Fingertip Amputations

The fingertip is the part of the terminal phalanx that is distal to the insertion of extensor and flexor tendons. Fingertip injuries can be the result of crushing, tearing (lacerating) or tissue loss (amputating injuries).

Learning Bite

Fractures proximal to the waist of the terminal phalanx, or intra-articular fractures in fingertip injuries, require specialist surgical assessment to determine the need for internal stabilisation.

Transverse amputations

Partial amputations are commonly seen in crush injuries. Children may get fingertips crushed in doors or furniture.

Fingertip injuries with tissue loss can be classified by the residual defect.

Transverse amputations are classified as shown in the table and image.

Type I Fingertip soft-tissue loss only
Type II Fingertip loss at the level of the proximal third of the nail plate
Type III Fingertip loss at the level of the eponychial fold
Type IV Fingertip loss proximal to the DIP joint

Oblique fingertip defects

Oblique fingertip defects can be classified in one of three ways – volar, dorsal and lateral [3].

Non-operative treatment

Emergency physician

Conservative treatment has the advantage of convenience, simplicity and low associated costs. Some fingertip injuries can be managed adequately in an emergency department under the care of an emergency physician.

The little finger of a ‘size 6’ glove makes a good finger tourniquet. A small hole is cut into the tip and the finger glove is rolled on to the finger from distal to proximal. This serves to exsanguinate the digit and provides tourniquet to the digit.

Learning Bite

It is imperative that the tourniquet is removed and finger circulation checked before occlusive dressings are applied.

ED specialist

Fingertip injuries suitable for management by an ED specialist are:

  • Superficial skin loss defect <1 cm2 in Zone I
  • Transverse Type I fingertip amputations
  • Type I and Type II fingertip amputations in children
  • Oblique partial fingertip amputation without bone exposure
  • Stable fracture needing splintage only

Follow-up clinic and dressings facilities, as well as access to a physiotherapist, are required.

It is to be noted that children have greater tissue regeneration and modelling capacity.

ED procedure

The procedure for carrying out treatment of fingertip injuries in the ED is:

  • Local anaesthesia ring block, essential for assessment, treatment and analgesia
  • Cleanse thoroughly, remove dirt and foreign material
  • Trim off any devitalised tissue
  • Non-adherent dressings to be changed and the wound inspected 2-3 times weekly
  • A stable fracture of the terminal phalanx may be externally splinted for 2-3 weeks
  • A 1 cm2 defect takes an average of five weeks to heal [3]

Learning Bite:

The fingernail and its underlying matrix are supported by more than half the bone length of the underlying terminal phalanx.

Type I and Type II amputations have sufficient bone support for straight nail regrowth without hook nail deformity.

Following nail bed repair the avulsed nail can be placed in the nail fold, which acts as a template and stent for the nail bed and also decreases discomfort by acting as a natural protective cover.