Evaluation and management of fingertip injuries

INTRODUCTION — The repair of nail bed lacerations and fingertip avulsions is reviewed here. The management of subungual hematomas, finger fractures, and finger dislocations are discussed separately:

●(See "Subungual hematoma".)

●(See "Distal phalanx fractures".)

●(See "Digit dislocation reduction".)

MECHANISM OF INJURY — Isolated nail bed injury typically occurs as a result of direct blunt trauma (eg, crush in a door jamb) [1,2]. A nail bed injury almost always accompanies a partial or complete fingertip avulsion [3,4]. Fingertip avulsions often occur when the finger gets slammed in the door (latch side) or is caught along the edge of the door (hinge side). Most avulsions are partial avulsions of the fingertip, although full amputations are not rare.

Fingertip avulsions are also caused by knives, slicers, exercise equipment (eg, treadmills, exercise bicycles), power tools, and lawn mowers. In contrast to adults, complete or partial avulsions heal extremely well in children, especially before adolescence. In particular, the literature indicates that children younger than two years of age are very likely to demonstrate complete distal tip regeneration after amputation when managed without repair [5,6].

ANATOMY — Proper management of fingertip injuries requires knowledge of anatomy of the nail bed as well as familiarity with the motor and neurovascular anatomy of the finger (figure 1).

●The nail bed is a thin layer of epithelial tissue overlying the cortex of the distal phalanx. The richly vascularized nail bed lies directly beneath the nail plate and provides adherence and support for the nail.

●The skin that covers the proximal end is called the proximal fold or eponychium.

●The skin edge at the distal nail margin is called the hyponychium.

●The lateral margins of the nail are held in place by the lateral skin folds of the fingertip.

●The cuticle, an outgrowth of the proximal fold, provides a seal between the proximal fold and the nail plate.

●The germinal matrix is the proximal element of the nail bed responsible for most of the nail formation. The matrix begins 7 to 8 mm under the proximal fold, and its distal end is the white crescent called the lunula.

The fingertip has a rich blood supply provided by numerous branches of the ulnar and radial elements of the digital arteries. The pulp of the fingertip is composed of fatty and soft tissues with dense sensory innervation provided by the palmar digital nerves. Extension and flexion of the fingertip are provided by the extensor hood and flexor digitorum profundus tendons, respectively. (See "Finger and thumb anatomy", section on 'Finger extension' and "Finger and thumb anatomy", section on 'Finger flexion and pulley system'.)

EVALUATION — Proper management of nail bed lacerations and fingertip avulsions requires careful evaluation, including assessment for associated injuries and plain radiographs, prior to definitive care. This assessment should identify conditions that warrant prompt referral to a hand or orthopedic surgeon. (See 'Choice of procedure' below.)

History — Key historical elements include:

●Age and skeletal maturity – The need for surgical repair varies for fingertip amputation based upon age. In particular, children <2 years of age often heal well without grafting of large soft tissue defects or replantation of distal fingertip amputations that contain pulp and bone. (See 'Amputation' below.)

Management of bony injuries is also impacted by skeletal immaturity of the digits for pediatric patients younger than 12 years of age.

●Mechanism and time of injury – Crush injuries are associated with a greater risk of contamination. Injuries that are repaired when <24 hours old have a lower chance for infection.

●Digit position during injury (flexed versus extended) – The digit position during injury increases the chance for specific types of fractures or dislocations and may influence whether flexor or extensor tendons may have been disrupted.

●Dominant hand – Although the goal for all fingertip injuries is restoration of a sensate fingertip with a smooth and intact nail and normal range of motion, the clinician and patient may opt for a more complex procedure (eg, replantation) for the chance to maintain full or close to full function of a fingertip on the dominant hand, even if the likelihood for success is low.

●Occupation – In rare circumstances, such as when finger dexterity is crucial for high manual performance due to the patient's occupation, a more complex procedure such as replantation may be indicated.

●Prior hand conditions, injuries, or interventions – Prior hand injuries that have impacted baseline finger function and the presence of any residual foreign bodies from prior procedures are important to document prior to repair.

Physical examination — The clinician should determine the extent of damage to the fingertip with attention to injury to the nail, nail folds, nail bed, and germinal matrix and evaluate for associated proximal injuries to the finger or hand by testing neurovascular status and range of motion.

