Fingertip Injuries
Fingertip injuries
Definition
Fingertip injuries include any wounds to the area at tip of the finger. They range from a simple bruise or scrape to having the fingertip taken off. Fingertip injuries occur frequently in infants and children because hands are used to explore surroundings and play .
Description
Fingers each have three bones (phalanges); the thumb has two. The fingertip consists of the uppermost phalanx with surrounding muscle, tissue, nerves, and nail. A fingertip is a highly complex structure, with many specialized features, one of which is a rich network of sensory nerves. The fingernail is called the nail plate. Underneath the nail plate is the nail bed, the mostly pink tissue seen under the nail. The pulp is the area of skin opposite the fingernail and is usually very vulnerable to injury. Fingertip injuries are extremely common and varied. Blunt or crush injuries can cause bleeding under the nail plate (subungual hematomas), which can be very painful. Nails can also be torn off (nail avulsions), and the fingertip bone can be broken (fracture). Sharp or shearing injuries from knives and glass result in cuts (lacerations) and punctures. Occasionally, the end of the fingertip is torn off (amputated). When portions of the fingertip are missing, the injury is described as a partial amputation. When the finger is cut more than halfway through, the injury is described as a subtotal amputation. Burns and frostbite also commonly injure fingertips.
Demographics
In the United States, fingertip injuries account for approximately two-thirds of hand injuries in children. Damage to the nail bed is reported to occur in 15–24 percent of fingertip injuries. A Florida study of hand injuries in children conducted in 2002 showed that the most frequent hand injury setting was outdoors (47%). The most frequent injuries were lacerations (30%), followed by fractures (16%). The fingers were the most commonly injured part of the hand, particularly the thumb (19%), and fingertips were involved in 21 percent of cases. Children younger than two years suffered fingertip injuries mostly inside the home.
Causes and symptoms
In children, fingertip injuries are the result of accidents occurring at play or in the home. They involve cuts, by glass, knives, or other sharp objects; or crushing injuries, as when the fingertip gets caught in a door or window or is hit by a hammer or rock. Symptoms depend on the nature of the fingertip injury and may include some of the following:
- pain
- bleeding
- swelling
- tissue loss
- movement restriction
- amputation
When to call the doctor
Parents should always see a doctor right away if their child injures the tip of a finger or thumb. Fingertips contain many nerves and are extremely sensitive. Without prompt and proper care, a fingertip injury can disrupt the complex function of the hand, resulting in permanent deformity and disability. Bleeding from minor fingertip cuts often stop on its own with direct pressure applied to the wound with a clean cloth. If continuous pressure does not slow or stop the bleeding after 15 minutes, an emergency room visit is indicated.
Diagnosis
The treating physician begins a diagnosis by carefully evaluating the fingertip injury. Bones and joints are examined for motion and tenderness. Nerves are examined for sensory (feeling sensations) and motor (movement) function. As part of injury diagnosis, the treating physician also considers the following factors:
- nature of injury (crush or sharp)
- nail or nail bed involvement
- bone involvement
- viability the tip
- presence of foreign bodies
X rays may be required either to assess alignment of fingertip phalanx fractures or to detect presence of foreign bodies.
Treatment
Doctors provide individualized treatment for fingertip injuries based on the nature and extent of the injury. The treating physician usually gives an injection (digital block anesthesia) to stop pain in the affected finger. Then he or she may rinse the wound (irrigate) with a saline solution, inspect it for exposed bone, soft tissue loss, and nail or nail bed injury. Infected or dead tissue or foreign materials are also removed (debridement) to reduce risk of infection. If blood has accumulated under the nail (subungual hematoma), the doctor may drain it by piercing through the fingernail. Antibiotics and a tetanus shot may also be prescribed. The goal of treatment is a painless fingertip that has durable and feeling skin. A normal fingertip has sensation without pain, stable pulp padding, and an acceptable appearance. The hand should be able to pinch, grip, and perform other normal functions. In cases of severe injury and whenever possible, the doctor will try to maintain the fingertip's length and appearance and preserve its fingernail.
Surgery
Fingertip injuries often require surgical treatment, usually performed with local anesthesia. Fingertip repair surgery includes the following:
- Sutures: Laceration wounds are stitched (sutured) after application of a digital block.
- Nail bed surgery: If the nail bed is injured, the nail plate may be removed, the bed carefully debrided and repaired. The nail plate is then reinserted and the injury dressed. A finger splint may be applied.
- Fingertip amputation: Various methods are used for amputation injuries including simple amputation of the fingertip, full or partial skin grafts, and skin flaps.
