Digital Amputations Treatment &

Management
Author: Bradon J Wilhelmi, MD; ChieI Editor: Harris Gellman, MD
(http://emedicine.medscape.com/article/1238395-treatment)

Surgical Tberapy
Coals
%he primary initial goal in the treatment oI traumatic amputations is to evaluate the suitability oI
the amputated part Ior replantation. Amputations oI the thumb, multiple Iingers, the hand at the
level oI the wrist or distal Iorearm, and the upper extremity above the elbow should be evaluated
Ior replantation because patients can beneIit Iunctionally Irom replantation oI these appendages
even iI Iunction oI the part is less than optimal.
|3, 4|

OIten, replantation at these levels can achieve good Iunctional outcomes. However, replanted
single Iingers can be stiII and impede the opposition oI other Iingers to the thumb as well as
overall hand Iunction. Replanted single-Iinger amputations can achieve a better range oI motion
when the level is distal to the insertion oI the Ilexor digitorum superIicialis.
Slngleflnger replanLaLlon can be consldered when paLlenLs have ln[urles Lo oLher flngers of Lhe same
hand all of Lhese ln[urles requlre spllnL lmmoblllzaLlon and rehablllLaLlon LhaL lmpedes lmmedlaLe
reLurn Lo work Accordlngly slngleflnger replanLaLlon can be consldered ln speclal clrcumsLances 1he
surgeon musL noL become absorbed ln Lhe Lechnlcal challenge of Lhe replanLaLlon and neglecL Lhe oLher
assoclaLed ln[urles because poorer ouLcomes and greaLer flnanclal cosL (due Lo losL wages and Lhe cosL
of hosplLallzaLlon and Lherapy) can resulL
n perIorming an amputation, it is important to preserve Iunctional length. For example, an
above-elbow arm amputation should be replanted to provide the patient with a Iunctional elbow
on which a prosthesis can be Iitted, resulting in better Iunction than an above-elbow prosthesis.
Durable coverage at the end oI an amputation is critical to the Iunction oI an amputation. %his
may necessitate the use oI a local Ilap. Preservation oI sensibility on the amputation stump can
optimize the useIulness oI the remaining appendage.
Sometimes, local Ilaps can be used to bring sensate tissue to the stump tip. t is important to
minimize the risk oI painIul neuroma Iormation at the amputation stump and to prevent joint
contractures in the treatment oI amputations. Some local Ilaps can pose a risk oI joint contracture
to the involved Iinger and adjacent Iingers. Use oI the delayed groin Ilap can risk elbow and
shoulder joint contractures. Other critical objectives in the treatment oI amputations are early
return to work and Iitting with a prosthesis, when possible.
igital amputations
n perIorming digital amputations, provide a mobile, stable, painless stump with the least
interIerence Irom the remaining tendon and joint Iunction to provide the most useIul amputation
stump. %he remaining viable skin is conserved because it may be needed to provide durable soIt-
tissue coverage Ior the amputation stump. When possible, use volar skin Ior the stump coverage
because it provides skin that is thicker and more sensate than dorsal skin.
|7|

%here are several local options Ior tissue rearrangement oI volar skin over the amputation stump.
%hese include Iillet Ilaps, volar V-Y Ilaps, bilateral V-Y Ilaps, and homodigital island Ilaps.
|8, 9|
"Dog ears" in the acute traumatic amputation oIten should be leIt to eliminate tension and to
prevent compromising the blood Ilow to the remaining Ilaps achieving closure; these dog ears
disappear over time. I the wound is small, it can be allowed to heal spontaneously by
contraction and epithelialization. Wounds smaller than 1 cm can heal spontaneously in a
reasonable amount oI time. Larger wounds may require a skin graIt to heal quicker.
|10|
Split-
thickness graIts can be used Ior the beneIit oI wound contraction to result in a smaller area on the
tip, which is not normal pulp.
|

