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Emergency Medicine > TRAUMA AND ORTHOPEDICS
Fingertip Injuries
Article Last Updated: Sep 6, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Glen Vaughn, MD, Director, Department of Emergency Medicine, Defiance Hospital
Editors: Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
fingertip injury, fingertip injuries, finger tip injury, blunt injuries, crush injuries, subungual hematomas, nail root avulsions, fractures of the terminal phalanx, sharp injuries, shearing injuries, fingertip lacerations, avulsed fingertip, fingertip burns, fingertip frostbite, terminal phalanx, hand injuries, damage to the nailbed, fingertip amputations, nailbed laceration
Background
The fingertip is the part of the terminal phalanx that is distal to the insertion of extensor and flexor tendons. Fingertip injuries are extremely common. A functioning fingertip has sensation without pain, stable padding, and an acceptable appearance.
Pathophysiology
Fingertip injuries occur frequently because hands are used to explore surroundings. Common types of injuries include blunt or crush injuries to the fingernail creating subungual hematomas, nail root avulsions, and fractures of the terminal phalanx. Sharp or shearing injuries from knives and glass result in lacerations and avulsion types of soft tissue defects. Burns and frostbite commonly involve fingertips.
Frequency
United States
About 10% of all accidents encountered in the ED involve the hand. Hand injuries represent 11-14% of on-the-job injuries and 6% of compensation paid injuries. They account for approximately two thirds of hand injuries in children. Damage to the nail bed is reported to occur in 15-24% of fingertip injuries.
History
Ascertain the following information when gathering patient history:
- Mechanism of injury
- Hand dominance
- Occupation and hobbies
- Length of time since injury
- Tetanus immunization status
Physical
Evaluate the fingertip injury to determine the following:
- Crush versus sharp injuries
- Nail or nail bed involvement
- Bone involvement
- Viability of tip
- Presence of foreign body
Lab Studies
- No laboratory studies are indicated, other than standard preoperative labs if surgery is required.
Imaging Studies
- Radiographs may be necessary either to assess alignment of distal phalanx fractures or to detect presence of foreign bodies.
Prehospital Care
- Care for amputated part
- Cleanse gently.
- Cover in a saline-soaked gauze wrap.
- Place amputated part in a watertight bag.
- Place watertight bag with amputated part on water and ice for preservation.
- To avoid cold injury, do not place the amputated part directly on ice.
Emergency Department Care
- Preserve length, padding, and sensation of finger to the degree possible.
- Preserve proper nail growth capacity and function by paying specific attention to the eponychium.
- Prevent infection by considering prophylactic antibiotics.
- Minimize joint stiffness.
- Limit employment disability.
- Use a digital block to provide local anesthesia and avoid further swelling of the fingertip with direct infiltration of anesthesia into the affected area.
- Lacerations
- Suture simple lacerations with 5-0 or 6-0 nylon. Subcutaneous or deep dermal sutures are not indicated.
- Remove nail and inspect matrix when fingertip lacerations involve nail and injuries that avulse, split, or disrupt it. Replace all retrievable fragments of nail matrix as free grafts.
- Repair nail matrix according to the following steps:
- Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain.
- Remove nail.
- Debride gently.
- Clean and remove all foreign bodies.
- Repair nail matrix meticulously with fine absorbable suture (6-0 Monocryl).
- Reinsert nail plate or substitute.
- Tack the nail to the paronychia using suture material (6-0 Monocryl) or use a topical adhesive (eg, Histoacryl blue, 2-Octyl-cyanoacrylate) to secure the nail plate in place of sutures. Chloramphenicol ointment has also been suggested as an adhesive.
- Apply sterile nonadherent dressing and splint.
- Subungual hematoma
- Use electrocautery or a heated paperclip. A sharp instrument, such as an 18-gauge needle, should be avoided to prevent deep soft tissue injury.
- For patients who have significant crush injuries or subungual hematomas that involve lacerations to skin-fold or disrupt the nail, remove the nail and inspect the matrix.
- Conservative treatment without nail removal is recommended for patients with closed hematomas and an intact nail with no laceration to skin fold or nail disruption.
- Conservative treatment also is indicated for crush injuries that fracture the terminal phalanx but do not cause a subungual hematoma.
- Fingertip amputations
- Treatment is either surgical or conservative. The boundary between surgical and conservative treatment depends on the extent of involvement of the pulp, nail, and bone. Various surgical methods are used for amputation injuries including simple revision amputation, full- or partial-thickness skin grafts, local flaps, distal flaps, and neurovascular island pedicle flaps.
- Distal fingertip amputations may be treated conservatively in the ED. Various treatments may be provided in ED depending on the emergency physician's skills, training, and time availability. However, for distal amputations that involve significant tissue loss, the physician should discuss a treatment plan with the follow-up hand surgeon.
- Steps for conservative therapy
- Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain.
- Clean thoroughly with sterile solutions.
- Remove protruding bone with a bone rongeur to a level 3-5 mm below that of surrounding tissue.
- Apply sterile nonadherent dressing over the amputated part.
