What are the considerations for managing a finger laceration?

Management of Finger Lacerations

Finger lacerations require meticulous wound preparation, thorough structural assessment with formal exploration when indicated, and strict adherence to infection control protocols to prevent functional disability and infectious complications.

Initial Assessment and Infection Control

Hand Hygiene and Personal Protective Equipment

• Perform surgical hand antisepsis before any procedure using antimicrobial soap and water, or soap and water followed by alcohol-based surgical hand scrub with persistent activity 1, 2.
• Wear medical gloves when contacting blood or body fluids; remove gloves promptly after use and wash hands immediately to prevent microorganism transfer 1, 3.
• Remove and replace gloves that are torn, cut, or punctured as soon as feasible, then wash hands before regloving 1.
• Wear surgical mask and eye protection with solid side shields during procedures likely to generate splashing of blood 1.

Wound Preparation

• Irrigate with potable tap water rather than sterile saline, as this does not increase infection risk and is evidence-based 4.
• Use nonsterile gloves during laceration repair, as they do not increase wound infection risk compared with sterile gloves 4.
• There is no absolute "golden period" for wound closure—depending on wound type, closure may be reasonable even 18 or more hours after injury 4.

Structural Assessment and Diagnostic Accuracy

Clinical Examination Limitations

• Clinical examination alone misses approximately 30% of injuries to tendons and nerves, even when performed by hand surgeons 5.
• Emergency department physicians correctly identify only 68.2% of flexor tendon injuries and 65.6% of extensor tendon injuries 5.
• Hand surgeons achieve better accuracy but still miss 21.2% of nerve injuries and 25% of extensor tendon injuries 5.

Mandatory Formal Exploration

• Formal surgical exploration should be undertaken for all but the most superficial lacerations, as clinical examination is unreliable for excluding structural injury 5.
• Exploration must assess for injuries to flexor and extensor tendons, digital nerves, digital arteries, bones, joints, and the deep transverse metacarpal ligament 6.
• Longitudinal lacerations involving finger commissures and intermetacarpal clefts present multiple problems requiring assessment of intrinsic muscles, adjacent arteries, nerves, bones, and joints 6.

Advanced Imaging When Indicated

MRI for Complex Injuries

• MRI is ideal for evaluating tendon injuries and surgical planning, with 92% sensitivity and 100% specificity for flexor tendon injuries 1.
• MRI demonstrates 100% sensitivity and specificity for tendon re-tears after flexor tendon repair 1.
• For jersey finger (flexor digitorum profundus avulsion), MRI evaluates tendon retraction level, stump quality, and associated pulley injuries 1.
• MRI accurately depicts the A2 and A4 pulley system with 100% direct identification and 100% diagnostic accuracy for A2 pulley abnormalities 1.

Ultrasound for Dynamic Assessment

• Dynamic ultrasound allows direct visualization of joint malalignment in the absence of fracture 1.
• Ultrasound permits diagnosis of pulley system injuries with dynamic examination 1.

Anesthetic Considerations

Safe Use of Epinephrine

• Local anesthetic with epinephrine in concentrations up to 1:100,000 is safe for use on digits, contrary to traditional teaching 4.
• This evidence-based update eliminates the outdated prohibition against epinephrine use in digital blocks 4.

Wound Closure and Repair Principles

Timing and Technique

• Thorough cleansing with delayed closure may be appropriate for contaminated wounds 6.
• Accurate repair of all injured structures is essential for excellent appearance and early function 6.
• Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas 4.

Dressing Selection

• Wounds heal faster in moist environments; therefore, occlusive and semiocclusive dressings should be used when available 4.

Special Considerations for Complex Injuries

Degloving Injuries

• Complete degloving injuries represent one of the most difficult problems in hand surgery, with exposed tendons, nerves, and bones at risk for necrosis 7.
• Replantation of avulsed structures should be attempted when degloved skin is available and vessels are undamaged 7.
• For irreparable complete degloving of the thumb, early transfer of free composite flap from the foot is indicated 7.
• For multiple finger degloving injuries, radial forearm flap provides coverage as an emergency measure 7.

Tetanus Prophylaxis

• Tetanus prophylaxis should be provided if indicated based on wound characteristics and immunization history 4.

Rehabilitation

• Prompt appropriate rehabilitation following accurate structural repair is essential for early functional recovery 6, 8.
• Maximum functional recovery depends on recognition, accurate diagnosis, and prompt treatment institution 8.

Critical Pitfalls to Avoid

• Never rely solely on clinical examination to exclude tendon or nerve injury—formal exploration is mandatory when structural injury is suspected 5.
• Do not wash, disinfect, or sterilize gloves for reuse 1.
• Do not delay exploration to allow tendon, bone, and joint exposure to persist, as secondary reconstruction should be done as early as possible 7.
• Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears during procedures 1.