A stable and functional fingertip is essential for sensation, fine motor skills, grip strength, and the overall durability and cosmetic appearance of the hand. Fingertips, often the first point of contact during daily activities, are particularly susceptible to trauma. It’s no surprise that workplace injuries involving the hand account for nearly 500,000 cases annually in Canada, with fingertips being the most commonly injured area.
Fortunately, with a solid understanding of fingertip anatomy and management principles, most of these injuries can be effectively treated in the Emergency Department (ED). However, inadequate initial management can lead to significant long-term consequences, including chronic pain, altered sensation, nail deformities, and reduced grip strength.
Anatomy
It is important to have a basic understanding of fingertip anatomy in order to correctly identify potentially injured structures.

“OpenStax AnatPhys fig.5.13 – Nails – English labels” by OpenStax, license: CC BY. Source: book ‘Anatomy and Physiology’,
The fingertip’s intricate structure is what enables its exceptional functionality. Beneath the nail lies the distal phalanx, the bony foundation of the fingertip. The periosteum connects to the skin through fibrous septae, which form the finger pulp. These septae anchor the skin to the underlying bone, enhancing traction and grip.
The nail bed, a highly vascularized epithelial layer, rests above the distal phalanx and secures the nail plate. It comprises two key components:
- Germinal matrix: Found proximally under the nail fold and extending to the lunula (the white crescent), it generates 90% of nail growth by producing keratin for the nail plate.
- Sterile matrix: Extending from the lunula to the fingertip, it ensures adherence of the nail plate to the nail bed.
Additional anatomical landmarks include:
- Hyponychium: The skin under the nail’s free edge, forming the junction between the sterile matrix and fingertip skin.
- Paronychium: The lateral nail folds adjacent to the nail edges.
- Cuticle (eponychium): A protective seal originating from the proximal nail fold, creating a barrier between the skin and nail
- Tendon anatomy is equally critical. The extensor and flexor tendons insert at the base of the distal phalanx, just beyond the distal interphalangeal joint.
Blood supply to the fingertip comes from the digital arteries, branches of the radial and ulnar arteries. Sensory input is robust, with dense innervation provided by the digital nerves, which are terminal branches of the median and ulnar nerves.
Approach to Fingertip Injuries
A systematic approach is key to ensuring comprehensive assessment and optimal management of fingertip injuries in the ED. Following these seven steps can help avoid missed diagnoses and improve patient outcomes.
1. Radiographs
- Start by obtaining AP and lateral X-rays for most fingertip injuries. This helps identify underlying fractures or dislocations that may require additional management before addressing soft tissue injuries.
2. Neurovascular Assessment
- Perform a thorough neurovascular exam as the next step. While digital nerve injuries distal to the DIP often don’t require surgical repair, their identification remains critical.
- History: Look for complaints of numbness or paresthesias.
- Physical Exam: Use light touch to compare the injured finger to others. A specific question like, “Does this feel the same as your other fingers?” can provide useful insights.
- Two-point discrimination is a simple test, often performed with a bent paper clip. While subjective, it can help detect nerve injury.
- Documentation: Sensory findings at presentation may be altered due to pain or swelling, but careful documentation is crucial. Additionally, check and document capillary refill time when appropriate.
3. Analgesia
- Adequate analgesia is essential to facilitate both assessment and repair. Ensure neurovascular examination is complete before administering anesthesia.
Common digital nerve block techniques include:
- Traditional dorsal block: Anesthesia is injected into the radial and ulnar web spaces on the dorsum of the hand.
- Dorsal ring block: Inject anesthesia circumferentially around the base of the finger.
- Transthecal block: Inject into the flexor tendon sheath at the palmar crease.
- Subcutaneous block: Similar to a transthecal block but targets the subcutaneous tissue rather than the tendon sheath.
A combination of these approaches may be preferred depending on the provider’s experience and patient-specific factors.

Borbón TY, Qu P, Coleman‐Satterfield TT, Kearney R, Klein EJ. Digital nerve blocks: A systematic review and meta‐analysis. J Am Coll Emerg Physicians Open. 2022;3(4):e12753. doi:10.1002/emp2.12753.
A recent systematic review and meta-analysis by Borbón et al. (2022) compared various digital block techniques in terms of time to anesthesia, duration of anesthesia, and patient-reported pain. The results revealed no significant differences among the techniques for these metrics.