●Extent of injury – Direct inspection provides the extent of nail bed and fingertip damage. Often, a dry dressing has been applied to control bleeding and may be adherent to the wound. Soaking of the finger and dressing in sterile normal saline helps decrease the pain of removal. A tourniquet applied to the base of the finger may also be necessary to control bleeding during the examination.

Inspection should identify:

•Findings of nail bed injury such as (figure 1):

-Subungual hematoma

-Bleeding from under the nail

-Disruption of the nail folds

-Disruption of the germinal matrix (injury involving the lunula)

-Dislocation of the nail or nail plate

•For patients with finger amputations, what has been amputated:

-Pulp only

-Pulp with nail and/or bone

If amputated tissue is available for examination, the clinician should evaluate whether it is suitable for replantation (intact [not severely crushed or mangled] and relatively clean).

●Neurovascular status – Neurovascular status is examined as follows:

•Fingertip perfusion – Vascular compromise is suggested by the presence of distal pallor. The vascular status of fingers is also evaluated using capillary refill time. Although standard values for capillary refill time increase with age and certain disease states (eg, diabetes), normal capillary refill is generally less than two seconds [7]. Comparison of capillary refill time with an unaffected finger assists with interpretation.

•Fingertip sensation – Fingertip sensation testing should occur before a digital block is performed. Two-point discrimination is the most sensitive test for sensation in the fingers. Two-point discrimination of 4 to 5 mm is normal for most patients, with an upper limit of normal of 8 to 9 mm in older adult patients.

In cooperative patients, a caliper can be fashioned from a paper clip with the points held at about 10 mm. The patient is asked to close their eyes, and the paper clip points are placed against the skin along the long axis of the finger and away from the wound. The touch should be relatively light so as to minimize the stimulation of pressure receptors. It is important to assess sensation on both the radial and ulnar aspects of the finger as well as the dorsal and palmar sides. The points of the paper clip are gradually brought closer together.

In cooperative younger children, it may only be possible to test light touch. A cotton-tipped swab touched lightly on all aspects of the finger may suffice for this examination.

In very young or uncooperative children, the clinician may not be able to discern the presence or absence of nerve injury. Indirect evidence of intact sensory innervation is obtained by placing the finger in a bowl of warm water for five minutes. Intact innervation is indicated by wrinkling of the skin of the distal finger, whereas nerve injury results in persistence of smooth skin or less wrinkling compared with uninjured fingers [8,9].

●Range of motion – Range of motion testing of the injured finger often requires a digital block to control pain (see 'Procedural pain control' below). The examiner then isolates the distal phalangeal joint to test for flexion and extension (picture 1A-B).

Plain radiographs — Anterior-posterior (AP) and true lateral plain radiographs of the affected finger and, for amputations with possible loss of bone, any intact amputated tissue, are necessary before repair of a nail bed laceration or fingertip amputation.

Findings of interest include:

●Unstable fractures or dislocations, or fractures that warrant referral to a hand surgeon for definitive repair

●In children, a Salter-Harris epiphyseal fracture (ie, Seymour fracture)

●For fingertip amputations, degree of bone loss

Distal tuft fractures are the most common associated fractures seen with fingertip injuries, occurring in up to 50 percent of patients. Although technically an open fracture, tuft fractures do not significantly alter the immediate management, though they require splinting of the fingertip after repair [10]. (See "Distal phalanx fractures", section on 'Initial treatment'.)

MANAGEMENT

Indications for subspecialty consultation or referral — The following injuries often require advanced repair and warrant consultation with or referral to a hand surgeon or surgeon with similar expertise [11-13]:

●Infected wounds.

●Disruption of digital tendons.

●Displaced or unstable finger fractures that may require open reduction and internal fixation or pinning (eg, distal phalangeal base fractures, intra-articular fractures, transverse distal phalangeal fractures). In children, distal phalangeal epiphyseal (Seymour) fractures are rare and can be missed. This injury involves avulsion of the nail, and the juxta-epiphysial fracture is reliably identified via radiographs. (See "Distal phalanx fractures", section on 'Indications for surgical referral'.)

●Complicated digit dislocations (eg, open dislocation) or finger fractures proximal to the distal phalanx that may require open reduction. (See "Digit dislocation reduction", section on 'Contraindications and precautions' and "Overview of finger, hand, and wrist fractures", section on 'Middle and proximal phalanx fractures'.)

●Large soft tissue injuries (>1 cm) with absent, destroyed, or heavily contaminated tissues requiring nail bed or skin grafting.

