Practice Essentials
The fingertip is the part of the terminal phalanx that is distal to the insertion of extensor and flexor tendons and comprises the nail complex and the glabrous pulp.[1, 2, 3] Fingertip injuries are extremely common. A functioning fingertip has sensation without pain, stable padding, and an acceptable appearance. Fingertip injuries occur frequently because hands are used to explore surroundings. Common types of injuries include blunt or crush injuries to the fingernail creating subungual hematomas, nail root avulsions, and fractures of the terminal phalanx. Sharp or shearing injuries from knives and glass result in lacerations and avulsion types of soft tissue defects. Burns and frostbite commonly involve fingertips.
(See the image below.)
View Image | Significant nailbed injuries can occur from nail root avulsions. |
The most common causes of fingertip injuries include the following[1] :
Crush injury due to forces of compression. This can present as a closed or an open injury and can be associated with distal phalanx fractures. Most children who present with fingertip trauma have experienced a crush injury, usually from the hinge side of a door.[4]
A laceration is secondary to a household instrument (knife, scissors, and cans) or works tools (rotatory saw) involving pulp or nail and/or the nail bed complex.
Amputations involve both soft tissue loss and partial or complete distal phalanx loss. Such injuries can cause cosmetic and functional defects.
Other injury mechanisms are sudden flexion or extension forces leading to distal tendon avulsion injuries.
About 10% of all accidents presenting in the ED involve the hand. Hand injuries represent 11-14% of on-the-job injuries and 6% of compensation-paid injuries. They account for approximately two thirds of hand injuries in children. Damage to the nail bed is reported to occur in 15-24% of fingertip injuries.[2]
In a retrospective study by Yorlets et al of 1807 children with fingertip injuries, 50% of fingertip injuries occur in those younger than 7 years, 25% in those aged 7-12 years, and 25% in those aged 13-18 years. Mean age was 8 years, and 59% of the patients were male. The middle finger was the one most commonly affected. The types of injuries were as follows: 43% fractures, 34% nail bed, and 23% amputations.[4]
Diagnosis
Ascertain the following information when gathering patient history:
Evaluate the fingertip injury to determine the following[5] :
Treatment
The goals of treatment of any injured fingertip should be the restoration of a stable interface for object manipulation while looking as normal as possible. At the completion of treatment, the pulp should be stable and pain free, and the nail plate geometry should permit the manipulation of small objects.[6] Untreated nailbed lacerations may lead to subsequent nail deformities.
Keep the hand elevated. Analgesics may be necessary for the first few days. Radiographs may be necessary either to assess alignment of distal phalanx fractures or to detect presence of foreign bodies. Splint fractures in extension for 2 weeks. Check wound 2 days after ED treatment.
When amputation with loss of two thirds of the nail occurs, half of the fingers develop beaking or a curved nail.
Pediatric digital necrosis resulting in revision amputation has been reported as a complication of Coban digital dressings used to treat fingertip tuft fractures with nail bed lacerations.[7]
Full growth of nail takes an average of 100 days, but fingertip trauma may delay growth by 20 days.
Average healing time for fingertip amputation is 21-27 days.
Remove sutures after 7-10 days.
Emergency Department Care
Care for an amputated part of the fingertip includes the following:
Cleanse gently.
Cover in a saline-soaked gauze wrap.
Place amputated part in a watertight bag.
Place watertight bag with amputated part on water and ice for preservation.
To avoid cold injury, do not place the amputated part directly on ice.
ED care
Preserve length, padding, and sensation of finger to the degree possible.
Preserve proper nail growth capacity and function by paying specific attention to the eponychium.
Prevent infection by considering prophylactic antibiotics.
Minimize joint stiffness.
Limit employment disability.
Use a digital block to provide local anesthesia and avoid further swelling of the fingertip with direct infiltration of anesthesia into the affected area.
Lacerations
Suture simple lacerations with 5-0 or 6-0 nylon. Subcutaneous or deep dermal sutures are not indicated.
Remove nail and inspect matrix when fingertip lacerations involve nail and injuries that avulse, split, or disrupt it. Replace all retrievable fragments of nail matrix as free grafts.
Repair nail matrix according to the following steps: (1) Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain. (2) Remove nail.
See the image below.
View Image | Removal of the nail plate with iris scissors. |
Debride gently.
