Management of fingertip injuries
- Richard A Saladino, MD
Richard A Saladino, MD
- Professor of Pediatrics
- University of Pittsburgh School of Medicine
- Peter Antevy, MD
Peter Antevy, MD
- Pediatric Emergency Department
- Joe DiMaggio Children's Hospital
- Section Editors
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Nail bed injuries and fingertip avulsions occur frequently and may have significant associated functional or cosmetic morbidity. These injuries are commonly treated in an outpatient setting. Nail bed lacerations require careful repair and measures to preserve the nail folds and germinal matrix. Complete fingertip avulsions require debridement, cleansing, and local wound care.
The repair of nail bed lacerations and fingertip avulsions are reviewed here. The management of subungual hematoma is discussed separately. (See "Subungual hematoma".)
MECHANISM OF INJURY
Isolated nail bed injury typically occurs as a result of direct blunt trauma (eg, crush in a door jamb). A nail bed injury almost always accompanies a partial or complete fingertip avulsion [1-3]. Fingertip avulsions often occur in the setting of door closure upon the finger, either along the edge of the door on the side of the hinge or the latch. Most avulsions are partial avulsions of the fingertip, although full amputations are not rare.
Fingertip avulsions are also caused by knives, slicers, exercise equipment (eg, treadmills, exercise bicycles), power tools, and lawn mowers. In contrast to adults, complete or partial avulsions heal extremely well in children especially before adolescence. In particular, the literature indicates that children younger than two years of age are very likely to demonstrate complete distal tip regeneration after amputation when managed without repair [4,5].
Proper management of fingertip injuries requires knowledge of anatomy of the nail bed as well as familiarity with the motor and neurovascular anatomy of the finger (figure 1).
- Antevy, PM, Saladino, RA. Management of finger injuries. In: Textbook of Pediatric Emergency Procedures, 2nd edition, King, C, Henretig, FM (Eds), Lippincott, Williams & Wilkins, Philadelphia 2008. p.939.
- Ljungberg EM, Carlsson KS, Dahlin LB. Cost per case or total cost? The potential of prevention of hand injuries in young children - retrospective and prospective studies. BMC Pediatr 2008; 8:28.
- de Alwis W. Fingertip injuries. Emerg Med Australas 2006; 18:229.
- Rosenthal LJ, Reiner MA, Bleicher MA. Nonoperative management of distal fingertip amputations in children. Pediatrics 1979; 64:1.
- Al-Anazi AF. Fingertip injuries in paediatric patients - experiences at an emergency centre in Saudi Arabia. J Pak Med Assoc 2013; 63:675.
- Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg Am 1984; 9:247.
- Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin 1990; 6:23.
- Roberts, J. Fingernail avulsion and injury to the nail bed. Emerg Med News 1993; 15:3.
- Shepard GH. Management of acute nail bed avulsions. Hand Clin 1990; 6:39.
- Schriger DL, Baraff L. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med 1988; 17:932.
- Roberts, J, Hedges, J. Clinical Procedures in Emergency Medicine, 4th, WB Saunders, Philadelphia 2004.
- Lee DH, Mignemi ME, Crosby SN. Fingertip injuries: an update on management. J Am Acad Orthop Surg 2013; 21:756.
- Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am 2008; 33:250.
- Richards AM, Crick A, Cole RP. A novel method of securing the nail following nail bed repair. Plast Reconstr Surg 1999; 103:1983.
- O'Donovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the management of fingertip injuries in children. J Hand Surg Br 1999; 24:727.
- Sommer, NZ, Brown, RE. The perionychium. In: Green's Operative Hand Surgery, Volume 1, 6th edition, Wolfe, SW, Hotchkiss, RN, Pederson, WC, Kozin, SH (Eds), Elsevier Churchill Livingstone, Philadelphia 2011. p.333.
- Altergott C, Garcia FJ, Nager AL. Pediatric fingertip injuries: do prophylactic antibiotics alter infection rates? Pediatr Emerg Care 2008; 24:148.
- Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. J Hand Surg Br 2003; 28:388.
- Rubin G, Orbach H, Rinott M, et al. The use of prophylactic antibiotics in treatment of fingertip amputation: a randomized prospective trial. Am J Emerg Med 2015; 33:645.
- Grossman JA, Adams JP, Kunec J. Prophylactic antibiotics in simple hand lacerations. JAMA 1981; 245:1055.
- Roberts AH, Teddy PJ. A prospective trial of prophylactic antibiotics in hand lacerations. Br J Surg 1977; 64:394.
- Beesley JR, Bowden G, Hardy RH, Reynolds TD. Prophylactic antibiotics in minor hand injuries. Injury 1975; 6:366.
- Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J Craniofac Surg 2009; 20:1033.
- Russell RC, Casas LA. Management of fingertip injuries. Clin Plast Surg 1989; 16:405.
- Fetter-Zarzeka A, Joseph MM. Hand and fingertip injuries in children. Pediatr Emerg Care 2002; 18:341.
- MECHANISM OF INJURY
- INDICATIONS, CONTRAINDICATIONS, AND PRECAUTIONS
- Indications for subspecialty consultation or referral
- Patient counseling and informed consent
- Local anesthesia, analgesia, and sedation
- Fingertip skin avulsion
- Nail bed injury and repair
- Partial fingertip avulsion or amputation
- Complete fingertip avulsions or amputations
- ADDITIONAL CONSIDERATIONS
- Antibiotic therapy
- Tetanus prophylaxis
- Wound care and patient instructions
- SUMMARY AND RECOMMENDATIONS