What are the best practices for laceration repair at the proximal phalangeal joint?

Laceration Repair at the Proximal Phalangeal Joint

For lacerations at the proximal phalangeal joint, prioritize thorough wound irrigation, assess for tendon and bone involvement before closure, use layered repair with absorbable sutures for deeper structures, and avoid full-thickness sutures except on palmar surfaces—injuries involving flexor tendons or proximal phalanx fractures have significantly worse outcomes and require careful consideration of salvage versus amputation. 1, 2

Initial Assessment and Wound Preparation

Critical Structures to Evaluate

• Examine specifically for flexor digitorum profundus (FDP) and flexor digitorum sublimis (FDS) tendon lacerations, as these injuries dramatically worsen functional outcomes at the proximal phalangeal level 2
• Assess for proximal phalanx fractures, which when combined with tendon injury lead to significant loss of finger mobility and poor salvage outcomes 2
• Rule out involvement of synovial structures, particularly the proximal interphalangeal (PIP) joint, as synovial involvement worsens prognosis 3
• Obtain radiographs if mechanism suggests possible foreign body or fracture, noting that not all foreign bodies are visible on plain films 4

Wound Cleansing

• Perform copious irrigation with sterile normal saline or potable tap water using higher pressures and volumes (100-1000 mL) for effective debris removal 5
• For contaminated wounds, use copious irrigation with cautious debridement 5
• Consider wound preparation with povidone-iodine or chlorhexidine before closure 5

Repair Technique

Layered Closure Principles

• The dermis provides the skin's greatest tensile strength—accurately approximate the entire depth of the dermis to the opposite dermal layer for optimal repair strength 1
• Use 3-0 or 4-0 delayed absorbable sutures (polyglactin or poliglecaprone) for deeper dermal layers 5
• Avoid full-thickness sutures except on palmar and plantar surfaces where they are safe 1
• Epidermal coaptation provides cosmetic finish but does not contribute to wound strength 1
• Fat and muscle do not support sutures—do not rely on these layers for closure strength 1

Suture Selection

• Use monofilament sutures to reduce bacterial seeding 6
• Consider rapidly absorbing synthetic sutures to avoid removal necessity 6
• Employ continuous, non-locking suture technique to distribute tension evenly and avoid tissue edema or necrosis from excessive tension 7

Alternative Closure Methods

• Tissue adhesives may be considered for minor lacerations, providing painless closure with 2-3 minute procedure time and similar cosmetic outcomes to suturing 6

Special Considerations for Proximal Phalangeal Region

When Tendon or Bone Injury Present

• All patients with flexor tendon injury or proximal phalangeal fracture demonstrate loss of PIP joint motion and total active motion compared to soft tissue injuries alone 2
• If only FDP is lacerated (particularly zone I), finger salvage results may be acceptable, but associated distal interphalangeal joint injury may require K-wire stabilization and later fusion 2
• Injuries involving both FDS/FDP tendons AND proximal phalanx fracture have poor functional outcomes—carefully weigh salvage versus amputation 2

Immobilization

• With extensive lacerations or those near the PIP joint, apply a splint or sling for immobilization 1

Post-Repair Management

Wound Care

• Apply foot bandage or cast as appropriate for location 3
• Examine wound 2-3 days after suture placement for signs of infection 1
• Remove Steri-Strips at 5-7 days, assessing for complete wound edge approximation and absence of infection 5

Antimicrobial Prophylaxis

• Consider systemic antimicrobials based on contamination level and structures involved 3
• For contaminated or bite wounds, combine primary closure with preemptive antibiotics 5

Tetanus Prophylaxis

• Administer Tdap if last dose was >10 years ago for clean wounds or >5 years for contaminated wounds 5

Pain Management

• Use acetaminophen or ibuprofen for analgesia 6
• Consider topical anesthetics for temporary relief 6

Critical Pitfalls to Avoid

• Do not underestimate the prognostic significance of combined tendon and bone injury at the proximal phalanx—these injuries have substantially worse outcomes than isolated soft tissue lacerations 2
• Avoid leaving foreign bodies, as complete wound examination and debridement are essential 4, 1
• Do not suture fat or muscle layers expecting them to provide wound strength 1
• Avoid using locking suture techniques that cause excessive tension leading to tissue edema and necrosis 7