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Fingertip Injuries: An Update on Management

Article in The Journal of the American Academy of Orthopaedic Surgeons December 2013
DOI: 10.5435/JAAOS-21-12-756 Source: PubMed

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Megan E Mignemi
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Donald H. Lee, MD
Megan E. Mignemi, MD
Samuel N. Crosby, MD
From Vanderbilt Orthopaedics,
Nashville, TN.
Dr. Lee or an immediate family
member has received royalties,
research or institutional support, and
nonincome support (such as
equipment or services),
commercially derived honoraria, or
other non-researchrelated funding
(such as paid travel) from, and
serves as a paid consultant to,
Biomet, and serves as a board
member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons
and the American Society for
Surgery of the Hand. Dr. Crosby or
an immediate family member has
stock or stock options held in Pfizer
and has received research or
institutional support from Acumed,
Smith & Nephew, Synthes, and
Hand Innovations. Neither
Dr. Mignemi nor any immediate
family member has received
anything of value from or has stock
or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2013;21:
756-766
http://dx.doi.org/10.5435/
JAAOS-21-12-756
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
756
Review Article
Fingertip Injuries: An Update on
Management
Abstract
Injuries to the fingertip are common. The goal of treatment is
restoration of a painless, functional digit with protective sensation.
The amount of soft-tissue loss, the integrity of the nail bed, and the
age and physical demands of the patient should be considered
when selecting a treatment method. Some new products are
effective for management of injuries to the fingertip. The use of
2-octylcyanoacrylate for nail bed repair is faster than suture repair,
with equivalent results reported. Dermal regeneration template is
effective for coverage of digital injuries with exposed tendons or
bones that lack peritenon or periosteum. Although fingertip
replantation offers better functional results than does revision
amputation, replantation is more technically demanding and
requires longer recovery time. Complications associated with
management of injuries to the fingertip include nail deformities,
insensate digits, and painful neuromas.
I njury to the fingertip (ie, injury
distal to the insertion of the flexor
and extensor tendons), is common,
ment options range from healing by
secondary intention to flap coverage
or replantation. Although replace-
especially in young men who per- ment of the fingertip as a composite
form manual labor.1 The paucity of graft has been successful in children,7
local soft tissue available for cover- replantation of the fingertip in adults
age of these injuries and the presence often requires a vascular anastomo-
of the nail bed complicate manage- sis to produce a viable fingertip.8,9
ment. The nail itself plays an impor-
tant role in the normal function of
the hand by protecting the fingertip, Anatomy
providing counterforce to assist with
picking up small objects, and con- The distal phalanx lies in the dorsal
half of the fingertip. Its periosteum is
tributing to the tactile sensation of
the fingertip.2-4 Management of inju- connected to the dermis by multiple
ries to the nail bed is based on the in- fibrous septae, which serve to anchor
the skin to the bone. Volarly, the
tegrity of the nail plate and nail mar-
gin.5,6 pulp of the fingertip is highly vascu-
In patients who sustain amputation lar and composed of fibroadipose tis-
of the fingertip, the nature of the in- sue between the fibrous septae.
jury and the physical demands of the These septae attach to the glabrous
patient should be considered when skin of the hand, tethering the two
selecting a treatment method. For ex- tissues together to assist with trac-
ample, the presence of exposed bone tion during grip.
helps to guide management. Treat- The perionychium comprises the
Journal of the American Academy of Orthopaedic Surgeons

