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Fingertip Repair and Reconstruction

41 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Fingertip replantation is favored for amputations distal to the distal interphalangeal joint when feasible, offering superior functional and aesthetic outcomes compared to revision amputation [28]. However, this approach is more technically demanding and requires a longer recovery time than revision amputation [3]. For composite fingertip defects, there is insufficient evidence to determine the optimal treatment method due to the lack of prospective randomized trials and disparate retrospective case series [9]. Similarly, strong evidence such as randomized controlled trials is lacking to support clinical experience with very distal finger replantation, which is highly difficult to study via well-designed prospective trials [10].

When replantation is not indicated or feasible, various flap techniques provide effective reconstruction. Simultaneous primary reconstruction of dorsal and palmar injuries results in the restoration of a satisfying fingertip [2]. For bone exposure, the parallelogram flap is a better choice than the homodigital island flap [4]. Medium-sized volar defects can be repaired effectively using modified triangular neurovascular unilateral advancement flaps or digital artery dorsal perforator flaps [5]. The modified pivot flap offers reliable results with promising sensitivity and functional recovery [6], while the extended step-advancement flap serves as a viable alternative to replantation [7]. Extensive thumb pulp defects are well-addressed by the radial-based pedicled flap from the index finger, which provides thick, durable tissue with minimal donor morbidity [8].

For extensive pulp defects where other flaps are unsuitable, the heterodigital reversed flow neurovascular island flap is indicated as an alternative to microsurgical reconstruction [19]. Reverse flow homodigital flaps can be applied to two consecutive fingers without reducing finger length or function [1].

Anatomy & Pathophysiology

Fingertips are extremely important functional structures [14]. Secondary deformities from fingertip injuries can cause a great deal of inconvenience or disability [14]. Fingertip injuries in children are common and result in significant burden [49]. Most pediatric fingertip injuries occur at home, often involving doors or windows [49]. Fingertip injuries in children are mostly preventable [49].

Sensation recovery is of primary importance for fingertip injuries [16]. The appropriate understanding of the involved structures of a fingertip injury is necessary for management [12]. Meticulous management of fingertip injury structures can generally lead to a very aesthetic and functional fingertip [12].

Classification

Allen’s classification: This system is quoted by most surgeons in the UK for fingertip injuries, although the actual numerical level is rarely used in practical terms [20]. Initial discussions regarding replantation eligibility often focus on whether the injury is proximal enough to indicate an Allen’s Zone IV, defined as proximal to the nail fold [20]. Replantation of an amputation injury within any Allen’s classification is extremely rare in the UK [20]. Thumb fingertip reconstruction cases have been categorized according to Allen’s classification, with specific counts for type II, type III, and type IV injuries [38]. Fingertip reconstruction cases involving simultaneous flaps and nail bed grafts were also categorized according to Allen’s classification, with specific counts for type 2, type 3, and type 4 injuries [41].

Three-dimensional arterial concept: This classification is based on the damaged arterial system and is useful to predict the site of the ruptured artery to be anastomosed, which can make distal fingertip replantation easier [21].

Lister’s classification: The Gigogne flap study utilized a classification of distal digital amputation corresponding to Lister’s classification [36].

Gigogne flap study groups: The study divided clinical cases into two groups according to the proximal flap selected: VY advancement flaps or neurovascular homolateral island flaps [36].

Modified-Ishikawa classification: This classification was implemented in four studies included in a systematic review of composite grafts [42]. The review analyzed patients with class I, class II, and class III fingertip amputations according to the Modified-Ishikawa classification [42].

Other Considerations:

Clinical Presentation

Fingertips are extremely important functional structures, and secondary deformities can cause significant inconvenience or disability [14]. The precise management of a fingertip injury in adults depends on the degree of injury itself [11]. Appropriate understanding of the involved structures and meticulous management can generally lead to a very aesthetic and functional fingertip [12].