- Reconstructive flap surgery: If a fingertip injury exposes bone, and there is not enough tissue available on the fingertip to close it, the surgeon may need to shorten the bone and transfer a piece of skin and underlying fat and blood vessels from a healthy part of the patient's body to the injury site. A bulky dressing and splint supports the hand after surgery, with uninjured fingers left free to exercise . A second operation may be necessary after a few weeks to detach the flap from its origin.
- Fractured phalanx: In case of fingertip bone fracture, the bone is straightened and put in a splint or cast. A temporary metal pin may also be inserted into the bone to hold it in place until bone growth occurs. If bone is partly missing, the finger may be shortened or the surgeon may use a bone graft.
Prognosis
The outcome depends on the extent of traumatic damage to the fingertip and whether surgery is required. Small wounds to a fingertip's skin and pulp usually close on their own with complete healing within three to five weeks. In 60 percent of patients with subungual hematomas that involve more than 50 percent of the nail surface, laceration is repairable. This prognosis increases to over 95 percent when an associated fracture of the phalanx is present. Nail lacerations that are not treated may cause nail deformities. The average healing time for fingertip amputation is 21–27 days. In many cases, fingertip repair surgery gives back a large degree of feeling and function. However, infection, poor healing, loss of feeling or motion, blood clots, and adverse reactions to anesthesia are all possible complications of surgery. Mild to severe pain and sensitivity to cold following treatment for a fingertip amputation sometimes occur.
Prevention
Children should at all times be supervised in their activities. Parents should not allow children to use sharp tools and knives without supervision. They should teach them to always wash and thoroughly dry any tool or knife before use. Children should also be taught how to use knives properly, to always cut away from themselves, and to cut in small, controlled strokes.
Parental concerns
Parents should be aware that recovery from a serious fingertip injury may take months and require hand therapy. This may include hand exercises to improve movement and strength, heat and massage therapy , electrical nerve stimulation, splinting, traction, and special wrappings to control swelling.
KEY TERMS
Avulsion —The forcible separation of a piece from the entire structure.
Debridement —The surgical removal of dead tissue and/or foreign bodies from a wound or cut.
Laceration —A cut or separation of skin or other tissue by a tremendous force, producing irregular edges. Also called a tear.
Nail bed —The layer of tissue underneath the nail.
Phalanx —Plural, plananges. Any of the digital bones of the hand or foot. Humans have three phalanges to each finger and toe with the exception of the thumb and big toe which have only two each.
Sensory nerves —Sensory or afferent nerves carry impulses of sensation from the periphery or outward parts of the body to the brain and spinal cord.
Subungual hematoma —Accumulation of blood under a nail.
Tetanus —A potentially fatal infection caused by a toxin produced by the bacterium Clostridium tetani. The bacteria usually enter the body through a wound and the toxin they produce affects the central nervous system causing painful and often violent muscular contractions. Commonly called lockjaw.
See also Frostbite and frostnip.
Resources
BOOKS
Ziegler, Moritz, et al. Operative Pediatric Surgery. New York:
McGraw-Hill, 2003.
PERIODICALS
Boyd, R., and C. Libetta. "Reimplantation of the nail root in fingertip crush injuries in children." Emergency Medical Journal 19, no. 2 (March 2002): 341–45.
Braga-Silva, J., and M. Jaeger. "Repositioning and flap placement in fingertip injuries." Annals of Plastic Surgery 47, no. 1 (July 2001): 60–3.
Fetter-Zarzeka, A., and M. M. Joseph. "Hand and fingertip injuries in children." Pediatric Emergency Care 18, no. 5 (October 2002): 341–45.
Wang, Q. C., and B. A. Johnson. "Fingertip injuries." American Family Physician 63, no. 10 (May 2001): 1961–66.
ORGANIZATIONS
American Academy of Orthopaedic Surgeons (AAOS). 6300 North River Road, Rosemont, IL 60018–4262. Web site: <www.aaos.org>.
American College of Surgeons. 633 N. Saint Clair St., Chicago, IL 60611–3211. Web site: <www.facs.org>.
American Society for Surgery of the Hand (ASSH). 6300 North River Road, Suite 600, Rosemont, IL 60018. Web site: <www.assh.org>.
WEB SITES
"Fingertip Injuries/Amputations." Your Orthopaedic Connection, April 2001. Available online at <www.orthoinfo.org/fact/thr_report.cfm?Thread_ID=276&topcategory=Hand> (accessed November 29, 2004).
"Fingertip Injuries." HandWorld. Available online at <www.eatonhand.com/hw/hw011.htm> (accessed November 29, 2004).
Vaughn, Glen. "Fingertip Injuries." eMedicine, November 4, 2004. Available online at <www.emedicine.com/emerg/topic179.htm> (accessed November 29, 2004).
Monique Laberge, Ph.D.
