Fingertip avulsion: Difference between revisions
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==Background== | ==Background== | ||
*Due to blunt or penetrating trauma | |||
* | |||
{{Fingertip anatomy}} | |||
==Clinical Features== | ==Clinical Features== | ||
*Partial or complete amputation of distal phalanx of finger | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{DDX distal finger}} | |||
{{Hand and finger injury DDX}} | {{Hand and finger injury DDX}} | ||
== | ==Evaluation== | ||
*Xray | |||
===Fingertip Zones=== | ===Fingertip Zones=== | ||
*Zone I - Distal to tip of phalanx | *Zone I - Distal to tip of phalanx | ||
*Zone II - Between tip of phalanx and | *Zone II - Between tip of phalanx and lunula | ||
*Zone III - Proximal to | *Zone III - Proximal to lunula | ||
==Management== | ==Management== | ||
*Pain control ([[Digital block]]) | |||
===No exposed bone or nail bed involvement=== | ===No exposed bone or nail bed involvement=== | ||
*Zone I injuries - treat conservatively with serial dressing changes alone | *Zone I injuries - treat conservatively with serial dressing changes alone | ||
**Cover wound with non-adherent dressing | **Cover wound with non-adherent dressing | ||
**Instruct patient to soak fingertip in antibacterial soap-added water for 10min QD and then reapply non-adherent dressing | **Instruct patient to soak fingertip in antibacterial soap-added water for 10min QD and then reapply non-adherent dressing | ||
**Follow up with primary care in 2d | **Follow up with primary care provider in 2d | ||
**Most will have epithelialization in approximately 1 month<ref>Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.</ref> | **Most will have epithelialization in approximately 1 month<ref name="Lamon">Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.</ref> | ||
===Exposed Bone=== | ===Exposed Bone=== | ||
*Zone II injuries | *Zone II injuries | ||
**Consider hand surgery consult | **Consider hand surgery consult | ||
**Rongeur bone if bony protuberance | **Rongeur bone if bony protuberance | ||
**Trim digital nerves proximal to skin to avoid painful neuroma formation | |||
**Wound closure with flap | **Wound closure with flap | ||
**Follow up with hand surgery in 3-5d | **Follow up with hand surgery in 3-5d | ||
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**May require distal phalanx amputation | **May require distal phalanx amputation | ||
**Consider treating like Zone II | **Consider treating like Zone II | ||
**Healing time 3-6wks<ref> | **Healing time 3-6wks<ref name="Lamon" /> | ||
==Disposition== | |||
*Generally may be discharged | |||
*Hand surgery follow-up (especially if zone II or III injury) | |||
==See Also== | |||
*[[Finger amputation]] | |||
*[[Distal phalanx (finger) fracture]] | |||
==References== | ==References== |
Revision as of 11:24, 9 February 2019
Background
- Due to blunt or penetrating trauma
Nailtip Anatomy
- The perinychium includes the nail, the nailbed, and the surrounding tissue.
- The paronychia is the lateral nail folds
- The hyponychium is the palmar surface skin distal to the nail.
- The lunula is that white semi-moon shaped proximal portion of the nail.
- The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
- The germinal portion is proximal to the matrix and is responsible for nail growth.
Clinical Features
- Partial or complete amputation of distal phalanx of finger
Differential Diagnosis
Distal Finger (Including Nail) Injury
- Distal interphalangeal dislocation (finger)
- Distal phalanx (finger) fracture
- Finger amputation
- Fingertip avulsion
- Finger infection
- Nailbed laceration
- Nail avulsion
- Subungual hematoma
Hand and finger injuries
- Distal finger
- Other finger/thumb
- Boutonniere deformity
- Mallet finger
- Jammed finger
- Jersey finger
- Trigger finger
- Ring avulsion injury
- De Quervain tenosynovitis
- Infiltrative tenosynovitis
- Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
- Hand
- Wrist
- Drummer's wrist
- Ganglion cyst
- Lunotriquetral ligament instability
- Scaphoid fracture
- Extensor digitorum tenosynovitis
- Compressive neuropathy ("bracelet syndrome")
- Intersection syndrome
- Snapping Extensor Carpi Ulnaris
- Vaughn Jackson syndrome
- General
Evaluation
- Xray
Fingertip Zones
- Zone I - Distal to tip of phalanx
- Zone II - Between tip of phalanx and lunula
- Zone III - Proximal to lunula
Management
- Pain control (Digital block)
No exposed bone or nail bed involvement
- Zone I injuries - treat conservatively with serial dressing changes alone
- Cover wound with non-adherent dressing
- Instruct patient to soak fingertip in antibacterial soap-added water for 10min QD and then reapply non-adherent dressing
- Follow up with primary care provider in 2d
- Most will have epithelialization in approximately 1 month[1]
Exposed Bone
- Zone II injuries
- Consider hand surgery consult
- Rongeur bone if bony protuberance
- Trim digital nerves proximal to skin to avoid painful neuroma formation
- Wound closure with flap
- Follow up with hand surgery in 3-5d
- Healing time 3-6wks
- Zone III injuries
- Consult hand surgery if available
- May require distal phalanx amputation
- Consider treating like Zone II
- Healing time 3-6wks[1]
Disposition
- Generally may be discharged
- Hand surgery follow-up (especially if zone II or III injury)