What to do when someone suffers a traumatic amputation of the fingertip?

Management of Traumatic Fingertip Amputation

For a fingertip amputation, immediately control bleeding with direct pressure and a pressure dressing; if bleeding is uncontrolled despite direct compression, apply a tourniquet and transport urgently to definitive care while preserving the amputated part properly for potential replantation or composite grafting. 1

Immediate Hemorrhage Control

Direct manual compression with a pressure dressing is the first-line approach for fingertip amputations with simple hemorrhagic wounds. 1 This technique is sufficient for most fingertip injuries and should be maintained for several minutes to achieve hemostasis. 1

If direct compression fails to control bleeding, or if the amputation involves significant tissue loss, apply a tourniquet immediately. 1 Tourniquets are specifically recommended for traumatic amputations and represent a simple, efficient method to control hemorrhage when direct pressure is ineffective. 1

• The tourniquet should be applied proximal to the injury site on the affected limb. 1
• Re-evaluate the tourniquet's effectiveness and necessity as soon as possible to minimize ischemic complications. 1, 2
• Tourniquets can safely remain in place for up to 2 hours, though military data shows extremity survival even after 6 hours of application. 1, 2
• Prolonged or improper tourniquet placement can cause nerve paralysis and limb ischemia, though these complications are relatively rare. 1, 2

Preserve the Amputated Part

Immediately preserve the amputated fingertip properly, as replantation or composite grafting may be possible depending on the injury pattern. 3, 4

• Wrap the amputated part in saline-moistened gauze. 3
• Place it in a sealed plastic bag. 3
• Keep the bag on ice (not in direct contact with ice to avoid freezing injury). 3
• Do not place the amputated part directly on ice or in water. 3

Transport and Triage

Transport the patient to a specialized trauma center or facility with hand surgery/microsurgical capabilities without delay. 3 While fingertip amputations alone may not meet major trauma criteria requiring a Level I trauma center, access to hand surgery expertise is essential for optimal outcomes. 1, 3

• Do not delay transport for field imaging or prolonged stabilization attempts. 3
• Establish IV access during transport if the patient has other injuries or signs of shock. 3
• Begin active warming measures to prevent hypothermia, which impairs coagulation. 3

Definitive Treatment Considerations

The ultimate treatment depends on several factors that will be assessed by the hand surgeon:

For injuries with soft-tissue loss but no exposed bone, healing by secondary intention or skin grafting is preferred. 4 This approach provides excellent functional outcomes for superficial injuries.

When bone is exposed and sufficient nail matrix remains, coverage with a local advancement flap should be considered. 4 This preserves fingertip length and sensation while providing durable coverage.

Composite grafting (reattaching the amputated tip as a graft rather than replantation) has a 93.5% success rate in adults when proper technique is used, including bony segment excision, defatting, and deepithelialization. 5 This is particularly effective for clean, sharp amputations with small tissue segments (average 2.4 cm). 5

True microsurgical replantation may be considered for thumb amputations or larger fingertip segments in appropriate candidates. 3, 6 However, very distal tip amputations are often not suitable for replantation. 6

If the patient has advanced age, significant comorbidities, or the amputation angle doesn't permit flap coverage, bone shortening with primary closure is preferred. 4 This provides a reliable, one-stage solution with minimal complications.

Common Pitfalls to Avoid

• Do not repeatedly release and reapply tourniquets, as this aggravates local muscle injury and causes systemic complications like rhabdomyolysis. 3
• Do not assume all fingertip injuries are minor—assess for associated injuries to tendons, nerves, and deeper structures. 1
• Do not close traumatic amputations primarily in the emergency setting—formal closure should be delayed at least 5 days after adequate debridement to minimize infection risk (5.3% vs 43.2% infection rate). 7
• Do not discard the amputated part—even if replantation seems unlikely, it may be useful for composite grafting or as a source of tissue for reconstruction. 4, 5