Many factors influence the outcome of treating fingertip injuries, such as patient age, sex, occupation, hobbies, hand dominance, pre-existing medical conditions, and the fingertip injury’s anatomy. These injuries must be treated to preserve length, function, and sensation, as well as to ensure an acceptable appearance [1]. One-third of all traumatic injuries affect the hands [2], and the fingertips are the portion of the hand injured most frequently. Because it is the most distal and the last finger to be withdrawn, the middle finger is most at risk [3].

There have been several classifications of fingertip injuries, such as the Allen classification (1980) and the Ishikawa classification (1990) (distal digital amputation levels). These classifications are very simple to use, but they cannot describe the details of an injury.

Evans and Bernadis introduced the PNB classification, in which the injury is divided into its effect on the fingertip bone, nail, and pulp, and each component is divided into 7 or 8 items that allow the injuries to be described more precisely. This results in a three-digit number that describes the injury accurately and can be used to document injuries without having to resort to lengthy descriptions. It may also be used as a guide for treatment and indications for referral [4]. In PNB 356 and PNB 455 and 466, surgical treatment is most suitable, and PNB 386 and PNB 666 and 700 indicate the boundary between surgical and conservative treatment [5]. Many controversies exist regarding treatment of the condition, but the management choice relies on the category of injury, the patient’s occupation, hobbies, and cosmetic demands. When it is mandatory to return to manual work early, terminalization is the best treatment, and in certain cases, such as the thumb and index finger, a flap may be preferred based upon its length, sensation, and appearance [6].

Healing by Secondary Intention

• Composite Grafts;

• Revision Amputation;

• Skin Grafts;

• Local Flaps;

• Regional and Distant Flaps;

• Replantation.

1) To investigate the etiology of acute fingertip injuries in Sudanese patients.

2) To determine high risk groups in relation to age, gender, and occupation and compare this with the international literature.

3) To study the association between fingertip injuries and hand dominance.

4) To evaluate wound characteristics according to the PNB classification, and discuss the options for management available.

This is a prospective descriptive study performed during a-one-year period. The study included a sample of 103 consecutive patients who presented to the Omdurman teaching hospital trauma department with 144 acutely injured fingertips (88 males, 15 females, mean age of 27.5, SD = 15.5, age range = 1.2 - 88, Figure 1), and injuries of more than 16 hours’ duration were excluded. Initially, a comprehensive history was recorded for each patient. The participants were consented and completed a questionnaire on age, sex, contact numbers, occupation,

hand dominance, presenting symptoms, and mode of trauma. A thorough physical examination and plain X-ray findings were recorded. Wounds were assessed using the PNB classification. Data were analyzed using SPSS v.25. The Chi-square test was used, and a p-value of 0.05 or less was considered significant.

Males were affected six times more than females (Figure 1). The age group in the patient population affected most commonly was 16 - 20 years (20.4% of cases), followed by 31 - 35 years (15.5%), and 21 - 25 years (11%). Children younger than 5 years constituted 11% of the total study population. Based upon the occupation analysis, seasonal and factory workers were injured most commonly, 29% and 22%, respectively. Dominant hand injuries were most common and were seen in 65% of the cases (Table 1).

The result of the Fisher exact test was significant at p = 0.0004 and showed a strong association between hand dominance and trauma. The most commonly observed injuries were related to machine use (Figure 2). Sharp and blunt injuries were observed that involved the left hand, while the predominant injuries of the right hand were attributable to machinery-related trauma (Table 2). Most patients presented with pain, while 73% presented with bleeding, and 38% had tissue loss. Fifty percent of patients presented within 2 hours after the trauma while 29.9% were seen 2 - 4 hours following injury. Four percent presented more than 12 hours after the time of trauma.

With respect to the trauma environment, 68% of the injuries occurred at work, and 26.2% at home. The remaining accidents occurred on the road or in school. Half of the injuries were attributable to machinery use and 25% were caused by blunt trauma. Injuries with sharp objects constituted 18.4%. Door-trapping was the commonest injury in children under 5 years (Table 3).

p = 0.001.

p = 0.04.

p = 0.019.

The mechanism of trauma was found to have an impact on the number of fingertips injured, machines and blunt trauma tend to affect more than one digit (Table 4).

The index finger was injured most frequently (31.9%). The middle finger sustained 27.1% of the total injuries, while the ring finger sustained 18%. The little fingers and thumb were affected equally (11%). The commonest finger susceptible to machine injury was found to be the middle finger, while the index finger was more prone to blunt trauma (Table 5).

