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Fingertip Amputation

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Fingertip Amputation, Finger Tip Amputation, Composite Fingertip Graft Reimplantation

  • See also
  1. V-Y Plasty
  2. Finger Laceration
  3. Limb Amputation
  • Classification
  • Ishikawa Subzones
  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
  4. Zone IV Fingertip Amputation
    1. Region of distal phalanx adjacent to the DIP joint
    2. May be included in Zone III injuries in some classifications
  • 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
  • Management
  • General measures
  1. Irrigate, clean and debride the wound well
  2. Update Tetanus status
  3. Tobacco Cessation (promotes improved Wound Healing)
  4. 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]
  5. 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
  • Management
  • Reimplantation by Hand Surgery Specialist
  1. Consider composite graft for Zone II amputations (see below)
  2. Discuss with hand surgery as to whether patient is a candidate
  3. Finger tip reimplantation has a high success rate
    1. Jazayeri (2013) Plast Reconstr Surg 132(5): 1207-17 [PubMed]
  4. See Limb Amputation
    1. Care of the amputated part
    2. Care of the amputation stump site
  • Management
  • Composite Fingertip Graft Reimplantation (by emergency clinician)
  1. Simple non-neurovascular attachment by emergency clinician
  2. Risks of graft necrosis, infection, poor functional or cosmetic outcome, or digital pain
  3. Procedure
    1. Anesthesia with Digital Block
    2. Apply digital Tourniquet (e.g. Tourni-Cot)
      1. May use an exam glove finger that has been cut off and tied at finger base
    3. Clean and Irrigate the wound
    4. Consider Fingernail removal and nail reattachment after amputated part is secured
    5. Prepare amputated part
      1. Consider excising protruding bone fragments and protruding fat
    6. Prepare the wound stump
      1. Consider debriding macerated skin edges
    7. Amputated Part Reattachment
      1. Align the amputated stump and amputated part
      2. Suture in place, typically with absorbable interrupted Sutures
      3. Replace Fingernail (if removed) and secure (see Nail Replacement)
  4. Wound Dressing
    1. Antibiotic ointment (e.g. Bacitracin)
    2. Bulky dressing (e.g. tube gauze) - not too tight
    3. Consider finger splint
  5. Disposition
    1. Close follow-up within one week (preferably with hand specialist if available)
    2. Consider Antibiotics coverage (optional)
    3. May keep dressing in place until follow-up if this is available within a few days
      1. Otherwise, patient should recheck wound and re-dress daily after the first few days
      2. Return for graft necrosis, signs infection
  6. References
    1. Warrington (2024) Crit Dec Emerg Med 38(7): 18-9
  • Management
  • Non-Reimplantation Techniques
  1. See V-Y Plasty
  2. Anesthesia
    1. See Digital Block
  3. 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
    5. Consider skin adhesive technique to control distal fingertip bleeding
      1. Apply finger Tourniquet (e.g. tourni-cot)
      2. De-engorge the finger using a venipuncture Tourniquet (dries the distal tip)
        1. Appy repeatedly from proximal to distal (expect to see dark blood from fingertip)
      3. Apply several layers of Tissue Adhesive to the fingertip
      4. Lin (2015) J Emerg Med 48(6):702-5 +PMID: 25886984 [PubMed]
  4. Zone II Fingertip Amputation
    1. Consider composite graft as above (if amputated tip is available)
    2. Dorsal Plane Amputation (angled toward finger dorsum)
      1. More nail bed avulsed than pulp
      2. Consider repair with V-Y Plasty
    3. Transverse Plane Amputation (perpendicular to finger)
      1. Equal amounts of nail bed and pulp avulsed
      2. Consider repair with V-Y Plasty
    4. Volar Plane Amputation (angled toward volar finger)
      1. More pulp avulsed than nail bed
      2. Do not use V-Y Plasty for this avulsion
  5. Zone III or Zone IV Fingertip Amputation
    1. Amputate distal phalanx
    2. Composite Graft (see above) is controversial in Zone III and IV injuries
      1. Contraindicated in some guidelines, but may be attempted with close follow-up
  • References
  1. Hori (2015) Crit Dec Emerg Med 29(3): 2-7