A 1996 narrative review by Fassler providing a structured decision framework for fingertip injuries — the most common hand injury. Treatment selection is driven by whether bone is exposed, the amputation level and angle, remaining sterile matrix length, and patient-specific factors including age and systemic disease. Options range from secondary intention healing to local flaps, regional flaps, and revision amputation.
Two decisions drive every fingertip injury: is bone exposed, and how much sterile matrix is left. No exposed bone and wound ≤1 cm²: dress it and let it heal. Larger wounds get a full-thickness hypothenar graft. Once bone is exposed, measure the remaining sterile matrix — less than 5 mm means revision amputation, because no flap will give you an acceptable nail on that stump.
When a regional flap is appropriate, divide it at 12-14 days without exception. Stiffness risk climbs sharply beyond that window, and suturing the cut edge under tension causes marginal necrosis. Leave small open areas to heal on their own.
The germinal matrix drives nail outcomes more than anything else. A technically perfect repair of the sterile matrix will not compensate for germinal matrix loss. These patients need realistic counseling about permanent nail deformity from the start.
A 1996 narrative review by Fassler providing a structured decision framework for fingertip injuries — the most common hand injury. Treatment selection is driven by whether bone is exposed, the amputation level and angle, remaining sterile matrix length, and patient-specific factors including age and systemic disease. Options range from secondary intention healing to local flaps, regional flaps, and revision amputation.
Two decisions drive every fingertip injury: is bone exposed, and how much sterile matrix is left. No exposed bone and wound ≤1 cm²: dress it and let it heal. Larger wounds get a full-thickness hypothenar graft. Once bone is exposed, measure the remaining sterile matrix — less than 5 mm means revision amputation, because no flap will give you an acceptable nail on that stump.
When a regional flap is appropriate, divide it at 12-14 days without exception. Stiffness risk climbs sharply beyond that window, and suturing the cut edge under tension causes marginal necrosis. Leave small open areas to heal on their own.
The germinal matrix drives nail outcomes more than anything else. A technically perfect repair of the sterile matrix will not compensate for germinal matrix loss. These patients need realistic counseling about permanent nail deformity from the start.