Author: Dr. John Hurley
Editor: Dr. John Kiel
It is the same story but different person and day. The story changes ever so slightly consisting of a 29 yo M at a fish packaging plant or a 56 yo M working on his lawnmower but don’t forget the 47 yo F who works at a warehouse on the conveyor belt. Car, van, disposal, engine are also indicted. Different people with different lives but the mechanism, pathology and can’t miss exam findings are all the same.
What do we look for and how do we treat this patient with a distal phalanx crush, nail avulsion, fx? The management for an amputation of a digit, or part of a digit, is very similar with a focus on how the amputated specimen was cared for (wrapped in a bag on ice in another bag, etc) and which digit it was.
To start off we need to treat the patient with reassurance and pain medication because they may be confronting significant disfigurement or the loss of their dominant hand.
Consider PO or IV medication for pain and anxiety control so that you can adequately examine and interrogate the wound. Of course, do not forget to check on the patients Tetanus status. Once hemostasis is gained and sensation has been established for a baseline, then it is important to provide focused pain control for localized injury. This brings up the topic of systemic control versus local pain control including but not limited to joint, digital and hematoma blocks. That will not be covered here but there are countless resources available for you to create your own thoughts and practice styles.
Now the patient’s pain is controlled and a baseline sensory achieved. The wound must now be interrogated. Ensure once again that you have hemostasis, then evaluate with a 3 view Hand XR for fractures. Evaluate the functionality and stability of the FDS and FDP along with any bone that is exposed. This is followed with inspection to identify any nail bed or cuticle involvement. Once the extent of the damage is known then you will gather your supplies.
Know your Ortho departments wishes regarding tendon and bone involvement. Should you Rongeur the exposed bone or not? Do they prefer to use flaps, grafts or secondary intention for the soft tissue insult? What is their view on re-implantation of a digit or part of a digit (some departments only will consider re-implanting if the amputation involved the thumb, 2 or more fingers or is on a pediatric patient).
The cleaning and repairing of the wound is just walking down the path that you have already laid out. Ensure proper irrigation of the wound with copious amount of Tap or Sterile water, whichever you prefer. Ensure that the nail bed is sutured together with a small absorbable suture if it was involved and splint the cuticle open with a piece of aluminum (often taken from the suture packaging) ensuring that it stays open for future nail bed growth. Repair any other soft tissue concerns on the distal finger and then apply a non-adherent dressing followed by a finger splint ensuring the proper splinting positioning based on the presence of tendon involvement (flexion versus extension).
Ensure proper follow up with Ortho in the following 1-2 weeks and consider antibiotics, although there is limited evidence supporting the use of them in distal phalanx injuries as long as the wound was thoroughly irrigated and cleaned.