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Objective:To retrospectively analyse the clinical effect of sensation reconstructed free medial plantar artery perforator flap in repair of digit-tip defects.Methods:From March 2017 to February 2021, 11 cases with digit-tip defect were repaired by medial plantar artery perforator flap in the Department of Hand Surgery of Xuzhou Renci Hospital. The cutaneous sensory nerves were separated when the flap was harvested, and then the sensory nerves were sutured to the palmar nerves of the digits to reconstruct the sensation of the flap. All wounds had exposure of phalangeal bones, the size of the digit-tip defects was 1.2 cm×1.0 cm-2.5 cm×2.2 cm, the size of the flaps was 1.6 cm×1.5 cm-3.0 cm×2.7 cm. Ten donor sites were directly sutured and 1 was repaired by skin grafting. All patients were included in the postoperative follow-up through outpatient clinic and WeChat reviews to collect relevant information, including texture, sweating, stability, sensation, degree of bloating, blood circulation, usage of the flaps and skin and scars at the donor sites.Results:All flaps survived besides 1 case had venous occlusion occurred 12 hours after the operation, and the venous occlusion was relieved by releasing the dressing and removing some of sutures, and the flap survived smoothly. The wounds in the donor sites healed well. The postoperative follow-up period lasted for 6-18 months, with an average of 10.7 months. The flaps were soft, wear-resistant, and stable. The skin texture was restored with a small amount or normal sweating. One flap had mild bloated, and another flap showed a slightly poor colour of the flap together with a lower temperature. The sensory recovery of the flaps was good, reaching S 3+ or above. The TPD had achieved 6.0-8.5 mm, with an average of 7.1 mm. One patient had concerns in using the affected digit and 3 cases were in protective use of the affected digits. There was no wear and ulcer in the foot donor sites. According to Wang Shuhuan's assessment of flap function and Evaluation Trial Standards of Upper Limb Partial Functional of Hand Surgery of Chinese Medical Association, the patients in this group were scored excellent in 8 cases and good in 3 cases. Conclusion:The application of free medial plantar artery perforator flap in repair of digit-tip wounds can achieve good repairs. The donor site is hidden without effect on walking. It is one of the ideal donor sites for repairing digit-tip wounds.
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Objective:To investigate the clinical effect of free chimeric bone flap pedicled with superficial palmar branch of radial artery in reconstruction of partial finger with composite tissue defect.Methods:From July, 2018 to January, 2020, 9 cases of compound tissue defect of fingers were reconstructed by free transfer of chimeric bone flap pedicled with superficial palmar branch of radial artery. The wrist transverse striated flap and distal radius bone flap pedicled with superficial palmar branch of radial artery were harvested in operations. The size of flap were 2.0 cm × 4.0 cm -3.0 cm × 6.5 cm, and the length of bone flaps were 1.5-2.5 cm. All patients entered monthly follow-up by clinic visit in 6 months after the surgery, and thereafter by WeChat interviews.Results:All of the 9 chimeric bone flaps survived well. The average healing time of bone flap was 1.7 months, and the average length of reconstructed finger was 2.4(1.8-3.0) cm; The appearance of the affected fingers restored well, the scars of the donor sites were mild, and average of the TPD of the flaps was 6.6(5.3-8.6) mm at 6 months after the surgery. The function of the affected finger was evaluated according to the Trial Standard of the Upper Limb Function Evaluation proposed by the Hand Surgery Society of the Chinese Medical Association: excellent in 7 cases, good in 1 case and medium in 1 case.Conclusion:Free chimeric bone flap pedicled with superficial palmar branch of radial artery can be used in reconstruction of the soft tissue and bone defects of fingers at the same time. It restores the functional length of fingers, improves the function and appearance of fingers, with less damage to the donor site. It is a simple method for reconstruction of finger defects.
