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Management of partial fingertip amputation in adults: Operative and non

operative treatment

Article  in  Injury · October 2017

DOI: 10.1016/j.injury.2017.10.042

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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Management of partial fingertip amputation in adults: Operative and

non operative treatment
Kunal Sindhua , Steven F. DeFrodab,* , Andrew P. Harrisb , Joseph A. Gilb
a
Department of Medicine, Mount Sinai Beth Israel, New York, NY 10003, United States
b
Department of Orthopaedic Surgery, Brown University, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 0290, United States

A R T I C L E I N F O A B S T R A C T

Article history: Background: Hand and finger injuries account for approximately 4.8 million visits to emergency
Accepted 28 October 2017 departments each year. These injuries can cause a great deal of distress for both patients and providers
and are often initially encountered in urgent care clinics, community hospitals, and level one trauma
Keywords: centers. Tip amputation injuries vary widely in mechanism, ranging from sharp lacerations to crush
Finger injuries that present with varying degrees of contamination. The severity of damage to soft tissue, bone,
Amputation arteries and nerves is dependent upon the mechanism and guides treatment decision-making. The
Replant
management algorithm can oftentimes be complex, as a wide variety of providers, including
Soft tissue coverage
orthopedists, general surgeons, plastic surgeons and emergency physicians, may care for these injuries,
depending on location and local culture. We review the common mechanisms for tip amputation and the
optimal treatment in adults, based on the severity of the injury, degree of wound contamination, and the
facilities available to the provider.
Methods: Pubmed was searched using text words for articles related to management of fingertip injuries
in adults. Bibliographies of matching articles were searched for additional relevant articles, which were
then also reviewed. 107 articles were reviewed in total, and 61 were deemed relevant for inclusion. All
clinical studies and reviews were included. Particular attention was paid to articles published within the
past 15 years.
Results: In the United States, up to 90% of fingertip amputations are treated with non-replant techniques.
In comparison, the majority of amputations in Asian countries are replanted due to moral values and
importance of body integrity. Tip amputation injuries can be managed with local debridement, complex
reconstruction, or simply with irrigation and application of a sterile dressing.
Conclusion: In the United States, most fingertip amputations in adults are treated with non-replant
techniques. However, the precise management of a fingertip injury in adults depends on the degree of
injury itself, and a number of operative and non-operative techniques may be successfully employed.
© 2017 Elsevier Ltd. All rights reserved.

Contents

Anatomy . . . . . . . . . . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Mechanism of injury . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Sharp injury . . . . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Crush injury . . . . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Neurovascular injury . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Treatment . . . . . . . . . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Non-Operative . . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Antibiotics . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Local irrigation and debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Operative treatment . . . . . . ........... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

* Corresponding author.
E-mail address: sdefroda@gmail.com (S.F. DeFroda).

https://doi.org/10.1016/j.injury.2017.10.042
0020-1383/© 2017 Elsevier Ltd. All rights reserved.

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Nail bed repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Soft tissue coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Revision tip amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Replantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Limitations of this literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Anatomy Mechanism of injury

