Approach to Evaluation and Management of Traumatic Finger Amputations
Emergency medicine providers play a pivotal role in the initial assessment, stabilization, and coordination of care, making timely diagnosis and appropriate intervention essential…
introduction
Traumatic fingertip amputations are among the most frequently encountered hand injuries in the emergency department, particularly affecting individuals engaged in manual labor using hand tools with metal blades. A review of data from the National Electronic Injury Surveillance System from 1997 to 2016 showed that 464,026 patients sustained a finger amputation in the US, with an estimated yearly incidence of 7.5/100,000 person-years.
Finger amputations, which can range from simple soft tissue loss to complex avulsions involving bone and nail bed, are susceptible to significant bleeding and pain as the fingers are highly vascularized and innervated. Prompt recognition and management are critical, as delays in treatment can lead to poor functional and cosmetic outcomes, including chronic pain, infection, and permanent loss of dexterity. Emergency medicine providers play a pivotal role in the initial assessment, stabilization, and coordination of care, making timely diagnosis and appropriate intervention essential for optimizing long-term recovery.
For the emergency medicine provider, the initial evaluation of these injuries involves taking a detailed history and performing a thorough neurovascular exam. Assessment of these injuries must also include an evaluation for damage to underlying structures, as this will aid in appropriately classifying the severity of the injury when consulting with hand specialists.
There are differing opinions on the optimal way to manage finger amputations, such as whether to perform primary closure of the wound versus allowing the wound to heal by secondary intention. In reality, recommendations for management are based on multiple factors including whether the injury involves the patient’s dominant hand, the patient’s occupation and recreational interests, the size of the soft tissue defect, whether there is nail plate or nail bed involvement, the presence of exposed bone, and the availability of hand surgeons for follow up.
The ultimate goal of a hand surgeon managing fingertip injuries is to restore sensation and durability in the fingertip and ensure proper bone support to allow for nail growth. However, in the acute setting, primary goals are to achieve adequate pain control, provide wound care, including appropriate soft tissue coverage, offer instructions for continued home management, and arrange for short-interval follow-up with a hand surgeon.
This discussion will focus on management options for fingertip avulsions/amputations and indications for emergent hand surgeon consultation in the emergency department.
discussion
Finger Tip Anatomy Review
The anatomy of the human finger is beautiful in its complexity. There are many vital structures, but here we will highlight a few that are essential to know when caring for fingertip injuries in the acute setting.
Pulp: Fibrous and fatty tissue at the end of the finger. Fibrous tissue helps attach to the underlying bone. Contains sensory receptors.
Nail bed: Nail bed consists of the sterile matrix (responsible for attaching the nail plate, or what is colloquially referred to as the “nail”) and the germinal matrix (a specialized part of the matrix responsible for nail regrowth that starts at the lunula and extends proximally).
Lunula: The crescent-shaped white part of the proximal nail bed outlines the location of the germinal matrix and lies just proximal to the cuticle/eponychium.
Extensor Digitorum Tendon (not pictured): Attaches at the base of the distal phalanx on the dorsal aspect (near the level of the lunula).
Flexor Tendon (not pictured): Attaches at the base of the distal phalanx on the volar aspect (near the level of the lunula).
Figure 1. Finger Tip Anatomy
Classifying Finger Amputations
Allen’s classification is used most commonly and is based on the anatomic level of amputation, which is outlined below.
Allen’s Classification of Fingertip Injuries
I: Pulp only (distal to entire nail bed)
II: Pulp and distal half of nail bed, no loss of distal phalanx
III: Pulp, proximal half of nail bed (up to lunula), with distal phalanx fracture
IV: Pulp, nail bed injury proximal to lunula, distal phalanx fracture. This is generally considered a complete or partial finger amputation, not just fingertip amputation.
