Fingertip Amputations for Surgeons

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Fingertip Amputations: Notes for Surgeons

First posted January 7, 2009 Last updated March 29, 2010

Background

I have been asked occasionally by other hand surgeons about some of the details of the Tegaderm technique cited on my website for treating fingertip injuries. I formerly tried the Cuttler and Atasoy flaps that we were all taught in Fellowship and are shown in all the textbooks. I am now of the opinion, 20 years out from Fellowship, having been both in academics and in private practice, that teaching these flaps and putting them in the textbooks is the single greatest error, if not horror, that exists in hand surgery. The flaps are fun to do, true. They are a part of our history, true. But they are very expensive and can lead to much worse results than if the patient just stayed home; and better results can be obtained by much simpler, more reliable, less expensive, less painful techniques.

At the 1998 meeting of the International Federation of Societies for Surgery of the Hand in Vancouver, British Columbia, I attended a symposium on fingertip injuries. The papers presented showed many variations on the Cuttler and Atasoy flaps, and new ones besides. Being a shy and retiring sort of guy, I raised my hand and challenged the authors as to their results, and asked if a better result could not be achieved with much less cost and suffering on the part of the patient, by using semipermeable membranes. I cited on paper (see Mennen, 1993, at bottom of this page) as proof. The following discussion was friendly and lively, and with many surgeons taking positions on one side or the other. The chair of the meeting concluded by declaring that the controversy would only be resolved by a prospective study, and said that since I had started it all, I was appointed head of the research group.

I accepted this charge with a seriousness of purpose: patients could be helped considerably if this question was answered. I convened a meeting of interested surgeons the next day, we hashed out some details, and agreed to work once we had returned to our respective institutions. I corresponded with the authors of some of the most respected texts and with the authors of the papers from the symposium. I applied for and obtained a $10,000 grant and created a website. It contained a detailed history of the problem, the many options available, and proposed a prospective, uncontrolled, randomized study (each surgeon could do whatever technique they thought best), and proposed a uniform outcome tool that could be completed online. I spent a lot of time designing the study, and felt it was rather good. The outcome would be able to narrow the options down to one or a few techniques. Unfortunately, as so often happens, the surgeons who wrote the papers or volunteered to participate did not follow through, and after a few years of trying, I resolved myself to the fact that few surgeons are interested enough to put the time into it. Even the chairman of the symposium declined to work on the project he had set to me. Such is life: we all are busy and have our own priorities. Unfortunately, the horror of flaps continues unabated, with the textbooks creating a new crop of experiments each year as a new year of fellows reads them. Most surgeons abandon them as they progress in experience, but many patients are needlessly subjected to a technique which should have died a quiet death some years before my time.

I do not remember how I came across the semi-permeable membrane technique, but I learned it early in my career. I read with interest the 1993 paper by Mennen and Wiese, and tried it about that time. I have used it for about 20 years (as of 2010), with ever increasing appreciation for its effectiveness in terms of outcome and patient satisfaction. I recommend it to you.

Tegaderm Technique

I believe this technique was developed by basic scientists who were studying pressure ulcers. I adapted it for use on fingertips, and then found that Mennen and Weise had used it before me. Any semi-permeable membrane will work, I believe. I contacted 3M for information about Tegaderm, the only semi-permeable membrane that I knew of at the time. They were kind enough to give me a large box of Tegaderm. Therefore, my experience is with Tegaderm. It is designed to allow some water to evaporate but it keeps the cytokines in the place where the body needs them: the open wound. It has been my experience that the re-epithelialization of the wound happens much faster under the Tegaderm than under necrotic tissue and vastly faster than under so-called non-adherent dressings like Xeroform, even when I soak them in bacitractin. They always get infiltrated with blood which turns to cement, and tears off the healing epidermis as you change dressings.

First, obtain a solid block with buffered lidocaine (10% by volume). Buffering the lidocaine removes all the sting and it takes effect more quickly. (Inadequate blocks or failing to buffer the lidocaine are both inexcusable, for a hand surgeon. I can't believe some of the stories told to me by my patients.) There is absolutely no need for any part of the subsequent procedure to hurt. I also like to mix 0.5% bupivicaine with the lidocaine (50:50 mixture), so that the patient also has a restful night's sleep afterward. First, obtain a solid block.

Next, use a finger tourniquet. The fingertip has such a great blood supply that you will never be able so see anything without a tourniquet. I use the cut finger of a sterile glove, rolled on like a condom (if you can come up with a better analogy, please let me know; otherwise, don't complain about mine) to both exsanguinate the finger and function as a tourniquet. Clean the wound as you normally would, removing clearly dead tissue but I would not be aggressive in removing questionable tissue. Small amounts of dead tissue in the wound has not been a problem in my experience. Suture any lacerations extending from the level of the amputation and suture the nailbed, if possible. I recommend 6-0 chromic suture, so nothing needs to be removed later. This is especially true for children, who learn from their ER experience that doctors hurt them and they will never allow you near their fingertip again. (I usually have to have the mother remove the dressing while I look at it from four feet away.) Replace the nail plate into the nail fold. If there is amputated tissue available, use the standard de-fatting technique and suture in place.

