A fingertip injury is defined as any soft tissue, nail or bony injury distal to the dorsal and volar skin creases at the distal interphalangeal joint and insertions of long flexor and extensor tendons of a finger or thumb. The fingertips are exposed to all aspects of daily living, recreation and work and it is perhaps no surprise they are the most commonly injured part of the hand

1. Preparedby: Supervisedby:
Dr. Abdullah K. Ghafour Dr. Hamid A. Jaff
4th year IBFMS trainee
FINGER TIP INJURY

2. Overview
 Epidemiology
 Finger Tip Anatomy
 Diagnosis andEvaluation
 Classifications
 ED-management
 Managementofspecific injuries
 complications
 conclusion
 References

3. Epidemiology
o A fingertip injury is defined as any soft tissue, nail or bony injury distal to the dorsal and volar skin creases at the
distal interphalangeal joint and insertions of long flexor and extensor tendons of a finger or thumb.
o Thefingertips are exposed to all aspects of daily living,
recreation and workand it is perhaps no surprise they
are the most commonly injuredpart of the hand.
o Integrityof the fingertip is important for manipulation, tactile sensibility, communication andaesthetics.
o Successful management of fingertip injuries requires consideration of individual patient requirements, detailed und
erstanding of the anatomy of the fingertip and experience in a rangeof reconstructive techniques.

4. o fingertip injuries account for approximately two-thirds of all hand injuries. The middle finger,
index finger and thumbare the most frequently injureddigits.
o Thenon-dominant handis most frequently involved and most injuries involve a single digit.
o The commonest mechanism is jamming or crushing the finger between a door and its frame, or
due to occupational activities.
o the incidenceis highest inyoungerchildrenand boys.

5. Anatomy
o Thefingertip has threemain structures – the pulp, nail and distal phalangeal bone.
o The pulp is a closed space and It has a dense thick fibrous layer under the epidermis of the entire fingertip. Fibrous
collagen bands anchorthe dense fibrous layerto the periosteum of the distal phalanx.
o Itplays a fundamental role ingrip, proprioception, and sensation.
o Nail consists of flattened keratinized squamous cells and is produced by the relatively thick germinal matrix
situated at the base of the nail bed.
o Inaddition to thenail bed and nail plate, other parts of the perionychiumare:
• Eponychium
• Paronychium
• Hyponychium
o Therate of growth is 0.1mm per day

7. Diagnosis and Evaluation
o In addition to patient-related factors such as age, hand dominance, general health, occupation, and hobbies, the
history should also includethe time and mechanism of injury.
o Any conditions that could compromise regional blood flow and thereby limit reconstructive options, such as
diabetes, tobacco use, or vasospastic disorders, should be duly noted.
o The injured finger should be evaluated to determine size, location, and geometry of any pulp defect, degree of nail-
bed involvement, and the presence or absence of exposed bone with complete evaluation of neurovascular status
and both tendon systems.
o Radiographs should be obtained of the injuredfinger, and also
of the amputated part if replantation is being considered.

8. Classifications
o Several systems exist to classify fingertip injuries.
o Theseclassification systems are used to describe theinjurypresent and to potentially guide thetreatment required.
• Allens (1980)
• Tamai (1982)
• Ishikawa(1990)
• Lister (1991)
• Fassler geometry system
(1996)
• Elashy (1997)
• Hirase (1997)
• PNB classification (2000)

9. o Allen’s classification (1990)is based on
thelevel of amputation.
o Fassler system (1996)is based onthe
geometry of pulp loss and whether bone
is exposed.
o PNB classification system was described by Evans and Bernadis (2000), based on damage to the 3
main components of the fingertip: pulp (P), nail (N), and bone (B)
 the system allows for generation of a 3-digit code that describes the extent and type of
injuryin more detail.

11. ED-management
o Thegoals of treatment are:
• minimization of pain
• Preserving sensation and length
• reducingthe time of functional impairment
• providing a cosmetically acceptable fingertip
• good functional outcome
o Patients should be provided with adequate analgesia depending on the injury and resulting pain, oral or parenteral dru
gs might be required.
o Anaesthetizing the affected finger via a digital nerve block using local anesthetic solutions might supplement or substi
tute use of opioids and will aid in cleaning the wound later on.
o Adequate cleaning and debridement of injuries should be undertaken in ED and it should be performed under a digital
nerveblock.
o bloodless field might be achieved with a digital tourniquet and the injury should be copiously irrigated with normal sal
ine.
o non-adherentcompression dressings and elevation used for hemostasis

12. o Antitetanus immunization should be provided for patients who are not adequately immunized.
o Prophylactic antibiotics might play a more important role in grossly contaminated wounds,
wounds with a significant amount of devitalized tissue and inopen fracturesof thedistal phalanx.
o The routine use of prophylactic antibiotics is controversial with studies showing conflicting results.