The fingertip is composed of a thick layer of overlying skin, a Sharp injury

core of pulp and bone, a protective fingernail, and branches of
innervating nerves and supplying vessels. Numerous papillary Injuries inflicted by sharp objects may result in laceration or
ridges within the epidermis produce unique fingerprints in every amputation. Following careful examination, simple lacerations can
individual. Multiple fibrous bands, interlaced with fat, make up the typically be treated with primary closure in the emergency
pulp and extend from the periosteum of the distal phalanx to the department after all nonviable tissue and dirt has been debrided
dermis [2]. The pulp makes up over half of the total volume of the [10]. Care should be taken to protect the wound until healing has
fingertip and plays an important role in soft tissue coverage and in occured [11,12]. If the nail is involved in the laceration, removal of
gripping objects [3]. the nail plate and exploration of the nail bed for potential repair is
Fingernails, which grow at an average rate of 0.1 millimeters per warranted [5].
day, adorn the dorsal surface of each digit and perform a variety of Amputations are more complex injuries often affecting the
functions. In addition to their cosmetic role, nails protect the dorsal fingertip, nail bed, and the neurovascular structures [5]. There are
surface of digits, increase the sensitivity of fingertips, and facilitate several fingertip injury classification systems including the Fassler,
pinching and scratching [4]. Each nail is composed of an Rosenthal, Allen, Tamai, Sebastin and Chung, and most recently the
eponychium (or cuticle), paronychium, hyponychium, nail bed, PNB “(P)ulp, (N)erve, (B)one” system (Table 1) [3]. Evans and
nail plate, and nail root. The eponychium refers to the soft tissue at Bernadis proposed the PNB system using a point system to provide
the proximal border of the nail, while the paronychium refers to a 3-digit code to better describe injury severity to the pulp, nerves,
the soft tissue at the lateral borders of the nail. The hyponychium is and bone. One study has successfully used this classification to
a keratinous plug located between the free distal edge of the nail guide treatment, although another found it to be too complex for
and the fingertip that acts as a physical and immunological barrier everyday clinical use [13]. Described in 1983, one of the most
to infection of the nail bed [5]. The nail bed consists of the proximal commonly used classifications is the Rosenthal system of fingertip
germinal matrix, which creates the keratin that composes the nail, amputations and is based on three zones: zone I injuries are distal
and the distal sterile matrix, which is responsible for the nail’s to the bony phalanx, zone II injuries are between the lunula and
adherence [6]. The junction between the germinal matrix and the distal phalanx, and zone III injuries are proximal to the lunula [14].
sterile matrix is the lunula. The nail plate is composed of a Zone I injuries can generally be treated conservatively because the
keratinous substance called onchyn, which is produced by death of germinal matrix remains intact. In contrast, zone II and III injuries
the germinal matrix cells. The proximal part of the nail plate is do not spare the germinal matrix and are thus generally managed
known as the nail root [3,7]. surgically [5].
The digital vessels and nerves arborize near the distal
interphalangeal (DIP) joint. Each main palmar digital artery sends Crush injury
branches to the nailbed and pulp [3,8]. The superficial palmar and
oblique communicant veins drain deoxygenated blood from the Crush injuries can present as open or closed and occur when
palmar surface of the finger [8]. The digital arteries run along the compressive forces damage the fingertip [15]. While injuries to the
sides of each digit, while the digital veins run along the dorsal pulp and bone may occur, they are generally self-limited and not
surface of each digit. Each digital nerve, derived from either the associated with significant sequelae. Instead, the most critical
median or ulnar nerve, sends branches to the paronychium, consequence of crush injuries is damage to the nail bed, which can
fingertip, and pulp volar to the corresponding digital artery. Given lead to altered nail growth, cosmetic deformity, and permanently
its importance in sensation, the fingertip is richly imbued with decreased grip and scratch capabilities [10].
sensory receptors [9]. Clinicians often underestimate the severity of crush injuries and
therefore delay the delivery of appropriate treatment. Therefore, it

Table 1
(P)ulp, (N)ail, and (B)one (PNB) Classification [3].

Pulp Nail Bone

0 No Injury 0 No Injury 0 No Injury
1 Laceration 1 Sterile matrix laceration 1 Tuft fracture
2 Crush 2 Germinal and sterile matrix laceration 2 Comminuted non-articular
3 Loss – distal transverse 3 Crush 3 Articular involvement
4 Loss – palmar oblique partial 4 Proximal nailbed dislocation 4 Displaced basal
5 Loss – dorsal oblique 5 Loss – distal third 5 Tip exposure
6 Loss – lateral 6 Loss – distal two thirds 6 Loss – distal half
7 Loss – complete 7 Loss – lateral 7 Loss – subtotal
8 Loss – complete 8 Loss – complete

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is imperative that all physicians evaluating patients with these Treatment