●For patients older than two years of age, proximal germinal matrix injuries (ie, injury to the lunula) requiring approximation and repair.

●Extensive proximal germinal matrix avulsions.

●Fingertip amputations that include loss of nail and/or bone in addition to the fingertip pulp (figure 1); fingertip amputations suitable for replantation or definitive surgical repair require emergency consultation and proper preparation of the amputated portion. (See 'Pulp and nail and/or bone' below.)

Consultation of a hand surgeon or other surgeon with similar expertise is also appropriate for complicated open nail bed injuries, partial fingertip avulsions, and pulp-only amputations that warrant surgical repair.

Choice of procedure — The need for and type of repair depends on the timing and severity of injury as well as patient characteristics (algorithm 1):

●Closed nail bed injuries – Nail bed lacerations do not require nail removal and repair when the nail is sufficiently intact within the nail folds (ie, nail continues to splint and approximate any nail bed or nail fold laceration) and a distal phalanx fracture, if present, is not significantly displaced. If a painful subungual hematoma is present, then trephination should be performed. (See "Subungual hematoma", section on 'Procedure'.)

In a retrospective study of 78 adults with fingertip injuries resulting in a subungual hematoma that was either greater than 50 percent or associated with a nondisplaced distal phalanx fracture (without frank nail disruption or nail fold laceration), conservative management (ie, trephination as needed, splinting) was associated with reduction in nail deformity compared with nail bed laceration repair, although the result was not statistically significant (5/13 [13 percent] versus 9/40 [23 percent], RR 0.58, 95% CI 0.42-1.25) [14]. Hand disability scores for the two groups also were not significantly different.

Other studies have also found no difference in the development of infection or nail deformity in patients undergoing trephination compared with nail bed laceration repair [15,16]. Since nail bed laceration repair is a painful and time-consuming procedure that typically requires digital nerve blockade and may require procedural sedation, many authors have questioned the traditional indications for repair of a subungual hematoma greater than 25 to 50 percent of the nail or the presence of a fracture [17-19].

●Open nail bed injuries and partial fingertip avulsions – Open nail bed injuries and partial fingertip avulsions that are uninfected and less than 24 hours old require repair that involves nail removal and nail bed suturing [11-13,17,20]. (See 'Isolated open nail bed injury' below.)

Controversy exists regarding replacing the nail or splint following nail bed suturing, which has traditionally been recommended since it may maintain the proximal nail fold during healing, prevent synechiae (nail bed scar that can cause nail deformity), reduce infection, and decrease pain during dressing changes. We replace the nail or splint if there is an associated proximal nail fold injury or comminuted, displaced tuft fracture. In one study of 586 patients with repaired nail bed injuries, worse cosmetic results were associated with nail fold injuries, crushing, avulsion, or fractures [21]. A trial of 451 children undergoing nail bed repair (79 percent with crush injuries) compared replacing the nail with simply applying a low-adherent dressing (without splinting open the nail fold); 32 patients (7 percent) had a pulp laceration and/or distal phalanx tuft fracture, and 6 patients (1 percent) had a germinal matrix injury (patients with fracture requiring fixation or nail bed laceration requiring reconstruction were excluded) [22]. There was no difference in cosmetic appearance of the nail (final follow-up occurred between 4 and 12 months after the injury) or infection rate at 7 to 10 days. Patients who had the nail replaced had a higher infection rate at the four-month follow-up visit (3.5 versus 0.9 percent), but fewer experienced pain during dressing changes (41 versus 48 percent), although these did not reach statistical significance.

●Amputations – The degree of injury and patient characteristics determine management:

•Pulp only – The approach to amputations of the fingertip pulp only depends on the size of the soft tissue defect, the status of the amputated pulp, and the age of the patient as discussed below. (See 'Finger pulp only' below.)

•Pulp and nail and/or bone – Because of the potential need for grafting, flap repair, or replantation, patients over two years of age with fingertip amputations involving more than the pulp require emergency consultation with a hand surgeon or other surgeon with similar expertise to determine the potential for replantation and to perform definitive surgical repair. (See 'Amputation' below.)

Preparation

Patient counseling and informed consent — Patients with fingertip injuries are usually anxious and in pain. The patient and, for children, the caretaker should receive an explanation of the injury and the procedural approach. In patients with significant nail bed lacerations and suspected damage to the area near the germinal matrix, the patient and family/caregivers should be advised that a deformed or absent nail may occur on the finger despite appropriate treatment.