13. o Regardless of the conservative or surgical nature of the treatment, the injured fingertip requires a
suitable dressing until the wound is healed.
o There is evidence for using dressings that are non-adherent to granulating tissue and semi-occlusive
(to allow oxygen in yet prevent bacterial contamination) while maintaining a slightly moist wound
surface to promote healing and it should not cause significant pain during removal. e.g. paraffin-
impregnated gauze, polyurethanefoam and silicone net dressing.
o A metal or plastic splint can be incorporated in the outermost layer of the dressing to protect
repaired tissue and assist patient comfort. A cap splint can also be used.

14. Management of specific injuries
o These injuries include simple lacerations, complex stellate lacerations, avulsion injurie
s, amputations or associate paronychialinjuries.
o A plain radiograph of the affected finger should be taken to rule out an associated fractur
e.
o Painless subungual haematomas can be treated conservatively if the nail plate is still adh
erentto the bed and not displaced out of the nail folds.
o Trephination and drainage of the subungual haematoma might provide significant pai
n relief. It can be performed with a heated paper clip or an ophthalmic cautery unit to avoi
d injuryto the nail bed.
 Nail& nailbedinjuries

15. o For cases of subungual haematomas greater than 50% of the nail bed, or associated with an
underlyingfracture, the nail should be avulsed and the nail bed debrided and repaired.
o Simple lacerations through the sterile matrix can be sutured in the outpatient setting with 6/0 a
bsorbable sutures.
o Lacerations through the nail fold, germinal matrix or dorsal roof should also be repaired
accurately. Back cuts at the two corners of the proximal nail fold can allow one to visualize the
germinal matrix and dorsal roof for this purpose.

16. o Nail plates removed are usually sutured back to act as a splint, this is to
prevent the dorsal roof from adhering to the nail bed before the new
nail grows.
o Artificial nails, or the silver foil from the suture package cut into shape
are used as splints when the patient’s own nail is missing, too damaged
or too dirty to be utilized.

17. o Thenail plate can be secured with a distally placed 5-0nylonsuture throughthe
hyponychiumorvia a horizontal mattress suture throughthe proximal nail fold.
o Earlyremoval of the proximal nail fold suture is necessary to prevent trackformation but a
distal hyponychiumsuture can be left infor 7–10days.
o A small hole should bemade inthe nail plate to allow for adequate drainage
o Thefingertip should bedressed with a non-adherentdressing and changedafter 3–5days.
A protective cap splint should be worn for 2weeks. Full growth of the nail mighttakea nu
mber of weeks

18. Management of specific injuries
 Soft-TissueLoss WithoutExposed Bone
 Simple dressings/Secondary Intention healing;
o Fingertip injuries with only skin loss less than 1 cm square usually can be trea
ted satisfactorily with healing bysecondary intention.
o This treatment is very effective in children and adults with minimal tissue loss a
nd well vascularized surroundingtissue.
o About 7 to 10 days after the injury, the patient is instructed to begin soakin
g the finger in a warm water–peroxide solution once a day and to apply a light
bandage and fingertip protector.

19. o Healing time during conservative treatment is approximately 3–6weeks
o Range of motion exercises are encouraged when the wound is completely epithelialized, an
d home program of desensitization is initiated.

20.  full-thickness skin graft;
o If the defect is larger without exposed bone, a full-thickness skin graft provides good coverag
e and the potential for returnof some sensation.
o Skin grafts applied to the palmar surface of the fingertip should be full thickness because the
y contract less, are more durable and less tender, and achieve better sensibility than split gr
afts.
o preferred donor sites include (hairless areas):
•Thehypothenar(prefered area)
•ulnar border of thehand
•proximal forearm
•Medial upper arm
•groin

21. o The graft is sutured over the defect, with a few sutures left long so that a moist cotton ball can
be secured over the graft to help maintain coaptation with the underlyingtissue.
o Thecotton ball is removed after about 7days, andrange-of- motion exercises are initiated.

