Menu Search Donate
clinical guideline banner

Fingertip injuries - management of

This document is only valid for the day on which it is accessed. Please read our disclaimer.

Introduction

  • Fingertip injuries in children are common
  • They can be managed conservatively with cleaning and dressing, repaired without removing the nail, or the nail can be removed and the nail bed repaired
  • Repair can be with tissue adhesive Dermabond (2-octylcanoacrylate) or absorbable sutures (Vicryl Rapide)
  • Dermabond is equivalent to sutures for nail bed repair in adults
  • Dermabond is acceptable for nail bed repair in children
  • Repair can occur in the Emergency Department or in the Operating Theatre
  • Emergency Department sedation may be required depending on the age of the child
  • All patients should be discussed with a senior clinician to decide the best treatment option

Anatomy

Fingertip diagram EMA 2006

(De Alwis, W. Fingertip Injuries. Emergency Medicine Australasia 2006.)

  • The nail plate grows from the germinal matrix along the nail bed (sterile matrix)
  • It is held in place by the proximal nail fold (eponychium / cuticle) and the lateral nail folds (paronychium)

Management

The following injuries should be referred to Orthopaedics for surgical repair in an operating theatre:

  • < 12 months old
  • Contraindication to ED procedural sedation (see Sedation guideline)
  • Ischaemic fingertip (CRT > 2 seconds)
  • Partial amputation (>50% of the lateral height)
  • Any fracture other than an isolated tuft fracture
  • ED unable to provide procedural sedation due to clinical priorities

Suggested Care

  • Isolated subungal haematomas should be treated conservatively with nail trephination only if pain is significant
  • Soft tissue lacerations should be repaired with either Dermabond or sutures
  • If the nail plate is damaged or avulsed, it should be removed and any nail bed lacerations repaired with Dermabond
  • Conservative management can be considered for nail plate injuries especially if nail plate is firmly attached at the proximal nail fold

Conservative Management

  • Irrigate finger
  • Apply Mepitel lubricated dressing
  • Apply gauze
  • Secure with Hypafix retention dressing

Repair WITHOUT Nail Removal

  • Consider procedural sedation
  • Chlorhexidine to finger
  • Consider Digital Nerve Block ( see below)
  • Irrigate finger
  • Repair skin lacerations with Vicryl Rapide sutures or Dermabond
  • Dressing as above

Repair WITH Nail Removal

  • Consider procedural sedation
  • Chlorhexidine to finger
  • Digital Nerve Block ( see below)
  • Irrigate finger
  • Apply digital tourniquet
  • Repair skin lacerations with Vicryl Rapide sutures or Dermabond
  • Remove nail plate by blunt dissecting with pointed tip Iris scissors (see picture below)
  • Repair nail bed lacerations with Dermabond
  • Re-insert nail plate under proximal nail fold and secure with Dermabond
  • If the nail is missing, sterile foil from a suture packet can be used instead
  • Dressing as above
  • Place in Boxing Glove bandage
  • Discharge on oral antibiotics ( see below)

nail1  nail2  nail3  nail4

nail5  nail6  nail7    nail8

Follow up

  • Patient should be reviewed at 1 week by GP for a dressing change and to check for signs of infection
  • Parents should be informed it will take up to 4 months for a new nail to fully grow

Regional Block

  • There are two approaches to provide regional anaesthesia to the finger
  • The dorsal approach blocks each digital nerve proximally
  • The volar approach requires one injection and uses the flexor tendon sheath to spread local anaesthetic only to the finger tip
  • A sterile technique with chlorhexidine skin prep is required for both approaches
  • Lignocaine works within 5-10 minutes and provides analgesia for up to 5 hours. Maximum dose is 3mg/kg
  • Bupivacaine works within 10-20 minutes and can provides analgesia for up to 24 hours. Maximum dose is 2mg/kg

Dorsal Approach

  • One injection each side of the finger
  • Direct the needle towards the volar side of the proximal phalanx
  • Aspirate before injecting
  • Continue injecting as you withdraw the needle

Dorsal approach 1

(Digital Nerve Block, New York School of Regional Anaesthesia. http://www.nysora.com)

Volar Approach

  • A single injection is made at the base of the finger in the midline
  • Direct the needle at 45 degrees to the skin injecting as you advance the needle
  • A loss of resistance indicates the needle is in the flexor tendon sheath
  • Injecting local anaesthetic at this point should cause swelling of the finger

 Volar approach

(Monsef Kasmaei V et al. Comparison of the single injection volar subcutaneous block and the two injection dorsal block for digital anaesthesia. Health 2013.)

Oral Antibiotics

  • Injuries with a nail bed laceration and tuft fracture are open fractures
  • There is poor evidence that prophylactic antibiotics prevent infection in finger tip injuries, even with an associated fracture
  • Oral antibiotics should be considered if the nail plate is removed
  • Cephalexin 25mg/kg twice daily for five days is a suitable choice

References

  • Interventions for treating fingertip entrapment injuries in children (Review), The Cochrane Collaboration 2014.
  • De Alwis, W. Fingertip Injuries. Emergency Medicine Australasia 2006
  • Langlois J, Thevenin-Lemoine C, Rogier A, Elkaim M, K Abelin-Genevois, R Vialle. The use of 2-octylcyanoacrylate (Dermabond) for the treatment of nail bed injuries in children: results of a prospective series of 30 patients Journal of Child Orthopaedics (2010)
  • Monsef Kasmaei V et al. Comparison of the single injection volar subcutaneous block and the two injection dorsal block for digital anaesthesia. Health 2013
  • Digital Nerve Block, New York School of Regional Anaesthesia. http://www.nysora.com
  • Strauss EJ, Weil WM, Jordan C, Paksima N A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008
  • Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg 1984

Did you find this information helpful?

Document Control

  • Date last published: 27 July 2016
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Marcus Chan, Jeremy Stanley
  • Owner: Marcus Chan
  • Editor: Greg Williams
  • Review frequency: 2 years

More From Starship