However, buffered lidocaine consistently resulted in lower pain scores compared to unbuffered lidocaine. Additionally, while the difference in pain scores between techniques may not reach statistical significance, patient preference often leans toward a single subcutaneous injection over multiple-injection approaches.
Key Takeaway:
- Digital nerve blocks are essential for any open fingertip injury to facilitate assessment and management.
- The specific technique likely doesn’t matter, but many experts favor a single subcutaneous block at the flexor crease at the base of the finger. Injecting 3–3.5 mL of local anesthetic in this manner provides effective anesthesia with minimal patient discomfort.
4. Hemostasis
- Hemostasis is critical in managing open fingertip injuries to create a bloodless field for thorough assessment and precise repair.
- A digital tourniquet is easily applied using readily available ED materials:
- Penrose drain with a hemostat: Wrap the drain around the base of the finger and secure it with a hemostat to form a tight ring.
- Glove technique: Cut the finger of a glove, remove its tip, and roll it down to the base of the finger to achieve compression.
This simple step ensures optimal visibility during repair and improves procedural outcomes.

Helman A. Hand Injuries – Pitfalls in Assessment. Emergency Medicine Cases. January 31, 2023. Accessed September 30, 2024.
5. Irrigation
- Proper irrigation is a cornerstone of managing open fingertip injuries. Evidence shows that tap water is as effective as sterile water in preventing wound infections.
- If necessary, debride any non-viable soft tissue, but take special care to avoid debriding the nail bed. Excessive debridement of this delicate structure can lead to scarring, splitting, and subsequent non-adherence of the nail plate.
6. Dressing & Splinting
- Every fingertip injury requires an appropriate dressing:
- Use non-adherent materials to minimize sticking and subsequent pain or re-injury during dressing changes.
- For injuries with a distal phalanx fracture, apply a fingertip splint for added protection and stability.
- In other cases, you can choose between splinting or applying a bulky gauze dressing based on the nature of the injury and patient comfort.
7. Tetanus and Antibiotics
- Don’t forget to check and update the patient’s tetanus status as part of wound care.
- The use of antibiotics in fingertip injuries remains controversial and is covered in more detail below. For now, remember that any decision on antibiotics should consider the specific injury, risk of infection, and patient comorbidities.
Subungal Hematoma
Subungual hematomas are commonly caused by crush injuries to the fingertip, leading to bleeding in the nail bed. The intact nail plate traps blood, creating pressure in a confined space and resulting in significant pain.
Trephination vs. Nail Plate Removal
Several studies have compared trephination to nail plate removal and laceration repair. The evidence suggests that outcomes—such as healing and complications—are equivalent between the two, regardless of hematoma size or the presence of a well-aligned fracture.
Since trephination is faster, less invasive, and carries a lower risk of nail bed injury, it is now the preferred approach in appropriate scenarios.
Indications for trephination:
- The nail folds are intact and not disrupted.
- The hematoma is causing pain or discomfort.
- The injury is acute (ideally within 48 hours).
Timing Considerations:
- Beyond 48 hours, most subungual hematomas will have clotted, making trephination less effective. However, it may still be worth attempting if the patient has severe pain. If unsuccessful, proceed with nail plate removal for decompression.
Size of Hematoma:
- It’s a myth that a subungual hematoma requires trephination if it involves >50% of the nail plate. If the hematoma is not painful, it can be left untreated, regardless of its size.
- That said, pain from a large hematoma is often significant, and draining it can provide immediate relief.
Procedure: Nail Trephination
Trephination is a straightforward and effective procedure for relieving pain caused by subungual hematomas. In the ED, the two most common methods involve using electrocautery or a needle to create a hole in the nail plate.
Key Points:
- The nail plate itself lacks nerve endings, making trephination typically painless. The hematoma also provides a protective layer between the nail plate and nail bed.
- Digital nerve blocks are generally not required, as the procedure is brief and provides immediate pain relief.
- Experts recommend blunt heated instruments (e.g., electrocautery) over sharp tools like needles to reduce the risk of nail bed trauma.
1. Prepare the Nail
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Clean the nail thoroughly before starting.
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Avoid alcohol-based solutions if using electrocautery due to flammability risks.
2. Create the Hole
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Use either electrocautery or a needle. Position the instrument at a 90-degree angle to the nail plate over the central area of the hematoma, avoiding the lunula and germinal matrix.