Dry off the intact skin. Do not apply any antibiotic ointment, as it prevents the Tegaderm from sticking. Also, the wound experts who developed it recommend against using any. I have not found it necessary to use any. With the tourniquet still in place, place the Tegaderm over the entire fingertip and down along the intact skin for at least a centimeter or so. You need to get a solid seal to keep the fluid in and the bacteria out. Cover with the dry dressing of choice. Then, in a deliberate manner, elevate the arm, place pressure over the wound, and remove the tourniquet. (Make a careful mental note to yourself to remove the tourniquet, and make sure you consciously consider the tourniquet at this stage. It is usually covered by the dressing, and if you are not careful, you will forget it some night when you are very busy and otherwise occupied. I expect if you forget once, you will never forget again. I did once, in a young girl, about age 7. Luckily, the tourniquet did not cut off all blood supply and the finger did great, but I will never trust to my luck again. One way to help remember it is to leave a tag of rummber sticking out when you cut off the finger from the glove, or clip a hemostat to the tourniquet when you place it. Whatever you do, realize that your attention will be distracted and do what you need to do to remember to remove the tourniquet.)

If you are not careful in applying pressure to the wound as you remove the tourniquet, the Tegaderm will simply fill with blood and the proper effect will be lost. Some bleeding will inevitably occur, but try very hard to limit it. If there is too much blood, I have waited for hemostasis, removed the Tegaderm, cleaned out the blood, and reapplied the Tegaderm. I routinely cover with oral antibiotics, but cannot justify this based on literature or experience with and without antibiotics. Finally, place a metal splint, to prevent trauma to the fingertip.

I change the dressing every approximately five days. I usually do the first one or two dressing changes and then allow the paient and their family to do the rest. As you will realize once you try this, it takes at least two or three hands to handle the Tegaderm without it adhering to itself and making a mess of the whole affair. Ask me how I know. Good thing Tegaderm is relatively cheap.

Why theTegaderm Technique Works

A fluid will accumulate under the Tegaderm will look like pus, so warn the patient and your staff. It is not pus, but water with cytokines and cells that have been attracted by the cytokines. Most of these are in the white cell line, so it will look like pus. You will note that the adjacent tissue is not red, not swollen, and not painful the way an infected fingertip would be, so have faith. It is NOT pus. (I have never had one develop a cellulitis or an abscess with this method.) There will be a cytokine cascade occurring in the fluid, which I am sure you have studied: first mitotic cytokines to increase cell division, then cytoattractive cytokines to bring pleuripotential mesenchymal stem cells to the area (both humorally derived and local tissue derived), and finally cytokines that help direct the semi-committed stem cells to differentiate into skin, and I believe, other supportive tissues. (I spent two years doing basic science research during residency. One of my lab projects involved using cytokines to prove that tendons heal intrinsically, which we now know they do.) The reason I believe other supportive tissues are elaborated is that the fingertips always round up a lot more than when you started. The tip never regains a completely round contour, but always much more than you would have expected.

I change the dressing about every 5 days, usually because the Tegaderm starts to fall off. You do not want a leak, which would let in bacteria. When you re-apply the Tegaderm, the skin must be dry, or the Tegaderm won't stick. The nice thing is it cannot stick to any new, moist cells that are forming. They are left completely undisturbed when you change the dressing. Any dead epidermis in contact with the fluid will be white, and may make you think the tissue is macerated. It is not, it is only dead epidermis soaked with fluid. But only the dead cells are soaked; the living cells cannot absorb more water than they want, due to homeostasis. I might cautiously debride obviously dead tissue, but leave most of it alone, dry the skin, allow it to air dry (but don't allow the living, healing tissue to dry), and re-apply. Usually after one or two dressing changes by me, I let the patient do it. It takes about three hands and a bit of practice to handle the Tegaderm, so I try to have family watch me as I do it, before asking them to do it.

I would be interested in any comments, positive or negative, about this material from surgeons who have experience with this technique or other techniques. I do not claim to be an expert on this, although I have studied it for a few years. I clain no objectivity on this subject: I am as biased by my experience as any other hand surgeon, or more so (as shown by the above material!) I am sure your experience would be valuable for me to hear, so please email me at NelsonDL followed by the "at" sign, followed by PacBell.net. (I have to write it this way to avoid spam-bots which prowl the Internet looking for email addresses.) Please include jpgs of your cases, as this helps the discussion immensely. I look forward to corresponding with you and hope this page improves the lives of your patients.

Brunelli, F. Treatment of fingertip amputations. In: Clayton Peimer, Editors. Surgery of the hand and upper extremity. New York: McGraw Hill,1996: 1069-1099.

Moberg E. Two-point discrimination test. A valuable part of hand surgical rehabilitation, e.g. in tetraplegia. Scand J Rehabil Med 1990;22(3):127-34.

Mielke K, Novak CB, Mackinnon SE, Feely CA. Hand sensibility measures used by therapists. Ann Plast Surg 1996 Mar;36(3):292-6.

Szabo RM, Gelberman RH, Dimick MP. Sensibility testing in patients with carpal tunnel syndrome. J Bone Joint Surg [Am] 1984 Jan;66(1):60-4.

Sturman MJ and Duran RJ. Late results of finger-tip injuries. JBJS 1968;45A: 289-298.

Remember the admonition from the Patient Education Links Page: the Internet has a lot of information, much of it incorrect. I have reviewed the sites that I have linked to, and have only linked to sites when I personally know the surgeon who posted it, or am a member of the organization that posted it. However, I may not agree with all that is on that site, and it may have changed since I reviewed it. If any of the information is not consistent with what I have told you, please download the material and bring it in.