Digital Amputations of the Upper Extremity Periprocedural Care

Updated: Apr 13, 2022
  • Author: Steven I Rabin, MD, FAAOS; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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Periprocedural Care

Preprocedural Planning

The primary initial goal in the treatment of traumatic amputations is to evaluate the suitability of the amputated part for replantation. Amputations of the thumb, multiple fingers, the hand at the level of the wrist or distal forearm, and the upper extremity above the elbow should be evaluated for replantation because patients can benefit from replantation of these appendages even if the resulting function of the part is less than optimal. [16, 17]  Patients with mangled digits may also benefit from amputation instead of reconstruction.

Although replantation at these levels can often achieve good functional outcomes, replanted single fingers may be stiff and impede the opposition of other fingers to the thumb, as well as overall hand function. Replanted single-finger amputations can achieve a better range of motion (ROM) when the level is distal to the insertion of the flexor digitorum superficialis (FDS). [15]  Complete digital amputations undergoing replantation surgery have a higher failure rate than incomplete digital amputations. [18]

Single-finger replantation can be considered when patients have injuries to other fingers of the same hand. All of these injuries require splint immobilization and rehabilitation that impede immediate return to work. Accordingly, single-finger replantation can be considered in special circumstances. The surgeon must not become absorbed in the technical challenge of the replantation to the point where the other associated injuries are neglected, because poorer outcomes and greater financial cost (due to lost wages and the cost of hospitalization and therapy) can result. [19]

In performing an amputation, it is important to preserve functional length. For example, an above-elbow arm amputation should be replanted to provide the patient with a functional elbow on which a prosthesis can be fitted, resulting in better function than an above-elbow prosthesis. Durable coverage at the end of an amputation is critical to the function of an amputation. This may necessitate the use of a local flap. Preservation of sensibility on the amputation stump can optimize the usefulness of the remaining appendage.

Sometimes, local flaps can be used to bring sensate tissue to the stump tip. It is important to minimize the risk of painful neuroma formation at the amputation stump and to prevent joint contractures. Some local flaps can pose a risk of joint contracture to the involved finger and adjacent fingers. Use of the delayed groin flap can risk elbow and shoulder joint contractures.

Other critical objectives in the treatment of amputations are early return to work and fitting with a prosthesis, when possible.

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Imaging Studies

Often, plain radiographic studies may be helpful to determine the most suitable level of amputation for traumatic crushing injuries. If the amputation is being performed for a tumor, other radiographic studies (eg, magnetic resonance imaging [MRI]) may be useful for determining the proximal extent of a tumor.

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