22. Management of specific injuries
 Soft-TissueLoss WithExposedBone
o Whenbone is exposed, satisfactory soft-tissue coverage must be obtained.
o There is almost never sufficient local tissue available to close primarily, and attempts to do so may result in s
kin necrosis, a painful fingertip, and prolonged morbidity.
o The choice of procedure is determined primarily on the basis of the level and angle of the amputation and t
heage and sex of thepatient.
o Surgical methods :
• Cap-technique
• Local Flaps
• Regional Flaps
• Revision Amputation
• Replantation

23. Cap-technique(Composite Grafting)
o Thesimple non-microvascular reattachmentof
the distal fragment has historically been associate
with good results only inchildren
o the severed tip was filleted and replaced as a "cap" over the skeletonized distal phalanx of
the stump. A 2mm remnantof germinal matrix was preserved for nail regrowth.
o survival is approximately 50%in child and youngadults while it is less than 30%in adults.
o Itshould neverbe performed in smokers or diabetics or in the setting of crushinjury.

24. Local Flaps
o A local flap is one in which the transferred tissue is confined to the injured digit, with at lea
st one side of the flap adjacent to the defect.
o they can be used in patients of any age, they preserve length, the donor defect does not
require a skin graft, and the transposed tissue is similar in quality, texture, and color to that
of the recipient site.
o Anearly range-of-motionprogram can be started.
• Volar V-Yflap (Atasoy – Kleinert plasty)
• KutlerLateral V-Yflaps
• Moberg Volarflap (Neurovascular AdvancementFlap)
• Homodigital Island flap

25.  Volar V-Yflap (Atasoy– Kleinert plasty)
o Itis an ideal method of treatment for transverse or dorsal oblique amputations.
o Itcan beused for all digits, including thethumb.
o Thedistal edge of the flap can be advanced only about 1cm.
o Not appropriate for treatment of amputations that are too proximal and those
with more tissue loss volarly thandorsally
o The nail bed and bone should be trimmed even with each other. The skin and
subcutaneous tissue are then incised, with great care being taken not to
damage theneurovascular bundles.

26. o Theskin edges of theflap need not be sutured too tightly, as this may compromise blood flow.
o Patients usually have normal or nearly normal sensibility of the fingertip and superb restoration
of contourand padding.

27.  Kutler Flap (Lateral V-Yflaps)
o Itis most appropriate for distal transverse amputations.
o Triangular flaps are designed on each side of the tip, with the bases being the distal edge of
the wound and the apices more proximal.
o The disadvantage of this technique is that the flaps are small and may be difficult to advance,
with the result that closure cannot be obtained without tension.

28.  Neurovascular Advancement Flap (Moberg Volar flap)
o For soft-tissue defects distal to finger or thumb that cannot be restored with a V-Y flap and for
those measuringno more than about 2cm inlength,
o Midaxial incisions are made on both sides, extending from the injury site to the
metacarpophalangeal crease.
o The entire volar skin flap, containing both neurovascular bundles, is dissected from the flexor
tendon sheath from distal to proximal and the flap is advanced over the bone.

29. If flap remains under tension, proximal
transverse incision is made and FTSG
placed over the defect

30.  Homodigital Island flap
o Single-stage reconstruction of the fingerpulp byharvesting the flap from the injuredfinger.
o Many homodigital neurovascular flaps based on one or two volar digital pedicles have been
described which can provide thefingertip with sensate coverage.(DDHDA,MDHDA,RHDA….)
o the dorsal finger skin is elevated to repair pulp deficits which cannot be closed with other
advancement flaps.
RHDA
DDHDA

31. o It can be used to close defects of 2 × 2.5 cm up to 2 × 4 cm just proximal to the tip and
hyponychium.
o It has excellent satisfaction with the function, sensation and appearance of the involved finger.

