II. Classification: Ishikawa Subzones
- 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
- Zone IV Fingertip Amputation
- Region of distal phalanx adjacent to the DIP joint
- May be included in Zone III injuries in some classifications
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
- Update Tetanus status
- Tobacco Cessation (promotes improved Wound Healing)
-
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 by Hand Surgery Specialist
- Consider composite graft for Zone II amputations (see below)
- 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 stump site
VI. Management: Composite Fingertip Graft Reimplantation (by emergency clinician)
- Simple non-neurovascular attachment by emergency clinician
- Risks of graft necrosis, infection, poor functional or cosmetic outcome, or digital pain
- Procedure
- Anesthesia with Digital Block
- Apply digital Tourniquet (e.g. Tourni-Cot)
- May use an exam glove finger that has been cut off and tied at finger base
- Clean and Irrigate the wound
- Consider Fingernail removal and nail reattachment after amputated part is secured
- Prepare amputated part
- Consider excising protruding bone fragments and protruding fat
- Prepare the wound stump
- Consider debriding macerated skin edges
- Amputated Part Reattachment
- Align the amputated stump and amputated part
- Suture in place, typically with absorbable interrupted Sutures
- Replace Fingernail (if removed) and secure (see Nail Replacement)
-
Wound Dressing
- Antibiotic ointment (e.g. Bacitracin)
- Bulky dressing (e.g. tube gauze) - not too tight
- Consider finger splint
- Disposition
- Close follow-up within one week (preferably with hand specialist if available)
- Consider Antibiotics coverage (optional)
- May keep dressing in place until follow-up if this is available within a few days
- Otherwise, patient should recheck wound and re-dress daily after the first few days
- Return for graft necrosis, signs infection
- References
- Warrington (2024) Crit Dec Emerg Med 38(7): 18-9
VII. Management: Non-Reimplantation Techniques
- See V-Y Plasty
-
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
- Consider composite graft as above (if amputated tip is available)
- 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
- Zone III or Zone IV Fingertip Amputation
- Amputate distal phalanx
- Composite Graft (see above) is controversial in Zone III and IV injuries
- Contraindicated in some guidelines, but may be attempted with close follow-up
VIII. References
- Hori (2015) Crit Dec Emerg Med 29(3): 2-7