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Lindee Abe, APRN
Fingertip avulsions and lacerations are common injuries in urgent care centers and emergency departments everywhere. Avulsions can happen any time of the year, but are most commonly seen in the warmer months. Lacerations that don’t involve muscle or tendon damage are straightforward. They can be treated easily in these settings. Mixed in with all the lacerations, we also see avulsion injuries. Avulsion injuries are more complex to fix than lacerations. This Is because they are difficult to close with sutures. Hopefully after this review of a few different techniques, you can have a few more tools in your toolbox and look forwards to seeing avulsion injuries in your practice.
Types of Avulsion Injuries
Avulsion injuries can happen to any extremity but occur frequently at the distal fingertip. One common mechanism of injury involves a mandolin slicer, but it can occur through many different mechanisms. An avulsion is different than laceration in that laceration is a cut vs. avulsion involves the removal of skin or part of the body. The patient most often presents because they are either missing part of a finger or the injury has been oozing for several hours and they can’t stop the bleeding. The Allen classification system is a commonly used tool to assess the extent of the fingertip injury.
| Type 1 | Involves only the pulp of the finger |
| Type 2 | Involves both the pulp and nail bed |
| Type 3 | Partial loss of distal phalanx, often requires flap coverage |
| Type 4 | Proximal to the lunula, often requires flap coverage |
The focus of this post will be Type 1 injuries. The first step with an avulsion injury is to try to control the bleeding. Most people will hold pressure for several minutes and then want to look at the wound to see if it’s still bleeding, not giving the body enough time to form a clot at the injury. Sometimes, all you will need is a simple pressure dressing for 10 minutes. However in most cases the provider isn’t that lucky.
Imaging Fingertip Avulsions
The next step would be to obtain an Xray. It is important to determine if there is an underlying fracture. If there is an underlying fracture, then antibiotics will be needed. These reduce the risk of infection of the bone and wound. As with any hand injury, you should perform a thorough exam to determine if there is two-point discrimination, intact pulses, and strength in the extremity. If it is a fingertip avulsion, there should be an assessment of both finger extension and flexion to evaluate the tendon. You should also inspect the finger nail. Injury to the finger nail bed requires additional attention and treatment.
Stop the Bleeding
Pressure Dressing and Tourniquets
The big question with avulsion injuries is how to stop the bleeding. Pressure dressings are usually not very effective. The key to being able to examine the extent of the avulsion, is to obtain a bloodless field. Many urgent care centers and emergency rooms have finger tourniquets that are excellent at doing just that. If a specialized finger tourniquet isn’t available, any method of providing a tourniquet will do.
Lidocaine and Epinephrine
The first technique to achieve hemostasis in these types of injuries is to have the patient soak the area in lidocaine with epinephrine. Simply filling a medicine cup with 10 mL or so of 1% lidocaine with epi can help control the initial oozing that occurs and also has the added benefit of pain control. This Is a good initial step, but will require definitive treatment for hemostasis.
Tissue Adhesive
One simple technique is to use tissue adhesive. The key when using tissue adhesive for this type or trauma, is to have the ability to dry the adhesive quickly enough so the blood doesn’t keep the area from drying. One solution is to use a source of tubing and connect it medical air in order to “blow dry” the area while the tourniquet is on the finger.
Hemostatic Gauze or Gel
An option for wounds that are less than 1 cm sq. is the application of hemostatic gauze or gel. Some examples of these include Surgicel, Gelgoam, and ActCel. These should be placed on the site while applying moderate pressure. An additional dressing should be placed on top. Instruct your patient to leave this in place for several days and that it should liquefy on its own over the course of 2-5 days. You should also instruct your patient to monitor for signs of infection.
Another technique described by an Australian hand surgery group involves the use of a tourniquet and then drying the wound and applying tegaderm to the skin with a pressure dressing over top followed by direct pressure for ten minutes. They also recommend having the patient hold their arm in the air to allow gravity to aid in hemostasis.
Cauterization of Fingertip Avulsions
When all else fails, performing a digital block with a small amount of lidocaine and epinephrine, followed by cauterization of the wound will provide excellent hemostasis and allow for easier healing. Following cauterization, the wound should be dressed and the patient should be instructed to change the dressing daily.
Specialist Involvement for Fingertip Avulsions
For wounds that are greater than 1 cm2, consultation with a hand specialist may be helpful. One option would be to use the skin removed from the area as a make-shift graft with several sutures to hold it in place. This would require the piece of tissue to be available and a compression dressing over the top of the area to prevent fluid accumulation. These options should be discussed with a hand specialist, if available.
Inspection, Irrigation, and Dressing
As previously mentioned, one of the most important steps with any of these techniques is the importance of examination in a bloodless field. This is an important step in any wound assessment to ensure there are not foreign bodies, visible tendon rupture, bone fragments, etc.
Retained foreign bodies are a common reason for lawsuits in laceration and wound cases. This is also the reason that irrigation is so important in wound care to decrease the risk of both infection and retained foreign bodies. Once you have achieved hemostasis, apply a sufficient dressing. Tube gauze is an excellent tool for fingertip injuries, especially in conjunction with nonadherent gauze as a base layer. There are some cases where a finger splint may also be useful. Specifically if the patient uses their hand a lot, it helps add a layer of protection for the first 5 days or so to allow the wound time to heal. Last but not least, don’t forget to assess tetanus status and administer a tetanus immunization if not up to date.
This post will hopefully be a source of several more tools to use the next time you encounter a Grade I avulsion to the finger. It was after having a difficult time controlling the bleeding in one of these cases that I sought out additional tips and tricks used by my peers and through research. By utilizing these techniques, you can achieve better patient satisfaction and better outcomes for the patient.
References:
British Columbia Provincial Nursing Skin and Wound Committee. GELFOAM Wound Care. Retrieved from https://www.clwk.ca/buddydrive/file/gelfoam/.
Emergency Medicine. (2016). Fingertip Avulsion, Superficial. Retrieved from https://aneskey.com/fingertip avulsion-superficial/.
Lin B. A novel, simple method for achieving hemostasis of fingertip dermal avulsion injuries. J Emerg Med. 2015;48(6):702-705
Tomlinson, J. Melbourne Hand Surgery. Retrieved from https://www.melbournehandsurgery.com/7-hands/259 fingertip-slicing-injuries.
Pencle, F., Doehrmann, R. & Waseem, M. (2022). Fingertip Injuries. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK436006/