32. Regional Flaps
o They are employed to preserve length and obtain coverage of amputations with a volar
oblique angle and amputations too proximal to allow performance of a local flap, as well
as to replace substantial loss of pulp tissue.
o The main disadvantage of these flaps is that their use involves a two stage procedure
requiringdivision of the flap.
o Because prolonged immobilization may result in stiffness
• Thenarflap
• Cross-finger flap (Innervated,Flag, Reversed, Volar,..)
• Heterodigital Island flap
• Distant Flaps ( axial, random, free)
• Switch flap, modified souquet flap , visor flap &pivot flap

33.  Thenar flap
o The thenar flap can be used for any fingertip, but sometimes the small finger can be difficult to
position comfortably.
o Flap width and length are determined on the basis of the size of the defect. The flap can be as
wide as 2 cm and should be 1.5 times as wide as the defect so as to restore the normal
rounded contour to the tip.
o A full-thickness skin graft is applied to the donor area from the non-hair-bearing area. If the
donor area is not too wide, it is sometimes possible to perform a primary closure.

34. o After 2-3weeks flap is detached from donor site.
o Stiffness of the proximal interphalangeal joint and tenderness of the donor site have been
concernswith this flap.

35.  Cross-finger flap
o The flap is outlined as a rectangle over the middle phalanx of the donor digit, with the hinge si
deadjacent to the injuredfinger
o The skin is incised on threesides, As the flap is raised, it is imperative that the paratenon of the
extensor tendon be preserved.
o A full-thicknessskin graft from elsewhere is applied to the donor defect.

36. o Variations in the design of the cross-finger flap can be made depending on the location and
size of thedefect.
o Thereis satisfactory recovery of sensibility ≈70%

37.  Heterodigital Island (Littler flap )
o Sensate, vascularized tissue from the ulnar side of uninjured finger is transferred to the injured o
ne,mostly from ringor long fingerto the thumb,in a single stage.
o Theneuro-vascularbundle dissected from the level of the palmar arch.
o Thedonor defect is covered with a full thickness skin graft.
o At the end of the procedure, a splint is applied with the MP and IP joints in slight flexion and
mobilization is started after 15days.

38. o Some authors prefer transffering only the digital artery and the venae comitantes in the
pedicle, without the digital nerve in order to minimize the sensory loss to the donor digit
“heterodigital arterialized flap”

39.  Distant Flaps
o Distant flaps come from body parts outside of the injuredupper extremity.
o threetypes:
• Axial (flaps that have a specific vascular pedicle)
• Random (flaps that lack a specific vascular pedicle)
• Freeflaps.
o In Axial flap the abdomen is a favorite donor site and the donor site can be closed directly for
flaps up to 12cm wide.
• superficial inferior epigastric artery flap
• Superficial CircumflexIliac ArteryFlap (Groin)
• Lateral Thoracic ArteryFlap.
o Free vascularised toe pulp flap provides excellent cover to replace the thumb pulp as well as
cosmetically acceptable but it may have risk of failure of vessel anastomosis.

40. Abdomenal axial flap
Superficial CircumflexIliac ArteryFlap (Groin)
Freevascularised toe pulp flap

41. Revision Amputation
o Shortening and primary closure of fingertip amputations is indicated in adults of any age when not
enoughsterile matrix remains (less than 5mm) to produce anadherent, stable nail.
o whenopen treatment, skin grafting, or flap coverage is not possible.
o Theremainingnail matrix must be ablated to prevent formation of irritating nail remnants.
o If the flexor and extensor tendon insertions cannot be preserved in the revision, the distal interpha
langeal joint should be disarticulated, distal traction is applied to the profundus and extensor tendo
ns, whichare thentransected and allowed to retract.

42. o The prominent volar condyles of the head of the middle phalanx are removed and digital nerves cu
t underslight tension to prevent painful neuroma
Ringavulsioninjury:A.preoperative,B. Postoperative,C. temporaryprosthesisfordressoccasions

43. Replantation of fingertip
o Replantation is a technically challenging and requiring microsurgical expertise but effective metho
d of treatment.
o At least 4 mm of skin proximal to the nail fold is required for potential suitable vessels for
anastomosis.
o Replantation in a single digit distal to the FDS insertion can give superior outcomes compared
with replantation more proximally in the finger.
o Contraindications to replantation include lack of microsurgical capability, lack of suitable vessels,
and crushinjuries.

44. Management of specific injuries
 ThumbPulp Reconstruction
o The principles of management of injuries of the thumb tip are similar to those for other digits. However, the
importance of preservation of lengthand restoration of sensibility is magnified.
o Although function of the thumb is usually satisfactory when the thumb has been shortened to the level of the
interphalangeal joint, the availability of local and regional flaps allows preservation of length inmost cases.

