Fingertip injuries and amputations are common in the emergency department, often occurring on weekends when consultants are not available. Some experienced physicians may consider rongeuring distal tuft amputation injuries, but simple closure and expert consultation for more difficult cases are suggested.
A fingertip amputation within zone III involving total amputation of the distal tip, fingernail, matrix, and tuft. Photos by M. Roberts.
Care of fingertip amputations in the ED should focus on removing debris and cleaning the wound as best as possible, closing the wound using available skin, bandaging and splinting for comfort, and considering the patient's risk for infection (antibiotics, tetanus update, etc.). It is also vital to control bleeding and provide pain relief. Follow-up with a specialist can usually be done in 24 to 72 hours, depending on the complexity of the wound. Full amputations with the part in hand should be referred immediately for possible reimplantation. Some of these injuries need a thorough washout in an OR or a revision of tendons and bones.
Management depends on the severity of the injury, degree of wound contamination, and available resources. (Injury. 2017;48:2643.) Consider the patient's age, comorbidities, occupation, hand dominance, and mechanism of injury.
Flap repair in the ED with applied bulky dressing. Photos by M. Roberts.
Anatomy of the fingertip. Photo: Lippincott Williams & Wilkins, 2018.
Fingertip amputations can be classified into three zones based on the extent of the injury to the bone. This knowledge is helpful when communicating with a hand or orthopedic specialist. Zone I injuries are distal to the bony phalanx and can be treated conservatively with frequent dressing changes over many weeks. Zone II injuries involve partial tuft or bone exposure, while Zone III injuries involve the loss of bone and nail. Zone I injuries are typically treated conservatively while Zone II and III injuries almost always need expert care. (Indian J Orthop. 2007;41:163; http://bit.ly/2BEyr8H.)
We do not recommend rongeuring the bone without experience or expert consultation. It is used in cases where the bone is exposed and skin is missing. Cutting the bone down using this tool will allow for a skin flap to cover the wound, which may not be possible otherwise. This technique may need to be mastered by physicians in rural settings or those who have limited access to specialty care.
- Young stable patient
- Dominant hand
- Multiple digits injured
- Sharp wounds, little damage
- Upper extremity (children)
- Associated life threats
- Severe crush injuries
- Inability to withstand surgery
- Single digit, unless thumb
- Avulsion injury
- Prolonged warm ischemia >12 hours
- Gross contamination
- Prior injury or surgery to that part
- Emotionally unstable patient
- Lower extremity
If the patient is a child and has multiple losses, salvage reimplantation is attempted and the relative contraindications are ignored. Courtesy of Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care, 7th edition, Philadelphia: Saunders/Elsevier, 2018.
Patients occasionally present with an amputated finger in a bag or on ice, and they can be eligible for replantation. Elevate the entire extremity and perform a digital nerve block. Wrap the distal portion of the injured finger in wet gauze. Do not place any of the loose parts directly in ice (frostbite), soak them in water (destroys remaining tissue), or scrub them with antiseptic. (Roberts & Hedges, 2018.) Control all bleeding with firm pressure, and use a tourniquet close to the amputated site if needed. Time is ischemia, so prompt referral, consultation, and transfer are imperative. Give IV antibiotics (i.e., Ancef, Unison), pain medication, and a tetanus shot while you are waiting for consultation or transfer. Multiple fingertip avulsions or amputations can be wrapped in wet saline gauze in a bulky but firm dressing.
If the amputation was caused by an animal and rabies is possible, you should administer the rabies vaccination and then rabies immunoglobin as you would for any other bite. Injecting the immunoglobulin around the bite site is necessary; the technique will vary by location. If you are unable to inject fully around the bite area, you can inject the rest of the immunoglobulin around the base or shaft of the affected finger.
A person exposed to rabies and never vaccinated should get four doses of the vaccine. The first is given on the day of presentation; the rest are given on the third, seventh, and 14th days. Find more information about doses and rabies vaccines, along with a free algorithm, from the CDC: http://bit.ly/2WaP1qd.
Watch a video of an amputated fingertip.
- Complete digital block immediately upon presentation.
- Image with plain film radiographs utilizing three views.
- For more complex injuries in Zones II and III, immediately consult a specialist. You may consider handling Zone I injuries yourself with consultation and immediate flap repair. (See video below.)
- Clean the wound thoroughly, but avoid scrubbing if the wound will be a candidate for reimplantation. Remove any foreign bodies.
- Avoid tube gauze in general; it's difficult to put on and take off and doesn't have any real benefit when compared with just wrapping the finger with Kerlix. (See the video below for more on this technique.)
- Don't spend a lot of time on cosmetics for these patients; they will get a revision. Preserve neurovascular status and know when to expedite care.
- Clean the whole hand before wrapping it. No one wants to go home with a bloody mess.
Plain film radiographs for distal fingertip zone III amputation.
Jim weighs in: Expedite the preoperative workup of the patient and immediately notify the reimplantation team because these are crucial factors in the patient care.
Martha weighs in: If you are closing the wound using our flap method, use Prolene. It holds a looser tension and is easier to see (blue) and remove (slicker) than black nylon.