Fingertip amputation

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

Distal finger
Other finger/thumb
- Boutonniere deformity
- Mallet finger
  - Swan neck deformity
- Jammed finger
- Jersey finger
- Trigger finger
- Ring avulsion injury
- De Quervain tenosynovitis
- Infiltrative tenosynovitis
- Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
Hand
- Dupuytren contracture
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
- Hand and finger dislocations
- Hand and finger fractures
- Gout and Pseudogout
- Hand and finger tendon injuries
- High-pressure injection injury
- Osteoarthritis
- Rheumatoid arthritis

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)

See Also

References

Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.

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