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Objective@#To explore the clinical effect of the flap from the rasceta area to repair the hand wound, with relayed superior carpal perforator flap of the ulnar artery to repair the donor site.@*Methods@#During July 2015 to July 2016, 11 cases of hand skin and soft tissue defects from 3.0 cm × 5.5 cm to 5.0 cm × 7.5 cm were treated. and the rasceta flap was used to repair the wound. The superior carpal perforator flap of ulnar artery was used to repair the donor site.@*Results@#All the 22 flaps survived after operation in 11 cases.Followed up for 6-12 months (average 8.5 months). The area of the superior carpal branch of ulnar artery skin flap is 4.0 cm ×6.5 cm to 6.5 cm× 8.5 cm. The skin flap appearance was good and the scar of the donor area was minimal. After 6 months of operation, the function of the affected limbs was evaluated according to the criteria of functional evaluation of the upper limb of the Chinese Medical Association, 8 cases were excellent, 3 were good, and the excellent rate was 88.9%.@*Conclusions@#Relayed superior carpal perforator flap of ulnar artery. Not only expands the repair area of the island flap, but also avoids the skin grafting in donor site. It is applicable to the recovery of the function and appearance of the affected limbs.
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Objective@#To summarize the effects of medial upper arm bilobed free flaps in the repair of two skin and soft tissue defects of hand.@*Methods@#From May 2014 to May 2016, 7 patients of two skin and soft tissue defects of hand with exposures of phalanges and tendons were treated in Xuzhou Renci Hospital, including 5 males and 2 females, aged from 19 to 41 years. Each defect area ranged from 3.0 cm×1.5 cm to 6.0 cm×3.0 cm. The medial upper arm bilobed free flaps were used to repair the defects, and the area of each lobe of the flaps ranged from 4.0 cm×2.0 cm to 8.0 cm×3.5 cm. The donor sites were sutured directly. The survival of the flaps was recorded. During follow-up, the recovery of donor and recipient sites was observed, the two-point discrimination distance of the flaps was measured, and the hand function was assessed by the trial criteria of the upper limb functional assessment of the Hand Surgery Society of the Chinese Medical Association.@*Results@#All flaps survived smoothly, and the wounds and donor site incisions were healed. All patients were followed up, and the follow-up time lasted for 6 to 15 months. The color and texture of the flaps were similar to the surrounding normal skin, and the shape of the flaps was good. There was no obvious scar in the donor site, and the elbow joint function was normal. One patient developed ulnar numbness one month after operation and relieved after 3 months of treatment with neurotrophic drugs and local physiotherapy, etc. Six months after operation, the two-point discrimination distance of the flaps was 5.5-8.0 mm, and the hand function evaluation was excellent in 3 cases, good in 3 cases, and middle in 1 case.@*Conclusions@#The medial upper arm bilobed free flap has both good texture and good appearance, and the scar of donor site is concealed. It is a good method to repair two skin and soft tissue defects of hand.
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Objective To explore the operative method and effect of replantation of complex severed thumb with the pedicled flap from the rasceta area.Methods From March,2015 to March,2017,12 cases of complicated thumb injury were treated by retrograde transfer flap pedicled with the superficial palmar branch of the radial artery.All digital arteries defective with soft tissue defect,the area was 1.5 cm×3.0 cm to 5.5 cm ×7.0 cm.The wound of the wrist donor site was sutured directly.Postoperative followed-up was performed to review if the flap survival.Results There was 1 case of venous reflux disorder.After removal of some sutures,the symptoms were relieved.All other fingers survived successfully,and the flap survived completely.The donor site incision healed at Ⅰ stage.The followed-up period was 12-18 (average,13.5) months.The appearance of the thumb and flap was satisfactory,and the scar in the donor site was not obvious.The thumb function was evaluated according to the evaluation standard of thumb and finger reconstruction function of the Chinese society of medical surgery.Eight cases were excellent,3 cases were good,and 1 case was medium.Conclusion The pedicled flap from the rasceta area has the advantages of simple operation and reliable blood supply.It can reconstruct the defect vessels and repair the wound at the same time.It is a new method for replantation of complicated severed thumb.
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Objective To explore the clinical effect of free chimeric bone flap based on the superficial pal-mar branch of radial artery to repair finger composite tissue defects. Methods From July, 2013 to January, 2016, 9 cases of finger composite tissue defect were repaired by free chimeric bone flap from the wrist crease area. The flap and bone flap were taken with the superficial palmar branch of the radial artery during the operation. The area of the flap was 1.5 cm×4.0 cm to 3.5 cm×6.5 cm, and the size of the bone flaps were 0.5 cm×1.0 cm×1.5 cm to 1.0 cm × 2.5 cm × 3.5 cm. Regular followed-up was done after the operation. Results Nine cases of chimeric bone flap survived well, and the average healing time of bone flap was 1.6(1.5-3.0) months. The function and appearance of the patients recovered well. The scars on the donor area was slight. The average two-point discrimination of flap was 6.6 (5.3 to 8.6) mm at 6 months after operation. According to the Evaluation Criteria of Thumb and Finger Reconstructive Function Assessment of the Upper Limb of the Chinese Medical Association, 7 cases were superior, 1 was good, 1 was medium. Conclusion The free chimeric bone flap pedicled with superficial palmar branch of radial artery can si-multaneously repair soft tissue and bone defects. It helps shorten the course of disease and speed up the recovery of finger function.It is a new choice to repair finger tissue defects.