Fingertip Injuries
Fingertip Injuries
Definition
Fingertip trauma covers cuts, accumulation of blood (hematoma), bone breakage, or amputation in the fingertip.
Description
The fingertips are specialized areas of the hand with highly developed sensory and manipulative functions. Large sensory and motor areas located in the brain regulate the precise and delicate functions of fingertips. The fingertip is the site where extensor and flexor tendons insert. Fingertip injuries are extremely common since the hands hold a wide array of objects. In 2001, the approximately 10% of all accidents in the United States referred for Emergency Room consults involve the hand. Hand injuries are frequently the result of job injuries and account for 11-14% of on-the-job injuries and 6% of compensation paid injuries. Injury to the nail bed occurs in approximately 15-24% of fingertip injuries.
Fingertip injuries can result in amputation or tissue loss. The injury is assessed whether the bone and underlying tissue are intact and the size of the wound area. The pulp is the area of skin opposite the fingernail and is usually very vulnerable to injury. Pulp injuries commonly occur in persons who use or are in close contact with fast moving mechanical devices. These injuries can crush, cut, and puncture. The fingertips can also be injured by common crushing accidents. This could cause the development of a subungal hematoma (an accumulation of blood under the nail). At the base of the distal phalanx (the first circular skin fold from the tip) injuries can occur that can fracture the underlying bone in the area. Quite commonly a hammer, closing a door, or sport accidents usually cause these injuries. These fractures can be simple, requiring little treatment or more complicated involving the joint. The accident may involve the point of insertion of a tendon. Usually this occurs when the terminal joint is being forced to flex while held straight. This motion typically occurs when tucking in sheets during bed making, a common cause of tendon injury. This injury causes a loss of extension (straightening the finger) ability.
Causes and symptoms
Accidental amputations will usually result in profuse bleeding and tissue loss. Injuries to the pulp can occur as from fast moving mechanical instruments, such as drills. These injuries may puncture the pulp. Injuries such as a subungal hematoma are caused by a crushing type injury. Fractures typically occur as the result of crushing injuries or tendon avulsion. These crushing injuries are frequently caused during sport injury and can be treated by simple interventions such as immobilization or more complex procedures if tendons are affected (the trauma is then treated as a tendon injury). Fractures can cause pain and, depending on the extent of swelling, there may be some restriction of movement. Tendon injuries can be caused when the terminal joint is exposed to force flexing motion (moving the finger toward the palm) while held straight.
Diagnosis
The attending clinician should evaluate the injury in a careful and systematic manner. The appearance of the hand can provide valuable information concerning presence of fractures, vascular status, and tendon involvement. Bones and joints should be evaluated for motion and tenderness. Nerves should be examined for sensory (feeling sensations) and motor (movement) functioning. Amputations usually profusely bleed and there is tissue loss. The wound is treated based on loss of tissue, bone, and wound area. Injuries to the pulp can be obvious during inspection. Subungal hematoma usually present a purplish-black discoloration under the nail. This is due to a hematoma underneath the nail. Radiographs may be required to assess the alignment of fractures or detect foreign bodies. Patients usually suffer from pain since injuries to the fingertip bone are usually painful and movement may be partially restricted due to swelling of the affected area. Tendon injuries usually result in the loss of ability to straighten or bend the finger.
Treatment
Amputation with bone and underlying tissue intact and a wound area 1 cm or less should be cleaned and treated with a dressing. With these types of wounds healthy tissue will usually grow and replace the injured area. Larger wounds may require surgical intervention. Puncture wounds should be cleaned and left open to heal. Patients typically receive antibiotics to prevent infection. A procedure called trephining treats subungal hematomas. This procedure is usually done with a straight cutting needle positioned over the nail. The clinician spins the needle with forefinger and thumb until a hole is made through the nail.
Patients who have extensive crush injuries or subungal hematomas involving laceration to skin folds or nail damage should have the nail removed to examine the underlying tissue (called the matrix). Patients who have a closed subungal hematoma with an intact nail and no other damage (no nail disruption or laceration) are treated conservatively. If the fracture is located two-thirds below the fingertip immobilization using a splint may be needed. Conservative treatment is recommended for crush injuries that fracture the terminal phalanx if a subungal hematoma is not present. Severe fractures near the fist circular skin crease may require surgical correction to prevent irregularity of the joint surface, which can cause difficulty with movement. Injury to a flexor tendon usually requires surgical repair. If this is not possible, the finger and wrist should be placed in a splint with specific positioning to prevent further damage.
Prognosis
Prognosis depends on the extent of traumatic damage to the affected area. Nail lacerations that are not treated may cause nail deformities. When amputation is accompanied with loss of two-thirds of the nail, half of the fingers develop beaking, or a curved nail. Aftercare and follow up are important components of treatment. The patient is advised to keep the hand elevated, check with a clinician two days after treatment, and to splint fractures for two weeks in the extended position. Usually a nail takes about 100 days to fully grow. Healing for an amputation takes about 21 to 27 days. This markedly decreases in elderly patients, primarily due to a compromised circulation normally part of advancing age.
