Soft Tissue Coverage of Fingertip Amputations

Soft Tissue Coverage of Fingertip Amputations

Jennifer Etcheson

Jeffrey Yao


  • FIG 1 depicts the anatomy of the fingertip.

  • Eponychium: the cuticle or the thin membrane over the dorsum of the nail at the nail fold

  • Perionychium: the skin at the lateral nail margin

  • Hyponychium: the skin below the distal aspect of the nail plate, consisting of a mass of keratin with a high concentration of lymphocytes and polymorphonuclear cells; serves as a barrier to infection

  • Nail root: portion of the nail plate proximal to the eponychial fold

  • Lunula: the curved white opacity representing the distal, visible portion of the germinal matrix

  • Germinal matrix: produces 90% of the nail plate volume

  • Sterile matrix: contributes to nail plate adherence

  • Nail plate: consists of flattened sheets of anuclear keratinized epithelium

  • Nail bed: the floor of the nail plate, comprising proximal germinal matrix and distal sterile matrix

  • Distal phalanx: lies deep to the nail bed

  • Pulp: composed of fibrous septa

FIG 1 • Cross-section of a fingertip depicting key anatomic structures.

Fingertip Amputation Classification (Tamai)

  • Zone I: distal to lunula

  • Zone II: DIP joint to lunula


  • Various mechanisms of trauma

    • Avulsion

    • Crush

    • Compression

    • Sharp

    • Dull


  • Fingertip injuries with no bone exposed will ultimately heal by secondary intention.

  • In the setting of wounds less than 1 cm2, secondary intention healing aided by daily dressing changes actually allows for increased recovery of sensation.

  • The use of secondary intention healing for larger injuries involves a prolonged period of dressing changes with associated risk of infection and unfavorable scarring.


  • Full history and physical examination

    • Mechanism of injury

    • Age

    • Handedness

    • Occupation

    • Level of cooperation and understanding

  • Injury assessment

    • Digit or digits involved: thumb versus finger

    • Transverse versus dorsal oblique-volar oblique versus radial-ulnar

    • Damage to nail or nail bed

    • Exposure of bone

    • Static and moving two-point discrimination: There is decreased density of innervation with increased two-point discrimination.

    • Terminal flexion and extension: Injury to tendons will require more significant flap coverage.

    • Vascularity: Prolonged capillary refill is suggestive of arterial injury.


  • Plain radiographs in orthogonal planes (posteroanterior, lateral)


  • Most fingertip amputations may be treated at the bedside using sterile technique and employing a metacarpal block, finger tourniquet, and loupe magnification.

  • There should be a low threshold for operative management.

  • If no bone is exposed, options include healing by secondary intention, primary closure, or skin grafting.

  • Secondary intention healing aided by daily dressing changes provides the best recovery of sensation and is appropriate for wounds less than 1 cm2.

  • Primary closure is an option only if there is minimal skin loss.

    • Tight closures should be avoided. This can minimize function by causing joint contracture and distal tip tenderness due to poor soft tissue coverage of the bony prominences.

    • Sewing the volar skin tightly to the distal nail may result in a cosmetically displeasing hook nail.

  • If a nail bed laceration is suspected, the nail plate should be removed with a Freer elevator, allowing repair of the nail bed with either 6-0 or 7-0 simple interrupted absorbable sutures (chromic gut). Loupe magnification is extremely helpful.

  • The eponychial fold should be stented open with either trimmed and carefully cleansed nail or other material (eg, foil from a suture pack) to prevent abnormal growth of the future nail.

  • With amputations through the germinal matrix, any remaining unrepairable matrix should be removed to prevent formation of a painful nail remnant.


  • The decision to take a patient with a fingertip injury to the operating room depends on the size of the defect, presence of exposed bone, angle of amputation, willingness of the patient to do dressing changes, and surgeon experience.

  • The goals are to preserve function and sensation and allow early return to activity.

  • In terms of functional outcome, healing by secondary intention provides equal or better results for defects less than 1 cm in diameter.

  • Full-thickness grafts are preferable to split-thickness grafts.

    • Split-thickness grafts should be used only on the ulnar side of the index, middle, and ring fingers.

    • Donor site options include the volar wrist skin (should be avoided, as it can mimic a suicide attempt laceration), antecubital skin, medial upper arm skin, and hypothenar skin.

  • These donor sites can be closed primarily.

  • If salvageable, the original skin from the amputated segment can be defatted and applied as a graft/biologic dressing.

  • If bone is exposed, options include bone shortening and primary closure and bone shortening and healing by secondary intention or fingertip flaps.

Preoperative Planning

  • Preliminary irrigation and débridement, exploration

  • Antibiotics

  • Patient comorbidities

    • Is the patient a diabetic? smoker? recreational drug user?

    • Is the tetanus status up-to-date?

  • Anesthesia assessment


  • Supine with standard hand table. An arm, forearm, or digital tourniquet is used. The arm is placed in the center of the hand table for equal access by the surgeon and assistant.


  • Once the decision to perform a flap has been made, the angle of amputation, patient age, and patient gender determines whether an advancement or regional flap is appropriate.

Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Soft Tissue Coverage of Fingertip Amputations
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