Figure 1
Illustration demonstrating the anatomy of the distal finger and nail bed and
the Tamai and Allen classifications for distal amputations of the fingertip. The
line through the lunula represents the divisions between Tamai zones I and
II. DIPJ = distal interphalangeal joint
nail plate and the surrounding tis-
sues, including the nail fold, epony-
chium, nail bed, hyponychium, and
paronychium (Figure 1). The palmar
floor of the nail fold is the germinal
matrix, which is responsible for most
nail growth. The germinal matrix ex-
tends from the nail fold to the lunula
of the nail. The portion of the nail
bed distal to the lunula is called the
sterile matrix, which adds a small
amount of thickness to the nail and
is responsible for keeping the nail
plate adhered to the nail fold.
In the fingertip, the palmar digital
arteries anastomose with each other
just distal to the flexor digitorum
profundus insertion, forming the dis-
tal transverse palmar arch. The arch
gives off multiple branches that
travel distally, with the central
branches typically being larger (0.4
December 2013, Vol 21, No 12
to 0.6 mm in diameter) than other
branches.10 The dorsal veins provide
most of the venous outflow for the
fingertip. For this reason, at least 4
mm of dorsal skin proximal to the
nail plate is needed for adequate ve-
nous anastomosis.
Nail Bed Injuries
Subungual hematoma, which is
caused by bleeding under the nail
plate, typically occurs after crush in-
jury to the fingertip. In a study of 47
patients with subungual hematoma,
Simon and Wolgin11 demonstrated
that nail bed lacerations requiring re-
pair occurred in 60% of patients
when the subungual hematoma was
>50% of the nail plate and in 95%
of patients when there was an associ-
Donald H. Lee, MD, et al
ated fracture of the distal phalanx.
Consequently, the traditional ap-
proach to subungual hematomas that
involve >25% to 50% of the nail
plate was to remove the nail, inspect
the sterile matrix, and repair any lac-
erations present.3,11 Equivalent out-
comes have been reported in patients
with an intact nail plate and injuries
to the nail bed managed with trephi-
nation alone or trephination with
nail removal and laceration repair,
regardless of hematoma size or the
presence of fracture.5,6 However,
trephination alone is associated with
substantially lower costs.
In the setting of concomitant dis-
ruption of the nail or a nail margin
with a subungual hematoma, the nail
is commonly removed and lacera-
tions are repaired. Although no evi-
dence exists to support this ap-
proach, it seems to be prudent in the
setting of a distal phalanx fracture to
achieve adequate dbridement of the
open fracture. Classic repair of the
nail bed consists of approximation of
the lacerated edges with small-caliber
(6.0 to 7.0) chromic or other absorb-
able suture (Figure 2). Once the re-
pair is complete, the native nail plate
may be replaced beneath the nail
fold and allowed to fall out as the
new nail plate grows. OShaughnessy
et al12 found no difference in out-
comes whether the nail plate was re-
placed or left off after repair.
Recently, promising results have
been achieved with the use of dermal
adhesives for repair of nail bed lacer-
ation. In a randomized controlled
trial, Strauss et al13 compared the ef-
ficacy of the adhesive 2-octylcya-
noacrylate (Dermabond, Ethicon)
with that of suture repair. The au-
thors reported no difference in the
results of both treatment groups, but
the adhesive group required less time
for repair than did the suture group.
When this technique is used, it is
critical to allow the adhesive to dry
before replacing the nail plate to pre-
757
Fingertip Injuries: An Update on Management
Figure 2
A, Preoperative photograph demonstrating a complex nail bed injury.
B, Intraoperative photograph demonstrating suture repair of a distal fingertip
injury involving the nail bed. The skin laceration has been sutured with
interrupted nylon sutures, and the nail bed has been repaired with interrupted
chromic sutures. C, Postoperative photograph demonstrating nail
replacement after nail bed repair.
vent it from sticking to the nail bed
repair.
When injury to the nail bed is asso-
ciated with fracture, a crush injury to
the tuft of the distal phalanx is the
most common fracture. Although of-
ten highly comminuted, these frac-
tures are stable secondary to the nu-
merous fibrous septae of the
surrounding soft tissue. Most of
these fractures can be treated nonsur-
gically by immobilizing the finger in
a splint (eg, stack, foam-laminated
aluminum) for 3 to 4 weeks. Frac-
tures of the distal phalanx that are
substantially displaced and extend
into the diaphysis and articular sur-
face may require surgical fixation
with a Kirschner wire or small
screw.14 In a prospective study of 110
patients with fractures of the distal
phalanx, DaCruz et al15 found that
substantial morbidity was associated
with these injuries. Six months
postinjury, only 17% of patients
with tuft fractures had fully recov-
ered, with most patients reporting re-
sidual numbness, cold sensitivity, hy-
peresthesia, and difficulty with fine
motor movement.
758
Management of Partial
Fingertip Amputations
Appropriate soft-tissue coverage of
fingertip wounds should be deter-
mined by the nature of the injury
and the physical demands and co-
morbidities of the patient. Manage-
ment of injury to the fingertip varies
from local wound care to complex
reconstruction and replantation. For
injuries with pulp loss and no distal
bone exposure, management options
include primary closure, healing by
secondary intention, completion am-
putation, full-thickness skin grafting,
and split-thickness skin grafting. Pri-
mary closure or healing by secondary
intention are preferable for partial
fingertip amputations when no bone
is exposed and when adequate soft-
tissue coverage is available volar-
ly.16,17
Injury to the fingertip that involves
the distal phalanx and is allowed to
heal by secondary intention can lead
to nail deformity in as many as 25%
of patients.18 A hook nail deformity
often develops in the setting of ex-
Journal of the American Academy of Orthopaedic Surgeons
posed bone in the perionychium and
a lack of adequate tissue volarly. Re-
covery of sensation after healing by
secondary intention has been found
to be superior to other surgical meth-
ods, and two-point discrimination
approaches normal after healing.16,17
In the setting of significant soft-
tissue loss on the volar aspect of the
distal finger, completion amputation
(ie, shortening and closure) is the
simplest procedure with the quickest
recovery in select patients. This can
be performed in the emergency de-
partment with the patient under lo-
cal anesthesia. The most important
parts of this procedure are full abla-
tion of the nail bed to prevent hook
nail deformity and identification and
transection of the digital nerves as
far proximal to the level of amputa-
tion as possible to prevent formation
of painful neuroma.
Autogenous skin grafts can also
be used to treat fingertip wounds;
however, a well-vascularized recipi-
ent bed is required. The dorsal skin
of the finger is thinner and looser
than the volar skin, making it more
amenable to skin grafting. The pri-
mary limitation of skin grafting is
that it does not provide any subcuta-
neous tissue or padding and cannot
be placed directly on bone or tendon,
which often precludes its use for
management of injuries to the finger-
tip. One advantage of full-thickness
grafts is that they prevent wound
contracture more than do split-
thickness grafts. Full-thickness grafts
require primary closure of the donor
site and a well-dbrided wound bed
with meticulous hemostasis, whereas
split-thickness graft donor sites can
heal by secondary intention and are
more forgiving with regard to prepa-
ration of the wound bed.
Although preservation of finger
length is important, flap reconstruc-
tion and replantation often require a
prolonged period of immobilization
and recovery. This may be unaccept-