Pulp injuries were seen in 97% of the cases and pulp laceration was the commonest presentation (39.6%, n = 139), followed by loss of the distal transverse pulp (18.7%). Complete pulp loss was seen in 12.2% of cases (Table 6). Nail bed injuries were seen in 87% of all cases. The sterile matrix laceration was the commonest injury, seen in 28.6% of cases (n = 126). Complete loss of the nail bed was observed in 9.5% of the cases (Table 7).

Bone injuries were observed in 72% of the cases. Tuft fractures were the most common bone injuries and were seen in 26% of cases (n = 104). Complete bone loss was observed in 7.7% of cases (Table 8).

With respect to management, 9% of the cases were treated conservatively, while 91% required various types of surgical repair, ranging from primary repair to skin grafting and tissue flaps (Table 9). Nail bed repair was performed on 48.8% of injured nails, while bone fixation was required in only 20.2% of the bones affected.

Although physicians underestimate the problem of fingertip injuries, it is the patient who pays the price of his unawareness, which is influenced by improper assessment and injudicious management. Despite the fact that hundreds of international publications have studied this problem in detail, the local literature is highly deficient in describing acute fingertip injuries. The male to female ratio in this study was 5.8:1, which is similar to the result in Saeed and Murtada’s unpublished study (2005) that estimated the male to female ratio in Sudanese hand trauma patients to be 5:1. Our ratio is higher compared to that in Indian (1.5:1) [1] and Nigerian studies (1.8:1) [7] and much lower compared to a study in the United Arab Emirates (11.5:1) [8]. This reflects cultural issues related to women’s work.

The age groups injured most commonly were children (younger than 5) and teenagers (16 - 20). The most frequent injuries in children were attributable to door jamming (54%), which is consistent with the results in Doraiswamy’s study [9]. Teenagers were injured frequently at work, which is likely attributable to local economic issues. In the United Arab Emirates, injuries were encountered largely between 25 to 29 years [8]. In our study, we found a higher percentage of job-related finger injuries (68%), which could be related to workers’ unawareness and a lack of safety measures. Further, most of the victims were teenagers and non-professional workers.

Injuries caused by machines were found in 45% of our cases, which is similar to Denise and Jerome’s study [10].

The dominant hand was reported to be injured in 65% of patients compared to Ihekire and Salawu’s study [7], which estimated that dominant hand injuries were 56.8%. All of these circumstances would alter the individual functional and economic outcome, particularly if the dominant hand is affected.

Treatment options depend greatly upon the surgeon’s preference, wound characteristics, and the other factors mentioned above. Primary repair was the most common modality of treatment observed in pulp lacerations. Although flaps have been used often in the literature to treat transverse pulp loss, such as the Atasoy (V. Y. flap) and Kutler flaps that provide sensation and padding of the fingertips, in our study, the Atasoy flap was used in 23 cases with minimal flap loss or hook nail deformities. These types of flaps are simple and can be performed by junior staff. Volar pulp loss has been treated often using a thenar split skin graft and was performed in 13 cases. Cross finger flaps typically compromise the adjacent finger and thenar flaps lead to joint stiffness. This is why they are not commonly used in our practice. Venkataswami’s triangular flap was a good choice to treat lateral oblique pulp defects and is used by senior staff for a better outcome, although Gan Muneuchi has challenged this, and argued against the benefit of surgery in trying to achieve any cosmetic results after nail loss [5].

Composite grafts were applied in 12 fingers with acceptable outcomes, particularly in children. Conservative management was adopted in 13 patients based upon their minimal tissue loss. Typically, thumb injuries were treated by simple repair (Moberg or Foucher flaps). Moberg flaps were constructed in 5 cases and were used for distal thumb amputation when it appeared to be impossible to use the V. Y. flap. The Foucher flap, which is based on the first dorsal metacarpal artery and radial nerve branches, was used in one case in the study.

Our findings are similar to the previously published article, with minor differences. Safety measures and education are highly recommended to prevent injuries in high-risk groups.

The authors declare no conflicts of interest regarding the publication of this paper.

Hamadelnil, A., Wuheb, A.A., Azim, A.M.A. and Ali, R.O.M. (2022) Acute Fingertip Injuries in Sudanese Patients: Patterns and Clinical Presentation. Modern Plastic Surgery, 12, 50-59. https://doi.org/10.4236/mps.2022.123005