40 yo M BIBEMS with no PMH presents with laceration to R index finger. Patient reports he was working on his car when a piece of metal fell and cut off part of his finger.

PMH – deniesPSH – deniesSoc Hx- denies x3Allergies – NKDAMeds – none

Case

Physical Exam –A&Ox3 NADVitals – T98.2 BP136/88 HR 77 RR 16 HEENT – wnlNeck – wnlLungs – CTA blHeart – S1, S2 RRRAbd – Soft NT/ND +BSExtremities – transverse amputation of 1.5cm of R index

finger in zone 2 including nail bed involvement, distal to the germinal matrix, +bone exposure. Decreased ROM at distal interphalangeal joint otherwise FROM in all digits, no sensory deficits no other signs of injury

Case

Vikas Goswamy MS4

SUNY Downstate

Fingertip Injuries

Hand Anatomy

Hand Anatomy

Finger Tip Anatomy

Defined as an injury at or about the level of the lunula

One of the most frequently injured parts of the hand

Can involve skin, soft tissue, nail, nail bed, bone

Fingertip Injuries

Fingertip Injuries

Fingertip InjuriesInvolving only Pulp

Tissue and SkinAmputations that

Involve < 1 cm of finger tip

No bone exposureNo nail or nail bed

involvement Can be treated

conservatively with wound care, education on cleaning, and follow up after 2 days

Fingertip InjuriesWith exposed bone

Management determined by size, geometry, mechanism, and angle of amputation

If <0.5cm but exposed bone, the bone can be trimmed using a rongeur to allow enough space for a soft tissue flap

Close by second intention with wound care after 2 days

For small injuries (<2cm) reattachment is generally not indicated

Fingertip InjuriesNail bed

Made up of the germinal matrix and the sterile matrix

Germinal matrix extends from the nail fold to the lunula

Sterile matrix extends from lunula to hyponychium

Fingertip InjuriesNail bed Involvement

Avulsion injuries to nail bed have poorer prognosis because germinal matrix fragments may be left under nail

If nail is available, use as graft and reattach with 6-0 or 7-0 absorbable mattress stitch

If not available toe nail graft can be used at later time

ReferencesDavenport M. Chapter 41. Injuries to the Arm,

Hand, Fingertip, and Nail. In: Ma OJ, Cline DM, Tintinalli JE, Stapczynski JS, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2014. http://www.accessemergencymedicine.com/content.aspx?aID=56328606. Accessed October 12, 2012.

AAFP http://www.aafp.org/afp/2001/0801/p455.html

Fingertip Injuries