In this section
This guideline will include the management and referral guidelines for injuries of the fingertip.
Can be classified by:
Simple laceration: Single linear laceration.
Stellate laceration: Multiple converging lacerations that typically resemble a star shape.
Crush injury: Complex crush injury that causes fragmentation.
Burst laceration: Laceration pattern caused by high energy blunt force.
Nail bed avulsion: Nail plate is forcefully torn away where a portion of nail bed attached.
Subungual haematoma: Bleeding within the space between nail bed and nail plate.
Partial / complete amputation: Traumatic injury that causes partial or complete removal of fingertip.
Fingertip injuries are common in children, particularly younger children ‘exploring’ without the awareness of risk.
The most common mechanism is a crush injury, often a door or hinge, but can also be caused by a direct blow or sharp objects
Three plain film views should be obtained; a lateral, AP and oblique views
Precise repair of the nail bed is important to optimise long-term cosmesis of the finger and nail. This is usually best performed by a hand surgery team under anaesthesia, particularly in younger children.
In young or uncooperative children, consider early analgesia, procedural sedation and age-appropriate distraction techniques. Older children may tolerate repair under a regional block.
Most fractures (tufts) are very small and don’t require reduction of the phalanx.
Check tetanus immunisation status.
Open finger injuries require a secure, robust dressing. Consider reinforcing with a splint and crepe bandage.
Neutral hand splint, which should be held in place with crepe bandage, with cotton placed between the fingers to protect the skin from maceration over the following week/s.
Management of specific injuries are listed in the table below.
Seymour fractures should be referred to hand surgery for urgent operative management.
Distal phalanx fracture/Tuft fracture
Seymour fractures are open fractures and are associated with significant complications. They may only have subtle radiographical changes.
The treatment of a subungual haematoma is controversial:
Most uncomplicated subungual haematoma injuries where nail margins are intact and there is no evidence of a displaced fracture, can be treated with either nail trephination or close follow up.
The degree of pain often influences the decision whether to person trephination. Seek senior clinician advise.
Subungual haematomas that do not meet the above criteria should have nail plate removal for nail bed assessment and repair.
Nail bed injuries
Simple nail bed lacerations require removal of the nail plate and repair of the nail bed by a trained clinician.
If a trained operator is not available is not available, refer to hand surgery.
Complicated nail bed injuries or injuries with underlying displaced fractures require hand surgery referral.
Burst lacerations of the pulp
Laceration under half the circumference of the finger:
Adhesive strips and in simple non-bleeding lacerations, consider tissue glue.
Lacerations over half the circumference of the finger:
Closure with absorbable sutures
(example as per laceration CPG); may require referral to hand surgery.
Avulsions of the pulp smaller than the size of the nail will heal very well and only require a simple non adherent dressing over the wound and review in 2-3 days.
Larger avulsions require hand surgery referral.
amputation (within trauma guideline)
Preserve the amputated finger.
Do not freeze or use dry ice.
Nail bed injuries should have follow up with hand surgery.
Nearly all other injuries can be followed up with GP within a week.
Increasing pain which is uncontrolled with simple analgesia and distraction should prompt urgent review as it may indicate a tight dressing or infection.
Delayed intervention (more than 2-3 days) has been associated with higher rates of complications.