Fingertip injuries are commonly seen by family and emergency physicians. Many of the cases are simple to treat and do not need specialized treatment by a hand surgeon. However, there are certain conditions where early intervention by a hand surgeon is warranted for better functional and aesthetic outcomes. Common injuries include mallet finger injury, crush injuries to the fingertip with resultant subungual hematoma, nail bed laceration, partial or complete amputation of the fingertips, pulp amputations, and fractures of the distal phalanges.

The fingertip is the most distal portion of the finger providing the tactile and sensory functions that are then relayed to the brain. It is anatomically defined as the portion of the finger distal to the insertion of the flexor digitorum superficialis and extensor tendons on the distal phalanx, or the interphalangeal joint when referring to the thumb. The neurovascular supply of the fingertip is via digital arteries and nerves which trifurcate near the distal interphalangeal joint.

Types of Fingertip injuries

Allen’s classifications are based on the four types listed below

  • Type 1: involves only the pulp
  • Type 2: involves the pulp and nail bed
  • Type 3: includes partial loss of the distal phalanx
  • Type 4: injury proximal to the lunula

Type 1 injuries may heal quite well by secondary intention. Type 3 and type 4 often require some flap coverage.

Causes of Fingertip injuries

Fingertip injuries can be classified by the mechanism of injury or the level of injury based on the frequently used Allen classification system.The most common mechanisms seen include the following

  • Crush injury – due to forces of compression. An example is a door closing on the finger, injury with a hammer, and objects being dropped on fingers. This can present as a closed or an open injury and can be associated with distal phalanx fractures.
  • A laceration –  is secondary to a household instrument (knife, scissors, and cans) or works tools (rotatory saw) involving pulp or nail and/or the nail bed complex.
  • Injury to the fingertip – occurs with direct, blunt trauma, penetrating trauma, and crush injuries.
  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of broken and fractures.
  • Sports injuries – Many fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms Of Fingertip injuries

The most common symptoms include

  • Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
  • Swelling
  • Tenderness
  • Bruising
  • Obvious deformity, such as a bent  wrist
  • Pain
  • The wrist hanging in a deformed way
  • Pain, especially when flexing the wrist
  • Deformity of the wrist, causing it to look crooked and bent.
  • Your wrist is in great pain.
  • Your wrist, arm, or hand is numb.
  • Your fingers are pale.
  • Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the arm/hand.

Diagnosis of Fingertip injuries

History and Physical

The main component to focus on assessment are

  • History – handedness, occupation, time of injury, place of injury (work-related)
  • Mechanism of injury – magnitude, direction, point of contact, and type of force that caused the trauma
  • Soft tissue damage
  • Finger alignment – cascade, digit scissoring, rotational defect
  • Open vs. Closed
  • Tendon nerve vessel damage – tendon ruptures may accompany dislocations such as the terminal extensor tendon rupture in the distal interphalangeal joint dislocation or a central slip rupture in a proximal interphalangeal joint dislocation. Tendon damage otherwise only usually occurs with associated lacerations or open combined injuries. Nerves and vessels are rarely injured as part of a simple fracture or dislocation but often suffer injury in major open hand trauma.

Radiographs

Diagnostic tests to consider include

  • Radiographs – PA and lateral and oblique
  • CT – rarely needed. May occasionally be helpful in operative planning with complex peri-articular fractures such as pilon fractures at the base of middle phalanx fractures. It can be used to detect foreign bodies like plastic, glass, and wood.
  • Ultrasound – detect objects that lack radiopacity
  • MRI – unclear diagnosis, foreign material, or tumor

Mostly phalangeal fractures are described by location (head, neck, shaft, base) and pattern (transverse, spiral, oblique, comminuted).

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History and Physical

  • Patients present primarily with pain, inability to use the affected digit, or bleeding. Important points to elucidate are demographics (age, sex, occupation, and drug, tobacco, and alcohol use), hand dominance, involved digit, mechanism of injury, and previous medical and surgical conditions. Physical examination should be done in a controlled setting with appropriate lighting to allow for visualization of the injury and a proper assessment based on history. Findings may reveal lacerations, closed or open fractures, and amputations of the tip.

Evaluation

Evaluation should include assessing for sensation, the range of motion at the interphalangeal joints, and capillary refill. X-rays of the affected digit and hand with two to three views are required.

Consultation with a hand surgery service is required for the following

  • Possible tendon injuries
  • Fractures (displaced or intra-articular)
  • Dislocations, such as open dislocation
  • Significant finger avulsion
  • Extensive laceration involving the proximal fold (eponychium)
  • Amputations with significant bone exposure

Treatment of Fingertip injuries

Primary goals of treatment include pain relief and attempting to reduce bleeding. Management is based on the type and severity of the injury.

Non-Surgical

Treatment available can be broadly

  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your fingertip injuries, then get medical care immediately. Fingertip Injuries cause significant pain in the front part of your nail, closer to the base of your hand. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. 
  • Apply ice to your fractured area– After you get home from the hospital phalangeal fractures (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels.
  • Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for three to five weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

 

Rest Your hand

.Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
  • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
  • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the radial and phalangeal fractures 
  • Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re depending on the severity of the break and the specific sport.

