From Door Slams to Hammers: Understanding Fingertip Injuries
⌚️ read time: 7.9 minutes
For the next two weeks, I’d like to talk about something that happens way more often than you might think — fingertip injuries.
Whether you caught it in a door, smashed it with a hammer, or had a particularly aggressive encounter with a kitchen knife, these injuries are incredibly common and, unfortunately, can be incredibly painful.
This week we’ll go through all things fingertip…and next week we’ll zoom in specifically on fingernail and nailbed injuries. Because those are their own beast.
Not all fingertip injuries are created equal
As you may remember from my previous articles, many of the injuries I see fall into specific patterns.
Fingertip injuries?
You wouldn’t believe the number of different ways people “achieve” this injury. This has got to be the most varied injury pattern I see in terms of the stories people tell.
I suppose it makes sense. Those fingertips are one of the primary ways in which we explore the world. And sometimes we get bit.
With all that variety, there’s no standard way that all fingertip injuries are treated. Some need surgery, and some don't. Knowing the difference can be tricky.
So let's break down what you need to know if you find yourself with a banged-up fingertip.
There’s a lot of anatomy in that fingertip
Your fingertip is more complex than you might think.
There's a small bone at the tip (called the distal phalanx), covered by skin, soft tissue, and your fingernail. Underneath that nail is something called the nail bed — think of it as the foundation your nail grows over. It’s literally a layer of cells that generates the nail at the base and adheres the nail further out toward the fingertip.
Then you've got nerves that give you sensation and blood vessels that keep everything alive. When you injure your fingertip, any or all of these structures might be involved. That's why the treatment of these injuries can be so varied.
Fingertip injury evaluation
When you come to see me for a fingertip injury, I'm looking at several things.
First, we'll get X-rays to check for fractures. Most of the time there will either be no fracture or there will be something called a "tuft fracture," a break near the tip of the distal phalanx. These are very much not a big deal and can be largely ignored in the majority of cases. This is especially true if your nail is intact…the nail acts as a built-in finger splint for that fracture. How cool!
What we don’t want to see is a break near the base of the distal phalanx that is highly displaced. This would be one of the reasons to take a fingertip injury to surgery for a pin to stabilize that bone.
Next, I'll check if you can still feel things normally (the nerves) and make sure your fingertip is getting good blood flow (the blood vessels). I find the best analogy for this is to imagine a large oak tree. For both the nerves and blood vessels, there are two primary tree trunks that service each finger. These trunks start in the hand and travel down the finger. At the level of the knuckle nearest your fingertip, the trunk ends and those nerves/blood vessels start to arborize, or branch out.
The fingertip is like the canopy. Traversed back and forth by tons of microscopic blood vessels and nerves that have branched all over the fingertip.
This is sort of good news/bad news.
The good news? It’s hard to damage a fingertip and make it permanently numb forever. There are just too many nerves to cut them all.
The bad news? If you have any laceration over your fingertip, you’re likely to cut at least a few small nerves. A permanent small patch of numbness is a common long-term consequence of bad fingertip injuries.
The next part of the evaluation is to look at the skin and soft tissues. Many fingertip injuries result in deep cuts. Fortunately for me, the majority of these injuries are seen first in the ER or urgent care and have already been cleaned and sutured.
Here’s something that continues to surprise even me. This should also be a big comfort to you if you’re suffering from a recent fingertip injury.
It almost doesn’t matter how ugly that fingertip injury looks at first.
Whether tattered skin edges, lumpy areas of skin after suturing, or big gaps in the wound. The fingertip has an unbelievable, almost salamander-like ability to heal.
And this goes for adults too. While kids can heal in even more unbelievable ways than adults, the vast vast majority of ugly fingertip injuries look remarkably good in three months.
Ugly as you-know-what for six weeks. But stunningly good thereafter.
And the last thing I evaluate is the nail and nailbed. But that’s a bigger discussion for next week.
To OR, or not to OR?
Now comes the tough part — deciding between surgery and no surgery. This isn't always straightforward.
One of the main determinants of this is the nailbed. We’ll discuss in detail next time, but as a short summary, surgery on a nail bed can decrease but not eliminate the chance of a long-term nail deformity after a bad injury. So the majority of this decision is focused on what the patient wants.
Sometimes what seems like a simple injury can be more complex — for instance, even a small cut over a broken bone technically counts as an open, or compound, fracture and might benefit from antibiotics and surgery. This is not quite as dramatic in the fingertip as elsewhere in the body, but it warrants evaluation by a hand surgeon to help with the decision.
Finally, as mentioned above, sometimes we need to put small pins in the distal phalanx fracture to hold everything in place while it heals. Nobody wants a crooked fingertip.
The outlook for fingertips
Whether you have surgery or not, there are some universal truths about fingertip recovery. This might surprise you, but as long as you don’t have a surgical fracture, early motion is crucial.
Yes, even if you have a tuft fracture and even if it's sore. With all the soft tissue trauma that occurs in these injuries, you have a perfect recipe to create permanent joint stiffness if you don’t start motion right away.
Remember, we know that ugly banged-up fingertip is going to look great in a couple months. But it will be stiff as a board if we don’t get it moving immediately. It can be easy to get distracted by ‘how bad it looks’ and forget that part of it will take care of itself. The motion though? You only get back what you put into it. Start wiggling that fingertip!
The rest of your recovery is more about knowing what to expect.
The first relates to the nerves. Your fingertip will likely be hypersensitive for a while. This is normal but can be annoying. And it can last as long as a year.
We can certainly teach you desensitization exercises that help. But the basics are easy. Just tickle, scratch, massage, and play with that uncomfortable fingertip as much as you can. Vary the pressure and vary the stimulation. This strategy will ‘teach’ your fingertip that it needs to become less sensitive, and that everything’s ok.
The next relates to the blood vessels. You are likely to suffer from ‘cold intolerance’ for a year or two.
Those new blood vessels that rush in to heal your fingertip are great! But they’re immature. Meaning they won’t know how to appropriately expand and contract to handle cold weather for a while. To you, this will translate to a fingertip that feels achy and painful the second it encounters cold temperatures. And yes, you heard me right when I said this lasts a year or two. Time to ask for mittens this holiday season.
Takeaways:
Don't underestimate fingertip injuries — they're complex and need proper evaluation to determine if surgery is necessary
Early motion and proper wound care are crucial, even though it might be uncomfortable at first
Be patient — complete healing takes months, but most people return to normal function with proper treatment
As I’ve mentioned, the nail and nailbed components of this injury are a bit more complex and deserve their own standalone piece. Tune in next week for that breakdown in full.
Until then, keep those fingertips safe!