A number of operative and non-operative techniques may be successfully employed for fingertip injuries in adults [11]. With proper management focusing on robust soft-tissue coverage, maximizing functional length, and preserving nail function, most patients with fingertip injuries can achieve good outcomes [25]. Fingertip injuries in pediatric patients and fingertip injuries without distal phalanx fractures achieved better cosmesis scores [27].

Investigations

Plain radiography: Indicated to assess for distal phalanx fractures. Fingertip injuries without distal phalanx fractures achieved better cosmesis scores when using repositioned native nail plate as a free graft or artificial nail plate [27].

Other Considerations: Classification Systems: A three-dimensional classification of distal fingertip amputation based on the arterial system is useful to predict the site of the ruptured artery to be anastomosed [21]. This arterial system classification can make distal fingertip replantation easier [21].

Treatment Selection: Conservative treatment is recommended as a safe and simple treatment after loss of a fingertip, even when bone is exposed in the wound [29]. Meticulous management of fingertip injuries, based on an understanding of involved structures, can generally lead to a very aesthetic and functional fingertip [12].

Reconstructive Options: * Modified pivot flap: A reliable technique for fingertip defect reconstruction with promising results in sensitivity and functional recovery [6]. * Extended step-advancement flap: A viable alternative to replantation of the avulsed amputated fingertip [7]. * Radial-based pedicled flap: Provides a simple, favourable alternative for reconstruction of extensive thumb pulp defects, offering thick and durable tissue with minimum dissection and donor side morbidity [8]. * Artificial dermis with medial toe flap: Application restores the appearance of the injured fingernail and preserves finger length and function without damaging the toenail [13]. * Thenar flap with bone and nail bed grafts: Tripartite reconstruction yields a functional and aesthetically pleasing outcome for fingertip injuries with bony loss [17]. This technique provides additional length and bone support to prevent a shortened fingertip [17] and avoids hook nail deformity [17]. * Short anterograde homodigital neurovascular island flap: Preserved good fingertip sensation, although two-point discrimination was significantly worse on the side treated compared to the contralateral side [31]. * Dorsal island pedicle flap: Can be used for coverage of extensive fingertip or pulp defects. It maintains a normal-length digit and restores sensation on both the radial and ulnar sides of the finger pulp [32].

Pediatric Outcomes: Fingertip injuries in pediatric patients achieved better cosmesis scores when using repositioned native nail plate as a free graft or artificial nail plate [27].

Treatment

Non-Operative

Conservative nonsurgical treatment of fingertip amputations, with or without bone exposure, can be managed successfully without surgical intervention [40]. Management of fingertip injuries using silver sulphadiazine dressings removes the need for hospital admission and operating theatre time [26]. Primary terminalization for acute fingertip injuries is associated with excellent long-term patient-reported outcomes, high levels of satisfaction, and a low rate of complications, despite one in three patients reporting long-term neuropathic pain [30].

Operative

Indications: The precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed [11]. The decision-making process should proceed from simpler techniques to more complicated ones [44]. A variety of treatment options for fingertip amputations range from least invasive to replantation, aiming to minimize pain, optimize healing, preserve sensibility and length, and provide acceptable cosmetic appearance, though no single recommended reference standard exists [46]. Primary flap reconstruction should be considered as the initial treatment of choice for damaged fingertip amputations in older patients with regard to ultimate range of motion [15].

Surgical Approach / Technique: Replantation is favored for fingertip amputations distal to the DIP joint if feasible, offering superior functional and aesthetic outcomes compared to alternatives [28]. Fingertip replantation offers better functional results than revision amputation but is more technically demanding and requires a longer recovery time [3]. There is a lack of strong evidence such as randomized controlled trials to support clinical experience with very distal finger replantation, though well-designed prospective studies are considered highly difficult to conduct [10]. In cases where replantation is not possible, has failed, or is refused by the patient, soft tissue reconstruction that preserves the length of the injured finger to the greatest extent possible is necessary [47]. Meticulous management of involved structures generally leads to a very aesthetic and functional fingertip [12]. Secondary deformities from fingertip injuries can cause great inconvenience or disability [14]. Preservation of the shape of the nail and the length of the finger is important in improving cosmetic appearance in fingertip reconstruction [47].

