II. Classification

  1. Zone I Fingertip Amputation
    1. Preserved distal phalanx without bone exposure
    2. Majority of nail bed and nail matrix intact
  2. Zone II Fingertip Amputation
    1. Amputation distal to lunula of nail bed
    2. Bony exposure of distal phalanx
  3. Zone III Fingertip Amputation
    1. Loss of entire nail bed
    2. Large portion of distal phalanx lost

III. Precautions

  1. See Finger Laceration
  2. Set expectations at time of initial presentation
    1. Affected finger may heal poorly and never return to original function
    2. Reattached partial amputations may not survive, but serve as a biologic dressing
    3. Delayed healing or scarring may occur
    4. Distal sensation may never return

IV. Management: General measures

  1. Irrigate, clean and debride the wound well
  2. Antibiotics are not needed in most cases
    1. Consider antibiotics only if grossly contaminated, immunocompromised state, diabetes, vascular disease
    2. Arora and Menchine in Herbert (2015) EM:Rap 15(10): 12
    3. Rubin (2015) Am J Emerg Med 33(5):645-7 +PMID: 25682579 [PubMed]
  3. Complicated wounds (e.g. larger wounds >2 cm or those involving bone)
    1. Wound may be cleaned, dressed and evaluated by hand surgery within 24 hours

V. Management: Reimplantation

  1. Discuss with hand surgery as to whether patient is a candidate
  2. Finger tip reimplantation has a high success rate
    1. Jazayeri (2013) Plast Reconstr Surg 132(5): 1207-17 [PubMed]
  3. See Limb Amputation
    1. Care of the amputated part
    2. Care of the amputation site

VI. Management: Non-Reimplantation Techniques

  1. Anesthesia
    1. See Digital Block
  2. Zone I Fingertip Amputation
    1. Wound left open for Healing by Secondary Intention
    2. Meticulous wound care with close observation
    3. Conservative debridement of excessive granulation tissue
    4. Topical antibiotic ointment for moist Wound Healing
  3. Zone II Fingertip Amputation
    1. Dorsal Plane Amputation (angled toward finger dorsum)
      1. More nail bed avulsed than pulp
      2. Consider repair with V-Y Plasty
    2. Transverse Plane Amputation (perpendicular to finger)
      1. Equal amounts of nail bed and pulp avulsed
      2. Consider repair with V-Y Plasty
    3. Volar Plane Amputation (angled toward volar finger)
      1. More pulp avulsed than nail bed
      2. Do not use V-Y Plasty for this avulsion
  4. Zone III Fingertip Amputation
    1. Amputate distal phalanx

VII. References

  1. Hori (2015) Crit Dec Emerg Med 29(3): 2-7

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