hand injury.

Methods: I- Clinical evaluation:

Two point discrimination test was conducted one year post injury for both the treated finger and the same finger in the opposite hand. The finger of the patient is touched with the two points widely separated using blunt objects then the patient must close his eyes and the pulp of the finger is touched firmly with either one point or two, starting with them far apart, and approximating them until he begins to make errors. The threshold is thus determined and the other hand can be compared. Normally a person should be able to recognize two points separated by as little as 2.6 mm on the finger pads5.

II- Neurophysiological evaluation: Sensory nerve conduction studies were carried

out in the clinical Neurophysiology Unit, Kasr El-Eini hospital one year post-injury using a Nihon Kohden? (Neuropack four mini) apparatus. The active and reference electrodes are 4 cm apart with the active placed 14 cm from the cathode and the stimulation is applied with ring electrodes around the digits with the cathode at the base of the digits and the ground is placed between the pickup and stimulating electrodes (orthodromic technique).

Normal values: peak latency 3.2?0.2 mseconds, amplitude 10-90uv and conduction velocity 48-64.9 m/seconds7.

III. Surgical techniques: A) Conservative management (group 1): Adequate wound debridement was done under regional ring block anesthesia, following that the wound is dressed with Vaseline impregnated gauze with fusidic acid. The finger is covered with the cut finger end of a sterile surgical glove for 48 hours. The patients are followed up in the out patient clinic and dressing is changed every 48 hours in the 1st week and twice weekly after that until healing occur. Patients started wide range of early motion exercise from first day post injury. B) Local flaps (group 2): Under local anesthesia, adequate wound debridement is done. Local flaps used are V-Y advancement flap (15 cases), cross

finger flap (10 cases) and thenar flap (6 cases). Dressing change is done every 48 hours for 4 days. This is followed by motion exercises except in cases with cross finger flap where it was done after flap separation after 21 days.

The incidence of infection, joint stiffness, cold intolerance and hypersensitivity was also noted.

Statistical Methods Data were expressed as meanstandard deviation

(SD) or percentage (%). Comparison between the numerical data of two groups was performed using unpaired t test, Chi-square test used for comparison between qualitative data which were presented as frequencies and percentages. Pearson's correlation coefficient was used to determine significant correlations between the different qualitative variables. SPSS computer program (version 11) was used for data analysis. P value is considered is considered highly significant (**) if it was 0.001.

RESULTS

Sixty-four finger tip injuries in 58 patients were included in the study. Forty fingers were injuries due to industrial accidents and 24 injuries due to domestic accidents. 40 patients were males (68.96 %) and 18 were females (31.04%). The mean age of the patients at the initial presentations was 36.1?8.75 years (range 19-55 years) (Table 1). 33 injured finger tips were treated using conservative management (Group 1) and 31 were treated using local flaps (Group 2). Two flaps were lost in group 2 so they were excluded from the study leaving only 29 injuries for evaluation in this group.

1- Conservative treatment (Group 1) : Thirty-three finger tip injuries were treated using

this method. After adequate debridement, the mean surface area of the defect was 1.6 cm2 (range 0.5-2.2 cm2). No infection in any finger occurred during the period of treatment.

Cold intolerance was detected in 9 fingers (27.3%) after 3 months and only in 2 fingers (6.1%) after one year. Hypersensitivity was noticed in 12 fingers (36.4%) after 3 months. After one year no hypersensitivity was noticed in any finger, as shown in Table (2). No joint stiffness was observed in any finger.

2- Local flaps (Group 2): Thirty-one fingers were treated using this method.

After adequate debridement the mean surface area of the defect was 1.6 cm2 (range 0.6-2.1 cm2). Flap separation in cross finger flap was done after 21 days. Two flaps were lost, so they were excluded from the study leaving only 29 cases for evaluation in this group.

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Amer et al.: Sensory recovery in finger tip injuries

Cold intolerance was observed in 8 fingers (27.6%) after 3 months and in 2 fingers (6.9%) after one year. Hypersensitivity was not noticed in any of the fingers after 3 or 12 months. Joint stiffness did not occur in any of the fingers. So, the difference in the development of cold intolerance and hypersensitivity between fingers treated conservatively and those treated with local flaps was not statistically significant after 12 month p>0.05, as shown in Table (2).

In the comparative and correlative results, we used only data of 58 fingers after excluding the two lost flaps and thumb, middle fingers, so we compared index's finger data only to be statistically compared and correlated.

I. Comparative results: 1. Two-point discrimination test: There was a highly statistically significant increase in two-point discrimination test in patients with index injury (local flaps, conservative), compared to the contra lateral healthy index (p ................
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