Procedural pain control — For most patients (including older children and adolescents), we suggest a digital nerve block (without procedural sedation). We prefer to use the modified transthecal technique (picture 2) because it is less traumatic and requires fewer needle sticks compared with the traditional web space block (picture 3). (See "Digital nerve block".)

Behavioral techniques are also helpful to reduce anxiety and perceived pain as well as to prevent lack of cooperation before and during the procedure. (See "Procedural sedation in children: Selection of medications", section on 'Nonpharmacologic interventions'.)

Young children and older, uncooperative patients may require mild or moderate sedation in addition to a digital block to prevent excessive movement during repair. (See "Procedural sedation in children: Selection of medications", section on 'Sedation for painful procedures' and "Procedural sedation in children: Approach".)

Repair techniques

Materials — The following equipment should be assembled:

●Digital tourniquet (picture 4), Penrose drain, or finger of a sterile glove (Penrose drain or glove finger require a hemostat to hold in place)

●Irrigation solution (eg, sterile normal saline)

●Large-volume (eg, 50 or 60 mL) Luer tip syringe with 19-gauge needle or irrigation device with splash shield (eg, Zerowet)

●Suture tray with, at minimum, needle driver, fine surgical (iris) scissors, and forceps

●Sterile paper or cloth drapes

●Absorbable suture (eg, 6-0 or 7-0 chromic gut) for nail bed repair

●Absorbable suture (eg, 4-0, 5-0 chromic gut or Vicryl Rapide) for suturing of skin

●Tissue adhesive/skin glue or absorbable suture (eg, 4-0 or 5-0 chromic gut) may be used to secure the nail in place

●No. 15 scalpel blade

●Vaseline-impregnated gauze

●Sterile gauze

●Finger splint

●Magnifying eyewear (optional)

Closed nail bed injury — Nail bed lacerations in which the nail is sufficiently intact within the nail folds (closed nail bed injury) do not require nail removal and nail bed repair. Acute subungual hematomas that are painful require trephination. (See "Subungual hematoma", section on 'Trephination'.)

Isolated open nail bed injury — With an open nail bed injury, the nail plate is displaced from the nail bed. The nail bed usually has a simple or complicated laceration; the distal phalanx is frequently fractured. The goal of repair is to restore a smooth nail bed that avoids cosmetic deformities of the nail upon regrowth [3,12,13,23,24]:

●Prior to repair and after assessing neurovascular status as above, perform a digital block. (See "Digital nerve block", section on 'Digital block procedures'.)

●While waiting for the block to take effect, have the patient soak the fingertip in normal saline.

●Place a digital tourniquet (picture 4) and note the time; total finger tourniquet time during repair should not exceed two hours [25,26].

●Remove the fingernail to fully expose the nail bed by gently separating the underlying adherent nail bed from the nail with fine-tipped (iris) scissors or small, curved hemostat (eg, Mosquito hemostat):

•Hold the tip parallel to the finger and angled slightly dorsally towards the nail.

•Insert the scissors or hemostat in a closed position between the nail and nail bed at the distal tip and advance the instrument slowly in the proximal direction. Open and spread the instrument while maintaining the tips against the undersurface of the nail to avoid further injury to the nail bed.

•Repeat this process along several tracts until the nail is completely freed from the underlying nail bed, proximal fold, and lateral folds.

●Once the nail is removed, the nail bed should be gently irrigated with at least 100 to 200 mL of sterile saline.

●Carefully approximate and suture the wound where it intersects the proximal and/or lateral folds using 5-0 chromic gut (picture 5).

●Close the wound on the skin of the finger pad using 4-0 or 5-0 absorbable suture (eg, chromic gut).

●Repair the nail bed using absorbable suture (eg, 6-0 or 7-0 chromic gut or Vicryl Rapide [27,28]) as follows:

•Align the edges of the nail bed precisely.

•Direct the needle from distal to proximal when passing the suture needle to avoid tearing the nail bed tissue and use the minimum number of sutures necessary to achieve adequate approximation (picture 6).

•Although evidence is limited, alternative methods include:

-Tissue adhesives –The nail bed may be repaired using a skin glue such as 2-octylcyanoacrylate (eg, Dermabond). As an example, in a study of 40 consecutive patients with acute nail bed lacerations, there was no statistical difference in physician-judged or patient-perceived cosmetic outcome, pain, or functional ability between repairs performed using skin glue versus 6-0 chromic suture. In addition, the average time for repair was clinically significantly shorter for the skin glue group (10 versus 28 minutes) [29]. In a systematic review of six studies (118 patients), including this randomized study, use of tissue adhesives was considered as effective as sutures for nail bed laceration repair [30].