Figure 2. Allen’s Classification of Fingertip Injuries (Photo Credit: https://ppemedical.com/blog/how-to-manage-fingertip-avulsions/)
Key History
Important history that can help determine appropriate treatment options includes:
-Time of the injury
-Mechanism of the injury (i.e., crush injury vs sharp injury, such as knife or saw)
-Patient’s age
-Patient’s hand dominance
-Patient’s occupation
-Patient’s past medical history, including vascular risk factors
-Tetanus vaccination status
Approach to Exam
Begin with neurovascular assessment (before performing a nerve block) and document.
Assess vascular status (radial pulse, cap refill, warm/cold, etc.)
Assess Motor Function:
A helpful mnemonic to remember ways to screen for motor dysfunction of the key peripheral nerves (median, radial, ulnar, and anterior interosseous) is: “Rock, Paper, Scissors, OK”
Median Nerve: patient makes a tight fist with thumb tucked inside
Radial Nerve: patient extends their wrist and fingers
Ulnar Nerve: patient tries to spread their index and middle fingers
Anterior Interosseous Nerve: patient tries to make the A-OK sign
Figure 3. Motor Hand Exam (Photo credit: https://www.emnote.org/emnotes/motor-hand-exam)
3. Assessing Sensory Function*
For sensory testing, the following key areas serve as a good screening test for sensory nerve dysfunction of the corresponding nerves:
Median Nerve: palmar aspect of the index finger or thumb
Radial Nerve: dorsal webspace between the thumb and index finger
Ulnar Nerve: the palmar aspect of the pinky finger
Finally, you will also want to test the digital nerves of each finger by touching the ulnar and radial aspects of each finger.
*Must be done before performing a digital block to establish a baseline exam
Examine the finger to determine the Allen Classification level, how significant the soft tissue defect is, whether contaminants are present, if exposed bone or tendon exists, and if a subungual hematoma or nail bed laceration is present.
Key Adjuncts to Facilitate Exam/Treatment
Perform a digital block to facilitate a good exam.
There are multiple methods to perform a digital nerve block. No single method is better than any other. The key is to be sure that you are anesthetizing the digital nerves on both the radial and ulnar aspect of the finger and both on the palmar and dorsal side of the finger (i.e., at 10 o’clock and 2 o’clock as well as at 4 o’clock and 8 o’clock). Lidocaine with epinephrine has not been shown to cause more complications than lidocaine without epinephrine. Two of the primary methods include:
Dorsal Approach: Patient places hand palm side down. Prep skin. Insert the needle at the dorsal webspace on either the radial or ulnar side of the finger. Advance the needle until it reaches the palmar aspect of the hand but does not puncture the skin. Aspirate and inject 2-3mL of lidocaine as the needle (25-27G) is withdrawn. The dorsal and palmar nerve on that side of the finger should now be anesthetized. Repeat on the opposite side of the finger (either dorsal or ulnar).
Volar Approach/Transthecal/Flexor Tendon Sheath Block: Patient places hand palm side up. Prep the skin. Insert the needle at the midpoint of the crease where the finger meets the palm or proximal to this over the metacarpal head until you hit bone, then pull back slightly. Aspirate and inject about 3mL of anesthetic. For additional coverage, angle the needle toward the webspace on each side of the finger and inject an additional 2-3mL of anesthetic.
Bleeding control
Again, several different methods can be useful. To name a few:
Apply a pre-made digital tourniquet
Cut the finger portion of a sterile glove, and then cut a hole at the tip. Slide the finger portion of the glove over the finger. Roll from the top down toward the base of the finger.
Wrap a Penrose drain around the proximal finger and secure it with a clamp.
Diagnostic Testing
Obtain an X-ray of the digit as well as the amputated piece if considering replantation.
Treatment/ Management
Update tetanus/Tdap
Prophylactic antibiotics are controversial
Approach to Fingertip Avulsions/Amputations
Finger tip injuries occur distal to the insertion of the deep flexor and extensor tendons at the level of the lunula. Usually, the initial management focuses on hemostasis, wound care, and pain control. In addition, many cases can be effectively managed by allowing healing by secondary intention with outpatient follow-up with a hand surgeon.