Clean and remove all foreign bodies.
Repair nail matrix meticulously with fine absorbable suture (6-0 Monocryl).
(See the image below.)
View Image | Suturing of a nailbed laceration. |
Reinsert nail plate or substitute.
Tack the nail to the paronychia using suture material (6-0 Monocryl) or use a topical adhesive (eg, Histoacryl blue, 2-Octyl-cyanoacrylate) to secure the nail plate in place of sutures. Chloramphenicol ointment has also been suggested as an adhesive.
Apply sterile nonadherent dressing[8, 9, 10, 11] and splint.
Subungual hematoma
Use electrocautery or a heated paperclip. A sharp instrument, such as an 18-gauge needle, should be avoided to prevent deep soft tissue injury.
For patients who have significant crush injuries or subungual hematomas that involve lacerations to skin-fold or disrupt the nail, remove the nail and inspect the matrix.
Conservative treatment without nail removal is recommended for patients with closed hematomas and an intact nail with no laceration to skin fold or nail disruption.[12]
Conservative treatment also is indicated for crush injuries that fracture the terminal phalanx but do not cause a subungual hematoma.
Fingertip amputations
Treatment is either surgical or conservative. The boundary between surgical and conservative treatment depends on the extent of involvement of the pulp, nail, and bone. Various surgical methods are used for amputation injuries, including simple revision amputation, full- or partial-thickness skin grafts, local flaps, distal flaps, kite flaps, and neurovascular island pedicle flaps.[13, 14, 15, 16, 17]
Distal fingertip amputations may be treated conservatively in the ED. Various treatments may be provided in the ED depending on the emergency physician's skills, training, and time availability. However, for distal amputations that involve significant tissue loss, the physician should discuss a treatment plan with the follow-up hand surgeon.
Steps for conservative therapy
Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain.
Clean thoroughly with sterile solutions.
Remove protruding bone with a bone rongeur to a level 3-5 mm below that of surrounding tissue.
Apply sterile nonadherent dressing over the amputated part.
Removal of splinter under nail
Administer anesthesia with a digital block.
Unroof the splinter by trimming the nail with iris scissors.
Epinephrine digital injections
Most patients who received epinephrine digital injections were asymptomatic or had minor effects. Typically, no significant systemic effects occurred.[18]
Treatment, although rarely required, may include warm water soaks, nitroglycerine paste, or local phentolamine injections.
Medication Summary
The goal of pharmacotherapy is to reduce pain and prevent complications. Tetanus immunization also may be indicated.
A study of the use of prophylactic antibiotics after fingertip amputation concluded that routine prophylactic use of antibiotics does not reduce the rate of infection after fingertip amputations. In the study, 29 patients were randomly assigned to the no-antibiotic group and 27 to the antibiotic group, but at follow-up, there was no infection in either group.[19]
Ibuprofen (I-Prin, Advil, Motrin IB, NeoProfen, Provil)
Clinical Context:
DOC for treatment of mild to moderate pain, if no contraindications are present. Inhibits inflammatory reactions and pain probably by decreasing activity of the enzyme cyclooxygenase, which inhibits prostaglandin synthesis.
Ketoprofen (Frotek, Ketophene Radiopaq)
Clinical Context:
Used for relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patient for response.
Flurbiprofen
Clinical Context:
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis that may result in analgesic and anti-inflammatory activities.
Class Summary
Commonly used for relief of mild to moderate pain. Effects of NSAIDs in treating pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, naproxen, and ketoprofen.
Acetaminophen (Tylenol, Acephen, Aspirin-free Anacin Extra Strength, Mapap, Pharbetol)
Clinical Context:
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
Tetanus toxoid adsorbed or fluid
Clinical Context:
Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children aged >7 years are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. May administer into deltoid or midlateral thigh muscles in children and adults. In infants, preferred site of administration is the mid thigh laterally.
Class Summary
Used for tetanus immunization. Administer booster injection in previously immunized individuals to prevent this potentially lethal syndrome.
Class Summary
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
Author
Glen Vaughn, MD, Director, Department of Emergency Medicine, Defiance Hospital
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Eric L Legome, MD, Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai
Disclosure: Nothing to disclose.
Chief Editor
Trevor John Mills, MD, MPH, Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI
Disclosure: Nothing to disclose.
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