Finger amputations
Amputated thumb

Definition

Finger amputations are serious injuries that involve the loss of phalanges of one or more fingers.

Amputation of 3/4 of the distal phalange of the middle finger

Pathology

Finger amputations mostly occur in the distal phalanges of the long fingers and may include the bone as well as the soft tissue including the skin, tendons, vessels, nerves and nail bed. Amputations may also affect one or multiple fingers and extend to the hand palm.

Minor finger injury of the soft tissue

Classification

Finger amputations are classified according to the extent of finger loss and the mechanisms leading to an amputation.

Minor finger injuries involve primarily the soft tissue without exposing the bone. These types of injuries normally do not require surgery but a thorough hygiene regime with dressing and disinfectants to prevent infections.

A repaired finger injury with a tissue flap

Extensive finger injuries with bone exposure may include damage to the phalanges. The bone is surgically shortened to allow reconstruction with a soft tissue flap to cover the wound.

Traumatic amputation of the thumb of a carpenter while working with a saw

Traumatic amputations consist in the total severing of the finger at the time of accident, which may occur at various phalange levels. Depending on the conditions of the amputated part and time from the accident, the surgeon may opt for replantation if conditions are suitable. In young children replantation can allow for a relative normal finger growth.

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Explosions are often the cause of severe finger injuries and amputations

Causes

Finger amputations are a frequent result of crush incidents or cutting injuries when handling sharp utensils and machines. Amputations occur either directly during the injury itself or as a consequent surgical amputation when the damage is so extensive that the finger cannot be preserved. Finger amputations arise from a large number of mechanisms such as:

Crush injuries

Tear

Severing by sharp knives, blades and machineries

Explosions

Manouvering cement mixers increases the risk of finger amputations

Risk factors

The main risk factors for finger amputations are:

Manoeuvring of industrial and farming tools and machineries (axes, mixers, chain saws)

Crush injuries (car doors, hammers, machine parts, pressure or fall of heavy objects)

Jamming doors

Home power tools

Lawn mowers

Handling of explosive material or devices

Finger amputations cause a severe bleeding and require immediate medical attention

Symptoms

The symptoms of a finger amputation are:

Sharp pain

Extensive bleeding

Movement restrictions

Finger and/or hand deformity

Separation of amputated finger extremity

X-ray of a middle and ring finger amputation and crush injury of the little finger

Diagnosis

The severity of finger amputation depends on the extent of tissue that has been lost and whether one or more fingers are involved. A partial or total finger amputation should be assessed immediately after injury and managed as described below. Medical examination will evaluate the possibility of replanting the amputated finger to determine: 

Changes in the anatomy of the affected finger(s) against the healthy fingers

Extent of damage to soft tissue and phalangeal bones

Severity of bleeding

Changes in finger/hand function

Risk of infection 

X-rays are taken to assess the degree of damage to the phalanges to guide therapy towards surgical reconstruction or potential finger replantation.

Treatment

Minimal surgery for the repair of a extensive finger injury

Nonoperative treatment

Management of finger amputations varies in relation to the number of fingers amputated, the phalangeal level at which the amputation has occurred and the integrity of the soft tissue remaining. Conservative or minimal surgical treatment is employed in minor finger amputations affecting the soft tissue. These are usually managed immediately in the Emergency Room and include:

Stop bleeding

Disinfection

Additional treatment includes:

Debridement (removal) of crushed soft tissue

Wound suturing

Hand elevation

Application of ice pads

Painkillers

Administration of NSAIDs/

Administration of antibiotics

Splint to prevent movement of the fingers

Surgical amputation is required when the finger has been severely damaged

Surgical treatment

After obtaining the X-rays the surgeon determines the degree of damage to the fingers and hands. The surgical approach takes into consideration the balance between finger amputation and replantation, relative to the functional outcome and cosmetics. In case of fingertip amputation, the surgeon removes the dead tissue, shortens the bone if necessary, and closes the extremity with a tissue flap.

If the amputation is extensive (involving the phalanges and soft tissue), the detached extremity is preserved under sterile and moist condition for a possible replantation. A soft tissue graft taken from other body parts may be required in case of abundant tissue loss. The goal of surgery is to create a suitable anatomy to eventually fit a finger prosthesis if replantation is not possible.

Reattachment of amputated fingers has a high rate of success but only achieves 50% of normal function. Replantation is not recommended if amputation occurs at the fingertip, single finger, finger base, crush injuries or infection, but is advised in children and following multiple amputations including the thumb.

For example, with the loss of the fifth finger, surgery may retain the corresponding fifth metacarpal bone of the hand, which is aesthetically less likable but functionally superior, or remove it to achieve a continuous contour of the palm. In the second case a smaller palm will lose part of the strength and gripping function.

Complications

Complications following a finger amputation differ relative to severity and treatment modalities.

After surgery:

Infection

Poor wound healing

Tissue defect

Loss of function

Loss of sensation

After finger replantation:

Poor circulation

Reduced movement

Loss of sensation

Altered temperature control

Prolonged period of recovery

A splint is used immediately after finger replantation prior to beginning physical therapy

Rehabilitation

A physical or occupational therapist provides the patient with an exercise plan to restore flexibility and strength of the hand following an amputation and learn the use of the hand with a finger prosthesis. Education is pivotal to modify activities when one or more fingers have been lost. Additional rehabilitative therapy includes:

Massage

Ice or heat packs

Electrotherapy

Splinting

Traction

Joint mobilisation

Stretches and return to activity plan

Protecting the hands with suitable gear prevents finger injuries and amputations. This approach is unsafe.

Prevention

The aim of prevention is to reduce the risk of finger amputations by protecting the hands in any physical activity. Common strategies are:

Use of gears to reduce exposure of fingers when using machines/tools

Construction of machines with safeguard technology

Implementation of occupational health and safety regulations in the workplace