-Adhesive polyurethane film dressing (Tegaderm or Opsite) – For small (1-2 mm) nailbed lacerations, the open wound may be covered with adhesive polyurethane film dressing [eg, Tegaderm or Opsite]) and changed weekly in follow-up.

●In a patient with a proximal nail fold injury or comminuted, displaced tuft fracture, we protect the repaired nail bed by splinting with the original nail, if possible:

•Gently clean the nail in a dilute solution of povidone iodine and normal saline. Soaking the nail during repair softens it and makes it easier to replace as describe below.

•Place a large hole, 3 to 4 mm in diameter, in the center of the nail using a sterile needle, scalpel, or electrocautery to allow drainage.

•Replace the nail beneath the proximal fold (picture 7). The least invasive technique to secure the nail in position is via a tissue adhesive (eg, Dermabond, Surgiseal, Histoacryl Blue, or Periacryl) [29,30]. The nail should be positioned in precise anatomic position by ensuring that the proximal aspect of the nail is underneath the eponychium in order to protect the germinal matrix. Place two to three drops of tissue glue in the areas of the nail folds and allow the stream of adhesive to seal the nail to the skin.

Alternatively, the nail plate may be sutured in place through the lateral skin folds with two 4-0 absorbable sutures (eg, Vicryl Rapide).

Although silicone splints are available, a retrospective analysis of complications after nail splinting with native nail versus silicone nail revealed significantly fewer nail deformities when the native nail was replaced compared with splinting with a silicone product [31].

•If the original nail cannot be used, place a nonadherent splint consisting of a single thickness of nonadherent sterile gauze (eg, Telfa gauze), 0.20-inch reinforced silicon sheeting, or sterile foil from the suture packet in the proximal fold and suture in place through the lateral skin folds using absorbable 4-0 suture; or use skin glue (picture 8). There are no comparative studies regarding which of these splinting material results in the best clinical outcomes [32].

●Remove the tourniquet.

●Apply a protective dressing consisting of the following layers [33]:

•Sterile, petrolatum-impregnated gauze directly over the wound site; nonadherence can be increased by liberally applying antibiotic ointment to the gauze

•Sterile dry gauze or a silicone net dressing

•Finger splint – options include (see "Basic techniques for splinting of musculoskeletal injuries", section on 'Finger splints'):

-Four-pronged distal finger splint (toad splint (picture 9)

-Finger splint that is placed around the end of the finger for dorsal and volar protection

-Volar finger splint, which should not be left in place for longer than one week (picture 10)

In young children, place a stockinette over the hand like a mitten to prevent the patient from pulling off the bandage.

Partial fingertip avulsion — Partial fingertip avulsions arise when the distal finger is crushed between two objects. The distal phalanx often sustains a fracture and the nail bed, nail, and pulp are disrupted but still partially attached to the proximal finger by a skin bridge. Partial fingertip avulsions may survive, provided some distal perfusion is preserved, especially in children younger than two years of age. At worst, the tip acts as a graft that may revascularize or act as a biologic dressing in older children, adolescents, and healthy adults.

In adults with increased infectious risk due to comorbidities (eg, peripheral artery disease, diabetes mellitus, advanced age), removal of the avulsed fingertip and treatment as for complete fingertip amputation may be advisable. (See 'Amputation' below.)

The goal of repair is to restore a functional and fully sensate fingertip [11,12]:

●Prior to repair and after careful neurovascular exam, perform a digital block. (See "Digital nerve block", section on 'Digital block procedures'.)

●While waiting for the block to take effect, have the patient soak the fingertip in normal saline.

●Place a digital tourniquet (picture 4).

●Carefully remove the fingernail to fully expose the nail bed by gently separating the underlying adherent nail bed from the nail using fine-tipped scissors or a small, curved hemostat (eg, Mosquito hemostat) as follows:

•Hold the tip parallel to the finger and angled slightly dorsally towards the nail.

•Insert the scissors or hemostat in a closed position between the nail and nail bed at the distal tip and advance the instrument slowly in the proximal direction. Open the instrument while maintaining the tips against the nail to avoid further injury to the nail bed.

•Repeat this process along several tracts until the nail is completely freed from the underlying nail bed, proximal fold, and lateral folds.