Implant Selection: When no bone is exposed, the open method is ideal for small or moderate-sized wounds, and skin grafting should be considered for larger wounds [44]. Distal transverse and dorsal oblique amputations with bone exposure can be treated with local tissue advancement that preserves length [44]. More proximal and volar oblique amputations can be managed with a regional flap to preserve length if enough sterile matrix remains for a stable nail and if there is no contraindication [44]. Shortening and primary skin closure can be used for amputations not amenable to other methods of treatment [44].

Adjuncts: The parallelogram flap is a better choice for the reconstruction of fingertip injury with bone exposure compared to the homodigital island flap [4]. Both modified triangular neurovascular unilateral advancement flaps and digital artery dorsal perforator flaps can effectively repair medium-sized fingertip defects [5]. The dorsal adipofascial turn-over flap provided a very durable covering for fingertip defects, preserved finger length, and resulted in satisfactory outcomes with no donor site morbidity except for one case of desquamation [23]. The dorsal island pedicle flap from an adjacent finger can be used for coverage of extensive fingertip or pulp defects, with maintenance of a normal-length digit and restoration of sensation on both the radial and ulnar sides of the finger pulp [32]. The heterodigital reversed flow neurovascular island flap is indicated for extensive pulp defects in fingers where reconstruction cannot be done using other flaps and serves as an alternative to microsurgical reconstruction [19].

Other Considerations: A radial-based pedicled flap from the index finger provides a simple, favorable alternative for reconstruction of extensive thumb pulp defects, offering thick and durable tissue with minimum dissection and donor side morbidity [8]. The radial-innervated cross-finger flap offers a large and relatively expendable donor area of innervated dorsal skin for reconstruction of the volar surface of the thumb without depriving a finger of its perceptive ability [18]. Tripartite reconstruction using the thenar flap with bone and nail bed grafts yields a functional and aesthetically pleasing outcome for fingertip injuries with bony loss, providing additional length and bone support to prevent a shortened fingertip and avoiding hook nail deformity [17]. The surgical technique using artificial dermis combined with a medial flap from the second toe restores the appearance of the injured fingernail and preserves the length and function of the injured finger without damaging the toenail [13].

Complications

Treatment Discrepancy: The optimal treatment for distal fingertip injuries remains controversial and differs from region to region within the United Kingdom [20]. Variations exist in how adults and children are treated for these injuries [20]. There is also discrepancy in the outcome measures used, with different emphases placed on wound healing alone versus longer-term outcomes such as nail deformity, nail growth, and long-term function [20].

Replantation Challenges: Replantation of fingertip injuries is more technically demanding than revision amputation [3]. It also requires a longer recovery time than revision amputation [3]. Despite various studies pointing to good distal replantation outcomes, there remains a reluctance to replant distal injuries in the United Kingdom [20]. Replantation of an amputation injury within any Allen's classification is extremely rare in the experience of the author [20].

Infection: The low incidence of infection (2.5%) and lack of a meaningful difference between groups call into question prophylactic antibiotic prescribing after distal fingertip injuries [52].

Recovery

Light activity (weeks): Patients can expect to return to work on average approximately 7 weeks after fingertip revision amputation [37].

Full activity (months): Fingertip revision amputation can achieve satisfactory motion [37].

Complete recovery / outcome plateau (months): Primary terminalization for acute fingertip injuries is associated with excellent long-term patient-reported outcomes [30]. Fingertip revision amputation can achieve almost normal sensibility [37].

Rehabilitation protocol: Evidence does not specify immobilisation duration or specific PT phasing for these procedures.

Functional milestones: Primary terminalization for acute fingertip injuries is associated with high levels of satisfaction [30]. One in three patients report long-term neuropathic pain following primary terminalization for acute fingertip injuries [30].

