Finger amputation: Difference between revisions

Latest revision as of 14:40, 12 December 2020

Background

Wrist and hand deeper palmar dissection

Due to either blunt or penetrating trauma

Clinical Features

Complete amputation at the level of the PIP joint of the right index finger without distal circulation, along with the crush fracture on the proximal phalangeal bone of middle, ring and little fingers.

Partial or complete amputation of finger(s)

Differential Diagnosis

Distal Finger (Including Nail) Injury

Hand and finger injuries

Distal finger
Other finger/thumb
- Boutonniere deformity
- Mallet finger
  - Swan neck deformity
- Jammed finger
- Jersey finger
- Trigger finger
- Ring avulsion injury
- De Quervain tenosynovitis
- Infiltrative tenosynovitis
- Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
Hand
- Dupuytren contracture
Wrist
- Drummer's wrist
- Ganglion cyst
- Lunotriquetral ligament instability
- Scaphoid fracture
- Extensor digitorum tenosynovitis
- Compressive neuropathy ("bracelet syndrome")
- Intersection syndrome
- Snapping Extensor Carpi Ulnaris
- Vaughn Jackson syndrome
General

Evaluation

An X-ray image of injured hand with finger amputations.

Workup

Hand/finger x-rays
- X-ray limb and amputated part (if available)
Consider pre-op labs

Diagnosis

Clinical diagnosis

Management

Pain control - (Digital block)
If amputated finger available, irrigate and wrap in moist sterile gauze
- Place in plastic bag and put bag in ice water (do not put finger directly on ice!)
Tetanus Prophylaxis if > 5 years since last vaccination
Antibiotics: Ancef 2 grams
Consult hand surgery regarding possible reimplantation vs revision amputation
- In general, amputation distal to DIP is not amenable to reimplantation
  - If bone is exposed, it may be trimmed back with a rongeur to just below the skin level
Acceptable warm ischemia times
- 12 hours for digit; 6 hours for muscle bearing extremity^[1]
Acceptable cold ischemia times (i.e. time amputated part is on ice)
- 24 hours for digit; 12 hours for a muscle bearing extremity^[1]

Indications for Reimplantation

Thumb amputation
Amputation of multiple digits
Amputation level between MCP and distal forearm
Amputations in children

Contraindications to Reimplantation

Severely crushed or mangled parts
Prolonged ischemia time
Single digit (except thumb)
Severe contamination
Age >60, poor health, atherosclerotic disease
Avulsion injury

Disposition

Admit

Plan for reimplantation or immediate surgery
Infection

Discharge

Distal phalanx amputation with controlled bleeding

External Links

References

↑ ^1.0 ^1.1 Lloyd MS. et al. Preoperative management of the amputated limb. Emerg Med J. Jul 2005;22(7):478-80

Authors:

[managment-1] 1.0 ^1.1 Lloyd MS. et al. Preoperative management of the amputated limb. Emerg Med J. Jul 2005;22(7):478-80

[1]

@@ Line 1: / Line 1: @@
-==Indications for Replantation==
+==Background==
-#Thumb
+[[File:Wrist and hand deeper palmar dissection.svg|thumb|Wrist and hand deeper palmar dissection]]
-#Multiple digits
+*Due to either blunt or penetrating trauma
-#Amputation level between palm and distal forearm
-#Proximal to FDS insertion
-#Amputations in children
-==Contraindications==
+==Clinical Features==
-#Severely crushed or mangled parts
+[[File:PMC4624359 13032 2015 28 Fig11 HTML.png|thumb|Complete amputation at the level of the PIP joint of the right index finger without distal circulation, along with the crush fracture on the proximal phalangeal bone of middle, ring and little fingers.]]
-#Prolonged warm ischemia time
+*Partial or complete amputation of finger(s)
-#Single digit
-#Severe contamination
-#Age >60, poor health, atherosclerotic disease
-#Avulsion injury
-#Lower extremity amputations
-==Warm Ischemia==
+==Differential Diagnosis==
-*12 hours for digit; 6 hours for muscle bearing extremity
+{{DDX distal finger}}
-==Cold Ischemia==
+{{Hand and finger injury DDX}}
-*24 hours for digit; 12 hours for a muscle bearing extremity
+==Evaluation==
+[[File:PMC4624359 13032 2015 28 Fig3 HTML.png|thumb|An X-ray image of injured hand with finger amputations.]]
+===Workup===
+*Hand/finger x-rays
+**X-ray limb and amputated part (if available)
+*Consider pre-op labs
+===Diagnosis===
+*Clinical diagnosis
+==Management==
+*Pain control - ([[Digital block]])
+*If amputated finger available, irrigate and wrap in moist sterile gauze
+**Place in plastic bag and put bag in ice water (do not put finger directly on ice!)
+*[[Tdap|Tetanus Prophylaxis]] if > 5 years since last vaccination
+*Antibiotics: Ancef 2 grams
+*Consult hand surgery regarding possible reimplantation vs revision amputation
+**In general, amputation distal to DIP is not amenable to reimplantation
+***If bone is exposed, it may be trimmed back with a rongeur to just below the skin level
+*Acceptable warm ischemia times
+**12 hours for digit; 6 hours for muscle bearing extremity<ref name="managment">Lloyd MS. et al.  Preoperative management of the amputated limb. Emerg Med J. Jul 2005;22(7):478-80</ref>
+*Acceptable cold ischemia times (i.e. time amputated part is on ice)
+**24 hours for digit; 12 hours for a muscle bearing extremity<ref name="managment"></ref>
+===Indications for Reimplantation===
+*Thumb amputation
+*Amputation of multiple digits
+*Amputation level between MCP and distal forearm
+*Amputations in children
+===Contraindications to Reimplantation===
+*Severely crushed or mangled parts
+*Prolonged ischemia time
+*Single digit (except thumb)
+*Severe contamination
+*Age >60, poor health, atherosclerotic disease
+*Avulsion injury
+==Disposition==
+===Admit===
+*Plan for reimplantation or immediate surgery
+*Infection
+===Discharge===
+*Distal phalanx amputation with controlled bleeding
+==External Links==
-==Treatment==
-#Pain control (digital block)
-#Irrigate amputated part
-#Place moist, sterile gauze around amputated part
-#Place in water tight container in ice water
-#X-ray limb and part
-#[[Tdap]]
-#[[Antibiotics (Main)|Abx]]
-##1st generation cephalosporin + gentamicin
-#Consult surgery
-##The management of distal fingertip amputation is controversial and should be individualized
-##Final judgement regarding reimplantation is by surgeon
-##Most amputations distal to the DIP are managed with local wound care and allowed to heal by secondary intention
-##If bone is exposed, it may be trimmed back with a rougeur to just below the skin level
 ==See Also==
-*[[High-Pressure Injection Injury]]
+*[[Fingertip laceration]]
+*[[Distal phalanx (finger) fracture]]
+*[[High-pressure injection injury]]
-==Source==
+==References==
-DeBonis 7/09 Adapted Burbulys
+<references/>
-[[Category:Ortho]]
+[[Category:Orthopedics]]
 [[Category:Trauma]]