Fingertip and nail bed injuries. Repair techniques for optimum outcome.

Most fingertip injuries can be treated in a procedure room, provided proper lighting and equipment are available. Sound judgment and knowledge of fingertip anatomy are essential. Determining the mechanism of injury is important, because it may indicate the degree of contamination, amount of tissue loss, and best treatment. Superficial wounds may be allowed to granulate and contract spontaneously. In children, even amputation may heal by secondary intention, with the fingertip sutured back in place as a biologic dressing. Split- and full-thickness skin grafts may be appropriate, but diminished sensibility limits their usefulness on volar surfaces. Local skin flaps are indicated when the wound bed is unsuitable for grafting or when skin is needed to cover exposed bone or tendon. Direct closure may be used in amputations of 2 to 3 mm. When the nail bed is lacerated, the nail plate must be removed and the wound repaired. Any free segments of nail bed should be sutured in place as a free graft. In children, treatment should be conservative, with emphasis on preservation of digital length.