Digital Amputations 

  • Author: Bradon J Wilhelmi, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: May 7, 2010
 

Background

An amputation is the removal of an extremity or appendage from the body. Amputations in the upper extremity can occur as a result of trauma, or they can be performed in the treatment of congenital or acquired conditions. Although successful replantation represents a technical triumph to the surgeon, the patient's best interests should direct the treatment of amputations.

The goals involved in the treatment of amputations of the upper extremity include the following: (1) preservation of the functional length, (2) durable coverage, (3) preservation of useful sensibility, (4) prevention of symptomatic neuromas, (5) prevention of adjacent joint contractures, (6) early return to work, and (7) early prosthetic fitting.[1, 2] These goals apply differently to different levels of amputation.

An image depicting digital amputation can be seen below.

In performing an index ray amputation, a dorsal loIn performing an index ray amputation, a dorsal longitudinal incision over the index metacarpal is used in conjunction with a circumferential skin incision at the midproximal phalangeal level. The skin is intentionally left long distally to avoid deficiency, which could result in a web-space contracture.
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Indications

Amputations can result from traumatic injury involving a variety of machines, they can be self-inflicted, or they may be required after traumatic events, such as electrical burns or frostbite. In addition, elective amputations may be indicated for tumor extirpation, vascular insufficiency, infection, or congenital malformation.

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Contributor Information and Disclosures
Author

Bradon J Wilhelmi, MD  Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine

Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph E Sheppard, MD  Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Robert J Nowinski, DO  Clinical Assistant Professor of Orthopaedic Surgery, Ohio State University College of Medicine and Public Health, Ohio University College of Osteopathic Medicine; Private Practice, Orthopedic and Neurological Consultants, Inc, Columbus, Ohio

Robert J Nowinski, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Osteopathic Surgeons, American Medical Association, American Osteopathic Association, Ohio Osteopathic Association, and Ohio State Medical Association

Disclosure: Tornier Grant/research funds Other; Tornier Honoraria Speaking and teaching

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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  2. Conolly WB, Goulston E. Problems of digital amputations: a clinical review of 260 patients and 301 amputations. Aust N Z J Surg. Sep 1973;43(2):118-23. [Medline].

  3. Datiashvili RO, Knox KR, Kaplan GM. Solutions to challenging digital replantations. Clin Plast Surg. 34(2);2007 Apr:167-75, vii. [Medline].

  4. Dautel G, Barbary S. Mini replants: fingertip replant distal to the IP or DIP joint. J Plast Reconstr Aesthet Surg. 2007;60(7):811-5. Epub 2007 May 23. [Medline].

  5. May JW Jr, Toth BA, Gardner M. Digital replantation distal to the proximal interphalangeal joint. J Hand Surg [Am]. Mar 1982;7(2):161-6. [Medline].

  6. Gavrilova N, Harijan A, Schiro S, Hultman CS, Lee C. Patterns of finger amputation and replantation in the setting of a rapidly growing immigrant population. Ann Plast Surg. May 2010;64(5):534-6. [Medline].

  7. Omer GE. Amputation. In: Hunter JM, Schneider LH, Makin EJ, Bell JA, eds. Rehabilitation of the Hand. St Louis, Mo: Mosby-Year Book; 1978:541.

  8. Wilhelmi BJ, Neumeister MW. Hand, finger nail and tip injuries. eMedicine from WebMD [serial online]. Updated June 28, 2006;Accessed March 10, 2008. Available at http://emedicine.medscape.com/article/1285680-overview.

  9. Yokoyama T, Tosa Y, Hashikawa M, Kadota S, Hosaka Y. Medial plantar venous flap technique for volar oblique amputation with no defects in the nail matrix and nail bed. J Plast Reconstr Aesthet Surg. Jan 20 2010;[Medline].

  10. Tribble DE. A special skin grafting technique for concave surfaces and for traumatic amputations of fingers. Am Surg. Feb 2010;76(2):172-5. [Medline].

  11. Chen SY, Wang CH, Fu JP, Chang SC, Chen SG. Composite Grafting for Traumatic Fingertip Amputation in Adults: Technique Reinforcement and Experience in 31 Digits. J Trauma. Apr 16 2010;[Medline].

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  14. Chase RA. Functional levels of amputation in the hand. Surg Clin North Am. Apr 1960;40:415-23. [Medline].

  15. Ennis WM, Huber HS. Traumatic amputations of the fingers. Surg Clin North Am. 1938;18:305.

  16. Whitaker LA, Graham WP 3rd, Riser WH, Kilgore E. Retaining the articular cartilage in finger joint amputations. Plast Reconstr Surg. May 1972;49(5):542-7. [Medline].

  17. Parkes A. The "lumbrical plus" finger. Hand. Sep 1970;2(2):164-5. [Medline].

  18. Roukis TS. Minimum-incision metatarsal ray resection: an observational case series. J Foot Ankle Surg. Jan-Feb 2010;49(1):52-4. [Medline].

