Primary Reapproximation of a Near-Amputated Distal Fingertip With Nail Bed Involvement and Minimal Soft Tissue Attachment: A Case Report.

Minimally attached near-complete distal fingertip amputations are often treated with revision amputation due to concerns of vascular compromise. Composite graft survival in adults has long been viewed as unpredictable, especially in smokers. Survival rates vary widely, and smoking has been identified as an independent risk factor for graft failure. We describe an 18-month follow-up of an Allen type II near-amputated distal fingertip (nail bed involvement without bone exposure), with an approximately 3-mm volar dermal bridge. The injury was managed with primary reapproximation using interrupted nylon sutures and a transungual nail plate suture for stabilization. Estimated ischemia time was approximately 2.5 hours. Despite chronic nicotine exposure, the patient achieved complete epithelialization, normal nail growth, preserved 4-mm static two-point discrimination, excellent cosmesis, and full functional recovery at 18 months. Only mild persistent subjective numbness compared to the contralateral fingertip was reported. This case demonstrates that when perfusion remains evident and the mechanism is a sharp cutting injury, primary salvage can succeed even with minimal attachment and a smoking history.