II. Classification
- Zone I Fingertip Amputation
- Preserved distal phalanx without bone exposure
- Majority of nail bed and nail matrix intact
- Zone II Fingertip Amputation
- Amputation distal to lunula of nail bed
- Bony exposure of distal phalanx
- Zone III Fingertip Amputation
- Loss of entire nail bed
- Large portion of distal phalanx lost
III. Precautions
- See Finger Laceration
- Set expectations at time of initial presentation
- Affected finger may heal poorly and never return to original function
- Reattached partial amputations may not survive, but serve as a biologic dressing
- Delayed healing or scarring may occur
- Distal Sensation may never return
IV. Management: General measures
- Irrigate, clean and debride the wound well
- Antibiotics are not needed in most cases
- Consider antibiotics only if grossly contaminated, Immunocompromised state, diabetes, vascular disease
- Arora and Menchine in Herbert (2015) EM:Rap 15(10): 12
- Rubin (2015) Am J Emerg Med 33(5):645-7 +PMID: 25682579 [PubMed]
- Complicated wounds (e.g. larger wounds >2 cm or those involving bone)
- Wound may be cleaned, dressed and evaluated by hand surgery within 24 hours
V. Management: Reimplantation
- Discuss with hand surgery as to whether patient is a candidate
- Finger tip reimplantation has a high success rate
- See Limb Amputation
- Care of the amputated part
- Care of the amputation site
VI. Management: Non-Reimplantation Techniques
-
Anesthesia
- See Digital Block
- Zone I Fingertip Amputation
- Wound left open for Healing by Secondary Intention
- Meticulous wound care with close observation
- Conservative Debridement of excessive granulation tissue
- Topical Antibiotic ointment for moist Wound Healing
- Consider skin adhesive technique to control distal fingertip bleeding
- Apply finger Tourniquet (e.g. tourni-cot)
- De-engorge the finger using a venipuncture Tourniquet (dries the distal tip)
- Appy repeatedly from proximal to distal (expect to see dark blood from fingertip)
- Apply several layers of Tissue Adhesive to the fingertip
- Lin (2015) J Emerg Med 48(6):702-5 +PMID: 25886984 [PubMed]
- Zone II Fingertip Amputation
- Dorsal Plane Amputation (angled toward finger dorsum)
- More nail bed avulsed than pulp
- Consider repair with V-Y Plasty
- Transverse Plane Amputation (perpendicular to finger)
- Equal amounts of nail bed and pulp avulsed
- Consider repair with V-Y Plasty
- Volar Plane Amputation (angled toward volar finger)
- More pulp avulsed than nail bed
- Do not use V-Y Plasty for this avulsion
- Dorsal Plane Amputation (angled toward finger dorsum)
- Zone III Fingertip Amputation
- Amputate distal phalanx
VII. References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7