Regarding the treatment oI the bone in a digital amputation, the bone under the stump end must
be smooth. Remaining bone chips and devitalized bone should be removed. %he bone at the
stump end can be smoothed by using a rongeur and Iile. Bone length is not as important as a
stump with mobile nonsensitive coverage. %he bone oI the distal phalanx must be oI adequate
length to support the nail bed and nail growth.
|12, 13, 14, 15|
With digital amputations involving the
thumb, length is important.
%he articular cartilage can be preserved when the amputation occurs at the level oI the
interphalangeal joint. %his articular cartilage can provide a shock pad Ior trauma and potentially
causes less pain under than skin than the bone edges. Whitaker et al clinically evaluated the
preservation oI the articular cartilage with digital amputations and Iound a better outcome when
the cartilage was leIt on the stump end.
|16|
%he protruding condyles and anterior aspect oI the
phalanx may be trimmed to provide a less bulbous stump.
n addressing the nerve at the stump end, it is important to avoid neuroma Iormation in this
location. %he nerve end should be in a position away Irom the stump end or an anticipated point-
oI-contact pressure. %o minimize the risk oI neuroma Iormation at the stump end, traction
neurectomy oI the digital nerve should be perIormed bilaterally Ior each digital amputation. %he
nerve is longitudinally distracted in the distal direction and then transected to allow Ior proximal
retraction, leaving the nerve end 1-1.5 cm Irom the Iingertip.
Preservation oI a tendon insertion improves the active mobility and Iunction oI an amputation
stump. %hereIore, when possible, tendon insertions should be preserved. However, the
amputation level is oIten proximal to the tendon insertion. %he Ilexor digitorum proIundus
tendon should never be sutured over the bone end or to the extensor because this can result in the
quadriga eIIect. %he quadriga eIIect results in less excursion oI the adjacent normal Iingers
because oI the common proIundus muscle Irom which all the proIundus tendons originate. %he
amputated Iinger, which has a tighter proIundus tendon, reaches the palm beIore the other Iingers
do and results in a weaker grip.
Another complication oI tendon imbalance is the lumbrical plus posture, which is the paradoxical
extension oI the involved Iinger's proximal interphalangeal joint with attempted Ilexion. %his
occurs when the proIundus tendon is allowed to retract proximally, resulting in a pull on the
lumbrical muscle as it originates Irom the proIundus. %he lumbricals contribute to
metacarpophalangeal joint Ilexion and interphalangeal joint extension. %his proximal pulling oI
the proIundus pulls the lumbrical tighter to extend the interphalangeal joints paradoxically with
attempted Ilexion.
|17|
However, lumbrical plus posture aIter amputations oI the distal
interphalangeal joint is rare. Also, adhesions can result; thereIore, early motion oI the amputated
Iinger is recommended.
%he digital arteries should be identiIied and ligated with small-caliber sutures or be cauterized.
%he visible veins can be cauterized as well. %hen, the skin is loosely approximated to make sure
there is no tension on the skin edges. I there is tension on the skin, the bone may be shortened or
local Ilaps can be used.
When amputations are at the level oI the distal phalanx, preservation oI the proIundus insertion is
critical. An intact proIundus improves Iunctional contribution oI the amputated Iinger and
improves grip strength by providing active Ilexion at the distal interphalangeal joints in
conjunction with the other Iingers. Preservation oI enough bone to support normal nail growth is
perhaps the most crucial predictor oI Iunctional length with amputations at this level.
Amputations at the level oI the distal interphalangeal joint can be closed over the articular
surIace oI the middle phalanx. Local Ilaps can be used to provide soIt tissue Ior closure over the
middle phalanx, iI needed. %he volar V-Y Ilap is the standard local Ilap option Ior injuries at this
level. %he volar V-Y Ilap is Iashioned with the apex oI the V at the proximal interphalangeal
crease. When amputations are through the middle phalanx, preserving the Ilexor digitorum
superIicialis insertion, which inserts on the middle third oI the middle phalanx, is desirable.
Amputations proximal to the superIicialis insertion leave the amputated Iinger without active
motion control at the proximal interphalangeal joint level and only with active motion at the
metacarpophalangeal level.
Amputations at the proximal interphalangeal joint can be closed over the articular surIace oI the
proximal phalanx as can those at the distal interphalangeal joint. Amputations at this level can
still actively Ilex at the metacarpophalangeal joint through the action oI the intrinsic muscles. I
the amputation is near the metacarpophalangeal joint, especially in the long and ring Iingers,
dropping small objects because oI the deIect can be addressed with a Iinger prosthesis or ray
amputation, with or without transposition.


