Last Updated on February 5, 2025
Fingertip injuries are injuries to the part of the terminal phalanx distal to the insertion of the extensor and flexor tendons. The tips of longer fingers tend to be injured more as these are used frequently to explore the surroundings.
Common types of fingertip 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. They can include crushing, tearing, or amputating injuries to the tips of fingers and thumbs. Damage to the skin and soft tissue, bone (distal phalanx), or the nail and nailbed can also occur.
Significant nailbed injuries can occur from nail root avulsions.
Hand injuries comprise about 10% of the reported injuries. More than half of the fingertip injuries are reported in those younger than 7 years.
The middle finger has been reported to be most commonly affected.
About half of injuries are fractures and about 35 percent are nail-bed injuries. Twenty-five percent of fingertip injuries are amputations.
Relevant Anatomy
The fingertip is the most distal portion of the finger anatomically defined as the portion of the finger distal to the insertion of the flexor digitorum superficialis and extensor tendons on the distal phalanx. In the case of thumb, it is the region distal to the interphalangeal joint.
It is a highly sensitive part of the hand developed for sensory perception and object manipulation by hand. It is very rich in blood supply which is via the digital arteries and nerve supply via digital nerves.
The volar pulp has highly specialized structures like sensory Pacinian, Meissner corpuscles, and Merkel cells which provide detailed discrimination of touch and feel sensations
The dorsal surface consists of the nail fold, nail bed, and nail plate.
The eponychium is the tissue just proximal to the nail while lateral fost tissue folds around the nail are called paronychium lateral nail folds.. The hyponychium is a plug of keratinous material situated beneath the distal edge of the nail where the nail bed meets the skin.
The lunula is the white portion of the proximal nail that demarcates the sterile area from the germinal matrix beneath. The area distal to lunula is sterile and here is where the nail adheres. The germinal matrix is proximal to the sterile matrix and is responsible for nail growth.
Causes of Fingertip Injuries
The most common causes of fingertip injuries are
- Crush injury – can be open or closed and generally involves distal phalanx fractures. Injury due to crushing in hinge side of the door is most common in children.
- Laceration involving pulp or nail/nailbed – occurs due to sharp object
- Amputations
- Sudden flexion or extension forces lead to tendon avulsion injuries.
Classification of Fingertip Injuries
Mostly used classification of fingertip injuries is that described by Allen.
This classification divides injuries of the fingertips into four types. The classification is based on the level of injury.
- Type 1-These injuries involve only the pulp
- Type 2- Type 2 fingertip injuries involve the pulp and nail bed.
- Type 3- Type 3 injuries of the fingertip include partial loss of the distal phalanx.
- Type 4- Type 4 injuries are proximal to the lunula.
Type 1 injuries may heal quite well by secondary intention. Type 3 and 4 often require some type of flap coverage.
Clinical Presentation of Fingertip Injuries
Patients would present mainly with pain and inability to use the affected digit. Bleeding may be present if a wound is present. The mechanism of injury should be recorded. Note for hand dominance, involved digit, and neurovascular status. The injured digit should be assessed for sensation, the range of motion at the interphalangeal joints, and capillary refill.
The medical and surgical conditions of the patient should be noted. An examination can provide a fair idea about the nature of the injury which could be
- Tendon injuries
- Fractures/Dislocations
- Finger avulsion
- Laceration involving /not involving eponychium
- Amputations with/without significant bone exposure
Imaging in Fingertip Injuries
Ap and lateral x-rays are done to look for any bony involvement.
Approach to Treatment of Fingertip Injuries
The goals of treatment of any injured fingertip are
- Restoration of appearance to as normal as possible
- Restoration of a pain-free pulp that has a stable interface for tactile sensation
- Preservation/restoration of tactile abilities [sensory perception abilities]
- Restoration of the nail plate to preserve nail growth capacity
- Minimize joint stiffness.
Restoration of sensibility, stable skin coverage, and adequate padding are the goals of reconstruction.
There are many treatment options, which range from allowing the wound to heal by secondary intention to flap coverage or revision amputation. No single procedure can be recommended, but each case must be individualized depending on the needs of the patient and the type of injury
Age, occupation, avocation, and general health of the patient need to be considered for selecting the treatment.
Any associated nail bed injuries, angle of injury, amount of exposed bone, digit injured, and concomitant injuries also should be considered.
Medications are used to provide pain relief and prevent complications. The following is a general list of drugs used in these injuries but an individualized approach is indicated.
- Nonsteroidal anti-inflammatory agents for pain relief
- Antibiotics
- Tetanus immunization with tetanus toxoid
- Human tetanus immune globulin if farm injuries or dirty wound or patient is unimmunized
Nonoperative Treatment
Healing by Secondary Intention
This is the simplest form of treatment. The simplest treatment of fingertip injuries is to allow the wound to heal by secondary intention. Initial treatment is done with irrigation and soft dressing.
If required, the wound can be debrided. Healing is usually completed by 3 to 6 weeks depending on the size of the defect. It is indicated in
- Adults and children with no bone or tendon exposed with < 2cm of skin loss
- Children with exposed bone
Operative Treatment
Primary Wound Closure
It means a simple suturing of the laceration.
Soft Tissue Coverage
- Fingertip amputation with no exposed bone and > 2cm of tissue loss
- Partial amputation where the distal part is of adequate integrity for coverage of the wound especially in children.
Implantation
If the finger is amputated more than 2 mm proximal to the lunula, then replantation can be considered though microvascular anastomosis is difficult at this level. This procedure requires a hand specialist.