Other Considerations: Primary terminalization for acute fingertip injuries is associated with a low rate of complications [30].

Key Evidence

  • [L4] These flaps can be applied to two consecutive fingers without reducing finger length or function. [1] (10.1016/j.injury.2014.06.009)
  • [L4] Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip. [2] (10.1177/1753193413489794)
  • [L5] Although fingertip replantation offers better functional results than does revision amputation, replantation is more technically demanding and requires longer recovery time. [3] (10.5435/00124635-201312000-00006)
  • [L2] This method is a better choice for reconstruction of fingertip injury. [4] (10.1186/s13018-022-03214-1)
  • [L3] Both flaps can effectively repair medium-sized fingertip defects. [5] (10.1186/s13018-024-04608-z)
  • [L4] The modified pivot flap demonstrates a reliable technique for fingertip defect reconstruction with promising results in terms of sensitivity and functional recovery. [6] (10.1177/1753193420956320)
  • [L4] It is a viable alternative to replantation of the fingertip. [7] (10.1016/j.jhsa.2010.10.008)
  • [L4] The presented flap provided a simple yet favourable alternative for reconstruction of the thumb tip, with thick and durable tissue requiring minimum dissection and donor side morbidity. [8] (10.1177/1753193418778447)
  • [L5] There is insufficient evidence to determine the best treatment method for composite defects of the fingertips due to the lack of prospective randomized trials and disparate retrospective case series. [9] (10.1016/j.jhsa.2008.07.001)
  • [L5] The authors state there is a lack of strong evidence such as randomized controlled trials to support clinical experience with very distal finger replantation, though they believe it is highly difficult to conduct well-designed prospective studies for this procedure. [10] (10.1177/1753193419873554)
  • [Paper] However, the precise management of a fingertip injury in adults depends on the degree of injury itself, and a number of operative and non-operative techniques may be successfully employed. [11] (10.1016/j.injury.2017.10.042)
  • [L5] The appropriate understanding of the involved structures of a fingertip injury as well as the meticulous management of these injuries can generally lead to a very esthetic and functional fingertip. [12] (10.1016/s0749-0712(02)00075-6)
  • [L4] The surgical technique restores the appearance of the injured fingernail and preserves the length and function of the injured finger without damaging the toenail. [13] (10.1016/j.jhsa.2023.12.003)
  • [L5] Fingertips are extremely important functional structures, and secondary deformities can cause a great deal of inconvenience if not disability. [14] (10.1016/s0749-0712(21)01040-4)
  • [L4] In the event of a damaged fingertip amputation in older patients, primary flap reconstruction should be considered as the initial treatment of choice, with regard to the ultimate range of motion. [15] (10.1177/15589447221081863)
  • [L5] Sensation recovery is of primary importance for fingertip injuries. [16] (10.1177/1753193419876496)
  • [L4] This technique yields a functional and aesthetically pleasing outcome for fingertip injuries with bony loss, providing additional length and bone support to prevent a shortened fingertip and avoiding hook nail deformity. [17] (10.1016/j.jhsa.2017.09.011)
  • [L4] The radial-innervated cross-finger flap offers a large and relatively expendable donor area of innervated dorsal skin for reconstruction of the volar surface of the thumb without depriving a finger of its perceptive ability. [18] (10.2106/00004623-196951070-00001)
