Indications and contraindications

• Indications:

  • Thumb​

  • Single digit zone 1

  • Multiple digits

  • Hand amputation through palm

  • Distal wrist amputation

  • Child

  • More proximal arm (sharp, clean injury pattern)

• Contraindication:​

  • Single digit zone 2

  • Severely crushed or mangled parts

  • Multi-level amputations

  • Multiple traumas or severe medical problems (relative contraindication)

Distal tip amputations

• Amputations distal to DIPJ

  • Generally difficult​ due to venous paucity

• Tamai classification​

  • Zone 1 - distal to lunula​

  • Zone 2 - DIPJ to lunula

• Chung's fingertip classification​

  • Zone IA​ - distal to lunula through sterile matrix

    • Artery: very difficult​; Vein: impossible; Nerve: impossible

  • Zone IB - between lunula and root of nailbed​

    • Artery: difficult; Vein: very difficult; Nerve: very difficult​

  • Zone IC - between FDP insertion and neck of middle phalanx​

    • Artery: easy; Vein: difficult; Nerve: easy​

  • Zone ID - between neck of middle phalanx and FDS insertion​

    • Artery: easy​; Vein: easy; Nerve: easy

Ring avulsion injuries

• Type I: soft tissue injury without vascular compromise

• Type II: soft tissue damage with arterial and/or venous compromise​​

  • Treatment: local or flow-through venous flaps, vascular repair using vein grafts​

• Type III - complete degloving of soft tissues

  • Treatment: primary ray amputation​

Pre-operative workup

• In emergency department:

  • Primary survey and stabilisation based on ATLS principles

  • Management of life threatening injuries

  • Broad-spectrum IV antibiotics and tetanus

  • X-ray hand and amputate

  • Store amputate in saline-soaked gauze, in ziplock bag, on ice

• Upon transfer to plastics department

  • Prompt patient assessment

    • History - mechanism (guillotine, avulsion, crush), time of injury​

    • Examination of digit and amputate​​

  • Inform theatre team, check for microscope availability

  • Details to discuss during consent process:

    • Potential replant failure​

    • Need for bone, nerve and vein graft

    • Need for further surgery

    • Prolonged rehabilitation course

    • Realistic prognosis - sensation, mobility and function

  • Factors when considering replantation​

    • Age​ and co-morbidities

    • Handedness and occupation/hobbies

    • Likely compliance with post-operative care and rehabilitation

Surgical principles

• GA or axillary block

• Two-team approach:

  • 1st team brings amputated part for examination with loupes or microscope in back table

    • Bilateral longitudinal mid-axial incisions

    • Tag neurovascular structures​ - nerves 6-0 Ethilon; arteries and veins 6-0 Prolene

    • Bony preparation with two retrograde K-wires

  • 2nd team

    • Meticulous exploration, debridement and irrigation of proximal part​

    • Identifies all vital structures

    • May place core sutures into tendons before bony fixation

    • Bone shortening as necessary

• Order of repair (our preferred order) - bone, flexor, artery, vein, extensor​​, nerve (see relevant pages)

• Vein grafts from volar wrist or dorsal foot​​

• Loose skin closure, skin grafts, local flaps

• Antibiotic ointment, Tullegras, gauze, wool, crepe loosely applied to enable postoperative monitoring of fingertip

• Protective splinting 

Postoperative care

• Fingertip assessment - capillary refill, colour, turgor, temperature

• Warming blanket to keep digit warm

• Pillow elevation

• IV hydration and fluid input/output monitoring

• Consider VTE prophylaxis

• Leech therapy or heparin wick if venous congestion - Aeromonas prophylaxis if leeching

• Smoking cessation

Secondary procedures

• Required in 60% of cases

• Extensor/ flexor tenolysis or release of joint contractures

• ORIF for non-unions

• Webspace release

• Amputations