Fingertip avulsion: Difference between revisions

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==Background==
==Background==
[[File:Human nail anatomy.jpg|thumb|A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.]]
*Due to blunt or penetrating trauma
*Consult hand surgeon for all patients with [[Amputation]] proximal to the lunula (crescent-shaped whitish area)


===Anatomy===
{{Fingertip anatomy}}
*The '''perinychium''' includes the nail, the nailbed, and the surrounding tissue.
*The '''paronychia''' is the lateral nail folds
*The '''hyponychium''' is the palmar surface skin distal to the nail.
*The '''lunula''' is that white semi-moon shaped proximal portion of the nail.
*The '''sterile matrix''' is deep to the nail, adheres to it and is distal to the lunule. 
*The '''germinal''' portion is proximal to the matrix and is responsible for nail growth.


==Clinical Features==
==Clinical Features==
*Partial or complete amputation of distal phalanx of finger


==Differential Diagnosis==
==Differential Diagnosis==
{{DDX distal finger}}
{{Hand and finger injury DDX}}
{{Hand and finger injury DDX}}


==Evaluation==
==Evaluation==
===Workup===
*Xray
===Fingertip Zones===
===Fingertip Zones===
[[File:Fingertip avulsion.JPG|thumb]]
*Zone I - Distal to tip of phalanx
*Zone I - Distal to tip of phalanx
*Zone II - Between tip of phalanx and lunule
*Zone II - Between tip of phalanx and lunula
*Zone III - Proximal to lunule
*Zone III - Proximal to lunula


==Management==
==Management==
*Pain control ([[Digital block]])
*Irrigate and debride non-viable tissue
*Replantation rarely indicated for zone I-III amputations
*Patients more likely to benefit from replantation for thumb and index finger amputations
===No exposed bone or nail bed involvement===
===No exposed bone or nail bed involvement===
*Zone I injuries - treat conservatively with serial dressing changes alone
*Zone I injuries - treat conservatively with serial dressing changes alone
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**Consider hand surgery consult
**Consider hand surgery consult
**Rongeur bone if bony protuberance
**Rongeur bone if bony protuberance
**Wound closure with flap
**Trim digital nerves proximal to skin to avoid painful neuroma formation
**Consider nail removal if significant involvement, possibility of hook nail deformity it damaged nail left in situ
**Conservative treatment with non-adherent dressing generally preferred<ref>https://pubmed.ncbi.nlm.nih.gov/31185316/</ref><ref>https://pubmed.ncbi.nlm.nih.gov/25191157/</ref> vs. wound closure with flap
**Follow up with hand surgery in 3-5d
**Follow up with hand surgery in 3-5d
**Healing time 3-6wks
**Healing time 3-6wks
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==Disposition==
==Disposition==
*Generally may be discharged
*Hand surgery follow-up (especially if zone II or III injury)
==See Also==
*[[Finger amputation]]
*[[Distal phalanx (finger) fracture]]


{{Special lacerations see also}}


==References==
==References==

Latest revision as of 19:22, 1 March 2023

Background

  • Due to blunt or penetrating trauma

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • The perionychium includes the nail bed and the paronychium.
  • The paronychium is the lateral nail fold (soft tissue lateral to the nail bed).
  • The hyponychium is the palmar surface skin distal to the nail.
  • The lunula is that white semi-moon shaped proximal portion of the nail.
  • The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
  • The germinal portion is proximal to the matrix and is responsible for nail growth.

Clinical Features

  • Partial or complete amputation of distal phalanx of finger

Differential Diagnosis

Distal Finger (Including Nail) Injury

Hand and finger injuries

Evaluation

Workup

  • Xray

Fingertip Zones

Fingertip avulsion.JPG
  • Zone I - Distal to tip of phalanx
  • Zone II - Between tip of phalanx and lunula
  • Zone III - Proximal to lunula

Management

  • Pain control (Digital block)
  • Irrigate and debride non-viable tissue
  • Replantation rarely indicated for zone I-III amputations
  • Patients more likely to benefit from replantation for thumb and index finger amputations

No exposed bone or nail bed involvement

  • Zone I injuries - treat conservatively with serial dressing changes alone
    • Cover wound with non-adherent dressing
    • Instruct patient to soak fingertip in antibacterial soap-added water for 10min QD and then reapply non-adherent dressing
    • Follow up with primary care provider in 2d
    • Most will have epithelialization in approximately 1 month[1]

Exposed Bone

  • Zone II injuries
    • Consider hand surgery consult
    • Rongeur bone if bony protuberance
    • Trim digital nerves proximal to skin to avoid painful neuroma formation
    • Consider nail removal if significant involvement, possibility of hook nail deformity it damaged nail left in situ
    • Conservative treatment with non-adherent dressing generally preferred[2][3] vs. wound closure with flap
    • Follow up with hand surgery in 3-5d
    • Healing time 3-6wks
  • Zone III injuries
    • Consult hand surgery if available
    • May require distal phalanx amputation
    • Consider treating like Zone II
    • Healing time 3-6wks[1]

Disposition

  • Generally may be discharged
  • Hand surgery follow-up (especially if zone II or III injury)

See Also

Special Lacerations by Body Part

References

  1. ↑ 1.0 1.1 Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.
  2. ↑ https://pubmed.ncbi.nlm.nih.gov/31185316/
  3. ↑ https://pubmed.ncbi.nlm.nih.gov/25191157/
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