  • [L4] This new procedure is indicated for extensive pulp defects in fingers in which reconstruction cannot be done using other flaps and as an alternative to microsurgical reconstruction. [19] (10.1054/jhsb.1999.0164)
  • [L5] [20] (10.1177/1753193419871664)
  • [Paper] This three-dimensional concept classification, based on the damaged arterial system, is useful to predict the site of the ruptured artery to be anastomosed and can make distal fingertip replantation easier. [21] (10.1007/s12593-012-0086-7)
  • [L4] [23] (10.1054/jhsb.1999.0223)
  • [L5] With proper management focusing on robust soft-tissue coverage, maximizing functional length, and preserving nail function, most patients with fingertip injuries can achieve good outcomes. [25] (10.5435/jaaos-d-24-00818)
  • [L4] The management of fingertip injuries by this method has a number of advantages, including the removal of the need for hospital admission and operating theatre time. [26] (10.1016/s0020-1383(99)00296-x)
  • [L3] Fingertip injuries in pediatric patients and fingertip injuries without distal phalanx fractures achieved better cosmesis scores. [27] (10.1016/j.jhsg.2023.04.002)
  • [L5] Replantation is favored for fingertip amputations distal to the DIP joint if feasible, offering superior functional and aesthetic outcomes compared to alternatives. [28] (10.1177/1753193419873555)
  • [L4] Conservative treatment is recommended as a safe and simple treatment after loss of a fingertip, even when bone is exposed in the wound. [29] (10.1016/0020-1383(87)90138-0)
  • [L4] Primary terminalization for acute fingertip injuries is associated with excellent long-term patient-reported outcomes, high levels of satisfaction, and a low rate of complications, despite one in three patients reporting long-term neuropathic pain. [30] (10.1177/17531934241247276)
  • [L4] The procedure preserved good fingertip sensation, though two-point discrimination was significantly worse than the contralateral side. [31] (10.1016/j.otsr.2021.102981)
  • [L4] The dorsal island pedicle flap from an adjacent finger can be used for coverage of extensive fingertip or pulp defects, with maintenance of a normal-length digit and restoration of sensation on both the radial and ulnar sides of the finger pulp. [32] (10.1016/j.jhsa.2009.06.021)
  • [L4] [36] (10.1177/1753193408098904)
  • [L1] On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery. [37] (10.1007/s11552-012-9487-0)
  • [Paper] [38] (10.1007/s00402-015-2163-4)
  • [L4] This study demonstrated that conservative nonsurgical treatment of fingertip amputations with or without bone exposure can be treated successfully without surgical intervention. [40] (10.1016/j.jht.2013.08.018)
  • [L4] [41] (10.1016/j.jhsa.2013.03.032)
  • [L1] [42] (10.1186/s13018-024-05230-9)
  • [L5] [44] (10.5435/00124635-199603000-00003)
  • [L5] This review presents a variety of treatment options for fingertip amputations ranging from least invasive to replantation, aiming to minimize pain, optimize healing, preserve sensibility and length, and provide acceptable cosmetic appearance, though no single recommended reference standard exists. [46] (10.1016/j.jhsa.2014.04.025)
  • [L4] [47] (10.1177/1753193414552649)
  • [L4] Fingertip injuries in children are common and result in significant burden, yet are mostly preventable, with most injuries occurring at home in a door or window. [49] (10.1177/1558944716670139)
  • [L3] The low incidence of infection (2.5%) and lack of a meaningful difference between groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. [52] (10.1016/j.jhsg.2023.07.010)