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If using a needle, gently rotate it with constant downward pressure until blood is expressed. Withdraw immediately to avoid contact with the nail bed.
3. Ensure Adequate Drainage
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The hole should be large enough to allow continuous drainage for 24–36 hours.
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If using a small bore needle, multiple holes may be necessary to prevent plugging or reaccumulation. A large bore needle typically requires a single 3–4 mm hole.
4. Dress the Site
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Apply a non-adherent dressing to protect the site while drainage continues.
When to remove the nail plate:
In some situations, nail plate removal and repair of underlying lacerations are necessary. These include:
- Nail margin disruption
- Highly comminuted or malaligned fractures
- Patients on anticoagulation or dual antiplatelet therapy (DAPT)
- Failed trephination attempts
- Presence of artificial nails
- Artificial nails can obscure underlying injuries like subungual hematomas. Additionally, the materials used to create artificial nails are flammable, raising concerns about the safety of trephination with electrocautery.
- A 2022 study by Blereau et al. investigated this issue by exposing 200 acrylic nails (attached to simulated digits) to trephination with electrocautery. Alarming findings revealed that 41.5% of the nails ignited during the procedure.
- Key Takeaway: If you suspect a subungual hematoma hidden beneath an artificial nail, remove the nail plate to inspect the nail bed directly.
Nail Bed Lacerations
Nail bed lacerations are often caused by sharp or crush injuries. These injuries are almost universally manageable in the ED.
If part of the nail plate remains intact, it should be gently removed to fully inspect the nail bed and perform necessary repairs. Proper management of nail bed lacerations helps prevent long-term cosmetic and functional complications.
Procedure: Nail Plate Removal
Nail plate removal is a simple procedure, usually well-tolerated with a good digital nerve block.
1. Digital Tourniquet
- Apply a digital tourniquet to create a bloodless field.
2. Separate the Nail Plate
- Use scissors from a suture kit:
- Gently slide the scissors under the nail plate.
- Use a side-to-side motion to separate the plate from the nail bed, continuing until reaching the proximal nail fold.
3. Remove the Nail Plate
- Once separated, use a hemostat to carefully extract the nail plate from the proximal nail fold.
- Be cautious to avoid damaging the underlying nail bed or overlying folds.
4. Inspect the Nail Bed
- Irrigate copiously to clean the area and improve visualization.
- Avoid aggressive debridement, as even severely contused nail beds often heal well without intervention.
- Inspect the avulsed nail for fragments of the nail bed, which should be replaced if present.
Sutures vs Glue?
- Traditional repair of nail bed lacerations involves small-caliber absorbable sutures (e.g., 6.0). However, tissue glue is increasingly considered as a faster and easier alternative.
- A 2019 literature review (Edwards et al.) analyzed six studies on glue for nail bed repair. While the quality of evidence was low, results suggested that glue produces good cosmetic outcomes without significant adverse effects.
- When to Consider Glue
- Pediatric patients or others for whom a prolonged procedure may be challenging.
- Small, uncomplicated lacerations.
Replacing the Nail
The traditional approach to nail bed repair includes replacing the nail to stent the proximal nail fold and facilitate new nail growth.
1. Clean the Nail
- Thoroughly clean the nail and remove any debris. Create a small hole for drainage, similar to subungual hematoma trephination.
2. Reposition the Nail
- Place the cleaned nail back into the nail fold. Secure it with:
- A single suture distally through the nail plate and into the hyponychium.
- A suture through the proximal nail fold
- Alternatively, the nail can be left in place without securing.
3. If Nail is Unusable
- Create an artificial stent using non-adherent gauze or the inside of an absorbable suture packet. Secure it in the same way.
- Evidence on Stenting:
- The NINJA trial (Jain et al. 2023), a multicenter RCT, found no difference in infection rates or cosmetic outcomes between nail replacement and leaving the proximal fold open. While the study was conducted in pediatric populations, it raises questions about the necessity of stenting.
Nail Bed Repair Bottomlines:
- Nail Plate Removal: If the nail is disrupted, remove it to inspect and repair the nail bed.
- Irrigation Over Debridement: Irrigate thoroughly but avoid aggressive debridement to prevent scarring and nail growth issues.
- Sutures vs. Glue: Evidence supports glue as equivalent to sutures, though sutures remain preferred by many experts. Consider glue for faster repairs, especially in pediatric patients.