able to the young, active patient who
performs manual labor. The pro-
longed recovery period should be
discussed in detail with the patient
before treatment.
Injuries with exposed bone and a
lack of available soft tissue for cover-
age often require flap reconstruction
if completion amputation is not de-
sired by the patient. When a small
area of coverage is needed, local
flaps offer the lowest donor site mor-
bidity. Local flaps are taken from a
donor site with healthy tissue adja-
cent to the wound on the injured
digit. Examples of local flaps include
the Atasoy-Kleinert V-Y flap, the
Kutler lateral V-Y flap, and the the-
nar advancement (ie, Moberg) flap.
Local Flaps
Atasoy-Kleinert V-Y Flap
This flap is best used for transverse
or dorsal oblique amputations and
can be used for all digits. Use of this
flap is contraindicated in patients
with volar oblique amputations and
more tissue loss volarly. The distal
edge of the wound is the base of the
flap; the flaps apex should extend to
the distal interphalangeal crease (Fig-
ure 3). The skin and subcutaneous
tissue are then incised, including the
fibrous septa anchoring the pulp tis-
sue to the bone. Damage to the neu-
rovascular bundles should be
avoided. The flap can be advanced
up to 1 cm over the defect and se-
cured with sutures, creating a
Y-shaped repair.
Kutler Lateral V-Y Flap
The Kutler lateral V-Y flap is better
suited for volar oblique amputations
that have more tissue loss volarly
than dorsally, but it can also be used
for transverse amputations. The flap
is similar to the Atasoy flap except
that two flaps are used and the bases
of the flaps are the radial and ulnar
sides of the wound (Figure 4). Unlike
December 2013, Vol 21, No 12
Donald H. Lee, MD, et al
Figure 3
Illustrations demonstrating the Atasoy-Kleinert V-Y flap technique. A, The
distal edge of the wound is the base of the flap and the apex of the flap
should extend to the distal interphalangeal crease. The skin, subcutaneous
tissue, and fibrous septa are incised (B) and the flap is secured over the
defect with sutures (C).
the Atasoy flap, this flap provides large to allow for local flap coverage.
only 3 to 4 mm of advancement. Regional flaps commonly used for
management of injury to the finger-
Moberg Flap tip include the cross-finger flap, the-
The Moberg flap is used for soft-tissue nar flap, and thenar-H flap. In these
defects of the thumb and can be used techniques, a pocket or trapdoor flap
when a V-Y advancement flap cannot is made for the fingertip and relies
provide adequate coverage of the defect on blood flow from the donor site to
and the defect measures <2 cm. Mid- allow the flap to incorporate onto
axial incisions are made on both the the fingertip. This type of reconstruc-
radial and ulnar side of the thumb, ex- tion requires a second operation to
tending proximally to the metacar- detach the fingertip from the donor
pophalangeal crease (Figure 5). The en- site 3 to 4 weeks after the initial pro-
tire volar skin flap, including the cedure. If the flap has a large enough
neurovascular bundles, is dissected off donor pedicle, the pedicle can be
the flexor tendon and advanced over clamped to ensure continued capil-
the defect. The interphalangeal joint lary refill and to confirm that the
may need to be flexed to facilitate cov- flap is ready to be divided. One dis-
erage of the wound. advantage to these regional flaps is
that they require a prolonged period
Regional Flaps of immobilization while the flap in-
Regional flaps use tissue that is not corporates, which may cause stiff-
adjacent to the defect. These flaps ness or contractures in the interpha-
are useful when the wound is too langeal joints of the injured finger.
759
Fingertip Injuries: An Update on Management