See Also

References

[1] Reconstruction of multiple fingertip injuries with reverse flow homodigital flap. Injury. 2014. DOI: 10.1016/j.injury.2014.06.009

[2] Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413489794

[3] Fingertip Injuries: An Update on Management. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201312000-00006

[4] Parallelogram flap versus homodigital island flap in the treatment of fingertip defects with bone exposure: a prospective controlled study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03214-1

[5] Comparison treatment of medium-sized volar fingertips defects with modified triangular neurovascular unilateral advancement flap versus digital artery dorsal perforator flap. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04608-z

[6] Fingertip defect reconstruction with a modified pivot flap. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420956320

[7] Extended Step-Advancement Flap for Avulsed Amputated Fingertip—A New Technique to Preserve Finger Length: Case Series. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.10.008

[8] Reconstruction of extensive pulp defects of the thumb with a radial-based pedicled flap from the index finger. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418778447

[9] Fingertip Reconstruction. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.07.001

[10] Finger amputations and pulp defects distal to the distal interphalangeal joint. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419873554

[11] Management of partial fingertip amputation in adults: Operative and non operative treatment. Injury. 2017. DOI: 10.1016/j.injury.2017.10.042

[12] Acute nail bed injuries. Hand Clinics. 2002. DOI: 10.1016/s0749-0712(02)00075-6

[13] Application of Artificial Dermis Combined With a Medial Flap From the Second Toe to Repair Degloving Injury of the Fingertip. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.12.003

[14] COMPLICATIONS OF FINGERTIP INJURIES. Hand Clinics. 1994. DOI: 10.1016/s0749-0712(21)01040-4

[15] Reconstructive Timing of Nail Preserved Fingertip Injury With Reverse Digital Artery Island Flap. HAND. 2022. DOI: 10.1177/15589447221081863

[16] Fingertip repair methods: choices for different fingers and sides emphasizing sensation. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419876496

[17] A Technique for Tripartite Reconstruction of Fingertip Injuries Using the Thenar Flap With Bone and Nail Bed Grafts. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.09.011

[18] Radial-Innervated Cross-Finger Flap from Index to Provide Sensory Pulp to Injured Thumb. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00001

[19] The Heterodigital Reversed Flow Neurovascular Island Flap for Fingertip Injuries. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0164

[20] Favoured treatments for fingertip defects and finger amputation distal to the distal interphalangeal joint in my unit and in Japan. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419871664

[21] Classification of Distal Fingertip Amputation Based on the Arterial System for Replantation. Journal of Hand and Microsurgery. 2013. DOI: 10.1007/s12593-012-0086-7

[23] Dorsal Adipofascial Turn-Ovesr Flap for Fingertip Amputations. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0223

[25] Fingertip Injuries: A Review and Update on Management. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00818

[26] Late review of the use of silver sulphadiazine dressings for the treatment of fingertip injuries. Injury. 2000. DOI: 10.1016/s0020-1383(99)00296-x

[27] Appearance Outcomes of Repositioned Native Nail Plate as a Free Graft and Artificial Nail Plate in the Reconstruction of the Fingertip Injuries. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.04.002

[28] Management of fingertip injuries in Scotland and the United Kingdom. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419873555

[29] Conservative treatment of fingertip injuries. Injury. 1987. DOI: 10.1016/0020-1383(87)90138-0

[30] Long-term outcomes after terminalization for acute fingertip injuries. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241247276

[31] Long-term outcome of a “short” anterograde homodigital neurovascular island flap with a simple or double V-Y plasty. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102981

[32] Coverage of Fingertip Defect Using a Dorsal Island Pedicle Flap Including Both Dorsal Digital Nerves. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.06.021

[36] The Gigogne Flap: An Original Technique for an Optimal Pulp Reconstruction. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408098904

[37] A Systematic Review of Outcomes of Revision Amputation Treatment for Fingertip Amputations. HAND. 2013. DOI: 10.1007/s11552-012-9487-0

[38] Thumb fingertip reconstruction with palmar V–Y flaps combined with bone and nail bed grafts following amputation. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2163-4

[40] Conservative Wound Care Treatment of Fingertip Amputation Injuries With and Without Bone Exposure. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.08.018

[41] Fingertip Reconstruction With Simultaneous Flaps and Nail Bed Grafts Following Amputation. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.032

[42] Factors predicting composite grafts survivability in patients with fingertip amputations; a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05230-9

[44] Fingertip Injuries: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199603000-00003

[46] Management of Fingertip Amputations. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.025

[47] Modified anterograde pedicle advancement flap in fingertip injury. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414552649

[49] Fingertip Injuries in Children: Epidemiology, Financial Burden, and Implications for Prevention. HAND. 2016. DOI: 10.1177/1558944716670139

[52] Antibiotic Prophylaxis in the Management of Distal Fingertip Amputation and Crush Injury. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.07.010

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i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.