Missing Something....Fingertip Amputations

HPI:
Middle age male with no significant PMH presents to the ED after amputating his right index distal fingertip. 

Physical Examination: Patient has a right transverse (slightly volar oblique) index fingertip amputation with distal tuft visible within the wound. The laceration grazed the nailbed. Sensation is intact in the radial/medial/ulnar distributions of the hand including throughout the index finger. Radial pulse is palpable and the finger has good capillary refill. 

Radiology:
XR of right hand is notable for distal tuft amputation but negative for foreign body. 

Management:
Approximately 1mm of the nail plate was removed exposing the edge of the nailbed. Soft tissues, including the fat volarly and the nailbed dorsally were elevated off of the distal phalanx. Distal phalanx was then rongeured until sufficient soft tissue could be mobilized to cover the bone. The soft tissue was then sutured close. The wound was covered with Xeroform and dressed. Ancef was given prior to discharge. Orthopedic follow up was arranged for the following day. 

Discussion:

• Fingertip amputations are commonly encountered in the ED. Goals of treatment are to preserve as much of the finger as possible and leave bone support for nail growth. Initial management includes a thorough history surrounding the mechanism of amputation as well as an extensive physical examination to range of motion to assess tendon involvement and extent of exposed bone. Obtain AP/lateral radiographs to assess for bony involvement.  Treatment depends on extent of fingertip amputation. 
  
• Patients with no bone or tendon exposed with less than 2cm of skin loss are typically managed non-operatively with healing by secondary intention
  
• Revision amputation or primary closer is reserved for amputation with exposed bone and the ability to rongeur bone proximally without compromising the nail bed
  
• Patients with no exposed bone but greater than 2cm of tissue loss require full thickness skin grafting from the hypothenar region 
  
• More complicated amputations with exposed bone or tendon and rongeuring is not possible will require complex flap recontronction
  

Key Points:

• Extensive history and physical are essential to evaluate the mechanism and extent of injury
  
• Bone and tendon involvement as well as extent of soft tissue injury dictate operative versus non-operative management
  
• Involve orthopedic consultants early for any bone or tendon involvement, especially in the dominant hand