A NEW CLASSIFICATION FOR FINGERTIP INJURIES

D. M. EVANS and C. BERNADIS

From the Department of Plastic Surgery, Guy's and St Thomas' Hospital, London, UK

A new classication of ngertip injuries is presented. The PNB classication separates the injury
into its eect on the three components of the ngertip: pulp, nail and bone. This provides a three
digit number that accurately describes the injury. This new classication can be used to record and
document injuries, without having to resort to lengthy description. It could also be used to provide
detailed instructions for treatment and indications for referral. Examples of the application of the
classication are given.
Journal of Hand Surgery (British and European Volume, 2000) 25B: 1: 5860

Fingertip injuries are common, potentially disabling and
costly, and very variable in terms of the detail of injured
structures. At present it is necessary to resort to wordy
Table 1The PNB classication of ngertip injuries
Pulp
0 No injury
1 Laceration
2 Crush
3 Lossdistal transverse
4 Losspalmar oblique partial
5 Lossdorsal oblique
6 Losslateral
7 Losscomplete
Nail
0 No injury
1 Sterile matrix laceration
2 Germinalsterile matrix laceration
3 Crush
4 Proximal nailbed dislocation
5 Lossdistal third
6 Lossdistal two thirds
7 Losslateral
8 Losscomplete
Bone
0 No injury
1 Tuft #
2 Comminuted non-articular #
3 Articular #
4 Displaced basal #
5 Tip exposure
6 Lossdistal half
7 Losssubtotal (tendon insertions intact)
8 Losscomplete
description in order to communicate the details of an
injury, for example in the provision of advice or
instructions for treatment. Since there are many ways
of treating ngertip injuries, it is essential to be able to
describe them succinctly.
There have been few attempts to classify ngertip
injuries. Lister (1991) presented his algorithm for
recommending treatment, based on a sequence of
questions. Although this provided a logical approach
to decision-making, it did not provide a means of
describing an injury, and nail injuries were not included
in the classication.
Ishikawa et al. (1990) classied distal digital amputa-
tion levels, and their scheme can be adapted to include
ngertip injuries. The ngertip is divided into zones
based on the nail. Four levels are described distal to
the DIP joint, with subgroups according to the angle
of amputation. Smith and Elliot (in press) used this
system to explain which injuries could be covered using
the Tranquilli-Leali ap or a neurovascular island ap.
This classication is only concerned with amputations,
and cannot include injuries without tissue loss. The
classication of Elsahy (1997) is similarly concerned
with distal amputations, using the nail as the basis for
classication.
Hirase (1997) used the level of arterial anastomosis
for a similar classication. Again this was linked to
amputation, and did not allow denition of the wide
variations in ngertip injuries.
Three structures comprise the ngertip: the soft tissue, the
nail and its supporting structures, and the distal phalanx.

Table 2Examples of PNB classication groups with possible recommendations for treatment

PNB Group A possible recommended treatment policy

P3, N0 or 5,B1 or 5 Child or adultocclusive dressing (e.g. Hyphecan, Lee et al. 1995), or adultneurovascular
(NVI; step advancement ap, Evans and Martin, 1988)
P6, N6, B0 or 1 Occlusive dressing if defect small. NVI advancement if
critical tactile area
P4 or 7, N0 or 5, B5 NVI (step-advancement) ap
P3,4 or 7,N0 or 5, B6 or 7 Bone graft and step advancement ap if appropriate; excise germinal matrix and close if not
P0, 1 or 3, N6 or 8, B6 or 7 Excise germinal matrix, close skin or step advancement
P0, N4, B4 K wire, replace dislocated germinal matrix
P4 or 7, N6 or 8, B6 or 7 Replantation if indicated, or NVI (step advancement)
P7, N8, B8 Replantation if possible, teminalization if not

58
CLASSIFICATION FOR FINGERTIP INJURIES 59

Fig 1 Transverse amputation with loss of distal pulp, nail and bone,
PNB356.

Fig 4 Steep palmar oblique loss, losing all of the pulp, PNB401.

Fig 5 Dorsal oblique loss, most of nail, sparing pulp, PNB061.

Fig 2 More proximal transverse loss removing two-thirds of nail,
PNB366.

Fig 3 Palmar oblique loss, taking more pulp than nail, PNB355. Fig 6 Lateral oblique loss, PNB670.
60
Fig 7 Dislocation of nail and germinal matrix with transverse distal
phalangeal fracture, PNB044.
Fig 8 Transverse amputation through proximal distal phalanx,
sparing tendon attachments, PNB787.
Since all three can be injured or lost in dierent
combinations, it seems logical to dene a ngertip
injury according to damage to each of them. The
``PNB'' (pulp, nail, bone) classication is based on the
TNM classication of malignant disease. Table 1 shows
the subdivisions used in each category, starting from 0,
indicating no damage, to the highest number in each
group, indicating total loss of that structure. For any
given injury the three numbers are joined to give a three-
digit number that accurately denes that injury.
Examples are given in Figures 1 to 9.
THE JOURNAL OF HAND SURGERY VOL. 25B No. 1 FEBRUARY 2000
Fig 9 Transverse amputation through DIP joint, dividing tendon
insertions, PNB788.
The PNB classication could have a number of uses.
When a patient presents with a ngertip injury, the
number can be quickly derived from the chart, and used
when making referral or requesting instructions about
treatment. Similarly, outline instructions for treatment
or indications for referral could be supplied to accident
departments or outlying hospitals using PNB numbers
or groups of numbers to dene categories of injury. The
system could also provide a sound basis for comparative
studies of the results of treatment. Because of the
numerical nature of the system, it could readily be used
for collection of data on a computer programme.
Acknowledgements
We are grateful to Donald Sammut FRCS (Plast) for kindly providing the
drawings of ngertip injuries, and to Adam Hodgson for preparing them for
publication.
References
Elsahy NI (1997). When to replant a ngertip after its complete amputation.
Plastic and Reconstructive Surgery, 60: 1421.
Evans DM, Martin DL (1988). Step-advancement island ap for ngertip
reconstruction. British Journal of Plastic Surgery, 41: 105111.
Hirase Y (1997). Salvage of ngertip amputated at nail level. Annals of Plastic
Surgery, 38: 151157.
Ishikawa K, Ogawa Y, Soeda H, Yoshida Y (1990). A new classication of the
amputation level for the distal part of the nger. Journal of the Japanese
Society of Reconstructive Microsurgery, 3: 5462.
Lee LP, Lau PY, Chan CW (1995). A simple and ecient treatment for ngertip
injuries. Journal of Hand Surgery, 20B: 6371.
Lister G. V-Y Advancement aps. In: Foucher G (Ed.) Fingertip and nailbed
injuries. The Hand and Upper Limb series. Edinburgh, Churchill
Livingstone, 1991: 5261.
Smith KL, Elliot D. The extended Segmuller ap. Plastic and Reconstructive
Surgery (in press).
Received: 21 June 1999
Accepted after revision: 19 August 1999
D. M. Evans FRCS, The Hand Clinic, Oakley Green, Windsor SL4 4LH, UK.
E-mail: dmevans@dial.pipex.com
# 2000 The British Society for Surgery of the Hand
DOI: 10.1054/jhsb.1999.0305, available online at http://www.idealibrary.com on