eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Fingertip Injuries: Treatment & Medication
Updated: Oct 6, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Care for amputated part
- Cleanse gently.
- Cover in a saline-soaked gauze wrap.
- Place amputated part in a watertight bag.
- Place watertight bag with amputated part on water and ice for preservation.
- To avoid cold injury, do not place the amputated part directly on ice.
Emergency Department Care
- Preserve length, padding, and sensation of finger to the degree possible.
- Preserve proper nail growth capacity and function by paying specific attention to the eponychium.
- Prevent infection by considering prophylactic antibiotics.
- Minimize joint stiffness.
- Limit employment disability.
- Use a digital block to provide local anesthesia and avoid further swelling of the fingertip with direct infiltration of anesthesia into the affected area.
- Lacerations
- Suture simple lacerations with 5-0 or 6-0 nylon. Subcutaneous or deep dermal sutures are not indicated.
- Remove nail and inspect matrix when fingertip lacerations involve nail and injuries that avulse, split, or disrupt it. Replace all retrievable fragments of nail matrix as free grafts.
- Repair nail matrix according to the following steps:
- Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain.
- Remove nail.
Removal of the nail plate with iris scissors.
- Debride gently.
- Clean and remove all foreign bodies.
- Repair nail matrix meticulously with fine absorbable suture (6-0 Monocryl).
Suturing of a nailbed laceration.
- Reinsert nail plate or substitute.
- Tack the nail to the paronychia using suture material (6-0 Monocryl) or use a topical adhesive (eg, Histoacryl blue, 2-Octyl-cyanoacrylate) to secure the nail plate in place of sutures. Chloramphenicol ointment has also been suggested as an adhesive.
- Apply sterile nonadherent dressing and splint.
- Subungual hematoma
- Use electrocautery or a heated paperclip. A sharp instrument, such as an 18-gauge needle, should be avoided to prevent deep soft tissue injury.
- For patients who have significant crush injuries or subungual hematomas that involve lacerations to skin-fold or disrupt the nail, remove the nail and inspect the matrix.
- Conservative treatment without nail removal is recommended for patients with closed hematomas and an intact nail with no laceration to skin fold or nail disruption.3
- Conservative treatment also is indicated for crush injuries that fracture the terminal phalanx but do not cause a subungual hematoma.
- Fingertip amputations
- Treatment is either surgical or conservative. The boundary between surgical and conservative treatment depends on the extent of involvement of the pulp, nail, and bone. Various surgical methods are used for amputation injuries including simple revision amputation, full- or partial-thickness skin grafts, local flaps, distal flaps, and neurovascular island pedicle flaps.4,5
- Distal fingertip amputations may be treated conservatively in the ED. Various treatments may be provided in ED depending on the emergency physician's skills, training, and time availability. However, for distal amputations that involve significant tissue loss, the physician should discuss a treatment plan with the follow-up hand surgeon.
- Steps for conservative therapy
- Administer anesthesia with a digital block and establish a bloodless field with a Penrose drain.
- Clean thoroughly with sterile solutions.
- Remove protruding bone with a bone rongeur to a level 3-5 mm below that of surrounding tissue.
- Apply sterile nonadherent dressing over the amputated part.
- Removal of splinter under nail
- Administer anesthesia with a digital block.
- Unroof the splinter by trimming the nail with iris scissors.
Consultations
- Hand surgeon
Medication
The goal of pharmacotherapy is to reduce pain. Tetanus immunization also may be indicated.
Nonsteroidal anti-inflammatory agents (NSAIDs)
Commonly used for relief of mild to moderate pain. Effects of NSAIDs in treating pain tend to be patient specific, yet ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, naproxen, and ketoprofen.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for treatment of mild to moderate pain, if no contraindications are present. Inhibits inflammatory reactions and pain probably by decreasing activity of the enzyme cyclooxygenase, which inhibits prostaglandin synthesis.
Adult
200-400 mg PO q4-6h prn; not to exceed 3.2 g/d
Pediatric
<6 years: Not established
6 months to 12 years: 10 mg/kg q6-8h; not to exceed 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses >75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 14 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg PO bid; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Flurbiprofen (Ansaid)
Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis that may result in analgesic and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d PO is fine
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose PO based on codeine content q4-6h or 1-2 tabs q4h; not to exceed 12 tabs/d
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone bitartrate and acetaminophen (Vicodin ES)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose PO oxycodone; not to exceed 5 mg/dose of oxycodone q4-6h prn
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen that patient is receiving; do not exceed 4000 mg/24 h of acetaminophen (higher doses may cause liver toxicity)
Toxoid
Used for tetanus immunization. Administer booster injection in previously immunized individuals to prevent this potentially lethal syndrome.
Tetanus toxoid
Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children aged >7 years are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. May administer into deltoid or midlateral thigh muscles in children and adults. In infants, preferred site of administration is the mid thigh laterally.
Adult
Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is, nevertheless, clinically insignificant and does not preclude its concurrent use)
Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
Immunoglobulins
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
Tetanus immune globulins (Hyper-Tet)
Used for the passive immunization of persons with wounds that may be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3000-10,000 U IM
Pediatric
Prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3000-10,000 U IM
None reported
Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications because they are usually incompatible
More on Fingertip Injuries |
| Overview: Fingertip Injuries |
| Differential Diagnoses & Workup: Fingertip Injuries |
 Treatment & Medication: Fingertip Injuries |
| Follow-up: Fingertip Injuries |
| Multimedia: Fingertip Injuries |
| References |
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References
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Further Reading
Keywords
fingertip injury, fingertip injuries, finger tip injury, blunt injuries, crush injuries, subungual hematomas, nail root avulsions, fractures of the terminal phalanx, sharp injuries, shearing injuries, fingertip lacerations, avulsed fingertip, fingertip burns, fingertip frostbite, terminal phalanx, hand injuries, damage to the nailbed, fingertip amputations, nailbed laceration
