FINGERTIP INJURIES
SUBUNGUAL HEMATOMA
- Many crush injuries to the fingertips will damage the
nail and underlying matrix, causing blood beneath the
nail and throbbing pain. These injuries may also be
associated with tuft fractures of the distal phalanx,
which are typically open fractures because they com-
municate through the nail matrix disruption (Idler
et al, 1990b). - Hematoma involving less than 50% of the nail matrix
may be drained using a heated paperclip, an 18-gauge
needle, or a battery-operated cautery to create one or
multiple holes in the nail. An anesthetic digital block
may be necessary prior to drainage. Soaking the
finger in sterile water with peroxide will facilitate
drainage. A sterile dressing should then be applied,
with a Stack splint in cases involving fracture (Idler
et al, 1990b; Fassler, 1996). - Hematoma involving more than 50% of the underly-
ing nailbed is presumed to be associated with an open
fracture. Radiographs, surgical removal of the nail,
thorough irrigation and debridement of the wound,
repair of the nail matrix, and replacement of the nail
with splinting are recommended (Fassler, 1996).
NAIL AVULSION
- If nail avulsion occurs without damage to the under-
lying sterile matrix, the wound should be thoroughly
cleansed and dressed with a nonadherent dressing. If
the proximal portion of the nail has also been avulsed
from the nail fold and germinal matrix, the patient’s
cleansed nail or a piece of sterile gauze or foil should
be slid under the eponychial fold to prevent adherence
(Fassler, 1996). - If any part of the sterile or germinal matrix has been
torn or lacerated, removal of any remaining nail frag-
ments and repair of the nail bed injury are mandatory.
Again, the eponychial fold should be splinted open
(Fassler, 1996).
FINGERPAD INJURIES
- Simple lacerations may be cleansed and sutured using
nonabsorbable monofilament in adults or absorbable
suture in children. Grossly contaminated wounds may
be cleansed and left open.
•Partial amputations with soft tissue loss measuring
less than 1 cm^2 will heal by secondary intention and
may be treated with cleansing and serial dressing
changes. Even larger defects will heal well in chil-
dren. Larger wounds involving exposed bone or
tendon, nail bed injury, or more proximal amputation
should be emergently treated by a hand surgeon (Idler
et al, 1990b; Fassler, 1996).JOINT INJURIES OF THE FINGERS- Dislocations are usually clinically apparent; are char-
acterized by pain, limited movement, and digit defor-
mity; and should be radiographed prior to reduction to
assess for associated fracture if there is any crepitus,
bony point tenderness, or open injury. - Other dislocations can be reduced, splinted, and a
post-reduction radiograph obtained. Any irreducible
dislocation or dislocation associated with an open
wound requires emergent referral. - Local or regional anesthesia may be necessary to
obtain adequate pain relief and relaxation for reduc-
tion. Digital blocks are placed by injecting the ulnar
and radial webspaces of a digit, anesthetizing the
dorsal and volar digital nerves. The local anesthetic
should not contain epinephrine, which could cause
digital ischemia.
DISTAL INTERPHALANGEAL JOINT- Distal interphalangeal (DIP) joint dislocations are
uncommon, almost always dorsal, and often open.
These injuries are frequently associated with extensor
disruption (see section on Mallet Finger). - If there is no open wound or tendon rupture and
closed reduction is possible, extension splinting for
2–3 weeks is recommended.
PROXIMAL INTERPHALANGEAL JOINT- Proximal interphalangeal(PIP) joint injuries are the
most common joint injuries in sports, primarily occur-
ring in athletes who participate in contact sports and
ball-handling (Morgan and Slowman, 2001; Rettig,
Coyle, and Hunt, 2002).
DORSALDISLOCATIONS- These injuries are frequently seen in football and
basketball. Dorsal dislocations are most common
and result from hyperextension with axial load. This
causes distal volar plate rupture with or without
bony avulsion. A true lateral x-ray should be
obtained to rule out a fracture (Rettig, Coyle, and
Hunt, 2002).
306 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE