Action
High-pressure injection injury
- ED transfer for emergent consult with hand surgeon (Class II)
Fight bite
- ED transfer or emergent consult with hand surgeon (Class II)
Compartment syndrome
- ED transfer for emergent consult with hand surgeon (Class II)
Subungual hematoma, uncomplicated
- Nail plate trephination alone (Class II)
Subunqual hematoma with nail plate disruption
- Nail plate removal and nail bed matrix repair (Class II-lIl)
- Consider consult with hand surgeon for nail bed matrix repair (Class III)
Fingertip amputation
- Repair and refer to hand surgeon, zones I-Ill (Class III)
- ED transfer or consult with hand surgeon for surgical repair, zone III (Class II-III)
Background
Absence of nail plate or margin disruption with or without uncomplicated tuft fracture.
Nail plate, stellate nail plate iniurv, complicated distal phalanx fracture.
Fingertip Amputation
Fingertip amputations are classified into zones I, II, or III injuries. Early goals of care include appropriate storage of the amputated part, hemorrhage control, analgesia, and wound care. Two-view radiographs are recommended to identify fracture.
Zone I injuries, in which no bone is exposed, undergo wound care followed by placement of a nonadherent dressing and healing by secondary intention. Lamon et al performed a study of 25 consecutive patients with zone I injuries who underwent conservative management with wound care, semi-occlusive dressings, and healing by secondary intention. In these patients, the authors reported preservation of finger length, normal sensory function in 88%, infection rate of 0%, and mean epithelialization time of 29 days.
Zones II and III injuries undergo wound care, rongeur of exposed bone, and wound closure, followed by placement of a nonadherent dressing. Severe zone III injuries may require distal phalanx amputation. Fingertip amputation patients with evidence of exposed bone should be treated with local wound care and transferred to an emergency department (ED) with hand surgery coverage or referred immediately to a hand surgeon for emergent consultation. Replantation strategies for fingertip amputation are controversial and should be left to the discretion of a hand surgeon.