Figure 4

Illustrations demonstrating the Kutler lateral V-Y flap technique. A, Advancement flaps are marked out on the mid-
lateral aspects of the digit. B, The skin, subcutaneous tissue, and underlying septa are incised, and the flaps are
elevated. The flaps are mobilized longitudinally over the fingertip (C) and secured using loose sutures (D).

Figure 5 Thenar and Thenar-H Flaps

Thenar and thenar-H flaps can be
used to cover loss of volar tissue on
the fingertips of the two radial digits
only because the ulnar digits often
lack the excursion to comfortably
reach the thenar eminence. The the-
nar flap is designed with the radial
border parallel and adjacent to the
crease of the metacarpophalangeal
joint of the thumb. The base of the
flap is proximal and can be as wide
as 2 cm. The flap is elevated with its
underlying subcutaneous tissue, with
care taken to protect the radial digi-
Illustrations demonstrating the use of a Moberg (ie, thenar advancement) flap tal nerve. The flap is then sewn to
for coverage of a soft-tissue defect of the thumb (A). B, A midaxial incision is the fingertip defect, and a full-
made on both the radial and ulnar sides of the thumb, extending proximally thickness skin graft is applied to the
to the metacarpophalangeal crease. The volar skin flap and neurovascular donor site. For a thenar-H flap, the
bundles are dissected off the flexor tendon and advanced over the defect.
C, The flap is secured with sutures. flap is designed as an H in the the-
nar eminence, creating two flaps
one based distally and one based
proximally. These flaps are sutured
Cross-finger Flap subcutaneous tissue, preserving the to the fingertip. Once the flap is de-
The cross-finger flap can be used to paratenon of the extensor tendon. tached, a full-thickness skin graft is
cover volar tissue loss on any digit The flap is reflected on the hinge and applied to the defect.
(Figure 6). The flap is designed as a sutured in place to the injured finger.
rectangle over the middle phalanx of A full-thickness skin graft is applied Island Flaps
the donor digit, with the hinge side to the donor site. Similarly, a reverse Island flaps with a neurovascular pedi-
located adjacent to the injured finger. cross-finger flap can be used to cover cle also can be used for fingertip cov-
The incision extends through the dorsal soft-tissue defects. erage. These flaps have two advantag-