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Objective To investigate the surgical method and clinical effect of chimeric flap pedicled with the palmar branch of the radial artery from the wrist crease area for repairing the complex defect of the thumb.Methods Data of 11 cases with thumb complex tissue defects admitted during June 2013 to June 2015 were retrospectively analyzed.There were 7 males and 4 females,aged from 16 to 56 years,with an average age of 31.5 years.The soft tissue defect of the affected finger ranged from 3.0 cm×1.3 cm to 6.3 cm×2.0 cm,and the bone defect ranged from 1.3 cm×0.8 cm×0.4 cm to 2.8 cm×1.3 cm×0.8 cm.All the cases were repaired by chimeric flap pedicled with the superficial palmar branch of radial artery of the wrist crease area.The chimeric flap was transferred through the thenar part of the subcutaneous tunnel to the thumb surface to repair the defect of the composite tissue.The flap area ranged from 4.0 cm×1.5 cm to 7.0 cm×3.0 cm and the bone flap size ranged from 1.5 cm×1.0 cm×0.5 cm to 3.0 cm× 1.5 cm× 1.0 cm.The function of the finger was evaluated postoperatively according to the upper extremity functional tentative evaluation criteria of thumb and finger reconstruction by Hand Surgery of Chinese Medical Association.Results All 11 cases of wrist transverse bone flap survived.The average healing time of the bone flap was 1.6 (range,1.5-3) months,and the bone graft was not absorbed.The function and appearance of the finger was good with only a linear scar;6 months after surgery,the two-point discrimination on average was 7.1 mm (range,5.5-9.0 mm).At the latest follow-up according to the upper extremity functional tentative evaluation criteria of thumb and finger reconstruction by Hand Surgery of Chinese Medical Association,finger function were excellent in 9 cases,good in 1 case,with the excellent rate of 90.9％ (10/11).Conclusion The chimeric bone flap pedicled with the superficial palmar branch of radial artery can repair skin,soft tissue and bone defects of thumb simultaneously.It has the advantages of simple operation,safe blood supply,speeding up fracture healing,good functional recovery and concealed scar in donor area.It is a new choice to repair the complex tissue defect of thumb.
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Objective To explore the clinical experience and surgical method of the repairment of frontal plantar tissue defects by using "tennis racket"-like flap with the medial plantar retrograde,and to study the reliability in the clinical application of the medial plantar retrograde flap.Methods From June 2011 to June 2016,"tennis racket"-like flap with the medial plantar retrograde was used to repair the frontal plantar tissue defects in 10 cases.The cutting range of flap was from 3.5 cm × 2.0 cm to 8.0 cm x 4.0 cm in size;in all patients the donor area was covered by skin grafts.Results All flaps survived and wounds healed by first intention.In 10 patients the donor sites healed primarily with a straight scar,and the appearance and texture of the flaps were satisfactory.All patients were followed up from 6 to 24 months (mean 12 months).According to the Chinese foot function evaluation standard trial evaluation,the outcomes were excellent in 9 cases,good in 7 cases,and medium in 2 cases.Conclusions "Tennis racket"-like flap with the medial plantar retrograde is less anatomic variation with reliable blood supply,and sensory recovery is quick;the donor site is a small crater and cicatrial contractures are light;the cost is low.All patients are treated on one session and therefore it is an ideal method for the repairment of frontal plantar tissue defects.