- Nail Replacement: While evidence on stenting is mixed, replacing the nail is still commonly practiced. If replaced, secure it with a single suture and avoid glue to minimize infection risk.
Fingertip Amputations
When should we call a hand surgeon urgently for replantation, and when can care be deferred? While practices vary between centers, our local protocol in Ottawa involves conservative management for fingertip amputations at the DIP level or more distal, as the vessels are too small for replantation. These cases can be referred for rapid outpatient follow-up and do not require urgent intervention.
When to Call a Hand Surgeon:
- For fingertip amputations, consult a hand surgeon under the following conditions (assuming a clean cut and the severed part is available):
- Thumb involvement: Critical for hand function, especially at or proximal to the IP joint.
- Proximal amputations: Around the level of the middle phalanx.
- Multiple fingertip amputations.
Handling the Amputated Part:
- Wrap the severed part in saline-soaked gauze, place it in a plastic bag, and immerse the bag in an ice-water mixture.
Classification of Fingertip Amputations
Fingertip amputations are typically classified into zones:
- Zone I: Tip of the finger is severed, distal phalanx intact, no exposed bone, <1 cm of soft tissue loss.
- Zone II: Amputation distal to the lunula, exposing the distal phalanx.
- Zone III: Amputation proximal to the lunula, often involving a significant portion of the distal phalanx and bone.
Management by Zone
Zone I Amputations
- Digital nerve block and tourniquet use.
- Thorough irrigation and debridement of devitalized tissue.
- X-ray to rule out a distal phalanx fracture.
- Apply a non-adherent bulky dressing with ample petroleum jelly to keep the wound moist.
Zone II & III Amputations
- Perform all steps for Zone I injuries.
- Use bone rongeurs to clip bone 1–2 mm below the soft tissue level. Avoid rongeuring >0.5 cm to prevent damage to tendon attachments.
- Suture skin flaps only if they can be closed without tension. High-tension closures risk ischemia and delayed healing.
- If unable to close, allow healing by secondary intention. For hemostasis, consider applying Dermabond to the wound surface.
- Healing by secondary intention may take weeks to months, and sensation can take 12–18 months to return fully.
Pediatric Finger Amputations
In pediatric patients, even with exposed bone, a composite graft can be attempted by suturing the severed part back in place. This technique has a higher success rate in younger children (1–2 years old). If the amputated part is unavailable or nonviable, allow healing by secondary intention.
Distal Phalanx Fractures
Up to 50% of nail bed injuries are associated with distal phalanx fractures, classified into:
- Tuft fractures: Common, stable, and managed with splinting for 2–4 weeks.
- Shaft fractures: Transverse fractures are stable; longitudinal fractures are more unstable. Reduce displaced fractures and splint from the middle to the distal phalanx, leaving the PIP joint mobile.
- Base fractures: Usually unstable and intra-articular, including mallet finger (dorsal base) and jersey finger (volar base).
Seymour Fractures
Seymour fractures are transverse fractures of the distal phalanx involving the physis, often accompanied by a nail bed injury. These injuries require:
- Nail removal.
- Copious irrigation and reduction of the fracture.
- Nail bed repair and splinting in slight extension.
- Antibiotics to reduce infection risk.
Unrecognized Seymour fractures can lead to nail deformities, physeal arrest, or osteomyelitis, so maintain a high index of suspicion.
Antibiotics for Open Fractures
The need for antibiotics in open distal phalanx fractures is debated. While principles of open fracture management advocate for antibiotics, distal phalanx fractures may differ due to:
- Excellent blood supply to the hand.
- Lower risk of periosteal stripping and contamination.
- Thorough ED irrigation facilitated by digital nerve blocks.
- Evidence:
- A 2016 systematic review (Metcalfe et al.) found no significant reduction in infection rates with antibiotics for open distal phalanx fractures when proper wound care was performed.
Indications for Antibiotic Prophylaxis
Consider antibiotics in the following scenarios:
- High-risk injuries: Gross contamination, animal/human bites.
- High-risk patients: Immunocompromised, peripheral vascular disease, smokers, etc.
- Open wounds: E.g., amputations left to heal by secondary intention.
- Seymour fractures.
For simple wounds in healthy patients, there is no strong evidence supporting prophylactic antibiotics when adequate wound care is provided.
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