45. o Mostly used methods:
• Moberg AdvancementFlap
• Cross-Finger Flap FromIndex Finger
• First Dorsal Metacarpal Artery–IslandPedicle Flap
• Neurovascular-IslandPedicle Flap

46. Management of specific injuries
 Distalphalangealfractures
o Approximately 50%of nail bed injuries areassociate with an underlying distal phalangeal fracture
o No specific treatment is indicated for an isolated tuft fracture except analgesics and protection with a s
uitable cap splint for 2–3weeks.
o If the tuft fracture is associated with a simple nail be or pulp laceration, meticulous wound cleaning in the
ED and repair of the laceration are required. repair of the nail bed usually stabilizes such a fracture.

47. o Displaced, closed injuries to the distal phalanx shaft may need to be reduced anatomically and stab
ilized in order to prevent subsequent injury to the overlying sterile matrix and late nail deformity. E
ither by closed reduction and splinting, or it may be accomplished with a longitudinal K-wire or s
mall screw placed distal to proximal.

48. Management of specific injuries
 Fingertip Injuries inChildren
o Most crush-and avulsion-type fingertip amputations
inchildrencan be managed by the open method.
Especially inchildrenless than 2 yearsof age.
o A relatively normal-appearing fingertip can be formed, evenwhen bone is exposed
o For amputations through sterile-matrix region, protruding bone is trimmed even with the soft tissue, and healin
g by secondary intention is allowed.
o If there is a clean, sharp amputation through any portion of the nail and the distal segment is available, the tip ca
nbe simply reattached as a composite graft.

49. Complications
o Some cold intolerance in30– 50%adults with pulp loss
o Loss of oralteration in sensation in 30%regardless of thetype of treatment
o loss of pinch strength
o Nail deformities:
• Non-adherenceor ridging of nail plate
• Split nail
• Crooked nail plate
• Hooked nail
o Neuroma,or painful nerve regenerationfollowing theinjury
o Stiffness of IPJ
o cosmetic concerns
o prolonged time away from workthat often seems disproportionate to the magnitude of the injury

50. Conclusion
o Fingertip injuries should not be takenlightly as theycan result in significant morbidity if poorly treated.
o Functional as well as aesthetic considerations have to be taken into account when treating fingertip
injuries.
o Most fingertip injuries can be treated by the emergency physician, but there are some conditions that
requirereferral to hand surgeons for optimal management.
o A comprehensive discussion with the patient at the outset is essential. This enables selection of the most
appropriate surgical option for that patient and their injury, sets realistic expectations and empowers the
patient to play a positive role in theirrecovery.

51. Summary of management methods

52. References
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• Steven L. Peterson, Emma L. Peterson, Michael J. Wheatley: Management of Fingertip Amputations.
JHand SurgAm. 2014;39(10):2093e2101
• Alwis W.; Fingertip injuries. Emergency Medicine Australasia (2006) 18 , 229–237
• Yeo C J, Sebastin S J, Chong A K S: Fingertip injuries. Singapore Med J 2010; 51(1): 78-87
• Elliott H. Rose et al: The "cap" technique: Nonmicrosurgical reattachment of fingertip amputations. J
HAND SURG 1989;14A:513-18.
• Gan Muneuchi et al: The PNB Classification for Treatment of Fingertip Injuries, The Boundary Between
Conservative Treatment and Surgical Treatment. Ann Plast Surg 2005;54: 604–609
• P. Tos et al: Surgical treatment of acute fingernail injuries. J Orthopaed Traumatol (2012) 13:57–62
• Joshua A. Lemmon et al: Soft-Tissue Injuries of the Fingerti; Methods of Evaluation and Treatment. An
Algorithmic Approach. Plast. Reconstr. Surg. 122: 105e, 2008
• Rose E. et al: The "cap" technique: Nonmicrosurgical reattachment of fingertip amputations. J HAND
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• D. M. Evans ,C. Bernadis: A New Classification For Fingertip Injuries. Journal of Hand Surgery (British
and European Volume, 2000) 25B: 1: 58±60
• F. Page, C. Langley, M. Lamyman: Focus On Management of fingertip injuries. The British Editorial
Society of Bone & Joint Surgery (2016)
• Chao Chen et al: Repair of multiple finger defects using the dorsal homodigital island flaps. Injury, Int. J.
Care Injured 44 (2013) 1582–1588

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54. "The smallest pain in our little finger gives us more concern than the
destruction of millions of our fellow beings." William Hazlitt
Discussion time