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Objective To analyze the characteristics of medial sural artery perforator (MSAP) flap, and to ex-plore the practicality of repair of small and medium-sized defects of dorsum pedis with the flap. Methods Between March, 2012 to December, 2015, 12 patients with variable defects of 4.0 cm×3.0 cm to 4.0 cm×6.0 cm underwent MSAP flap reconstruction. There were 7 males and 5 females, aged from 19 to 49 years (mean, 32 years). The disease causes were crush injury in 6 cases, machine saw injury in 5 cases, and hot crush injury in 1 case. The size of flaps ranged from 4.0 cm × 5.0 cm to 5.0 cm×7.0 cm. All of the donor site was sutured directly. Postoperative follow up was done termly. Results All 12 flaps survived. The flap was similar to the surrounding normal skin, and all patients returned to ambulation. Eleven cases survived without a hitch, the other 1 of venous congestion was salvaged by venous thrombectomy and reanastomosis. Fol-lowed-up 5-24 months postoperative, the color of the flap was similar to the surrounding skin. All patients recovered walk-ing and shoe wearing function. The calf residual linear scar. Conclusion The MSAP flap provides thin soft tissue cover-age, enabling good functional recovery after defect reconstruction dorsum of forefoot, show the evident advantages.
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Objective To investigate the clinical effects of large flow-through venous flap for salvaging the limb on the verge of amputation complicated with arterial defect.Methods Between March 2012 and January 2015,large flow-through venous flap was used in 10 patients with upper limb on the verge of amputation to reconstruct artery defect and large-area skin and soft tissue defect,including 6 males and 4 females with a mean age of 27.9 years (range,18 to 41 years).Injury was caused by machine crush in 4 patients,twisting belt pulley in 4,and traffic accident in 2.The dimension of skin defect ranged from 6.5 cm× 10.0 cm to 10.5 cm × 18.0 cm (mean,9.0 cm × 12.0 cm).Vascular defect length ranged from 6.0 to 16.0 cm (mean,12.3 cm).Time from injury to operation was 1.5-5.5 h (mean,3.5 h).After operation,flap survival,appearance,texture and sensation were recorded.Upper limb function was evaluated using the standard set up by hand surgery branch of Chinese Medical Association.Results The flap varied in size from 8.0 cm×12.0 cm-12.0 cm ×20.0 cm (mean,10.0 cm × 13.5 cm).One patient was amputated due to severe postoperative infection,and 9 patients were successfully operated.The flap showed small-area necrosis on the distal end in 2 patients,which was cured after dressing change,while survived completely in 7 patients.The donor wounds healed in one stage.After 12-27 months of follow-up (mean,13.7 months),the thickness,texture and appearance of the flap were close to the surrounding normal tissues and the skin protective sensation was restored.The functional results were excellent in 6 patients,good in 2 and poor in 1,with the excellent and good rate of 89％.Conclusion Large flow-through venous flap can reconstruct upper-limb vascular defect while repairing large-area wound,and has advantages of easy operation,less damage to the donor site and good appearance.
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Objective To research the clinical outcomes of repairing donor site of abdomen flap by V-Y flap pedicled with deep circumflex iliac artery perforator musculocutaneous.Methods Nine cases with skin defects of hand were treated with lower abdomen flap from December, 2011 to March, 2013, abdominal donor sites could not be directly sutured, and pedicled with deep circumflex iliac artery perforator musculocutaneous.The flap was 8 cm × 16 cm-12 cm × 24 cm in size.Results The average healing time of the V-Y flap pedicled with deep circumflex iliac artery perforator musculocutaneous was 17 days.The patients were followed-up for 3 months to 18 months, averaged of 9 months.The appearance and the texture of the flaps were good.Abdominal wound healing was flat, with no significant depression and navel no significant skew.Patients were satisfied with function and appearance.Conclusion This procedure is easy and effective.The treatment result is satisfactory.It is improvement for repairing donor site of tradition abdomen flap.
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Objective To analyze the outcome of applying venous flow-through flap in replantation of complex severed finger.Methods From March,2011 to August,2012,15 cases of complex severed fingers were repaired by flow-through flap with two sets of venous system of forearm vein and one stage repair of wound.The time from injury to operation was 1.5-5.5 h (mean 2.5 h).Vascular defect length ranged from 1.5 to 11.0 cm (mean 3.6 cm);and soft tissue defect of 1.5 cm × 3.0 cm to 11.0 cm × 11.0 cm.All digits had severe soft tissue defect and segmental defect of blood vessels.All the finger blood circulation was disorder.Results All flaps and replanted fingers survived completely,except 1 case of postoperative venous crisis occurred which was remission after the vascular transplantation,and 1 case of skin flap necrosis at the distal part which was healed after skin grafting; Fourteen cases were followed-up from 7 to 20 months.At the final followed-up the flaps were of good consistency and appearance.Function of the finger was graded excellent in 7 cases,good in 5 cases,and poor in 2 cases.All flaps and replanted fingers survived completely over a period of 12 to 30 months follow-up.The flaps were of good consistency and appearance.Function of the finger was graded excellent in 7 cases and good in 5 cases.Conclusion With less injury at donor site,and good repair results,venous flow-through flap is well indicated in complex finger replantation with soft tissue defect and vascule defect.
