Hisham M. Awan
Fingertip injuries are the most common hand injuries presenting to emergency departments.
Fingertip injuries with soft tissue loss may be time-intensive and challenging to treat.
Goals of management include preserving finger length, restoring a sensate, durable tip, and preserving bony support for nail growth when possible.
Fingertip anatomy (Figure 53.1)
Eponychium—also known as the cuticle, soft tissue at distal margin of proximal nail fold
Paronychium—lateral margins of nail fold
Hyponychium—barrier to microorganisms where nail bed meets skin of fingertip
Lunula—crescent-shaped structure seen at junction between sterile and germinal matrices
Sterile matrix—lies directly beneath the nail plate where it adheres to the nail bed
Germinal matrix—just proximal to the sterile matrix, responsible for majority of nail growth
History and physical examination
Determine mechanism of injury, including avulsion, crush, or laceration.
Assess zone of injury and characteristics of laceration and presence or absence of exposed bone, which will ultimately guide management (Figure 53.2).
Evaluate range of motion to determine flexor or extensor tendon involvement.
FIGURE 53.1 Sagittal section of fingertip anatomy. Reprinted with permission from Wolfson A, Cloutier R, Hendey G, et al. Harwood-Nuss’ Clinical Practice of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
Accurate categorization of fingertip injuries is critical for guiding treatment.
These injuries can be classified into four main patterns (Figure 53.3):
Type 1 transverse tip amputations without exposed bone may be treated with healing by secondary intention.
Type 2 injuries with more extensive soft tissue loss and exposed bone may be treated with skeletal shortening and primary closure, but are often associated with nail plate abnormalities, especially when >50% of nail plate is removed.
Type 3 injuries near distal interphalangeal (DIP) joint may be considered for replantation or revision amputation. Replantation is most successful when amputation is proximal to area of paronychium through proximal aspect of distal phalanx.
Type 4 injuries often require soft tissue reconstruction.
Fingertip injuries without exposed bone may be treated based on the size of soft tissue deficit:
If <1 cm2 of tip involved, may allow to heal by secondary intention or closed primarily (revision amputation)
If >1 cm2 of tip involved, full-thickness skin or composite grafts required
Fingertip injuries with exposed bone are treated based on orientation of tissue loss (Figure 53.4):
Volar oblique injury
Neurovascular island flaps
Distant flaps (chest, abdomen, or groin)
Moberg advancement flap for volar oblique thumb injury
V-Y advancement flap
Kutler paired V-Y lateral advancement flaps
Moberg advancement flap for transverse thumb injury
Dorsal oblique injury
V-Y advancement flap
Reverse cross-finger flaps
First dorsal metacarpal artery “kite” flap or heterodigital island flap for dorsal thumb injury
FIGURE 53.3 Classification system for fingertip amputations. With permission from Biswas D, Wysocki RW, Fernandez JJ, Cohen MS. Local and regional flaps for hand coverage. J Hand Surg Am. 2014;39(5):992-1004.
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