1. 40 yo M BIBEMS with no PMH presents with laceration to R index finger. Patient reports he was working on his car when a piece of metal fell and cut off part of his finger. PMH – denies PSH – denies Soc Hx- denies x3 Allergies – NKDA Meds – none

2. Physical Exam – A&Ox3 NAD Vitals – T98.2 BP136/88 HR 77 RR 16 HEENT – wnl Neck – wnl Lungs – CTA bl Heart – S1, S2 RRR Abd – Soft NT/ND +BS Extremities – transverse amputation of 1.5cm of R index finger in zone 2 including nail bed involvement, distal to the germinal matrix, +bone exposure. Decreased ROM at distal interphalangeal joint otherwise FROM in all digits, no sensory deficits no other signs of injury

3. Vikas Goswamy MS4 SUNY Downstate

7. Defined as an injury at or about the level of the lunula One of the most frequently injured parts of the hand Can involve skin, soft tissue, nail, nail bed, bone

9. Involving only Pulp Tissue and Skin Amputations that Involve < 1 cm of finger tip No bone exposure No nail or nail bed involvement Can be treated conservatively with wound care, education on cleaning, and follow up after 2 days

10. With exposed bone Management determined by size, geometry, mechanism, and angle of amputation If <0.5cm but exposed bone, the bone can be trimmed using a rongeur to allow enough space for a soft tissue flap Close by second intention with wound care after 2 days For small injuries (<2cm) reattachment is generally not indicated

11. Nail bed Made up of the germinal matrix and the sterile matrix Germinal matrix extends from the nail fold to the lunula Sterile matrix extends from lunula to hyponychium

12. Nail bed Involvement Avulsion injuries to nail bed have poorer prognosis because germinal matrix fragments may be left under nail If nail is available, use as graft and reattach with 6-0 or 7-0 absorbable mattress stitch If not available toe nail graft can be used at later time

13. References Davenport M. Chapter 41. Injuries to the Arm, Hand, Fingertip, and Nail. In: Ma OJ, Cline DM, Tintinalli JE, Stapczynski JS, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2014. http://www.accessemergencymedicine.com/content.asp x?aID=56328606. Accessed October 12, 2012. AAFP http://www.aafp.org/afp/2001/0801/p455.html