Amputations of Fingers :

Evaluation, Diagnosis and

Closure Technique (Grafts,
Flaps)

Hand and Microsurgery

Chief : ZP
Members: LA
Moderator: VC
Supervisor: dr. M. Ruksal Saleh, Ph.D, Sp.OT (K)
PRINCIPLES OF FINGER AMPUTATIONS

 The volar skin flap should be long enough to cover the volar surface and tip
of the osseous structures and preferably to join the dorsal flap without
tension
 The ends of the digital nerves should be dissected carefully from the volar
flap, gently placed under tension so as not to rupture more proximal axons,
and resected at least 6 mm proximal to the end of the soft tissue flap.

Campbell's Operative Orthopaedics 12th

Amputation of Fingers

 FINGERTIP AMPUTATIONS
 AMPUTATIONS OF SINGLE FINGERS
 AMPUTATIONS OF THE THUMB
 AMPUTATIONS OF MULTIPLE DIGITS

Campbell's Operative Orthopaedics 12th

 FINGERTIP AMPUTATIONS
 Techniques useful in closing amputations of
fingertip. A, For amputations at more distal
levels, free split graft is applied; at more
proximal levels, bone is shortened to permit
closure, or if length is essential, dorsal flaps
can be used. B, For amputations through
brown area, bone can be shortened to
permit closure or cross finger or thenar flap
can be used. C, For amputations through
brown area, bone can be shortened to
permit closure, exposed bone can be
resected and split-thickness graft applied,
Kutler advancement flaps can be used, or
cross finger flap can be applied. In small
children, fingertips commonly heal without
grafts.

Campbell's Operative Orthopaedics 12th

 Evaluation

•History
• mechanism
• avulsion
• laceration
• crush
•Physical exam
• inspection
• often, characteristics of laceration will guide management
• presence or absence of exposed bone
• range of motion
• flexor and extensor tendon involvement

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 Classification

Lloyd Champagne. Digital Tip Amputations from the Perspective of the Nail,
Advances in Orthopedics Volume 2016 (2016), Article ID 1967192.
 TREATMENT

 Non Operative
 Secondary intention technique
 initial treatment with irrigation and soft dressing
 after 7-10 days, soaks in water-peroxide solution daily followed by application of
soft dressing and fingertip protector
 complete healing takes 3-5 weeks

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 Surgical Technique

 Operative
 Primary closure with removal of exposed bone (revision amputation)
technique
 must ablate remaining nail matrix
 prevents formation of irritating nail remnants

 if flexor or extensor tendon insertions cannot be preserve, disarticulate DIP joint

 transect digital nerves and remaining tendons as proximal as possible
 palmar skin is brought over bone and sutured to dorsal skin

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 Surgical Technique

 Full thickness skin grafting from hypothenar region technique

 split thickness grafts not used because they are
 contractile
 tender
 less durable
 donor site is closed primarily
 graft is sutured over defect
 cotton ball secured over graft helps maintain coaptation with underlying tissue
 post-operative care
 cotton ball removed after 7 days
 range of motion encouraged after 7 days

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 Flap Techniques

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 1. Finger Tip : V-Y advancement flap

 indications
 straight or dorsal oblique finger tip lacerations

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1. Finger Tip :Digital Island Artery

 indications straight or dorsal oblique finger tip lacerations

 volar oblique finger tip lacerations

Harsh Amin. Flaps Hand - Hand Reconstruction. 2014

 1. Finger Tip : Thenar flap

 indications volar oblique finger tip lacerations to index or middle finger in

patients < 30 years

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 2. Volar Proximal Finger : Cross finger
flap
 indications volar oblique finger tip lacerations in patients > 30 years

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 3. Dorsal Proximal Finger : Axial flag
flap from long finger
 Indications volar proximal finger dorsal proximal finger & MCP lacerations

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
4. Volar Thumb
Moberg advancement
volar flap
 indications
 volar thumb if < 2 cm

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 4. Volar Thumb : Neurovascular Island
Flap
 indications
 volar thumb up to 4 cm

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 5. Dorsal Thumb : First dorsal
metacarpal artery flap
 indications
 dorsal thumb lacerations
 volar thumb lacerations if > 2 cm

