Slideshow
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Figure 1. Anteroposterior radiograph of right hand.
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Figure 2. Lateral radiographic view of right hand.
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Figure 3. Photograph of the injured thumb.
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Figure 4. Photograph of injured fingers.
A 65-year-old man presents to the emergency department with fingertip amputations to the thumb, index, and middle fingers of the right hand after a table saw injury that occurred 2 hours earlier. Radiographs of the hand (Figures 1 and 2) show bone loss of the distal phalanx of the thumb, index, and middle fingers. Photographs of the patient’s dorsal hand show the fingertip amputations (Figures 3 and 4). The index and middle fingers have more dorsal skin loss with a dorsal oblique fingertip amputation pattern. The thumb has more volar involvement with a volar-oblique type amputation pattern.
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Fingertip amputations can be extremely painful and complicated injuries that are best treated by a hand specialist. The goal of treatment is to save as much of the finger as possible while maintaining a functional digit. Factors that determine treatment include how much soft tissue is left on the finger, orientation of amputation (guillotine vs oblique), bone exposure, and whether more dorsal or volar skin is remaining.1,2
Partial fingertip amputations (<1.5 cm) without bone exposure and adequate skin on the volar side can often heal with primary closure or when left open to heal by secondary intention. Healing by secondary intention usually occurs within 4 weeks and is associated with less time out of work and fewer complications compared with flap procedures. Injuries with exposed bone and limited soft tissue coverage volarly often require removal of some or all of the distal phalanx to allow for skin closure. Any remaining nail bed should be visualized and removed to prevent a hook-nail deformity and digital nerves must be transected as far proximally as possible to prevent the development of a painful neuroma.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
References
1. DaCruz DJ, Slade RJ, Malone W. Fractures of the distal phalanges. J Hand Surg Br. 1988;13(3):350-352. doi:10.1016/0266-7681(88)90111-8
2. Neustein TM, Payne SH Jr, Seiler JG 3rd. Treatment of fingertip injuries. JBJS Reviews. 2020;8(4):e0182. doi:10.2106/JBJS.RVW.19.00182
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