BOLD Bones: The crushed finger

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.  

Further Reading:

The Nuts & Bolts of Finger Amputation

A 21-year-old, right-hand dominant male without significant past medical history, presents to your emergency department after a pallet of bricks fell on his left, ring finger, while at work just prior to arrival. His vaccinations are up to date.

Fingertip Injury * LITFL * Bamboozler

aka Bone and Joint Bamboozler 011 A 56 year old women presents to your minor injuries room, holding a blood soaked tea towel around her middle finger. She reports her blender got jammed, and as she was attempting to fix it…the blender blades whirred into motion…

Fingertip Amputations: What YOU need to know – Brown Emergency Medicine

Case: A maintenance worker raised her hand blindly into a utility closet to fix a broken light and her hand hit part of a rapidly moving conveyor belt. She immediately pulls her hand back, but it is too late, blood is everywhere and her fingertip is found on the floor.

Fingertip injuries

Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

Jay Khadpe MD

Associate Professor of Emergency Medicine
Associate Residency Director
University of Florida College of Medicine – Jacksonville

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