Fingertip Injuries/Amputations

Cross section of the fingertip.

adapted/modified from the AAOS website

Injuries to the fingertips are common in accidents at home, at work, and at play. They can occur when a fingertip slams in a car door; while chopping vegetables; or even when clearing debris from a lawnmower or snowblower.

Fingertip injuries can be crushing, tearing (lacerating), or amputating injuries to the tips of fingers and thumbs. Injury can include damage to skin and soft tissue, bone (distal phalanx), or to the nail and nailbed. The tips of longer fingers tend to be injured more often because they are last to escape from harm's way.

First Aid

A doctor should examine an injury to the tip of a finger or thumb. Fingertips are rich with nerves and are extremely sensitive. Without prompt and proper care, a fingertip injury can disrupt the complex function of the hand, possibly resulting in permanent deformity and disability.

In preparing to see a doctor:

• Elevate the injury and apply ice to reduce bleeding and swelling.
• Cover the fingertip wound with a dry, sterile dressing.
• Immobilize the affected hand and wrist with a short splint.

If a fingertip is completely cut off:

• Gently cleanse the amputated part with water (preferably saline).
• Cover it in gauze wrap.
• Put it in a watertight bag.
• Place the bag on ice.
• Do not put the amputated part directly on ice. You could further damage it.

Take the amputated part with you to the emergency room.

Treatment

How a doctor will treat a fingertip injury/amputation depends on the angle of the cut and the extent of the injury. Health and lifestyle will also be considered.

The doctor will ask a number of questions:

• How and when did the injury happen?
• Is the injury on the dominant hand?
• What does the patient do for a living and for recreational activities?
• Have there been other hand problems, like osteoarthritis or systemic diseases (i.e., diabetes, rheumatoid arthritis)?
• Is tetanus immunization current?

Immediate Care

Sometimes an injection (digital block anesthesia) is given to stop pain in the affected finger. The wound is washed out (irrigated) with a saline solution. The doctor will assess the wound, looking for exposed bone, missing tissue, and injury to the nail. The wound will be cleaned (debrided), removing dead (devitalized) tissue and contaminants. This will reduce the chances of infection.

X-rays may be needed if broken (fractured) bones are suspected. If blood has built up under the nail (subungual hematoma), the doctor may pierce the fingernail to relieve the pressure. An antibiotic and/or tetanus shot may be given to prevent infection.

Treatment

A doctor will decide on a plan for treatment after the injury is completely assessed. The goal of treatment is to have a pain-free fingertip that is covered by healthy skin. The hand should be able to feel, pinch, and grip and it should be able to perform its normal functions. If possible, attempts will be made to preserve the length and appearance of the finger.

Tissue Injury Without Exposed Bone

The surgeon will make a visual inspection of the fingertip to choose the best way to treat a fingertip injury. Here, wounds made along the green lines probably can heal on their own. Wounds made along blue lines will probably need some sort of surgery or

If the wound to a fingertip's skin and fleshy tissue is small, it may close on its own. A protective dressing may be placed over the wound with instructions to change the bandage regularly. A splint may be recommended to protect the area while it heals. After 48 hours, range-of-motion finger exercises may be started. After about 24 to 48 hours, it may be recommended that the finger be soaked daily in a solution of warm water and peroxide or betadine. Complete healing usually takes 3 to 5 weeks.

If the wound to the fingertip is large, the remaining skin may not be large enough to cover the open area. In this case, if the wound is left to heal itself, the skin around the wound may not be durable enough. A piece of skin (skin graft) may be taken from a donor site, such as the palm of the hand, and used to cover the injury. Both the wound and the donor site are closed during surgery.

Exposed Bone Injury

Once the fingertip wound has been cleaned, a flap of skin can be lifted from the back of the finger and sewn (sutured) over the wound.

If the injury exposes bone, it may be that there will not be enough tissue around the wound to stitch (suture) the wound closed. Sometimes the bone needs to be shortened. This usually does not hurt hand function.

It may also be necessary to cover the wound with skin (along with the fat and blood vessels underneath) from a healthy part of the same hand This is called reconstructive flap surgery. Some areas of the hand that are used as donor areas are the injured finger itself (triangular volar advancement flap); an uninjured finger (cross-finger flap); and the palm of the hand (thenar flap).

Once the fingertip wound has been cleaned, a flap of skin can be lifted from the back of the finger and sewn (sutured) over the wound.

Reproduced with permission from Frassler PR: Fingertip Injuries: Evaluation and Treatment. J Am Acad Orthop Surg 1996;4

In some cases, the skin is not fully removed from the donor area. Instead, it is partly removed and sewn over the wound. The donor area remains partially connected to the flap. The defect is sewn closed with the graft. A bulky dressing protects the area. A splint can be used to support the hand. The uninjured fingers are left free to exercise. A second operation may be necessary a few weeks later. This operation will detach the flap from its donor site.

If the amputated part is large (it includes the entire nail and a lot of the skin on the back of the finger), the surgeon may consider the pros and cons of reattaching the amputated part (replantation). This is a long, complicated surgical procedure.

Young Children

Doctors treat fingertip amputations somewhat differently in children younger than 6 years of age. After thoroughly cleaning and preparing an amputated fingertip, the surgeon may reattach it to the finger. The fingertip may continue to grow relatively normally, even if bone was exposed. This is especially possible in children younger than 2 years of age.

Considerations

In many cases, surgery can return a large degree of feeling and function to a fingertip injury. Infection, poor healing, loss of feeling or motion, and adverse reactions to anesthesia are all possible complications of surgery.

Outcome

After the injury heals, mild to severe pain and sensitivity to cold may continue for a year or may even be permanent. Recovery may take several months. Physical therapy of the hand may be needed to improve movement and strength. Other therapies that may be recommended may include heat and massage therapy, electric stimulation of the nerves in the hand, splinting, traction, and special wrappings to control swelling.