History and Examination

The majority of fingertip injuries are isolated injuries and can be managed in the emergency department (ED). Complex or extensive injuries calling for skin grafting or technically demanding skills will require consultation with a specialist, as will those associated with other bodily injuries. Before evaluating the injury, an adequate history must be taken. Specific considerations must be taken into account if the digit involved is the thumb or index finger. In the thumb, it is crucial to establish a functional, sensate tip with preservation of as much length as possible. The second most important digit to consider is the index finger, where the goal is to preserve pinch.2 The mechanism of injury (crush versus clean cut), age, hand dominance, occupation, and future hand use will influence the method of repair. Where the function of the fingers is vital to the patient's occupation (e.g., that of a concert pianist), early consultation with a hand or plastic surgeon is necessary.

In all cases, however, one is dealing with contaminated wounds in the hand; therefore examination and care of the involved digit must begin with meticulous attention to wound care. In addition to active tetanus toxoid immunization, a severely contaminated wound—one that has been in contact with soil, feces, or organic material—may require passive immunization using tetanus immune globulin (TIG) at the time of presentation. Further examination of the involved digit includes assessment of the extent of damage to the soft tissue, the nail, and nail bed; the level and angle of amputation; the presence or absence of exposed bone; and vascular status (e.g., capillary refill). A sterile needle applied along either side of the involved digit can easily test for sensation. Similarly, the ability to flex and extend at the distal interphalangeal (DIP) joint suggests that the integrity of the flexor and extensor tendons is at least partially intact.

Radiographic evaluation with anteroposterior (AP), lateral, and oblique views of the involved finger is necessary to assess for bone injuries and retained radiopaque foreign bodies.

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