Fingertip Amputation Periprocedural Care

Because functional requirements differ from one individual to the next, management options must always be discussed with the patient.

Management starts with a history elicited from the patient regarding the nature of the injury, age, hand dominance, occupation, recreational activities (including playing sports and musical instruments), previous history of hand injuries or problems, and other systemic diseases that affect wound healing.

A complete hand examination should be performed, estimating the amount of injury to the fingertip, angles and levels of amputation, loss of tissue, involvement of nail, involvement of other fingers, neurovascular involvement, and function of the hand. Investigations include radiographs of the affected finger to reveal whether the injury is associated with any underlying fractures or foreign bodies; fractures may require further treatment.

After assessment of the fingertip injury, a treatment plan should be formulated. If more than one option is available, the potential benefits and risks of each option should be discussed with the patient before the final treatment is selected.

The choice of surgical instruments is left to the surgeon. In general, a basic surgical tray is all that is needed. Possible instruments include the following:

• Hand surgery instruments - Scissors, retractors, needle holders, scalpel, forceps, clamps, elevators
• Bone instruments (if bone end must be trimmed) - Drill and accessories, osteotomes, mallet, retractors, curettes
• Tendon and nerve repair instruments - Tendon strippers
• Irrigation supplies (for wound cleaning)

Anesthesia

Fingertip amputations can be performed with general anesthesia or regional anesthesia. Regional anesthesia is generally preferred, and many simple procedures can be performed with digital blocks. If multiple fingers are involved because of the injury, or proximal tissues are involved either as a flap or skin graft, then a Bier block or general anesthesia may be used.

Preferred anesthesia for each procedure is as follows:

• Open technique - Digital block for pain control, including during cleaning and dressing
• Skin graft - Wrist block, Bier block, general anesthesia
• Reamputation - Digital block
• V-Y flap - Digital block
• Volar flap advancement - Bier block, general anesthesia
• Bipedicle dorsal flap - Bier block, general anesthesia
• Crossfinger flap - Wrist block, Bier block, general anesthesia
• Thenar flap - Wrist block, Bier block, general anesthesia

Digital nerve blocks can be performed via either a volar or a dorsal approach. The author prefers to use the dorsal approach because the volar approach usually results in incomplete dorsal anesthesia. Because of this, more anesthetic may be required to be administered locally or dorsally to numb the dorsal digital nerves. For more information, see Digital Nerve Block.

The volar approach includes the following steps:

• Prepare the area with antiseptic solution
• Pass the needle over the flexor sheath at the level of metacarpophalangeal (MCP) joint, then direct the injection on either side of the flexor tendon

The dorsal approach includes the following steps:

• Clean the web spaces at the base of the finger with antiseptic solution (preferably chlorhexidine)
• Insert needle into the dorsal skin, brushing aside the head of the metacarpal
• Before inserting deep, create a wheal dorsally by injecting local anesthetic into the dorsal skin, blocking the dorsal digital nerves
• Then direct the needle volarly and block the digital nerves by injecting additional local anesthetic

With such an injection, widening of the webspace may be seen. Repeat the same procedure on the other side of the metacarpal.

Positioning

Position the patient supine on the operating table with the affected arm supported over an arm board.

For procedures involving areas proximal to the MCP joint, an arm tourniquet is used. For procedures not involving areas proximal to the MCP joint, a digital tourniquet can be used. A digital tourniquet can be made at the operating table with an elastic glove, as follows:

• Cut off a finger of a glove; cut the tip off as well, so that it looks like a cylindrical tube with openings at both ends
• Insert the tube on the finger, starting distally and gently rolling down proximally until it reaches the base of the finger; this process of rolling the tube down the finger acts to exsanguinate the finger
• When the base is reached, a small curved artery forceps is used to hold the rolled tube and then rotated to act as a tourniquet