injuries have a low clinical threshold before undertaking more
aggressive treatment measures. A simple radiograph of the
crushed finger is critical as it provides information regarding
the extent of the underlying bone and soft tissue injury that could
be underappreciated on physical examination. Since 50% of nail
bed injuries are associated with fractures of the distal phalanx, a
fracture seen on radiograph can alert the physician to assess for
damage of the nail bed [16]. A subungual hematoma can provide
information, as well. A 1987 study found that 60% of patients with
subungual hematoma comprising >50% of the nail had an
associated nail bed laceration, and 95% of patients with concurrent
subungual hematoma and distal phalanx fracture had an
associated nail bed laceration [17,18]. With severe crush injuries,
damage to both the sterile and germinal matrices may occur in
conjunction. In these cases, and in others where the extent of
damage to the nail bed is unknown, the nail should be removed and
the nail bed should be examined [10,18].
The distal phalanx acts as a support that promotes the proper
growth of the nail bed. Thus, in cases where a fracture has
occurred, prompt reduction is essential to prevent long-term
detrimental changes in nail growth, stability, and function. The
most common fracture associated with a nail bed injury is a crush
injury of the tuft of the distal phalanx. Most of these fractures are
stable and can be treated with a splint to immobilize the affected
finger for 3–4 weeks [18]. However, in more severe cases
complicated by a displaced fracture, surgical fixation may be
necessary [5,18,19]. Unfortunately, the seriousness of these
fractures is frequently misjudged and undertreated, leading to
significant long-term morbidity. Particularly difficult cases to
diagnose are those in which the nail is avulsed from the proximal
nail fold. These injuries, which often present in a benign manner,
may mask an underlying open phalangeal fracture; if missed, the
relocation of the nail plate and reduction of the fracture can be
delayed [5].
Neurovascular injury
Damage to neurovascular structures can occur with laceration,
crush, or amputation injuries of the fingertip. Isolated neural
damage in the finger produces sensory deficits, leaving motor
function intact. The small size of the terminal branches of digital
nerves can make the repair of these injuries challenging. If a nerve
laceration is observed during the exploration of a fingertip injury,
the injured nerve, if irreparable, should be dissected out and
sharply transected as proximally as possible to prevent potential
neuroma formation. In a retrospective study of digital nerve
injuries by Van Der Avoort et al., the rate of symptomatic neuroma
formation for patients with finger amputation was found to be 7.8%
compared to 1% for patients without amputation that underwent
nerve repair [20]. Although in comparison, Wilkens et al. found an
unplanned reoperation rate of 44% for repair versus 21% for
treatment with immediate revision amputation for combined
finger injuries [21].
Injury to the digital arteries distal to the DIP joint is often
successfully managed with a combination of continuous pressure
and repair of the overlying skin laceration. If bleeding continues in
spite of these interventions, a small suture may be used to tie off
the damaged vessel if the contralateral digital artery is intact.
However, care must be taken not to accidently tie off the adjacent
digital nerve as well, which can cause significant pain due to
neuroma formation [22]. Re-anastomosis procedures may be
performed in the proximal aspect of the digits; however, repair
distal to DIP joint is often challenging given that the digital arteries
arborize distal to the DIP joint.
Non-Operative
Fingertip injuries characterized by small pulp defects (<1 cm2)
and/or simple skin lacerations can generally be managed non-
operatively. Simple skin lacerations can typically be treated with
primary closure in the emergency department using absorbable
interrupted suture after irrigation and debridement of all
nonviable tissue and dirt has occurred (Fig. 1) [10]. Loose
approximation of the defect will allow for drainage of any
remaining contaminants over time as the soft tissue heals by
secondary intention. Alternatively, small superficial, uncontami-
nated pulp injuries without bone exposure may be treated in the
emergency department with clinical follow up and serial dressing
changes [3,4,11]. There are conflicting ideologies on coverage for
fingertip injuries that argue over the need for definitive closure
versus healing by secondary intention, but healing by secondary
intention in select cases does appear to produce positive results.
Allen et al. found that even more proximal amputations, through
the lunula, would heal secondarily, but these injuries had a higher
incidence of nail deformity [23]. Cold intolerance and changes in
sensitivity were low, but more common in proximal injuries.
Overall only 4 of 60 patients in the series were unhappy at a 6-
month follow-up, with zero patients having experienced a
reduction in range of motion and only one having developed
decreased grip strength [23]. Additionally, Lee et al. reviewed the
functional outcomes in 156 patients with fingertip injuries [24].
The injuries were smaller (<1 cm in diameter), but 63% of patients
did have injuries in which bone was exposed. The only intervention
performed was shortening of the bone at the time of injury to the
level of the fat to allow healing by secondary intention. The average
time to healing was 32 days and 85% of laborers returned to work
within 1 month [24].
Healing time, aesthetic result, sensation, infection, and grip
strength are the most common outcome measures tracked in the
evaluation of the efficacy of successful non-operative manage-
ment. On average, complete wound healing can be expected by 4
weeks, while defects <1 cm with no bony defect may heal as
quickly as two weeks [25–27]. Most patients are ultimately pleased
with their cosmetic outcome. The finger pulp has been shown to
Fig. 1. Acute Repair of complex distal thumb crush injury with absorbable suture.