●Once the nail is removed, the wound should be gently irrigated with at least 100 to 200 mL of sterile saline.

●Secure the avulsed fingertip in anatomic position with 4-0 absorbable suture (eg, chromic gut or Vicryl Rapide) using the proximal and lateral folds as anatomic landmarks. The first sutures should be placed where the wound margin intersects with the lateral fold or lateral border of the proximal fold (picture 5).

●Repair the skin laceration along the volar aspect of the fingertip using 5-0 chromic gut or Vicryl Rapide. (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)

●Repair the nail bed and proceed as previously described. (See 'Isolated open nail bed injury' above.)

Amputation

Finger pulp only — The pulp of the fingertip (figure 1) may be amputated by being pinched in a metal door or cut off by a knife or other sharp implement (eg, box cutter). The resulting injury often leaves a circular wound on the distal fingertip with exposure of the subcutaneous tissue. The approach to this wound depends upon the age of the patient and degree of injury as follows [12,24]:

●Children younger than two years of age: Apply a nonadherent dressing without grafting because cosmetic outcomes are usually good in this population. The dressing consists of a layer of sterile petrolatum-impregnated gauze covered with sterile dry gauze or a silicone net dressing; a clean sock or stockinette should be placed over the hand to prevent the child from pulling off the dressing.

●Patients two years of age and older:

•Amputated tissue available and usable – Suture the cleaned and defatted amputated pulp in place to serve as a biologic dressing using absorbable suture (eg, 5-0 chromic gut) and simple interrupted stitches. (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)

•Amputated tissue not available or not usable – If the amputated tissue is not available or is mangled or heavily contaminated, clean and dress the wound with a semiocclusive, nonadherent dressing and promptly consult a hand surgeon or surgeon with similar expertise within 24 hours for possible grafting or complex repair.

Pulp and nail and/or bone — Because of the potential need for grafting, flap repair, or replantation, most patients with fingertip amputations involving more than the pulp (figure 1) require emergency consultation with a hand surgeon or other surgeon with similar expertise to determine the potential for replantation or definitive surgical repair [11,34]. Tissue salvage and replantation techniques common to adult injuries have been increasingly used for children with pulp, nail, and bone fingertip amputations as well [11,20,34]. (See 'Indications for subspecialty consultation or referral' above.)

The amputated part requires careful evaluation and handling as follows [34]:

●Rinse with sterile normal saline to remove gross contaminants

●Wrap in a moistened, sterile gauze

●Place in a waterproof plastic bag and store in a container of ice water (avoid direct contact with ice)

●Obtain anteroposterior and lateral radiographs of the amputated part

Further care

Tetanus prophylaxis — The clinician should determine the patient's tetanus vaccination status and provide prophylaxis if indicated (table 1). (See "Tetanus-diphtheria toxoid vaccination in adults" and "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Schedules'.)

Wound care and patient instructions — The patient and, in children, the caretaker should be advised to leave the dressing and (if applicable) the finger splint in place until the follow-up visit, which should occur within seven days. For most healthy patients with clean or minimally contaminated fingertip injuries, we suggest not routinely administering empiric antibiotics. However, empiric prophylactic antibiotics may be appropriate for patients with any one of the following:

●Animal and human bite wounds to the hand, including those that cause fingertip injuries (see "Animal bites (dogs, cats, and other mammals): Evaluation and management" and "Human bites: Evaluation and management")

●Excessive wound contamination (eg, soil contamination)

●Vascular insufficiency (eg, devascularized wound, peripheral artery disease), immunocompromise, or diabetes mellitus although there is little evidence to support this practice (see "Skin laceration repair with sutures", section on 'Prophylactic antibiotics')

Otherwise, proper wound care consisting of copious irrigation and removal of contaminants and dead tissue, as needed, is the most effective means to reduce infection. (See "Basic principles of wound management", section on 'Wound debridement'.)

In randomized trials performed in children and adults with fingertip injuries (including individuals with open tuft fractures) managed with or without prophylactic antibiotics, infection rates were similarly low in both groups (<4 percent) [35-37].

These findings are consistent with studies in healthy patients undergoing wound repair for skin lacerations (including simple hand lacerations) that demonstrated similar infection rates with or without prophylactic antibiotics [35-37].

Patients and caretakers should understand that a small amount of blood may continue to ooze under the nail for one to two days.

