Fingertip avulsion

Background

  • Due to blunt or penetrating trauma

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • 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

Hand and finger injuries

Evaluation

Workup

  • Xray

Fingertip Zones

Fingertip avulsion.JPG
  • 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)
  • Irrigate and debride non-viable tissue
  • Replantation rarely indicated for zone I-III amputations
  • Patients more likely to benefit from replantation for thumb and index finger amputations

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
    • Consider nail removal if significant involvement, possibility of hook nail deformity it damaged nail left in situ
    • Conservative treatment with non-adherent dressing generally preferred[2][3] vs. 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)

See Also

Special Lacerations by Body Part

References

  1. 1.0 1.1 Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.
  2. https://pubmed.ncbi.nlm.nih.gov/31185316/
  3. https://pubmed.ncbi.nlm.nih.gov/25191157/