Fingertip Injury
Injury distal to the DIP joint: nail, nail bed, pulp or distal phalanx.
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Plastic SurgeryManagement
Fingertip Injury Management Algorithm
Fingertip Injury Management Algorithm: Fingertip Injury → Refer now: bite, high-pressure injection, suspected Seymour fracture → Assess, X-ray and check...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Refer now: bite, high-pressure injection, suspected Seymour fracture
- Animal or human bite, or heavily contaminated wound: irrigate, give antibiotics, refer for washout in theatre
- High-pressure injection (grease, paint): surgical emergency, even if the wound looks small
- Child with nail bed injury plus a fracture at or near the growth plate (base of the distal phalanx), nail base out of the eponychial fold, or DIP held flexed: suspect Seymour fracture (open physeal fracture; X-ray changes may be subtle). Start antibiotics and refer urgently. A tuft fracture is not a Seymour fracture
03Action Assess, X-ray and check tetanus
Anaesthesia: digital block. Young or uncooperative child: consider procedural sedation.
- X-ray all fingertip injuries: AP, lateral and oblique views
- Check tetanus status. Tetanus-prone wound: tetanus-toxoid vaccine with or without tetanus immunoglobulin (Australian Immunisation Handbook)
- Loss of DIP flexion or extension: suspect tendon injury; refer hand surgery
- Clean wound, including tuft or undisplaced open distal phalanx fracture: no routine antibiotics (does not apply to suspected Seymour fracture, bites or heavy contamination)
04Decision Fingertip tissue lost (partial or complete amputation)?
- If Yes
05Decision Partial amputation: tip still attached by a skin or tissue bridge?
- If Yes
06Action Tip still attached: do not cut the bridge; urgent hand surgery referral
The tissue bridge may keep the tip alive and makes repair more likely.
- Put the tip back in its normal position
- Cover with saline-moistened sterile gauze and a secure dressing
- Splint the finger to protect the tip
If No07Decision Tip detached or missing: part available and possibly suitable for replantation?
Thumb, several digits, a child, or a clean cut: discuss with hand surgery now.
- If Yes
08Action Detached part suitable: urgent hand surgery for replantation or composite graft
- Wrap the detached part in saline-moistened sterile gauze, seal in a plastic bag, and put the bag on ice or cold packs
- Do not freeze the part, and do not use dry ice
- Label the container and keep it with the patient
- Crush, avulsion, or severe illness: replantation less likely. Child: composite graft often survives only partly, and rarely over age 4
If No09Decision Part not suitable or not available: bone exposed?
- If Yes
10Decision Bone exposed: refer hand surgery; choose cover by the angle of tissue loss
Thumb: preserve length (for example Moberg flap); hand surgery decides. Child with a small area of exposed bone: secondary intention may be enough; discuss with hand surgery. Older age, arthritis or uncontrolled diabetes: revision amputation is often preferred.
- Transverse / dorsal-oblique
11End Transverse or dorsal-oblique loss: volar V-Y (Atasoy) advancement flap
Needs enough volar pulp to advance; gives sensate cover.
- Volar-oblique
12Action Volar-oblique pulp loss: cross-finger flap or thenar flap
Two-stage flaps; the surgeon divides the flap at about 3 weeks.
- Thenar flap: index or middle finger in younger patients; older patients risk PIP joint stiffness
- Any angle / flap not wanted
13End Finger, any angle or no flap: shorten bone and close (revision amputation)
Fastest return to work. Not for the thumb without hand surgery advice. Trim the nail bed back to the bone end; do not fold the nail bed over the tip (hook nail). Less than 5 mm of nail bed left: hand surgery may ablate the nail remnant.
If No14Action No bone exposed: heal by secondary intention
- Non-adherent dressing; review in 2 to 3 days
- Larger pulp loss also often heals well; full-thickness skin graft (hypothenar donor) is an option
- Child: pulp loss larger than the nail: refer hand surgery
If No15Action No tissue loss: treat nail bed, pulp and fracture
Nail bed repair: arrange hand surgery follow-up. Pulp laceration: adhesive strips, glue or sutures. Open wound or fracture: secure non-adherent dressing; consider a splint.
- Displaced distal phalanx fracture, or intra-articular fracture over one-third of the joint surface: refer hand surgery. Tuft fracture: usually no reduction needed
- Child: haematoma over 50% of the nail, distal phalanx fracture with nail injury, crushed nail bed, nail avulsion, laceration into the nail bed or nail folds, or repair needs GA: refer hand surgery (not urgent)
- Subungual haematoma with nail and nail margins intact, no displaced fracture: trephine if painful, or observe
- Nail avulsed or nail margins disrupted, no displaced fracture: remove nail and repair nail bed (trained clinician), or refer
Guideline Source
Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg 2008;122(3):105e-117e
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- ED triage and referral guide: flap, graft and replantation choices need a hand or plastic surgeon.
- No antibiotic or tetanus doses: use local open-fracture and bite protocols and national tetanus guidance.
- Evidence is mainly expert review and case series; size cut-offs for secondary intention vary between sources.
- Does not cover burns, frostbite or injuries proximal to the DIP joint.
Contraindicated Populations
High-pressure injection injury (refer hand surgery as an emergency)Injury proximal to the DIP jointFingertip burns or frostbite
Applicable Regions
USAUUKEU
AU: Children: RCH Melbourne CPG Fingertip and nail injuries (ED). Tetanus: Australian Immunisation Handbook.
UK: Refer by the local hand trauma pathway.
US: Tetanus: CDC/ACIP recommendations.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Fingertip Injury Management Algorithm?
The Fingertip Injury Management Algorithm is a management clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg 2008;122(3):105e-117e.
What guideline is the Fingertip Injury Management Algorithm based on?
This algorithm is based on Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg 2008;122(3):105e-117e (DOI: 10.1097/PRS.0b013e3181823be0).
What are the limitations of the Fingertip Injury Management Algorithm?
Known limitations include: ED triage and referral guide: flap, graft and replantation choices need a hand or plastic surgeon.; No antibiotic or tetanus doses: use local open-fracture and bite protocols and national tetanus guidance.; Evidence is mainly expert review and case series; size cut-offs for secondary intention vary between sources.; Does not cover burns, frostbite or injuries proximal to the DIP joint.. Individual patient factors may require deviation from these recommendations.
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