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<p><b>OBJECTIVE</b>To investigate the clinical application of V-Y flap pedicled with the lateral superior genicular perforator for donor site defect after harvesting anterolateral thigh flap.</p><p><b>METHODS</b>From June 2011 to June 2012, 9 cases with defects at hands and feet were treated with anterolateral thigh flaps. The defects left at the donor sites were consequently reconstructed with V-Y flap pedicled with the lateral superior genicular perforator. The defects left by V-Y flap were closed directly.</p><p><b>RESULTS</b>All the 9 anterolateral thigh flap survived completely. 5 flaps underwent thinning surgery 6-8 months after operation. The flaps had a good appearance, texture, color and elasticity. The 8 perforator flaps survived completely with partial necrosis in 1 flap at the proximal end. The average healing time was 17 days. There was no obvious depression at donor sites with normal function.</p><p><b>CONCLUSIONS</b>The method is easily performed with optional therapeutic effect. It is a modified improvement for the anterolateral thigh flap.</p>
Subject(s)
Adolescent , Adult , Female , Humans , Male , Middle Aged , Young Adult , Plastic Surgery Procedures , Methods , Skin Transplantation , Methods , Surgical Flaps , Thigh , General SurgeryABSTRACT
Objective To introduce the surgical method of reverse radial side of dorsal artery the fascial pedicle island bone flap for the treatment of thumb composite tissue defects,and to evaluate its short term clinical outcome.Methods From May 2010 to March 2012,9 cases with composite tissue defects at thumb were treated with reverse radial side of dorsal artery the fascial pedicle island bone flap,including 5 males and 4 female with an average age of 38 years (range,13-68).All injuries were caused by planer.The time of injury to operation was 3-8 hours,all patients showed in both thumb root plane beyond volar or dorsal,skin and soft tissue defect accompanied by distal phalanx defect.Skin and soft tissue of thumb defect size was 1.0 cm ×1.8 cm to 2.0 cm × 2.2 cm.Preoperative hands anteroposterior and lateral X-ray were routine taken.Imaging findings were associated with the thumb base beyond the distal phalanx fractures,bone defect length was 0.4-0.7 cm.We cut thumb radial side of the dorsal artery fascia flap during surgery operation according to the thumb side wound defect case.The size of the bone flap was 0.2 cm× 0.6 cm to 0.4 cm × 0.8 cm,properly inserting intramedullary distal phalanx fixed base,9-0 line will flap inside the dorsal nerve and a nerve suture flap reconstruction feeling.Results All bone flaps were survived completely,no case occur venous disorders,flap blood circulation was stable,donor skin graft was survival in stage Ⅰ.This group of patients incision were healing 2 weeks after surgery.All the patients were followed up as scheduled,and the follow-up time was 6-12 months.All flaps survived,and the colors,texture,contour of the flaps were good.The two-points discrimination distance was 7.0-10.0 mm on the flap,Thumb distal phalanx healing time was 1.0-1.5 months.Bone absorption was not observed in graft.The thumb function was assessed as excellent in 7 fingers,good in 2 fingers,no complication occurred in donor site.Conclusion The main artery and nerve will not be sacrifice,when the bone flap is used.There are blood into the backbone of the first metacarpal nearly 1/3 of the bone to reconstruct thumb bone defect,the operative procedures is available and easy to be performed,which is a new method for the treatment of thumb composite tissue defects.
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@#Objective To evaluate the treatment effect of hand reconstruction with bilateral multiple toe transplantation. Methods There are four schedules as follow applied in 102 cases: (1) bilateral second toes to thumb and index finger transplantation in 86 cases; (2) wrap-around flap to thumb and second toe on opposite side to index or middle finger transplantation in 11 cases; (3) wrap-around flap to thumb and bilateral second toes to index and middle fingers transplantation in 8 cases; (4) bilateral wrap-around flap to bilateral thumb and second toe to index finger transplantation in 1 case. Results All reconstructed finger survived in 102 cases except for partial wrap-around flap necrosis in one case and second toe in two cases. Sixty-two patients got more than one-year following up. Two points discrimination in reconstructed finger was between 8 to 14 mm in all cases. The reconstructed finger grew synchronously with toe among children. Thumb opposition function recovered in all cases except for one case. Donor site: no limp or hallux eversion observed in all cases. Conclusion There is less damage on foot and most hand function recovery using bilateral multiple toe transplantation to repair hand or multiple fingers defect.
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[Objective]To look for rehabilitation means for swollen and painful hands,and feet.[Method]A Herbal bath was used to bathe swollen hands and feet after wrist and ankle fractures.The design of the clinical trial was randomized,single-blinded with placebo.Parameters measured included hand or foot volume,joint motions and self-evaluation.[Result]Results showed that positive outcome was observed in swelling control and joint motions as well as self-evaluation.[Conclusion]Herbal bath produced good results in the control of hand and foot swellings.
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Objective To report microsurgical treatment of severed palm caused by crush injury. Methods From 1998 to 2002, 14 patients with severed palm and destructive crush injury were treated in our hospital. According to the specific severity and level of different injuries, replantation of severed palm with vessel transfer, replantation of fingers to the distal forearm with resection of wrist and palm, replantation of severed palm combined the thumb reconstruction were applied to reserve a maximal part of hand or fingers. Results Of the 14 cases of replantation, 3 experienced death of middle or index finger and the others all survived. The follow up of 11 cases lasted more than 6 months. After functional exercises, 10 cases recovered the function of pinch, and 1 case nearly regained normal functions. All of them regained sensation and the two point discrimination was 8 to 10 mm. Conclusion Reasonable replantation for severed palm with crush injury is still a method to regain part of hand functions.
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Objective To investigate the clinical effect of systemic rehabilitation on stiffness of finger joints after hand injury. Methods A total of 213 stiff fingers were observed in patients with hand injury. All the patients were administered with therapeutic exercise, physical modalities and splinting. The improvement of the patients in terms of active range of motion (AROM) and passive range of motion (PROM) of their fingers was graded as excellent, good, adequate or poor according to the standard the authors set. Results With regard to their AROM and PROM, 82.2% and 94.8% of the patients got excellent improvement, 97.7% and 100% of the patients got excellent to adequate improvement, respectively. The finger function was increased from 17% to 56%. Conclusion Systemic rehabilitation can increase the AROM and PROM of stiff finger effectively and improve the patients' hand function.
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Objective Research reconstruction methods of complicated hand injury and transfer types of combined free tissues Methods Applying combined three free tissues to reconstruct extent hand injury 36 cases, there were total four types Results Thirty six cases with 108 free tissues were all survival, the wounds were healed After more than 1 year follow up, restoration of the sensation of pain and temperature were recovered in the transplantation toe and wrap around flap, the two point discrimination was 6～12 mm The function of pinch and opposed was restored The patients can comply the day of life Conclusion Utilization the combined three free tissue transfer to reconstruction complicates hand injuries The time of operation is long, more trauma, reasonable arrange of hand surgeons and have a good knowledge of microsurgery, but the times of operations is less, and shorted the therapy procedure and early rehabilitation
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Objective To summerize clinical application of the trifoliated flap from the dorsal foot. Methods The flaps,which were made of the first dorsal metatarsal flap, medial foot flap and lateral foot flap,were designed on the basis of the anatomy of flap whose common pedicle was anterior tibial artery or dorsal foot artery and whose other branches was medial tarsal artery or medial anterior, melleolar artery and lateral tarsal artery respectively,the single flaps were harvested to repair multi-finger skin defect.The flaps from both feet were repaired digit degloving injuries. Results Thirty-one patients were treated by trifoliated flap from the dorsal foot.29 of 31 flaps survived completely.Two flaps in patient necrosised.One flap in two patients necrosised. Conclusion The trifoliated flap from the dorsal foot is a good procedure for coverage problems in multiple-finger avulsion and digit degloving in juries.