EM@3AM: Finger Amputation

Author: Christopher J. Nelson, MD (EM Resident Physician, UTSW, Dallas, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 28-year-old male presents as a transfer from an urgent care with report of left-hand injury. He is a construction worker and was using a table saw when he injured his left hand. The amputated part is wrapped in a plastic bag. He is right-handed.

Triage vital signs include BP 123/74, HR 98, T 98.8F oral, RR 16, SpO2 97% on RA.

Imaging from outside hospital are below:

What is the patient’s diagnosis? What’s the next step in your evaluation and treatment?


Answer: Finger Amputation

 

Background:

  • An average of over 46,400 finger amputations occurred in the US from 1997 to 20162
  • Bimodal distribution – below the age of 5 year and over the age of 65 years2
  • Doors and power saws are the most common mechanisms2
  • Goals of treatment are to restore function, sensation, durability, and proper nail growth
  • Improper treatment may lead to loss of function, pain, and poor cosmetic outcome3

 

Anatomy:

  • The hand consists of phalanges, metacarpal bones, and carpal bones
  • Each finger has a distal, middle, and proximal phalanges
  • The thumb has distal and proximal phalanges
  • Finger joints (distal to proximal):
    • Distal interphalangeal joints (DIP)
    • Proximal interphalangeal joints (PIP)
    • Metacarpophalangeal joints (MCP)
  • Thumb joints
    • Interphalangeal joint
    • Metacarpophalangeal joint
    • Carpometacarpal joint
  • Neurovascular components run on the lateral aspects of the digits
  • Naming digits is less likely confused than numbering – Thumb, index, long, ring and pinky
    • Varying numbering systems can otherwise lead to miscommunication

 

History and Exam:

  • Mechanism of injury
  • Time of injury
  • Other signs of injury (amputation may be a distracting injury to other injuries)
  • Amputated digit cold vs. warm (important for reimplantation time)5
  • Tetanus status
  • Dominant hand
  • History of blood thinners
  • History of diabetes and smoking, which are predictors of poor wound healing7
  • Examination of each digit’s sensation and strength
    • Isolating and examining extension/flexion of MCP, PIP, and DIP to assess flexor and extensor tendon involvement
  • Careful examination of nailbed/subungual hematoma
    • Treatment of nailbed injuries important to avoid cosmetic and functional loss in fingertip injuries6

 

Differential:

  • Finger amputation, fingertip amputation, finger laceration, nail/nailbed laceration, ring avulsion injury, crush injury

 

ED Evaluation:

  • Hand and finger x-rays, including amputated part
  • Consider preop labs
    • CBC, BMP, PT/INR, PTT
  • Time of amputations to guide reimplantation viability
    • Time between amputation/loss of blood supply to the digit prior to surgery
      • 12 hours of warm ischemia5
        • Time without cooling of amputated digit
      • 24 hours of cold ischemia5
        • Cooling of the digit
          • Covered in saline-moistened gauze in a sealed bag on ice

 

Management:7

  • Stabilize patient and perform primary and secondary survey
  • Irrigate amputated part and injury site with saline and wrap in moist sterile gauze
    • Palpate for obvious foreign body
    • Place amputated part in bag; place this in water with crushed ice
      • Direct contact with ice can cause irreversible damage to cells7
    • Limit handling of amputation when possible
    • Administer cefazolin 2 grams or clindamycin for penicillin allergy7,8
      • No difference in infection rates (antibiotics vs. none) if injury is a fingertip amputation with planned surgical management9
    • Tetanus prophylaxis
    • Analgesics – Local vs. systemic
      • Local
        • Digital blocks
          • Lidocaine 1% vs. Bupivacaine 0.5%
      • Systemic
        • May consider when multiple injuries or insufficient analgesic effect with digital blocks
        • Fentanyl, hydromorphone, or morphine
    • Early hand surgery consultation
    • General indications for replantation10
      • Thumb
      • Multiple digits
      • Single digit distal to the insertion of the flexor digitorum superficialis tendon
      • Pediatric amputations
    • General contraindications for reimplantation10
      • Severe crush/avulsion injuries
      • Single digit proximal to the insertion of the flexor digitorum superficialis tendon
      • Prolonged ischemic time
    • Reimplantation counseling
      • 80% viability after reimplantation10
      • ~50% motion compared to normal10
      • Requires prolonged physical therapy (PT)

 

Disposition:

  • Admit for patients with infection or if patient will undergo reimplantation
  • Discharge those with controlled bleeding and distal phalanx amputation

 

Pearls:

  • History involves mechanism, cold/warm ischemic time, tetanus, hand dominance, medical issues
  • Imaging should include amputated part
  • Place amputated part in moist gauze, avoid direct ice contact
  • Consider both systemic and local analgesics
  • Early surgical consult
  • Council patient on realistic outcomes, 80% viability, 50% motion and prolonged PT

References:

  1. Hacking, C. Traumatic finger amputation. Case study, Radiopaedia.org. Accessed on 24 December 2021) DOI: 0.53347/rID-37376.
  2. Reid DBC, Shah KN, Altorai AEM, et al. Epidemiology of Finger Amputations in the United States From 1997 to 2016. Jornal of Hand Surgery Global Online. 2019;1(2):45-51. DOI:10.1016/j.jhsg.2019.02.001.
  3. Kawaiah A, Thakur M, Garg S, et al. Fingertip Injuries and Amputations: A Review of the Literature. Cureus. 2020;12(5):e8291. doi:10.7759/cureus.8291.
  4. Netter FH. Atlas of Human Anatomy. Philadelphia, PA: Saunders/Elsevier, 2014;6:443.
  5. Chim H, Maricevich MA, Carlsen BT, et al. Challenges in replantation of complex amputations. Semin Plast Surg. 2013;27(4):182-189. doi:10.1055/s-0033-1360585.
  6. Tos P, Titolo P, Chirila NL, et al. Surgical treatment of acute fingernail injuries. J Orthop Traumatol 2012;13:57.
  7. Lloyd MS. et al. Preoperative management of the amputated limb. Emerg Med J. 2005;22(7):478-80.
  8. Rodriguez L, Jung HS, Goulet JA, et al. Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg. 2014;77(3):400-407. doi: 10.1097/TA.0000000000000398. PMID: 25159242.
  9. Rubin G et al. The use of prophylactic antibiotics in treatment of fingertip amputation: A randomized prospective trial. Am J Emerg Med 2015 May; 33:645.
  10. Rebowe RE, Tannan SC. Digit Replantation. [Updated 2021 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. https://www.ncbi.nlm.nih.gov/books/NBK448187/ Accessed on 01/10/2022.

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