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
6. First Web Space : Z-plasty with 60
degree flaps
 indications
 first web space lacerations
 technique
 can lead up to 75% increase in length
 7. Dorsal Hand :
GROIN FLAP
 Indications lesions to dorsal hand

https://www.orthobullets.com/hand/6060/fingertip-amputations-and-finger-flaps
 AMPUTATIONS OF SINGLE FINGERS
 INDEX RAY AMPUTATION

Technique for index ray amputation. A, Dorsal

skin incisions planned with marking pen.
Palmar skin incision can be outlined in
matching zigzag fashion to reduce skin suture
line contracture. B, Flexor digitorum
superficialis and flexor digitorum profundus
tendons severed proximal to lumbrical origin
after isolation and division of appropriate
neurovascular structures. C, First dorsal
interosseous retained for insertion into radial
base of middle finger proximal phalanx. D,
Appearance after index ray amputation

Campbell's Operative Orthopaedics 12th

 MIDDLE OR RING FINGER RAY AMPUTATIONS

 Middle finger ray resection. A and B, Clinical

appearance of unsalvageable contracted
and stiff middle finger after gunshot wound to
hand. C and D, Planned palmar and dorsal
incisions for ray resection. E and F, Cosmetic
appearance after partial middle finger
metacarpal amputation.

Campbell's Operative Orthopaedics 12th

TRANSPOSING THE INDEX RAY

Campbell's Operative Orthopaedics 12th

THUMB AMPUTATIONS

Campbell's Operative Orthopaedics 12th

 AMPUTATIONS OF MULTIPLE DIGITS

 Advancement pedicle flap for

thumb injuries. A, Deep thumb pad
defects exposing bone can be
covered with advancement
pedicle flap. B, Advancement of
neurovascular pedicle. C, Flexion
of distal joint of thumb is necessary
to permit placement of flap (see
text).

Campbell's Operative Orthopaedics 12th

 Quiz 1
 A 45-year-old carpenter sustained a table saw injury to his right hand while
at work earlier today. Evaluation in the Emergency Department reveals the
defect depicted in Figure A. An island volar advancement flap was
selected for wound closure. This method of thumb reconstruction is best
indicated for which of the following sized defects?

1. less than 1 cm
2. 1 cm
3. 1.5 cm
4. 2 cm
5. 2.5 cm
 Quiz 1
 A 45-year-old carpenter sustained a table saw injury to his right hand while
at work earlier today. Evaluation in the Emergency Department reveals the
defect depicted in Figure A. An island volar advancement flap was
selected for wound closure. This method of thumb reconstruction is best
indicated for which of the following sized defects?

1. less than 1 cm
2. 1 cm
3. 1.5 cm
4. 2 cm
5. 2.5 cm
 The clinical vignette is consistent with an oblique amputation of the distal phalanx of a thumb with a defect measuring >2.5
cm. Island volar advancement flaps are a safe and effective procedure for single-stage closure of considerably large
thumb defects measuring up to 3.5 cm in length.
The operative technique chosen for reconstruction of distal volar thumb defects depends largely on the size of the defect.
Island volar advancement flaps used for defects up to 3.5 cm are pure island flaps in which all of the proximal
attachments, with the exception of the neurovascular bundles, are divided to provide maximal advancement. Mobility up
to 4 cm can be achieved with elevation of the entire volar skin of the thumb from the underlying tendon sheath providing
a considerable advantage in thumb reconstruction. The island volar advancement flap is useful for coverage of the entire
distal phalanx from the IP joint crease to the nail bed.
Foucher et al. reviewed long-term clinical results of 13 neurovascular palmar advancement flaps for thumb tip coverage.
Specifically, they reported on Moberg and O’Brien flaps. The Moberg flap is a pedicled advancement flap proximally-
based on an intact skin pedicle of the thumb including both neurovascular bundles. The O’Brien flap is a modification of
the Moberg technique which advances a volar flap based on a subcutaneous pedicle including both neurovascular
bundles by incising the proximal skin and skin grafting the donor site. The study found that both flaps preserved near-normal
pulp sensibility, MP and IP joint motion, and grasp and pinch strength. They suggested that Moberg and O’Brien flaps
remain the first choice for coverage of 1-2 cm thumb pulp defects.
Baumeister et al. reported on the functional outcomes of 25 patients that underwent thumb pulp reconstructions utilizing
Moberg volar advancement flaps. They found that 72% of patients had no or only minor subjective complaints, 74% had
normal sensitivity, DASH scores showed only minor impairments, no flaps resulted in decreased grip strength, and only minor
restrictions were identified in active IP joint motion. All defects with a length less than or equal to 2 cm were successfully
reconstructed, whereas, patients presenting with defects >2 cm developed complications.
Mutaf et al. reviewed outcomes of 12 patients that underwent thumb reconstruction utilizing an island volar advancement
flap for traumatic distal thumb injuries measuring 3 to 3.5 cm in length. Their results showed that none of the flaps failed, no
patients had limited mobility or scar contractures, near-normal sensation was achieved, excellent recovery of pinch
strength occurred, and maximal preservation of thumb length was possible in all patients.
Figure A and Illustrations A through C represent a case example presented by Mutaf et al. Figure A depicts an oblique
amputation of the distal phalanx of a right thumb. Illustration A reveals elevation of an island volar advancement flap on
both sides of the digital neurovascular bundles in the same thumb. Illustration B reveals flap advancement and Illustration C
reveals a postoperative image of the same thumb 4 months after surgery.
Incorrect Answers:
Answers 1 & 2: Small or superficial defects may be amenable to conservative treatment or local flaps depending on the
location of the defect.
Answers 3 & 4: The Moberg flap with modifications to lengthen distal advancement as necessary is considered a standard
option for medium-sized defects of the thumb pulp less than or equal to 2 cm.
 Quiz 2
 A 6-year-old girl sustains transverse amputations through her long and ring fingertips after
getting her hand caught in a lawn mower. She presents to the emergency room 30
minutes after the injury with the amputated tissue which was placed on ice in a
waterproof bag. On physical exam the amputation levels are found to be 6 millimeters
distal to the lunula. The wounds are noted to be fairly contaminated with no evidence
of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the
most appropriate management at this time?