Ray amputations
[8]

O ndex flnger ray ampuLaLlons
4 1he lndex flnger ls Lhe mosL lmporLanL dlglL oLher Lhan Lhe Lhumb lL ls Lhe prlmary
flnger used wlLh Lhe plnch funcLlon f lengLh sensaLlon and moblllLy of Lhe lndex flnger
are lnadequaLe Lhe paLlenL bypasses Lhe lndex flnger Lo preferenLlally use Lhe mlddle
flnger for plnch funcLlons n Lhls clrcumsLance an lndex sLump can lmpede Lhe funcLlon
of Lhe mlddle flnger and Lhe overall funcLlon of Lhe hand 1hls ls Lhe prlmary lndlcaLlon
for a ray ampuLaLlon of Lhe lndex flnger
4 1he level of ampuLaLlon LhaL makes Lhe lndex flnger a candldaLe for a ray ampuLaLlon ls
conLroverslal A ray ampuLaLlon of Lhe lndex flnger should noL be performed acuLely for
ln[urles dlsLal Lo Lhe meLacarpophalangeal [olnL unless Lhe spare parLs are needed for
salvage of oLher dlglLs such as Lhe Lhumb 1he remalnlng lndex flnger may be lefL durlng
a Lrlal perlod afLer Lhe lnlLlal ln[ury f Lhe sLump lmpedes funcLlon lL can be elecLlvely
converLed Lo a ray ampuLaLlon Powever converslon Lo a ray ampuLaLlon can narrow
Lhe palm and resulL ln a loss of grlp sLrengLh and pronaLlon sLrengLh [usLlfylng a Lrlal
wlLh Lhe shorLer lndex flnger for laborers
4 ,urray eL al found LhaL power grlp key plnch and suplnaLlon sLrengLh are dlmlnlshed
by approxlmaLely 20 of normal wlLh lndex ray ampuLaLlons
19
ronaLlon sLrengLh ls
dlmlnlshed by 30 ln Lhe same group of paLlenLs 1he cosmeLlc appearance of an lndex
ray ampuLaLlon ls hlghly accepLable
4 n performlng an lndex ray ampuLaLlon a dorsal longlLudlnal lnclslon over Lhe lndex
meLacarpal ls used ln con[uncLlon wlLh a clrcumferenLlal skln lnclslon aL Lhe mldproxlmal
phalangeal level 1he skln ls lnLenLlonally lefL long dlsLally Lo avold deflclency LhaL could
resulL ln a webspace conLracLure See lmage below






O O 1he dorsal velns are llgaLed and Lhe exLensor Lendons are LransecLed 1he perlosLeum ls
scored and Lhe meLacarpal base ls LransecLed 1he dorsal lnLerosseous and lumbrlcal muscle
Lendons are LransecLed SLudles have shown no dlfference ln plnch sLrengLh wlLh dorsal
lnLerosseous Lransfer Lo Lhe second dorsal lnLerosseous muscle Lherefore Lhls Lechnlque ls noL
lndlcaLed
19
1hen Lhe flexor Lendons are dlvlded 1he dlglLal arLerles and nerves are dlvlded
dlsLal Lo Lhe branches Lo Lhe palmar skln nLerrupLed suLures are used for skln closure 1he hand
ls dressed llghLly Lo allow for early moLlon
O ,lddle and rlng flnger ray ampuLaLlons
O Jhen Lhe mlddle and rlng flngers are ampuLaLed aL a level near Lhe meLacarpophalangeal level
small ob[ecLs fall Lhrough Lhls area whlch ls creaLed by Lhe gap of Lhe mlsslng dlglL aLlenLs
descrlbe dlfflculLy ln reLrlevlng change from Lhelr pockeLs 1hls can be correcLed wlLh a ray
ampuLaLlon Powever Lhe loss ln grlp sLrengLh and pronaLlon sLrengLh has Lo be consldered
before performlng ray ampuLaLlons for Lhese cenLral dlglLs
O 1he prlnclples of a cenLral ray ampuLaLlon lnclude removal of Lhe ln[ured flnger aL Lhe
meLacarpal base correcLlng Lhe roLaLlonal deformlLy closlng Lhe space beLween Lhe 2 ad[acenL
unampuLaLed flngers and achlevlng a saLlsfacLory appearance of Lhe hand 1wo Lechnlques of
cenLral ray ampuLaLlon have been descrlbed Cne lnvolves Lhe Lransfer of Lhe lndex flnger ray
onLo Lhe Lhlrd meLacarpal base for Lhe mlddle flnger and Lhe small flnger ls Lransferred Lo Lhe
rlng meLacarpal base as seen ln Lhe flrsL lmage below 1he oLher Lechnlque lnvolves removlng
Lhe lnvolved flnger aL Lhe meLacarpal base as seen ln Lhe second lmage below 1he
dlsadvanLages of Lhe ray Lransfer procedure are Lhe requlremenL for posLoperaLlve
lmmoblllzaLlon and Lhe rlsk of nonunlon 1herefore Lhe auLhors preferred Lechnlque for cenLral
ray ampuLaLlon does noL lnvolve ray Lransfer