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
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Follow-Up Care

  • You will need to see your doctor regularly until your injury heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Medication

The following medications may be considered your doctor to relieve acute and immediate pain

Differential Diagnosis

Subungual Hematoma

  • A subungual hematoma is due to a crushing injury. It occurs commonly from workplace accidents and presents as severe, throbbing pain with nail discoloration. It is due to a disruption of the blood vessels of the nail bed. A potential space exists between the nail plate and the underlying nail bed and matrix.
  • More than 50% of such injuries require the trephination of the nail plate to allow decompression and drainage of the hematoma.
  • If it is associated with a fracture of the distal phalanx, examination of the nail bed is suggested, followed by immobilization using an aluminum splint until the patient has no further pain.

Nailbed Injuries

  • Nail and nail bed injuries include simple and complex lacerations, avulsion injuries, and amputations. Beware those nail bed injuries are usually associated with a partial or a complete fingertip avulsion.
  • Simple and complex lacerations should be approximated as best as possible while maintaining tissue integrity and cosmesis. In the pediatric population, absorbable sutures should be used, to mitigate the need for removal.
  • If there is associated partial nail avulsion or surrounding nail fold disruption, then nail removal is required. In general, when the nail bed is avulsed, it should always be repositioned, to obtain an anatomical reconstruction of the fingernail. Lacerations of the nail bed require blunt removal of the nail and primary closure of the nail bed with absorbable sutures. The nail should then be replaced to allow new nail growth, by maintaining the nail fold space. Beware that up to 50% of nail bed injuries may have an associated fracture of the distal phalanx. Avulsion injuries involving the nail bed have a poor prognosis.
  • Closed fractures that are minimally displaced can be splinted. If angulated or displaced, closed reduction is required displaced closed reduction is required with post-reduction films and outpatient follow-up. Unstable and intra-articular fractures necessitate evaluation by orthopedic or hand surgeons, as the operative intervention is often required. Open fracture management includes a digital nerve block, irrigation, and soft tissue repair. This also will stabilize the fracture allowing for the aluminum splint placement. The patient should receive antibiotics, and close follow-up is needed either by a hand or an orthopedic surgeon.
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Seymour Fractures (open physeal fracture of the distal phalanx)

  • Such fractures often occur through the cartilaginous growth plate. The insertion of the extensor tendon is proximal to the insertion of the flexor digitorum profundus. Fractures through the growth plate resulting in an extension of the proximal fragment and flexion of the distal fragment of the distal phalanx.
  • These fractures are usually open and are associated with relatively high rates of infection as well as growth arrest. Seymour fractures may mimic mallet fingers at presentation; but, the displacement occurs through the fracture rather than the distal interphalangeal (DIP) joint.

Mallet Finger

The mechanism of injury, in this case, is a flexion force directed to an actively extended finger. The extensor tendon avulses a fragment of the epiphysis resulting in an intraarticular fracture that may also extend into the metaphysis of the distal phalanx.  It is recognized as a Salter-Harris Type III or Type IV fracture.

A mallet finger occurs due to the disruption of the extensor mechanism presenting as a flexion deformity since it results in the inability to extend the DIP joint. It is the most common tendon injury among athletes.

It can be classified as follows

Type I tendon-only rupture

  • Requires an immobilized DIP joint in continuous full extension for six to ten weeks

Type II small avulsion fracture

  • Is similar to type I (if on x-ray, the splinted finger in extension is congruent with the rest of the non-injured articular surface of the distal phalanx on the distal articular surface of the middle phalanx)
  • Surgical intervention is required if an open injury is present, and 30% to 50% articular fracture is involved.

Type III  more than 25% of the articular surface is involved

  • This can be managed conservatively in most cases, except when associated with bony avulsion involving a third or more of the articular surface of the distal phalanx. At the opposite end of the spectrum is the flexor digitorum profundus avulsion, due to a forced extension of the flexed finger. In this case, the patient presents with a finger in extension and unable to flex at DIP Joint. Operative intervention is warranted.

Swan-neck Deformity

  • It causes extension of the proximal interphalangeal (PIP) joint due to the dorsal displacement of lateral bands. Chronic untreated mallet finger results in this deformity.

Boutonnière Deformity

  • This causes an extension of the DIP joint. The initial treatment includes immobilization of the PIP joint in continuous extension for five to six weeks, and hand surgery service follow-up.

Amputation

  • Amputations present a challenge in preserving function and restoring cosmesis. Non-operative management is indicated when there is no bone or tendon becomes exposed with less than 2 cm of skin loss. Operative primary closure can be performed if the exposed bone to be removed will not proximally compromise bony support to the nail bed. Flap reconstruction is indicated when removal of bone will compromise nail bed support. Several flap techniques have been described for finger and thumb amputations. These include V-Y plasty, home digital neurovascular island flap, and first dorsal metacarpal flap.
  • Secondary infections due to minor injuries such as a splinter, thorn, or nail-biting present either as a paronychia or felon. Paronychia involves the folds around the nail structures, and a felon abscess affects the fingertip pulp space. Pain, redness with a decreased movement of the affected digit are the most common manifestation. These entities require early evaluation, antibiotics, warm water or Betadine soaks, and possible incision and drainage when severe.

References

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