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elongate 6–7 mm with healing, even in the case of exposed bone
due to the thick fat of the fingertip being pulled over the bone by
the glaborous skin during secondary healing [27]. Nail deformity is
the most common complaint. A systematic review of 1592 fingertip
amputations by Yuan et al. reported on a multitude of compli-
cations and found that 6% of patients have residual nail defects
[27]. Hook nail occurs most commonly in more proximal injuries,
but also may occur even with surgical management with a flap
[28]. Sensation has been found to return to levels comparable to
the uninjured hand in a majority of patients [18,23,24]. Cold
intolerance can be a significant issue, with rates reported as high as
86% at 2 months; however, it frequently resolves by 1 year [26,28].
Infection is rare, and if it does occur it is generally superficial in
nature. One large review of the non-operative management of
finger injuries did not report a single episode of osteomyelitis [27].
Grip strength and range of motion can actually be better in non-
operative patients due to the lack of need for immobilization,
which generally causes joint stiffness [29]. Due to the shorter
finger length, pinch strength and fine motor skills may be
diminished [30].
Antibiotics
Antibiotics are often used prophylactically in immunocompro-
mised patients and those with contaminated wounds. However,
antibiotic use, even in these patients, is controversial [31]. A meta-
analysis by De Alwis et al. did not find any RCTs that specifically
looked at antibiotic use in patients with fingertip injuries.
However, several studies looked at antibiotic use in patients with
soft tissue injuries of the hand [10]. In one study of 104 patients
with clean wounds on the fingers and thumb and 40 patients with
clean wounds on the palm and wrist, there was no statistically
significant difference in infection rate between the antibiotic
treatment and placebo groups [32]. Studies examining prophylac-
tic antibiotic treatment in patients with open distal phalanx
fractures have yielded conflicting results [33,34]. One randomized
controlled trial (RCT) revealed no difference in infection rates
between treated and non-treated groups, while another showed a
significant increase in infection rate in patients not treated with
antibiotics [10,35]. Rubin et al. looked at prophylactic antibiotic use
in patients with fingertip amputations complicated by bone
exposure. No statistically significant difference in infection rate
between the antibiotic and control groups was found [31]. These
studies demonstrate that early, thorough wound care, rather than
prophylactic antibiotic use, appears to be the most important
factor in preventing future infections in patients with fingertip
injuries [10,31].
Local irrigation and debridement
Early wound care plays an important role in the management of
these cases, and may in fact be the most important factor in
preventing infections from developing [10]. Thus, fingertip injuries
should be thoroughly cleaned with copious amounts of normal
saline and all non-viable soft tissue should be debrided in the
emergency department [4,10,11,36]. Digital nerve block, proper
sterile technique, and care to avoid the nail bed during debride-
ment are essential. In patients who are not adequately immunized,
anti-tetanus prophylaxis is warranted [10].
Operative treatment
Nail bed repair
Simple lacerations affecting the sterile matrix or nail folds in
adults may be conservatively treated in the emergency department
using absorbable sutures [10–12,36]. Proximal injuries, however,
must be visualized and thoroughly assessed prior to any attempts
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at repair to ensure that the germinal matrix has not been
compromised [36]. Cases characterized by complex lacerations
of the nail bed, loss of portions of the nail bed, or avulsions of the
nail fold should be referred to a hand surgeon for further
management [4,12,36].
Dermabond, or 2-octylcyanoacrylate, has been proposed as an
alternative to absorbable suture as a method to conservatively
repair simple nail bed injuries. Of note, 2-octylcyanoacrylate is
believed to offer faster repair times and strength equivalent to that
of a standard 4-0 Monocryl suture [37]. Clinical studies have
backed these claims. Singer et al. found that patients treated with
this novel approach had similar cosmetic results and infection
rates as patients treated with standard suture [38]. Strauss et. al
found a 66% reduction in repair time using 2-octylcyanoacrylate as
compared to standard suture, with similar cosmetic and functional
outcomes in groups treated with either method [39].
Injuries to the nail bed are frequently complicated by the
formation of subungual hematomas, which can cause severe pain
[5]. In cases where the nail has not been displaced from the nail
fold and there is certainty that no damage has occurred to the nail
bed or distal phalanx, conservative management in the emergency
department with trephination for pain relief is sufficient [5,10].
However, if there is any question of damage to the nail bed or
fracture of the distal phalanx, removal of the nail bed, followed by
its repair and reduction of any associated fracture, is necessary [5].
A consultation with a hand surgeon may be necessary if the nailbed
is involved [4,36]. Acrylic nails should be removed and explored in
the emergency department if underlying trauma is suspected [40].
Soft tissue coverage
Patients with large and volar oblique injuries, exposed bone,
and associated distal phalanx fractures will often require flap
coverage [41]. The choice of the flap utilized depends primarily on
the digit involved and the shape and size of the wound [3].
Terminal pulp V-Y flaps, also known as Atasoy flaps, are most
effective in repairing small (<1 cm2) dorsal oblique and transverse
injuries; they cannot be used for volar oblique injuries [42,43]. The
distal edge of the wound serves as the triangular flap’s base, whose
apex is extended to the crease of the DIP joint. The skin and
subcutaneous tissue are then gently dissected and the flap’s edges
are loosely sutured in an effort to avoid neurovascular injury [18].
Both cross-finger and thenar flaps may be used to treat volar
oblique injuries and require 10–14 days of post-procedure
immobilization [3,42]. Thenar flaps, however, are generally used
for injuries to the second and third digits, while cross-finger flaps
may be used for injuries to any digit. The thenar flap is first created
with its radial border parallel to the crease of the MCP joint. As the
flap is elevated distally, care is taken to remain superficial to avoid
injury to radial digital nerve [18,42]. In contrast, the cross-finger
flap is a rectangular flap that is designed over the middle phalanx of
the donor digit. Its hinge, which is located adjacent to the injured
digit, is reflected and sutured to the primary defect. A full-
thickness skin graft is used to repair the donor site [3,18,42]. A 2016
study by Rabarin et al. of 22 patients who had received cross-finger
flaps reported positive long-term outcomes. Distal sensitivity,
without pain or neuromas, was maintained in every examined
patient. 32% reported cold intolerance [44].
Revision tip amputation
Digits amputated in zone 2, proximal to the insertion of the
flexor digitorum superficialis, are generally not replanted because
of the risk of subsequently developing stiffness, which can
interfere with hand function, is high [13]. Rather, revising the
amputation, which is simpler, cheaper, and associated with better
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functional outcomes than replantation in these patients, is