760 Journal of the American Academy of Orthopaedic Surgeons


Figure 6
A, Preoperative photograph demonstrating partial amputation of the fingertip. The injury was managed with a cross-
finger flap. B, Intraoperative photograph of the finger adjacent to the injured finger, with the planned donor site marked.
C, Postoperative photograph of the cross-finger flap before it is detached from the donor site.
es: they provide sensation to the
fingertip and may avoid the prolonged
period of immobilization required for
a cross-finger or thenar flap. However,
island flaps are more technically de-
manding than other regional flaps, and
studies have not yet proved that these
flaps result in better outcomes despite
the apparent advantages.19
Other Treatment Options
Distant flaps are an option when lo-
cal or regional flaps cannot be per-
formed. Groin, chest, and cross-arm
flaps are commonly used for soft-
tissue coverage in patients with inju-
ries to the fingertip (Figure 7). Simi-
lar to thenar and cross-finger flaps,
these flaps rely on donor site blood
supply while the flap incorporates
and can lead to stiffness secondary to
the prolonged period of immobiliza-
tion required for healing.
The use of acellular dermal regen-
eration templates for soft-tissue cov-
December 2013, Vol 21, No 12
erage of injuries to the hand and fin-
gertip has recently gained popularity
as an alternative management op-
tion. These templates can be placed
directly on exposed bone or tendon
within an appropriately dbrided
wound bed and then secured in place
with sutures or staples. A compres-
sive dressing or negative-pressure de-
vice is then used to further immobi-
lize the template. A full- or partial-
thickness skin graft can be placed on
the wound 3 to 4 weeks after appli-
cation for definitive coverage.
Taras et al20 reported on 21 digital
injuries treated with an acellular der-
mal regeneration template followed
by delayed application of full-
thickness epidermal autograft. In 20
of 21 digits, most of the skin graft
incorporated without the need for
further intervention at a minimum
1-year follow-up. Weigert et al21 re-
ported similar results in a series of
15 severe hand wounds treated with
Donald H. Lee, MD, et al
Integra dermal regeneration template
(Integra LifeSciences). The authors
reported good results in 13 wounds.
We prefer to use acellular dermal re-
generation templates in patients with
severe wounds of the hand and fin-
ger with exposed bone or tendon,
those with vascular disease, or those
with poor donor-site tissue that
would complicate regional flap cov-
erage.
Replantation
Complete distal fingertip amputa-
tions are one of the best indications
for replantation. Unlike more proxi-
mal amputations, distal finger re-
plantations have been shown to be
successful even after several days of
cold ischemia time.22 In a systematic
review of studies on replantation in
patients with distal digital amputa-
tion, Sebastin and Chung23 found
761
Fingertip Injuries: An Update on Management

Figure 7

Intraoperative (A and B) and postoperative (C and D) photographs demonstrating a chest wall flap for soft-tissue
coverage of an injury to the thumb. A, Preparation of the flap. B, The flap is sutured to the thumb, covering the defect.
C, Incorporation of the flap before its separation from the chest. D, The thumb after separation of the flap from the
chest wall.

that the mean survival rate of distal
finger replantations was approxi-
mately 86%. They also found that
repair of at least one vein substan-
tially improved survival of the digit.
The most common complications of
replantation were nail deformity
(23%) and pulp atrophy (14%). In a
series of 211 patients with complete
fingertip amputations, Li et al24 ex-
amined factors associated with sur-
vival of distal fingertip replantations.
They found that failure of the re-
planted digit was associated with
crush-type injuries, improper treat-
ment of the amputated digit, smok-
ing, and high platelet counts.
Many classifications exist for distal
fingertip amputations. The most
commonly used is the Tamai classifi-
cation, which divides fingertip inju-
ries into two zones25 (Figure 1). Zone
I is the area from the distal fingertip
to the lunula, and zone II extends
from the lunula to the distal inter-
phalangeal joint (DIPJ). For treat-
ment purposes, the Allen classifica-
tion is the most useful;18 it describes
the specific location of amputation
based on bony and nail bed anatomy
as well as the possibility of vessel
anastomosis during repair (Figure 1).
Tamai zone I replantations can be