Pain management consists of elevation of the hand above the heart and oral medications (eg, acetaminophen or ibuprofen). Oral opioid medications (eg, oxycodone) are typically not necessary. If used, the clinician should prescribe a limited supply to provide pain control during the first 48 hours after injury.

The patient should return for urgent evaluation if:

●The bandage becomes wet or soiled prior to the scheduled follow-up visit

●The patient develops:

•Signs of infection such as fever, redness extending up the finger, or marked dorsal hand swelling

•Bleeding that does not stop with application of pressure for 15 minutes

Follow-up — Further follow-up and care are based upon the type and degree of injury:

●Fingertip skin avulsions – Small defects (<1 cm) and sutured injuries warrant follow-up with the primary care provider for a wound check in two to three days. If the wound is sutured, the patient or caregiver should be advised at that visit that the sutured skin will likely not survive but that it will serve as a biological dressing and eventually slough off.

Continued home care consists of keeping the wound clean and dry and changing the dressing daily to every other day. Additional wound checks are at the discretion of the provider. A typical approach is to evaluate the wound again in approximately two weeks when healing should be well established.

Grafted defects should undergo follow-up as determined by the hand surgeon.

●Nail bed repair and sutured partial fingertip avulsions or amputations – The patient should follow up with a hand surgeon in five to seven days. The bandage should remain intact until the initial visit with the hand surgeon.

Thereafter, the timing of dressing changes and additional wound checks should be frequent enough to observe for problems with healing or infection but spaced such that disruption of wound and nail bed revascularization is minimized; this may vary according to the degree of injury. A weekly wound check is a common practice among hand surgeons. Some specialists advise dressing changes every other day while others prefer to only perform dressing changes as part of the wound check.

Patients and caretakers should understand that the sutured nail is acting only to maintain patency of the proximal fold by preventing adhesions between the eponychium and nail bed and that it will fall off within one to three weeks. Ultimately, a new nail will require 3 to 12 months to grow in [17].

If a tuft fracture is present, then finger splinting should continue for at least 14 days.

●Complete amputations – These injuries warrant follow-up with a hand surgeon in five to seven days. The bandage should remain intact until the initial visit with the hand surgeon. After the initial visit, these wounds should undergo regular dressing changes as determined by the hand surgeon. Regular evaluation is advised until healing is complete.

COMPLICATIONS — Complications of nail bed and partial fingertip avulsion repair consist of abnormality of nail growth and wound infections:

●Abnormal nail growth – Normal nail growth following a nail bed laceration requires a smooth nail bed. Extensive injury or failure to precisely approximate the nail bed may result in an irregular nail contour or a nonadherent nail [12,17,19,23,24].

Scarring may negatively impact the nail in several ways [12,23]:

•Germinal matrix scarring may cause failure of nail regrowth or an abnormally formed fingernail (eg, hypoplastic nail)

•Nail bed scarring can result in a nail that fails to adhere to the underlying nail bed

•Scar tissue formation may lead to a hyperaesthetic nail bed and fingertip

•Proximal (eponychial) fold scarring may yield a split nail or pain as the nail grows through the adhesion

•Lateral fold scarring may result in ingrown nails

Meticulous repair of the nail bed with careful approximation of the nail folds, minimal debridement of the nail bed, and use of the minimum number of sutures to adequately close the nail bed helps to minimize these undesirable cosmetic outcomes.

●Wound infection – The reported infection rate after hand and fingertip injuries is between 2 and 6 percent [35,37,38]. Careful wound debridement and irrigation are most important in preventing this complication. Prophylactic antibiotics do not significantly alter the rate of infection in healthy patients with minimally contaminated wounds. (See 'Wound care and patient instructions' above.)

Complications of fingertip amputation management are beyond the scope of this topic but are briefly discussed in the references [24,34].

SUMMARY AND RECOMMENDATIONS

●Mechanism of injury – Fingertip avulsions often occur in the setting of door closure upon the finger. A nail bed injury almost always accompanies a full or partial fingertip avulsion. Fingertip avulsions are also caused by knives, slicers, exercise equipment (eg, treadmills, exercise bicycles), power tools, and lawn mowers. (See 'Mechanism of injury' above.)