preferred (Fig. 2) [45]. Patients tolerate the procedure well and
recover quickly, returning to work in 47 days on average, or
approximately 1.5 months, as compared to 3.2–4.0 months after
replantation [30,46,47]. Revisions may also be considered in older
patients and in those with complex systemic comorbidities [48].
Revisions have been found to produce better sensory and
functional outcomes than local flap treatments. However, revisions
are associated with the highest rates of cold intolerance of any
fingertip injury treatment. Interestingly, a 2015 systematic review
by Yuan et al. found no significant differences among patients who
have received conservative, revision amputation, or local flap
treatment [49]. However, a 2014 literature review by Peterson et al.
found better functional outcomes associated with replantation
versus amputation revision, and little to no advantages from flap
reconstruction over healing by secondary intention generally [3].

Replantation
Replantation may be considered in some cases of fingertip
amputation if normal architecture is preserved such as occurs in a
sharp injury mechanism [10]. A vascular anastomosis is often
required to produce a viable replanted fingertip (Fig. 3) [18,50].
Immediately following the injury, the amputated digit should be
wrapped in sterile gauze soaked in normal saline, placed in a
plastic bag, and then stored in a mix of ice and water as the patient
is transported to the emergency department [10,55]. Amputated
fingertips, due to their lack of muscular tissue, can stay viable for
long periods of time: up to 6–12 h in cases of warm ischemia and
24–30 h in cases of cold ischemia [51–53]. Digital replantation is
currently indicated for injuries involving the thumb, single digits
distal to the insertion of the flexor digitorum superficialis tendon,
and multiple digits [18,54]. A 2011 systematic review by Sebastin
and Chung found a mean survival rate of 86% associated with 2273
distal digital replantations. No differences were found between
zone I and II replantations, but successful repair of a vein and a
clean-cut injuries were associated with better outcomes [13].
Contraindications for replantation include cases in which digits are
severely damaged by crush or contamination mechanisms, the
presence of peripheral vascular disease, and the presence of
systemic diseases associated with vascular compromise [55].
While the scope of amputation cases that fall under the
indications for replantation is vast, the operating surgeon must
make his or her decision to proceed with the procedure based on
the probability of a successful functional and cosmetic outcome
[53]. Numerous factors have been found to influence this process.
Digits that have undergone clean-cut amputation tend to have
significantly better restorative outcomes than digits that have been
crushed or avulsed [56]. Additionally, warm ischemia time of less
Fig. 3. Thump replantation procedure. Vascular anastomosis is crucial to the
success of this figure. Not the digital artery (white arrow) intact proximally.
than 12 h, or cold ischemia time of less than 30 h, is associated with
higher success rates [53]. Digital injuries in elderly patients, who
are more likely to suffer from numerous systemic comorbidities
that interfere with proper healing, and males, who may experience
more severe injuries, tend to have lower success rates than those in
younger and female patients, respectively [53,57]. While alcohol
consumption does not appear to influence the success rate of digit
replantation, smoking is associated with poorer results overall as
nicotine is a well-known vasoconstrictor; in fact, the replanted
digits of non-smokers have a survival rate that is 11.8 times higher
than that of smokers [57]. Lastly, patients with atherosclerosis,
autoimmune diseases, connective tissue diseases, and diabetes
mellitus, all signs of potential vascular compromise, tend to be
prone to poor results [53].
In cases of amputation, bone and tendon injuries should
generally be repaired first. Following successful tendon repair,
extensive arterial and venous repair is indicated as prior work has
shown that overall replantation results are correlated with the
number of vessels repaired. Digital nerve repair should be
addressed last. Epineural sutures are generally sufficient for this
process, but nerve grafts may be necessary [52]. Regardless of
repair, cold intolerance and painful neuroma formation are
potential sequela of digital nerve injury [10,26].
When replantation is not possible, composite grafting may be
considered. In this procedure, the amputated tip is directly sutured
to its parent finger after both ends have been thoroughly cleansed
and debrided. While composite grafting has historically been used
most frequently in young children, there is some evidence to