Revision Amputation and Primary Closure
Amputation at a proximal level is indicated in situations in which bone is exposed and the angle of the injury is such that other options are not appropriate.
As far as possible, the length of the phalanx should be preserved, especially in case of thumb. In distal injuries, care must be taken to ablate the remaining nail matrix to prevent the formation of irritating nail remnants.
If flexor or extensor tendon insertions cannot be preserved distal interphalangeal joint must be disarticulated. For closure, the palmar skin is brought over bone and sutured to dorsal skin as it has more mobility and provides good padding.
Treatment of Individual Injuries
Subungual hematoma
A subungual hematoma is often caused by a crushing injury. It presents as severe, throbbing pain with nail discoloration. More than 50% of such injuries require trephination [making a hole] of the nail plate for decompression and drainage of the hematoma. A nail bed examination should be done when there is an associated fracture of the phalanx suggested and there is a laceration of skin fold or nail disruption. After the pain is relieved, the finger should be splinted.
Nailbed Injuries
Nail and nail bed injuries include lacerations, avulsion injuries, and amputations.
Simple lacerations can be sutured with 5-0 or 6-0 nonabsorbable sutures like nylon. In children, however, absorbable sutures can be used. If a nail injury is present, the matrix should be inspected after nail removal. All retrievable fragments of the nail matrix should replaced as free grafts and repaired.
Sterile nonadherent dressing and splint should be used.
In simple nail avulsions, repositioning can be attempted to obtain an anatomical reconstruction.
If the fingertip injury is a partial or a complete fingertip avulsion, and there is partial nail avulsion or surrounding nail fold disruption, then nail removal should be done.
Closed fractures that are minimally displaced can be splinted or operative intervention may be needed.
Seymour Fractures
The term refers to physeal fracture of the distal phalanx. The fractures are usually open and have mallet finger-like deformity but the displacement occurs through the fracture rather than the distal interphalangeal joint. Reduction and K-wire fixation is usually needed.
Mallet Finger
This injury occurs when a flexion force is directed to an actively extended finger and results in the avulsion of the extensor tendon. It is the most common tendon injury among athletes.
It can be pure tendon rupture or there may be an avulsion fracture. Most of the former type responds to extension bracing of the finger but in avulsion fractures, k-wire fixation may be needed.
Amputation
Amputations can be treated conservatively or require some operative procedure.
Nonoperative management is indicated when there is no bone or tendon becomes exposed with less than 2 cm of skin loss.
However, surgery may needed if the removal of exposed bone would compromise the bony support of the nail bed. In such cases, some kind of flap surgery is indicated. Thus extent of involvement of the pulp, nail, and bone would determine the type of procedure.
For conservative management of such fingertip injuries, the protruding bone is removed [if required]with a bone rongeur to a level 2-5 mm below that of surrounding tissue and bone dressed.
Apply sterile nonadherent dressing over the amputated part.
Different Types of Graft Surgeries Used in Fingertip Injuries
VY flap
- Skin Grafts: Skin grafts can be used in injuries where there is skin loss but adequate subcutaneous tissue is present with no exposed bone.
- Local Flaps: In these procedures, adjacent local skin with its subcutaneous tissue is used to cover the defect. There are two common advancement flaps used for fingertip injuries.
- V-Y advancement flap: V-Y Advancement flap is used in fingertip injuries with dorsal angulation or for transverse amputations. A dorsal angulation injury is an injury that leaves more pulp than nail bed.
- Regional Flaps: Regional flaps are defined as flaps taken from other parts of the hand that do not use tissue adjacent to the defect and are used for injuries not amenable to local flaps. Two commonly used are the cross-finger and thenar flap
Crossfinger flap - Crossfinger flaps: Doraslflap, palmar flap
- Thenar flap: A thenar flap surgery involves covering of the amputated fingertip by bending it and suturing the wound to a flap in the thenar eminence at the level of the base of the thumb.
- Distant Flaps: Flaps are defined and obtained from areas of the body other than the injured, which are termed distant flaps. These flaps can be developed from the chest, abdomen, groin, or opposite arm.
- Graft for thumb injuries: Injury to thumb needs the special mention because of its importance in prehension or grasp. Preservation of the length of the thumb is more important functionally than in any other digit. Following are the common procedures used for thumb injuries.
- Moberg advancement flap- Moberg advancement flap involves advancing the volar skin with subcutaneous tissues and neurovascular bundles distally into a thumb tip defect.
- Palmar cross-finger flap
Island flap - Neurovascular island flaps- Neurovascular island flap transfers the soft tissue of the border of a finger along with its arterial and nerve supply [Neurovascular bundle] to the thumb. It is also known as the Littler flap.
- First Dorsal Metacarpal Artery Flap- The first metacarpal artery flap restores sensate skin to the volar thumb in a one-stage procedure without the need for microvascular repair. The flap can be used to cover thumb defects, either palmarly or dorsally, and can reach from the proximal portion of the thumb almost to its tip.
References
- George A, Alexander R, Manju C. Management of Nail Bed Injuries Associated with Fingertip Injuries. Indian J Orthop. 2017 Nov-Dec. 51 (6):709-713. [Link].
- Yorlets RR, Busa K, Eberlin KR, Raisolsadat MA, Bae DS, Waters PM, et al. Fingertip Injuries in Children: Epidemiology, Financial Burden, and Implications for Prevention. Hand (N Y). 2017 Jul. 12 (4):342-347.
- Martin-Playa P, Foo A. Approach to Fingertip Injuries. Clin Plast Surg. 2019 Jul. 46 (3):275-283.