Resources
BOOKS
Townshend, Courtney M., et al. Sabiston Textbook of Surgery. 16th ed. W. B. Saunders Company, 2001.
KEY TERMS
Distal— Movement away from the origin.
Flex— To bend.
Laceration— A cut in the skin
Phalanx— A bone of the fingers or toes.
Tendon— A structure that connects a skeletal muscle to bone.
Mallet Finger
Mallet Finger
Definition
Mallet finger refers to the involuntary flexion of the distal phalanx of a finger caused by the disruption or tearing of its extensor tendon.
Description
Tendons are the strong "cables" between muscles and bones that help control movements of the body. They consist of white, glistening, fibrous cords, of various length and thickness, either round or flattened, and lacking in elasticity. In mallet finger, which often occurs as a sports-related injury, the tendon on the back of the finger becomes damaged or torn near the outermost joint. Without the support provided by the tendon, the short bone at the tip of the finger drops downward at an awkward angle. This bone, referred to as the "distal phalanx" of a finger, is the one furthest from the palm. In addition to tendon damage, mallet finger may involve a fracture of the distal phalanx. Mallet finger is sometimes called baseball finger.
Causes and symptoms
Mallet finger usually occurs while playing a sport that involves a ball—for example, reaching out to catch a hard pass in basketball or bare-handing a baseball. Instead of landing on the palm of the hand, the ball accidentally hits the tip of an extended (or partially extended) finger. This straight-on impact causes instantaneous stretch of the tendon, which may overextend or tear away. Mallet finger can also result from hitting the hand against a hard object or receiving a cut from a sharp edge such as a knife.
Symptoms of mallet finger include pain and swelling around the top part of the finger, near the outermost joint. These symptoms occur right after the injury. Redness and swelling develop soon afterward. The tip of the finger has an abnormal-looking downward droop, and it may be difficult to fully extend the finger.
Diagnosis
Mallet finger is usually diagnosed after a relatively brief physical examination conducted by an emergency care physician or by an orthopedist, the type of doctor who specializes in such injuries. The downward droop of the fingertip is the major indication of mallet finger, along with the tenderness and pain that occurs in the affected area. X rays will be taken to determine if the bone at the top of the finger has been fractured. Mallet finger is typically covered by medical insurance.
Treatment
If symptoms of mallet finger appear, the affected individual should consult a physician or seek emergency care. In the meantime, ice (wrapped in a towel or cloth) can be applied to the affected area to help reduce swelling and alleviate pain.
Treatment usually involves wearing a splint around the top of the affected finger in order to keep it extended and allow the injury to heal. The splint must be worn at all times for six to eight weeks, though it may be briefly removed to wash the finger, but with extreme care so as not to allow the fingertip to bend. For the next six to eight weeks after that, the splint need only be worn during sleep or athletic activities.
If the bone at the top of the finger has sustained a large fracture, surgery may necessary. If the tendon was damaged due to a cut, stitches may be required both to repair the tendon and to adequately close the wound.
Over-the-counter (OTC) or prescription pain medication can be used to alleviate pain.
Alternative treatment
Acupuncture, therapeutic massage, and yoga are believed by some practitioners of alternative medicine to have generalized pain-relieving effects. Any of these therapies may provide additional comfort while the finger heals.
Prognosis
With proper treatment, most people regain full use of the affected finger.
Prevention
Caution should be used when playing ball sports or using knives or other sharp implements.
Resources
BOOKS
Brukner, Peter, et al. Clinical Sports Medicine : McGraw-Hill, 2000.
PERIODICALS
Lester, B., et al. "A simple effective splinting technique for the mallet finger." American Journal of Orthopedics March 2000: 202-6.
Takami H, et al. "Operative treatment of mallet finger due to intra-articular fracture of the distal phalanx." Archives of Orthopaedic and Trauma Surgery 120 (2000): 9-13.
ORGANIZATIONS
American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, IL 60018-4262. (800) 346-AAOS. 〈http://www.aaos.org〉.
KEY TERMS
Distal Phalanx— The outermost bone of any finger or toe.
Fracture— A break in bone.
Orthopedist— A doctor who specializes in disorders of the musculoskeletal system.
Phalanx— Any of the digital bones of the hand or foot. Humans have three phalanges to each finger and toe with the exception of the thumb and big toe which have only two each.
Tendon— A tough cord of dense white fibrous connective tissue that connects a muscle with some other part, especially a bone, and transmits the force which the muscle exerts.