PubMed · 13253232
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H WASSEN. 1955-07-29. [Plastic finger-tip coverage].. https://pubmed.ncbi.nlm.nih.gov/13253232/
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Nails enhance pulp sensibility, increase pulp stability and are necessary for fine prehension. A finger without a nail will compromise a musician's career if the finger involved is necessary to play a note (strings, keyboards) or hold a position (winds). Salvage of the nail is then a very important part of any surgical procedure in musicians with distal finger trauma. Surgical techniques will depend on the level and type of nail injury. Replantation is by far the best technique in distal finger amputation but, when not feasible, reposition-flap repair may be used. In isolated nail lesions, sutures, split-thickness nail bed graft, or nail matrix flaps are used according to the level and severity of the lesion.
Because the actual methods of assessment and the grading of these methods in favor at any one time have changed so much over the last 50 years, the usefulness of the considerable experience in this field for practitioners today is much reduced. Agreement on the systems of assessment to be used for the different parts of the flexor system would allow a better exchange of knowledge worldwide at this time and a more useful cumulative experience for the next 50 years. If an acceptable method of assessment of any particular injury and its treatment can be agreed on by all, two stages remain for us to audit our work. The first is identifying how much we must downgrade the expectations of the assessment to accommodate the imperfections of our treatments. Most patients would consider an "excellent" result to be a return to normal. Currently, using, for example, the first Strickland system of assessment, we are happy to call any result of primary repair of a zone 2 flexor tendon division greater than 85% of normal, "excellent." How much we should reasonably downgrade our assessments is a variable that one hopes would reduce with accumulated experience, but one that makes repeated adjustment of our methods of assessment essential. Having set the level of the "excellent," "good," "fair," and "poor" qualifying bands relative to normal digital function, it only remains to take our measuring instruments out of their boxes and measure!
Using a single, simple goniometer measuring the range of joint movement at each joint in the hand, the author has developed a simple method of assessing joint stiffness and algodystrophy. This not only involves testing all joints in the fingers but also is a simple technique that can be performed in the outpatient clinic. Arthrography has been used to measure resistance of passive motion of joints, finding that stiffness is worse in the morning and improves after physiotherapy and after injection with steroids. The author's method does not actively measure the resistance to passive motion in a joint, as does the arthrograph. As the patient recovers with time, however (see Fig. 2), the range of movement increases and this may be equivalent to the improvement seen in Bramley et al. Goniometry has been found to be a sensitive test for diagnosing algodystrophy. Together with dolorimetry, however, the specificity of the two tests combined increases significantly while maintaining adequate sensitivity to use as a diagnostic tool. Consequently, it is possible to diagnose algodystrophy at 1 week following Colles' fracture. This finding has important implications in that it probably means the initial injury is responsible for the disease causation rather than anything constitutional or psychological.