In general, the appropriate management for fingertip avulsion/ amputation injuries depends on whether there is skin and pulp tissue loss only, the size of the soft tissue defect, and whether there is exposed bone. A visual algorithm is shown, followed by further explanation.
Figure 4. Approach to Finger Injury
Simple soft tissue (pulp) amputations that are <1cm2 in surface area without exposed bone or nailbed involvement can be treated conservatively with serial dressing changes after adequate wound irrigation and control of bleeding and pain in the ED. A helpful method to control bleeding is to apply a finger tourniquet (as outlined above) and create a dry wound. Following this, approximately four layers of tissue adhesive should be used over the open area, allowing each layer to dry in between. After four layers are applied, remove the tourniquet and monitor for re-bleeding. If no rebleeding is present, wrap the wound in a nonadhesive dressing (such as Xeroform gauze) with an overlying bulky dressing and instruct the patient to soak the injured finger for 10 minutes per day in warm water with antibacterial soap, followed by tap water irrigation and reapply a new sterile non-adherent dressing. Repeat this process for 10-15 days and then advance to every other day. Instruct the patient that complete skin healing can take up to 8 weeks.
If the soft tissue (pulp) amputation is larger than 1cm2 in surface area, the amputated portion can be used as a full-thickness skin graft. Be sure to clean the amputated tissue and debride the nonviable tissue. The undersurface of the skin should be defatted with sharp scissors. Finally, the graft can be sutured to the defect.
Any nailbed lacerations should be repaired (beyond the scope of this post).
If there is exposed bone, the situation becomes a bit more complicated. Bones exposed beyond the soft tissue defect will not allow enough blood flow to the tip to support skin re-growth over the defect. Factors such as the defect's size, the amputation's angle, and the amputated tip's availability should determine management from here. Therefore, a discussion with a hand surgeon in this case would be prudent.
Some sources suggest that if the bony protuberance is less than 0.5cm in length and the soft tissue defect is less than 1cm2 in surface area, the bone can be trimmed back using a rongeur and the wound defect can be left to heal by secondary intention (with wound care instructions as previously outlined). Conversely, dorsal, obliquely angled wounds can theoretically be closed primarily in the ED after bone rongeuring. Importantly, if you are considering either of these, it is highly recommended that it is done so in consultation with a hand surgeon and that the ED provider is well-versed in using these techniques. Transverse or volar angled amputations should not be primarily closed in the ED given the risk of insufficient soft tissue repair without shortening the finger.
Additional indications to consult a hand surgeon in the emergency department include, but are not limited to: incomplete digital amputations in which the neurovascular bundle and portions of underlying bone remain intact (suggesting the need for fracture reduction, internal pin fixation, repair of soft tissues in the OR), complete digital tip amputations occurring proximal to the lunula (see below), fingertip injury in a patient with specific occupations where the finger is critical, or when the affected finger is a thumb or index finger.
Finger Amputations
For complete (i.e., not partial) finger amputations, the following steps should be taken:
Wrap the amputated portion in moist gauze
Place the wrapped portion in a plastic bag
Place the plastic bag in ice water (should remain viable for 6-12 hours)
Emergency consult with a hand surgeon
Key Take-aways
Fingertip injuries are common in the emergency department, and are considered high risk given the critical role that fingers play in our everyday lives
Oftentimes, “less is more” when it comes to finger injuries. Focus on performing a comprehensive exam, controlling pain and bleeding, providing good wound care, and ensuring close follow-up with a hand surgeon.
Choose a method for anesthesia and make sure adequate pain control has been achieved to facilitate further procedures. When feasible, perform a sensory exam prior to injecting anesthetic.
Know the indications for emergent hand surgeon consultation in the ED and how to care for a completely amputated digit.
Author: Jake Gruber, MD is a former resident at Brown Emergency Medicine Residency
Faculty Reviewer: Nathaniel Oz, MD is an attending physician at Brown Emergency Medicine
references
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