- Removal of splinter under nail
- Administer anesthesia with a digital block.
- Unroof the splinter by trimming the nail with iris scissors.
Consultations
The goal of pharmacotherapy is to reduce pain. Tetanus immunization also may be indicated.
Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)
Commonly used for relief of mild to moderate pain. Effects of NSAIDs in treating pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, naproxen, and ketoprofen.
| Drug Name | Ibuprofen (Ibuprin, Advil, Motrin) |
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| Description | DOC for treatment of mild to moderate pain, if no contraindications are present. Inhibits inflammatory reactions and pain probably by decreasing activity of the enzyme cyclooxygenase, which inhibits prostaglandin synthesis. |
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| Adult Dose | 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d |
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| Pediatric Dose | <6 years: Not established
6 months to 12 years: 10 mg/kg q6-8h; not to exceed 2.4 g/d
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Ketoprofen (Oruvail, Orudis, Actron) |
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| Description | Used for relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patient for response. |
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| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
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| Pediatric Dose | <3 months: Not established
3 months to 14 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Naproxen (Anaprox, Naprelan, Naprosyn) |
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| Description | Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis. |
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| Adult Dose | 500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d |
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| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg PO bid; not to exceed 10 mg/kg/d |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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| Drug Name | Flurbiprofen (Ansaid) |
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| Description | Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis that may result in analgesic and anti-inflammatory activities. |
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| Adult Dose | 200-300 mg/d PO divided bid/qid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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Drug Category: Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
| Drug Name | Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin) |
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| Description | DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. |
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| Adult Dose | 325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d PO is fine |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d |
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| Contraindications | Documented hypersensitivity; known G-6-P deficiency |
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| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
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| Drug Name | Acetaminophen and codeine (Tylenol #3) |
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| Description | Drug combination indicated for the treatment of mild to moderate pain. |
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| Adult Dose | 30-60 mg/dose PO based on codeine content q4-6h or 1-2 tabs q4h; not to exceed 12 tabs/d |
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| Pediatric Dose | 0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Toxicity increases with CNS depressants or tricyclic antidepressants |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction |
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| Drug Name | Hydrocodone bitartrate and acetaminophen (Vicodin ES) |
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| Description | Drug combination indicated for the relief of moderate to severe pain. |
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| Adult Dose | 1-2 tab or cap PO q4-6h prn |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h |
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| Contraindications | Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP) |
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| Interactions | Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction |
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| Drug Name | Oxycodone and acetaminophen (Percocet) |
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| Description | Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients. |
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| Adult Dose | 1-2 tab or cap PO q4-6h prn |
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| Pediatric Dose | 0.05-0.15 mg/kg/dose PO oxycodone; not to exceed 5 mg/dose of oxycodone q4-6h prn |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen that patient is receiving; do not exceed 4000 mg/24 h of acetaminophen (higher doses may cause liver toxicity) |
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Drug Category: Toxoid
Used for tetanus immunization. Administer booster injection in previously immunized individuals to prevent this potentially lethal syndrome.
| Drug Name | Tetanus toxoid |
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| Description | Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children aged > 7 years are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. May administer into deltoid or midlateral thigh muscles in children and adults. In infants, preferred site of administration is the mid thigh laterally. |
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| Adult Dose | Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y |
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| Pediatric Dose | Administer as in adults |
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| Contraindications | Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis |
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| Interactions | Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is, nevertheless, clinically insignificant and does not preclude its concurrent use) |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended |
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Drug Category: Immunoglobulins
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
| Drug Name | Tetanus immune globulins (Hyper-Tet) |
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| Description | Used for the passive immunization of persons with wounds that may be contaminated with tetanus spores. |
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| Adult Dose | Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3000-10,000 U IM |
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| Pediatric Dose | Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3000-10,000 U IM |
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| Contraindications | Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications because they are usually incompatible |
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Further Inpatient Care
Further Outpatient Care
- Keep hand elevated.
- Check wound 2 days after ED treatment.
- Analgesics may be necessary for first few days.
- Splint fractures in extension for 2 weeks.
Complications
- Untreated nailbed lacerations may lead to subsequent nail deformities.
- When amputation with loss of two thirds of the nail occurs, half of the fingers develop beaking or a curved nail.
Prognosis
- Oldest recorded patient to show fingertip regeneration was aged 11 years.
Patient Education
Special Concerns
- In 60% of patients with subungual hematomas that involve more than 50% of the nail surface, laceration is repairable. This figure increases to more than 95% when an associated fracture of the distal phalanx is present.
- Conservative treatment without nail removal is advocated for patients with closed hematomas (regardless of the size of hematoma) and intact nails with no skin-fold laceration or nail disruption.
- The nail complex requires intact distal bone and soft tissue support to prevent a hook-nail deformity.
- Because of its flammability, do not use ethyl chloride for anesthesia before trephinating a subungual hematoma with cautery. Be careful with artificial nails as well.
| Media file 1:
Significant nailbed injuries can occur from nail root avulsions. |
 |  View Full Size Image | |
Media type: Photo
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Fingertip Injuries excerpt Article Last Updated: Sep 6, 2006
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