%he technique oI central ray amputation involves the use oI a circumIerential incision at the
midproximal phalanx in conjunction with a dorsal longitudinal incision, as seen in the images
below. %he dorsal incision is extended through the extensor. %he periosteum is scored at the
level oI the metacarpal base. %he metacarpal is transected at its base. %hen, the hand is supinated,
and the Ilexor is divided. %he neurovascular bundles are divided proximally to avoid neuroma
Iormation at the skin incision. %he deep transverse metacarpal ligaments are identiIied on either
side oI the volar plate oI the involved Iinger at the metacarpophalangeal joint.

n transecting the deep transverse metacarpal ligaments, it is essential to preserve enough to
attach the ligaments to each other to minimize gap Iormation and rotational deIormity. %hen, the
ray is amputated. %he gap is compressed, and transverse Kirschner wires (K-wires) are placed
through the metacarpals on either side oI the ray amputation. %hreaded K-wires can help resist
the sliding oI the metacarpals on the K-wires like an accordion. %hen, the deep transverse
metacarpal ligaments are repaired with 2-0 Ethibond nonabsorbable sutures. %he threaded K-
wire can help prevent rotational deIormity. Active motion is begun early, and the K-wires can be
removed at 6 weeks. %his technique can be applied to ray amputation oI both the middle and the
ring Iingers, as seen in the image below. ncomplete closure oI the deIect and scissoring must be
careIully avoided with this technique.
Small flnger ray ampuLaLlons
O 1he small flnger plays a role ln grlpplng and hooklng ob[ecLs Small flnger ln[urles are Lhe mosL
dlfflculL Lo rehablllLaLe and Lhe flnger ofLen becomes sLlff and lmmoblle posslbly hlnderlng
hand funcLlon by caLchlng on pockeLs or oLher ob[ecLs n Lhls clrcumsLance small flnger
ampuLaLlon can be consldered n a laborer Lhe ampuLaLlon can be performed aL Lhe
meLacarpophalangeal [olnL Lo remove Lhe flall segmenL of Lhe proxlmal phalanx buL preserve a
broad palm
O f grlp sLrengLh ls noL a concern a more esLheLlc appearance can be obLalned wlLh a small flnger
ray ampuLaLlon n performlng a small flnger ray ampuLaLlon lL ls lmporLanL Lo preserve Lhe
lnserLlon of Lhe exLensor carpl ulnarls whlch lnserLs on Lhe base of Lhe flfLh meLacarpal
20
1hls
procedure ls performed Lhrough a LennlsracqueL lnclslon as seen ln Lhe lmage below
,oreover Lhe hypoLhenar muscles are preserved Lo cover Lhe gap and provlde paddlng Lo Lhe
ulnar slde of Lhe hand
1

Tbumb amputations
%he most critical digit to hand Iunction is the thumb. Amputations oI the thumb can be
debilitating. %he level oI amputation determines the signiIicance oI the Iunctional deIicit. n
general, the thumb is important as a post to which the Iingers oppose. %hereIore, in
contradistinction to the length oI the Iingers, the length oI the thumb is more important than
active motion.
When the thumb tip has been amputated, replantation can provide the patient with the best return
to Iunction, even iI interphalangeal joint Iusion is required. n the event that replantation cannot
be perIormed or is unsuccessIul, minimal bone shortening should be perIormed to provide a
smooth bone end over which to close the skin. n Iact, the bone should not be removed only to
obtain primary skin closure.
A volar rectangular advancement Ilap (Moberg) should be used to provide soIt-tissue closure and
preserve thumb length, as seen in the images below. %he volar advancement Ilap is raised as a
rectangle to include both neurovascular bundles to the metacarpophalangeal crease oI the thumb
proximally, and then it is advanced in the distal direction.

Transcarpal amputations
%ranscarpal amputations are rare. Usually, amputations at this level can be replanted and an
acceptable return oI Iunction is expected. When replantation is unsuccessIul or cannot be
perIormed, minimal reconstructive options exist Ior amputations through the carpus. n general,
patients can be Iitted with hand prostheses, which provide good cosmetic results. When the wrist
supplies active motion, the prosthesis can be operated without an attachment to the elbow or
shoulder harness.
Wrist disarticulations
Again, amputations at this level are rare and can oIten be replanted. Historically, amputations at
the below-elbow level have been Iavored over wrist disarticulations because oI the diIIiculty in
wrist prostheses. However, with advances in technology, amputations at this level can be
considered. Also, the wrist disarticulation level is preIerable in children compared with
disarticulation below the elbow to preserve growth potential. %he advantage oI preserving the
distal radioulnar joint is that Iull, active pronation and supination can improve the Iunction oI the
amputated appendage. %hereIore, when possible, the distal radioulnar joint should be preserved.
Also, the radial styloid Ilare should be preserved to improve prosthetic suspension. I possible,
the palmar skin should be used to cover the stump end to provide a thicker and more durable
coverage.
Below-elbow amputations
n general, below-elbow amputations should be perIormed to preserve as much length as possible
to preserve maximum pronation and supination. When traumatic amputations are more proximal,
even 2 cm oI ulnar bone length is suIIicient to Iit a below-elbow prosthesis. With more proximal
amputations, the biceps can be reattached to the ulna at a position that approximates the normal
resting length oI the muscle. I the biceps is reattached under too much tension, a Ilexion
contracture can result. A soIt-tissue deIicit may require the use oI a Iree Ilap or local Ilap to
preserve the elbow.
|21|