762 Journal of the American Academy of Orthopaedic Surgeons


done with arterial anastomosis with
or without venous anastomosis. To
perform a venous anastomosis, ap-
proximately 4 mm of dorsal skin
proximal to the nail plate is needed.
However, good results have also
been achieved with artery-only re-
plantation. Ito et al8 found that in
fingertip amputations distal to the
appearance of identifiable dorsal
veins, there was no difference in out-
come in digits treated with artery-
only replantation versus artery and
venous replantation. In a study of
162 zone I replantations, Lee et al9 re-
ported that the survival rate was 90%
when one vein was repaired compared
with 73.2% when no veins were re-
paired. This difference was statistically
significant (P = 0.008). Hahn and
Jung26 also found that fingertip sur-
vival correlated with the number of
vessels anastomosed in a study of
510 fingertip replantations. If no
vein is anastomosed, a combination
of internal anticoagulation and ex-
ternal bleeding should be used to
prevent venous congestion. Various
external bleeding techniques have
been described, including the use of
leeches, application of heparin-
soaked gauze directly on the nail
bed, and the use of stab incisions on
the paraungual region.27-29 Isolated
reports of successful nonarterialized
venous-only replantation and distal-
arterialtoproximal-venous anasto-
mosis replantation have been pub-
lished; however, the use of these
techniques is not widespread.30,31
Distal fingertip replantations have
been shown to have excellent out-
comes compared with those of com-
pletion amputations. Hattori et al32
compared the functional outcomes of
replantation and completion ampu-
tations and found that patients
treated with replantation had better
Disabilities of the Arm, Shoulder and
Hand scores; less pain; and higher
satisfaction than did those treated
with completion amputation. How-
December 2013, Vol 21, No 12
ever, the amputation group was able
to return to work at an average of 1
month postoperatively compared
with an average of 4 months in the
replantation group. Finally, in any
replantation, restoration of two-
point discrimination plays an impor-
tant role in a successful outcome. In
the review by Sebastin and Chung23
and the series by Hahn and Jung,26
the average two-point discrimination
achieved after fingertip replantation
was 7 mm.
Pediatric Considerations
In children, displaced fractures of the
distal phalangeal physis with overly-
ing nail bed laceration (ie, Seymour
fractures) are considered open frac-
tures and warrant special attention.
In some cases, the germinal matrix
becomes stuck within the fracture
site. Seymour fracture should be sus-
pected with any proximal nail avul-
sion or widening of the dorsal distal
phalangeal physis in children. Proper
treatment requires removal of the
nail plate, irrigation and dbride-
ment, administration of antibiotics,
reduction of the fracture, and nail
bed repair. Fractures may be immo-
bilized by replacing the nail plate in
the nail fold if adequate reduction is
achieved; however, in some cases,
longitudinal pinning is necessary to
been described that may increase
maintain adequate reduction. Com-
plications include osteomyelitis,
physeal arrest, and nail deformity.33,34
Composite Grafting
In children with fingertip amputa-
tions distal to the DIPJ, composite
grafting is one option for reconstruc-
tion. The amputated tip is sutured
back to the stump without formal
microvascular repair. (Figure 8). The
nail plate must be removed and the
nail bed repaired carefully before the
nail plate is placed back into the nail
Donald H. Lee, MD, et al
fold. Fractures of the distal phalanx
are usually reduced by reattaching
the amputated tip with sutures, but
some surgeons prefer to augment the
repair with Kirschner wires or an 18-
gauge needle for bony stabilization.
Absorbable sutures should be used
for most pediatric fingertip injuries
to avoid the stress of subsequent su-
ture removal. In a series of 50 chil-
dren with fingertip injuries treated
with composite grafting, Moiemen
and Elliot7 found that fingertips had
a much higher survival rate when re-
placed within 5 hours of injury. Al-
though the fingertip may survive, de-
velopment of necrosis on part of the
composite graft is common. The ne-
crotic part of the graft should be left
in place because it provides a bio-
logic dressing, and this section
should be allowed to granulate and
heal by secondary intention.
In adults with fingertip injuries,
marginal success has been reported
with the use of composite grafts.
Heistein and Cook35 found that, in
nonreplantable fingertips, composite
grafts placed distal to the DIPJ and
proximal to the eponychium had a
survival rate of 43% and 53%, re-
spectively. The authors also found
that smoking was the only factor
that had a significant, independent
association with composite graft ne-
crosis. Recently, new techniques have
composite graft survival in adults, in-
cluding excision of the bone and sub-
cutaneous fat in the amputated
digit,36 deepithelialization of the
stump and defatting of the ampu-
tated tip,37 and wrapping the digit in
aluminum foil postoperatively and
cooling in ice water (ie, Hirase tech-
nique).38
Complications
Injuries involving the nail bed are of-
ten associated with some type of nail
763
Fingertip Injuries: An Update on Management

