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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 description in order to communicate the details of an
costly, and very variable in terms of the detail of injured injury, for example in the provision of advice or
structures. At present it is necessary to resort to wordy instructions for treatment. Since there are many ways
of treating ngertip injuries, it is essential to be able to
Table 1The PNB classication of ngertip injuries describe them succinctly.
There have been few attempts to classify ngertip
Pulp injuries. Lister (1991) presented his algorithm for
0 No injury recommending treatment, based on a sequence of
1 Laceration
2 Crush questions. Although this provided a logical approach
3 Lossdistal transverse to decision-making, it did not provide a means of
4 Losspalmar oblique partial describing an injury, and nail injuries were not included
5 Lossdorsal oblique in the classication.
6 Losslateral
7 Losscomplete
Ishikawa et al. (1990) classied distal digital amputa-
tion levels, and their scheme can be adapted to include
Nail
0 No injury ngertip injuries. The ngertip is divided into zones
1 Sterile matrix laceration based on the nail. Four levels are described distal to
2 Germinalsterile matrix laceration the DIP joint, with subgroups according to the angle
3 Crush of amputation. Smith and Elliot (in press) used this
4 Proximal nailbed dislocation
5 Lossdistal third
system to explain which injuries could be covered using
6 Lossdistal two thirds the Tranquilli-Leali ap or a neurovascular island ap.
7 Losslateral This classication is only concerned with amputations,
8 Losscomplete and cannot include injuries without tissue loss. The
Bone classication of Elsahy (1997) is similarly concerned
0 No injury with distal amputations, using the nail as the basis for
1 Tuft #
2 Comminuted non-articular #
classication.
3 Articular # Hirase (1997) used the level of arterial anastomosis
4 Displaced basal # for a similar classication. Again this was linked to
5 Tip exposure amputation, and did not allow denition of the wide
6 Lossdistal half variations in ngertip injuries.
7 Losssubtotal (tendon insertions intact)
8 Losscomplete 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
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 3 Palmar oblique loss, taking more pulp than nail, PNB355. Fig 6 Lateral oblique loss, PNB670.
60 THE JOURNAL OF HAND SURGERY VOL. 25B No. 1 FEBRUARY 2000
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.
Fig 8 Transverse amputation through proximal distal phalanx, Hirase Y (1997). Salvage of ngertip amputated at nail level. Annals of Plastic
sparing tendon attachments, PNB787. 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.
Since all three can be injured or lost in dierent Lee LP, Lau PY, Chan CW (1995). A simple and ecient treatment for ngertip
injuries. Journal of Hand Surgery, 20B: 6371.
combinations, it seems logical to dene a ngertip Lister G. V-Y Advancement aps. In: Foucher G (Ed.) Fingertip and nailbed
injury according to damage to each of them. The injuries. The Hand and Upper Limb series. Edinburgh, Churchill
``PNB'' (pulp, nail, bone) classication is based on the Livingstone, 1991: 5261.
Smith KL, Elliot D. The extended Segmuller ap. Plastic and Reconstructive
TNM classication of malignant disease. Table 1 shows Surgery (in press).
the subdivisions used in each category, starting from 0,
indicating no damage, to the highest number in each Received: 21 June 1999
group, indicating total loss of that structure. For any Accepted after revision: 19 August 1999
D. M. Evans FRCS, The Hand Clinic, Oakley Green, Windsor SL4 4LH, UK.
given injury the three numbers are joined to give a three- E-mail: dmevans@dial.pipex.com
digit number that accurately denes that injury. # 2000 The British Society for Surgery of the Hand
Examples are given in Figures 1 to 9. DOI: 10.1054/jhsb.1999.0305, available online at http://www.idealibrary.com on