Fingertip avulsion: Difference between revisions
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*Zone II injuries | *Zone II injuries | ||
**Consider hand surgery consult | **Consider hand surgery consult | ||
**Irrigate and debride non-viable tissue | |||
**Rongeur bone if bony protuberance | **Rongeur bone if bony protuberance | ||
**Trim digital nerves proximal to skin to avoid painful neuroma formation | **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 | **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 | ||
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**Consider treating like Zone II | **Consider treating like Zone II | ||
**Healing time 3-6wks<ref name="Lamon" /> | **Healing time 3-6wks<ref name="Lamon" /> | ||
*Replantation rarely indicated for zone I-III amputations | |||
*Patients more likely to benefit from replantation for thumb and index finger amputations | |||
==Disposition== | ==Disposition== | ||
Revision as of 00:46, 4 December 2020
Background
- Due to blunt or penetrating trauma
Nailtip Anatomy
- 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
- Distal interphalangeal dislocation (finger)
- Distal phalanx (finger) fracture
- Finger amputation
- Fingertip avulsion
- Finger infection
- Nailbed laceration
- Nail avulsion
- Subungual hematoma
Hand and finger injuries
- Distal finger
- Other finger/thumb
- Boutonniere deformity
- Mallet finger
- Jammed finger
- Jersey finger
- Trigger finger
- Ring avulsion injury
- De Quervain tenosynovitis
- Infiltrative tenosynovitis
- Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
- Hand
- Wrist
- Drummer's wrist
- Ganglion cyst
- Lunotriquetral ligament instability
- Scaphoid fracture
- Extensor digitorum tenosynovitis
- Compressive neuropathy ("bracelet syndrome")
- Intersection syndrome
- Snapping Extensor Carpi Ulnaris
- Vaughn Jackson syndrome
- General
Evaluation
- Xray
Fingertip Zones
- 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)
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
- Irrigate and debride non-viable tissue
- 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]
- Replantation rarely indicated for zone I-III amputations
- Patients more likely to benefit from replantation for thumb and index finger amputations
Disposition
- Generally may be discharged
- Hand surgery follow-up (especially if zone II or III injury)
See Also
References
- ↑ 1.0 1.1 Lamon, RP, et al. Open treatment of fingertip amputations. Ann Emerg Med. 1983; 12(6):358-360.
- ↑ https://pubmed.ncbi.nlm.nih.gov/31185316/
- ↑ https://pubmed.ncbi.nlm.nih.gov/25191157/