●Evaluation – Proper management of fingertip injuries requires knowledge of the anatomy of the nail bed (figure 1) and careful evaluation to identify (see 'Anatomy' above and 'Evaluation' above):

•Neurovascular compromise

•Degree of nail and nail bed injury

•Additional injuries based on functional testing for tendon disruption and plain radiographs for fractures or dislocation

●Hand surgeon consultation – Prompt consultation with a hand surgeon is warranted for (see 'Indications for subspecialty consultation or referral' above):

•Infected wounds

•Fingertip injuries with associated tendon injuries

•Displaced finger fractures (other than tuft fractures)

•Complicated digit dislocations (eg, open dislocation)

•Large soft tissue injuries (>1 cm) with absent, destroyed, or heavily contaminated tissues requiring nail bed or skin grafting

•Proximal germinal matrix lacerations requiring approximation and repair

•Extensive proximal germinal matrix avulsions

•Fingertip amputations that include loss of pulp, nail, and bone

●Choice of procedure – The need for and type of repair depends on the timing and severity of injury (algorithm 1) (see 'Choice of procedure' above):

•Closed nail bed injury – Small nail bed lacerations do not require nail removal and repair when the nail is sufficiently intact within the nail folds (ie, nail continues to splint and approximate any nail bed or nail fold laceration) and a distal phalanx fracture, if present, is not significantly displaced. If a painful subungual hematoma is present in such patients, trephination is appropriate, as discussed separately. (See "Subungual hematoma", section on 'Procedure'.)

•Open nail bed injury – With an open nail bed injury, the nail plate is displaced from the nail bed and accompanied by a nail bed laceration; a distal phalanx fracture is also frequently present. These injuries require primary repair, provided that they are uninfected and <24 hours old. The nail must be removed completely for adequate examination and repair. (See 'Isolated open nail bed injury' above.)

•Partial fingertip avulsion – Partial fingertip avulsions arise when the distal finger is crushed between two objects. The distal phalanx often sustains a fracture and the nail bed, nail, and soft tissue are disrupted but still partially attached to the proximal finger by a skin bridge. Repair includes nail removal, securing of the partially avulsed fingertip in anatomic position, and open nail bed repair. (See 'Partial fingertip avulsion' above.)

•Amputation – The degree of injury and patient characteristics determine management:

-Pulp only – The approach to amputations of the fingertip pulp only depends on the size of the soft tissue defect, the status of the amputated pulp, and the age of the patient as discussed above. (See 'Finger pulp only' above.)

-Pulp and nail and/or bone – Because of the potential need for grafting, flap repair, or replantation, most patients over two years of age with fingertip amputations involving more than the pulp require emergency consultation with a hand surgeon or other surgeon with similar expertise to determine the potential for replantation and to perform definitive surgical repair. (See 'Amputation' above.)

●Procedural pain control – For most patients (including older children and adolescents), we suggest a digital nerve block (picture 2 and picture 3) without procedural sedation (Grade 2C). Behavioral techniques are also helpful to reduce anxiety and perceived pain as well as to prevent lack of cooperation before and during the procedure. (See "Procedural sedation in children: Selection of medications", section on 'Nonpharmacologic interventions'.)

Young children and older, uncooperative patients may require anxiolysis or moderate sedation in addition to a digital block to prevent excessive movement during repair. (See "Procedural sedation in children: Selection of medications", section on 'Sedation for painful procedures' and "Procedural sedation in children: Approach".)

●Repair techniques – Step-by-step instructions for repair of specific fingertip injuries are provided above. (See 'Repair techniques' above.)

●Wound care and infection prevention – Important measures to prevent infection include (see 'Further care' above):

•Tetanus prophylaxis – The clinician should determine the patient's tetanus vaccination status and provide prophylaxis, if indicated (table 1). (See 'Tetanus prophylaxis' above.)

•Wound and dressing care – The patient and, for children, the caretaker should be advised to leave the dressing and (if applicable) the finger splint in place until the follow-up visit, which should occur within seven days. (See 'Wound care and patient instructions' above.)

•No role for routine antibiotics – For most healthy patients with clean or minimally contaminated fingertip injuries, we suggest not routinely administering empiric antibiotics (Grade 2B). Proper wound care consisting of copious irrigation and removal of contaminants and dead tissue, as needed, is the most effective means to reduce the risk of infection. However, empiric prophylactic antibiotics may be appropriate for patients with any one of the following (see 'Wound care and patient instructions' above):

-Animal and human bites (see "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis')

-Excessive wound contamination (eg, soil contamination)

-Vascular insufficiency (eg, devascularized wound, peripheral artery disease), immunocompromise, or diabetes mellitus

●Follow-up – Timing of the follow-up visit is determined by the type and degree of injury. (See 'Follow-up' above.)