Case:

A maintenance worker raised her hand blindly into a utility closet to fix a broken light and her hand hit part of a rapidly moving conveyor belt. She immediately pulls her hand back, but it is too late, blood is everywhere and her fingertip is found on the floor. EMS brings the patient along with her amputated fingertip to the emergency department. The patient anxiously inquires if the amputated part can be reattached. Is reattachment an option, and what actions should the physician take to ensure proper care of this traumatic event?

Fingertip Amputations:

Unfortunately, fingertip injuries are exceedingly common in the emergency department (ED). Fingertip amputation is defined by an injury that occurs distal to the tendon insertions on the distal phalanx. Most will involve some kind of repair in the ED, and many will also require definitive operative care by a hand surgeon. Goals of care include pain reduction, preservation of sensation, and bony support for nail growth.

While some hand surgeons will attempt re-implantation of an amputated fingertip, success rates remain exceedingly low.[i] However, patients should be reassured that they will likely maintain most functionality of their hand.

Injuries involving minor tissue loss (usually less than 1 cm squared) without exposed bone may be allowed to heal by secondary intention. Options for more significant injuries include revision amputation (rongeuring of bone) with primary closure, skin grafting, and flap reconstruction.

Most of these injuries will require a digital nerve block for pain control and repair. Literature describes numerous methods of achieving a sufficient block, but you might consider a wing block to achieve full anesthesia of the distal fingertip. This technique involves injecting just proximal to the nail bed fold medially and laterally. Before performing a digital nerve block, ensure you fully assess the neurovascular status of the digit.  (For more information on the wing block: http://emedicine.medscape.com/article/80887-technique).

Hemostasis can be difficult to achieve with fingertip injuries. A quick and simple solution to hemostasis can be achieved by wrapping a Penrose drain around the finger proximally and securing the drain with a clamp (Image 3). [ii]

In general, most fingertip injuries should be referred for consultation with a hand specialist. The majority of these injuries can be followed up with a hand surgeon in 5-7 days. However, some patients may require evaluation in the emergency department, particularly those with associated infection, tendon injury, or significant bone exposure. [iii]

As always, with any wound, assess tetanus status and administer a tetanus booster if indicated. Antibiotics are not necessary with clean wounds, but they may be considered for contaminated or open/complex wounds. [iv] Patients should also be counseled to avoid tobacco use as it can impair healing.

All fingertip amputations should be evaluated for subungual hematoma and nail bed laceration. For those with subungual hematoma, trephination should be considered if the hematoma is acute (<48 hours) and painful. It should be performed with electrocautery or boring technique with a small gauge needle. It is not recommended to use a heated paper clip given concerns for safety. [v] If the nail bed is intact, it is not necessary to remove the nail after trephination.

For those with nail bed lacerations, the nail should be removed, and the laceration should be meticulously repaired. If the nail remains intact, it can be placed back over the nail bed after repair to act as a splint. If no amputation occurred, the patient should be aware that a new nail will likely grow again, but this may take as long as three to twelve months. [vi]

Case Conclusion:

Our patient’s fingertip was amputated proximal to the nail bed so the bone was further debrided and the wound was closed with sutures. She underwent definitive surgery (for repair of multiple displaced phalanx fractures) approximately two weeks later. Three months after the injury, she then underwent a nail ablation (removal of nail plate and matrix) of her amputated fingertip after her nail began to regrow and cause pain at the site.

Fingertip injuries are traumatic events for patients but when properly managed in the emergency department, patients can enjoy a return of nearly full function of their hand.

Final Pearls:

• Digital nerve blocks are typically the best method for anesthesia; consider the wing block.
• Bleeding can often be difficult to control; consider a penrose drain as a fast tourniquet.
• Always evaluate for subungual hematomas if the injury is acute, painful, and without a path for drainage.

Faculty Reviewer: Dr. Jeff Feden

References:

[i] Butler DP, Murugesan L, Ruston J, Woollard AC, Jemec B. The outcomes of digital tip amputation replacement as a composite graft in a paediatric population. J Hand Surg Eur Vol. 2016 Feb;41(2):164-70.

[ii] Aslan G, Sarifakioğlu N, Bingül F. Simple and effective device for finger tourniquet: a rolled penrose drain. Plast Reconstr Surg. 2003 Apr 15;111(5):1758-9.

[iii] Van beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990;6(1):23-35.

[iv] Altergott C, Garcia FJ, Nager AL. Pediatric fingertip injuries: do prophylactic antibiotics alter infection rates? Pediatr Emerg Care 2008; 24:148.

[v] Antevy PM, Saladino RA. Management of finger injuries. In: Textbook of Pediatric Emergency Procedures, 2nd, King C, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.939

[vi] Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J Craniofac Surg 2009; 20:1033.