Figure 8

A, Preoperative photograph demonstrating a pediatric distal fingertip amputation. B, Photograph of the amputated
fingertip before it is sutured to the stump. C, Postoperative photograph of the fingertip 2 weeks after composite
grafting.

Figure 9
Illustrations of nail deformities associated with injuries to the fingertip: hook
nail (A), nail ridge (B), and split nail (C).
deformity (Figure 9). The most com-
mon deformity is nail ridge, which is
caused by an uneven nail bed after re-
pair or an uneven dorsal distal phalan-
geal cortex. Management involves re-
moval of the nail plate and excision of
the matrix or deeper ridge. Split nails
are the result of scars within the germi-
nal matrix or bridging scars from the
dorsal nail fold to the germinal matrix.
Removal of the nail plate and careful
excision of the scar frequently corrects
the deformity. Hook nail deformities
can be a complication of digital ampu-
tations through the nail bed. This de-
formity occurs in the setting of a short-
ened nail bed with inadequate bone
available volarly to support the nail
plate. The shortened nail bed and lack
of supporting bone cause the nail plate
to curve palmarly along the remainder
of the phalanx. Hook nails are cosmet-
ically unappealing and can be painful.
Management includes ablation of the
nail with removal of the nail plate and
complete excision of the underlying
matrix.
Cold intolerance is another compli-
cation associated with injuries to the
fingertip. Rates of cold intolerance of
the injured digit following fingertip am-
putation are high regardless of manage-
ment method; several studies have re-
ported cold intolerance rates that range
from 30% to 100%.28,39,40 This com-
plication appears to be a problem
when the digital nerve is injured, re-
gardless of management.31,41-43 Al-
though cold intolerance typically im-
proves over time, patients who
sustain fingertip injuries with dam-
age to the digital nerve should be
counseled accordingly.
Nerve injuries, especially in the set-
ting of amputation, can also cause
painful neuromas. Neuromas of the
fingertip are problematic because of the
lack of surrounding soft tissue and the
high contact forces to which the digits
are subjected. Several methods of sur-
gical management for painful neuro-
mas have been described, including
neuroma excision, neurectomy, neurol-
ysis, bone and/or muscle reimplanta-
tion, placement of silicone caps, and
steroid injections. Outcomes of these
treatments vary and are dependent on
many factors, including patient charac-
teristics and nerve location. In a study
of 40 patients with painful neuromas,

764 Journal of the American Academy of Orthopaedic Surgeons


Burchiel et al44 reported surgical suc-
cess in 16 (40%) patients treated sur-
gically. If an attempt is not made to
repair a transected digital nerve, the
nerve should be truncated as proxi-
mally as possible to decrease the like-
lihood of symptomatic neuroma for-
mation.
Summary
Injury to the fingertip is common
and can be debilitating secondary to
the forces placed on the digits. Man-
agement of these injuries should be
aimed at preserving the length of the
digit when possible and providing
soft-tissue coverage with protective
sensation at a minimum. In injuries
with nail bed involvement, attention
must be given to the nail bed to pre-
vent cosmetically unappealing and
painful nail deformities. Injury to the
digital nerves should be addressed
properly to avoid painful neuromas.
Patients should be counseled on the
high likelihood of cold intolerance
and nail deformity despite adequate
treatment.
New technologies continue to
emerge and provide alternatives to
classic management of fingertip inju-
ries. These new methods should be
used with caution until adequate evi-
dence exists to support the use of
these techniques. Replantation of
amputated fingertips continues to
show good results, especially in
younger patients who do not smoke.
Finally, the physical demands and
medical comorbidites of the patient
should be considered before per-
forming replantation or major flap
reconstruction that may require a
prolonged convalescent period.
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