  19. Murray JF, Carman W, MacKenzie JK. Transmetacarpal amputation of the index finger: a clinical assessment of hand strength and complications. J Hand Surg [Am]. Nov 1977;2(6):471-81. [Medline].

  20. Swanson AB. Levels of amputation of fingers and hand -- considerations for treatment. Surg Clin North Am. Aug 1964;44:1115-26. [Medline].

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  22. Klein-Weigel P, Pavelka M, Dabernig J, et al. Macro- and microcirculatory assessment of cold sensitivity after traumatic finger amputation and microsurgical replantation. Arch Orthop Trauma Surg. Jul 2007;127(5):355-60. Epub 2007 Jan 20. [Medline].

 
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In performing an index ray amputation, a dorsal longitudinal incision over the index metacarpal is used in conjunction with a circumferential skin incision at the midproximal phalangeal level. The skin is intentionally left long distally to avoid deficiency, which could result in a web-space contracture.
The principles of a central ray amputation include removal of the injured finger at the metacarpal base, correcting the rotational deformity, closing the space between the 2 adjacent unamputated fingers, and achieving a satisfactory appearance of the hand.This illustration depicts 1 of 2 techniques that have been described regarding central ray amputation. The procedure involves the transfer of the index finger ray onto the third metacarpal base for the middle finger and the small finger to the ring metacarpal base. The disadvantages of the ray transfer procedure are the requirement for postoperative immobilization and the risk of nonunion.
The second central ray amputation technique involves removing the involved finger at the metacarpal base. The disadvantages of this technique are eventual widening of the web space and rotational deformity of the digit. The risk of these complications can be minimized by repairing the deep transverse intermetacarpal ligament and using a threaded Kirschner wire (K-wire) to secure the second to the fourth metacarpal.
The technique of central ray amputation involves the use of a circumferential incision at the midproximal phalanx in conjunction with a dorsal longitudinal incision. The dorsal incision is extended through the extensor. The periosteum is scored at the level of the metacarpal base.
In performing a central ray amputation, the dorsal incision is performed in a tennis racket configuration.
The volar incision is completed in the shape of a wedge to facilitate closure without a dog ear.
The dorsal incision is extended through the extensor. The periosteum is scored at the level of the metacarpal base.
With a central ray amputation, the metacarpal is transected at its base. The hand is then supinated and the flexor is divided.
The flexor tendon is divided and allowed to retract proximally.
The metacarpal base is transected with a sagittal saw.
The amputated central ray is shown here.
The proper digital nerves and arteries to the adjacent fingers are preserved from the common digital neurovascular bundles.
The neurovascular bundles are divided proximally to avoid neuroma formation at the skin incision.
The deep transverse metacarpal ligaments are identified on either side of the volar plate of the involved finger at the metacarpophalangeal joint. In transecting the deep transverse metacarpal ligaments, it is essential to preserve enough ligament to attach to each other to minimize gap formation and rotational deformity.
The deep transverse metacarpal ligaments are repaired with 2-0 Ethibond nonabsorbable sutures.
The gap is compressed, and transverse Kirschner wires (K-wires) are placed through the metacarpals on either side of the ray amputation. Threaded K-wires can help resist the sliding of the metacarpals on the K-wires like an accordion.
The threaded Kirschner wire can help to prevent rotational deformity.
Active motion is begun early, and the Kirschner wires can be removed at 6 weeks. This technique can be applied to ray amputation of both the middle and ring fingers.
In performing a central ray amputation of the ring finger, the deep transverse intermetacarpal ligament can be repaired to avoid the need for metacarpal transfer.
The procedure of small finger ray amputation is performed through a tennis racquet incision.
When the thumb tip has been amputated, replantation can provide the patient with the best return to function even if interphalangeal joint fusion is required.In the event that replantation cannot be performed or is unsuccessful, minimal bone shortening should be performed to provide a smooth bone end over which to close the skin. In fact, the bone should not be removed only to obtain primary skin closure. A volar rectangular advancement flap (Moberg) should be used to provide soft-tissue closure and preserve thumb length.
The volar advancement flap is raised as a rectangle to include both neurovascular bundles to the metacarpophalangeal crease of the thumb and is advanced in the distal direction.
The Moberg flap can be used to close 1- to 1.5-cm defects. If the amputation level is at or distal to the distal interphalangeal joint, the patient should not experience much functional loss.
The Moberg flap can allow for length preservation and coverage of the thumb tip with sensate skin because it contains both neurovascular bundles.
If the patient's amputation level is proximal to the interphalangeal joint, reconstruction with toe transfer should be considered. If the amputation is at the carpometacarpal level, pollicization can be considered.
This patient had a digital nerve neuroma (outlined in marker) following revision amputation. He had point tenderness over the neuroma. The skin and neuroma were removed.
The neuroma is dissected, and a traction neurectomy is performed.
 
 
 
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