1. Emergent replantation of the amputated parts

2. Revision amputation through the distal interphalangeal joint
3. Thorough irrigation and debridement followed by elective Moberg advancement flaps
4. Thorough irrigation and debridement followed by elective Z-plasty reconstruction
5. Thorough irrigation and debridement, soft dressing application, and follow-up within 1
week
 Quiz 2
 A 6-year-old girl sustains transverse amputations through her long and ring fingertips after
getting her hand caught in a lawn mower. She presents to the emergency room 30
minutes after the injury with the amputated tissue which was placed on ice in a
waterproof bag. On physical exam the amputation levels are found to be 6 millimeters
distal to the lunula. The wounds are noted to be fairly contaminated with no evidence
of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the
most appropriate management at this time?

1. Emergent replantation of the amputated parts

2. Revision amputation through the distal interphalangeal joint
3. Thorough irrigation and debridement followed by elective Moberg advancement flaps
4. Thorough irrigation and debridement followed by elective Z-plasty reconstruction
5. Thorough irrigation and debridement, soft dressing application, and follow-up within 1
week
 Distal fingertip amputations can be successfully managed with local wound care and healing by
secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially
true in the pediatric population.

Distal fingertip amputations are common injuries seen in the emergency department. If bone is
not exposed, the wounds can be successfully treated with local wound care and dressing
changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy
exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management
including a V-Y advancement flap or conservative management with dressing changes.

Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31
of the digits were treated with primary closure with or without shortening of bone and 54 digits
were treated with semiocclusive dressings. No complications were observed, and all healed
fingertips were well padded and painless.

Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for
transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting
hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is
not a reasonable expectation.

Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II
is distal to the lunula; and Zone III is proximal to the lunula.
 Quiz 3
 Which of the following hand injuries seen in Figures A-E is most appropriately treated with
a first dorsal metacarpal artery flap?

Figure A Figure C

Figure B

Figure D Figure E
 Quiz 3
 Which of the following hand injuries seen in Figures A-E is most appropriately treated with
a first dorsal metacarpal artery flap?

Figure A Figure C

Figure B

Figure D Figure E
 Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately
treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin
from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the
thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an
island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous
muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is
an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting
is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent
branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review
the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the
coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect.
Incorrect Answers:
Answer 1: Fingertip amputations with minimal soft tissue loss and no exposed bone can be allowed
to heal through secondary intention.
Answer 2: The posterior interosseous fasciocutaneous flap is an excellent option for lacerations to the
first web space.
Answer 4: This large soft tissue defect on the dorsum of the hand may be treated with a groin flap.
Answer 5: Fingertip amputations with exposed bone are best treated with local advancement flaps
such as a VY advancement flap.
THANK YOU