Fig. 2. A. Patient with multiple partial fingertip amputations following a lawn mower injury. B, C. The patients wounds were irrigate in the emergency department and
revision amputation was performed to debride injured bone and soft tissue and to provide adequate soft tissue coverage.

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JINJ 7475 No. of Pages 7
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support its use in adults. However, by its nature, the indications for
the use of composite grafting is limited to certain select cases of
injury [3,18].
In those patients who cannot undergo composite grafting,
wound closure by secondary intention or surgery may also be
considered [3]. For defects smaller than 1.5 cm2 with no bone
exposure, healing by secondary intention and surgical reconstruc-
tion appear to be equally efficacious in terms of healing and
functional outcomes [27,42]. As a result, the vast majority of
fingertip injuries are treated conservatively [41].
Treating fingertip amputations by secondary intention may
involve the use of occlusive, semiocclusive and simple adherent
sterile dressings, and subatmospheric wound therapy [58,59].
Semiocclusive dressing, in particular, has gained popularity in
recent years. The wound is dressed after cleaning and debride-
ment, and weekly wound cleaning and dressing changes are
initiated. Patients are instructed to continue to use the affected
hand as they normally would, without immobilization. Wound
closure, accompanied by a recovery in sensation, occurs within 2–8
weeks [43].
While treatment with secondary intention is generally suc-
cessful in indicated patients, care must be taken in patients with
bone shortening, in which support for the nail is compromised. In
these patients, in order to avoid the development of the hook nail
deformity as the wound closes, care must be undertaken to excise
the nail bed 2 mm proximal to the shortened bone [3,60]. In
patients who cannot maintain an open wound for an extended
period of time, skin grafts may be utilized. However, grafts do not
necessarily always lead to favorable outcomes in all patients and
may instead result in greater cold intolerance, compromised
durability, and persistent tenderness [3,58].
Limitations of this literature review
This review was limited to the management of fingertip injuries
in adults. As such, it does not cover injuries of the hand more
generally. Additionally, it does not include fingertip injuries in
children, whose management can vary significantly from that of a
more mature population. Moreover, this review covers only the
most common techniques used to manage fingertip injuries that
have been studied over time. Newer emerging, or experimental,
techniques are not included.
Conclusion
Hand and finger injuries are not an uncommon occurrence in
the United States, accounting for approximately 4.8 million visits to
emergency departments each year [1]. Traumatic finger amputa-
tions of varying zones total approximately 45,000 cases annually
[49]. Since the fingertip performs complex sensory and aesthetic
functions, the proper management of these injuries is crucial. All
fingertip injuries should be thoroughly cleaned and debrided.
While both sharp and crush injuries may present unique
challenges, physicians must ensure that patients with crush
injuries are thoroughly examined for nail bed injuries and distal
phalangeal fractures, as these can lead to significant long-term
morbidity if left untreated. The precise treatment strategy,
whether conservative or operative, primarily depends on the
extent of the injury and must be determined on a case-by-case
basis.
Funding
The authors have no financial disclosures or conflicts or
competing interests to report.
Please cite this article in press as: K. Sindhu, et al., Management of partial fingertip amputation in adults: Operative and non operative
treatment, Injury (2017), https://doi.org/10.1016/j.injury.2017.10.042
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