Krukenberg procedure
%he Krukenberg procedure is mentioned mainly Ior historical purposes. %his operation was Iirst
described by Krukenberg in 1917 and involves separating the ulna and radius Ior below-elbow
amputations to provide a pincerlike grasp that is motored by the pronator teres muscle. %he
indication Ior this operation is reserved Ior a blind person who is undergoing bilateral amputation
because it can provide prehension and tactile gnosis.
Elbow disarticulations
Elbow disarticulations are preIerred by surgeons and prosthetists over above-elbow amputations
because they allow Ior rotary Iorce transmission over the humerus, and the epicondyles provide
good support Ior the prosthesis. %he disadvantage oI an amputation at this level is that the
prosthesis has outside locking hinges, which can damage clothing.
bove-elbow amputations
n traumatic above-elbow amputations, bone resection should be avoided because maintenance
oI the stump length is critical to Iunction. %he longer humeral stump has better proximal
muscular control and provides a long lever to help maneuver the prosthesis. Even iI required Ior
primary closure, bone shortening should be avoided. Split-thickness skin graIting can be
considered over the stump end to preserve the stump length. t is essential to have bone below
the insertion oI the pectoralis major. Amputations that are more proximal to the pectoralis are
essentially shoulder disarticulations because shoulder motion is lost.
Complications in the amputated stump related to the bone include Iormation oI osteophytes and
osteomyelitis. %he risk Ior these bony complications can be minimized with appropriate bony
debridement at the initial treatment.
Early postoperative complications include wound hematoma, inIection, and necrosis. Hemostatic
control oI the amputation stump can be achieved initially with a tourniquet. %horoughly irrigate
and debride the amputation wounds to minimize the risk oI postoperative inIection. Devitalized
skin, tendon, and muscle should be removed to minimize the risk oI inIection as well.
Postoperatively, patients can experience symptoms oI pain in the amputated part or stump.
Phantom limb is the sensation oI Ieeling in the amputated part, and it is common aIter
amputations. Patients should be inIormed oI this potential complication preoperatively. %he
likelihood oI developing phantom limb pain is highest aIter severely mutilating amputations, and
it usually begins soon aIter the amputation. When made aware oI this potential symptom
preoperatively, patients seem to better tolerate this sensation.
Stump pain is usually a result oI a neuroma Iorming at the stump site. Sometimes, these
neuromas have to be excised and buried into muscle or bone to minimize the local pain, as seen
in the images below. Patients can have cold intolerance and hypersensitivity at the stump end.
|22|
Usually, this is a selI-limited process. Desensitization may hasten the resolution oI these
symptoms, and a transcutaneous electrical nerve stimulation (%ENS) unit may be helpIul.
Neurontin may also be eIIective.

Contracture prevention is critical in the treatment oI amputations. Local Ilap options Ior soIt-
tissue reconstruction oIten involve immobilization during a delay, which can result in contracture
Iormation oI an adjacent digit as with cross-Iinger or thenar Ilaps or oI the shoulder, elbow, and
wrist with the groin Ilap. t is imperative to begin early motion oI the amputated part to minimize
the risk oI contracture Iormation.
Finger tendon imbalance aIter Iinger amputations can result in a weakened grasp. When the
Ilexor digitorum proIundus is sutured over the stump end, the patient can develop a quadriga,
which can result in the amputated Iinger beating the others to the palm because oI the shorter
tendon, thus limiting the range oI motion oI the uninjured adjacent Iingers. When the Ilexor
digitorum proIundus tendon is allowed to retract proximally, this can result in the lumbrical plus
posture (ie, the paradoxical hyperextension oI the interphalangeal joints with Ilexion). %he
lumbrical plus posture can be treated by releasing the lumbrical or radial lateral band.