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X-Ray Finding
A complete traverse fracture in the proximal phalanx of the index finger. There is a very deep laceration at this site.

Impression
After reviewing the x-ray with the patient and his family, the physician examined the patient’s right hand, which shows an essentially complete amputation of the index finger through the proximal phalanx. Only about half a centimeter of skin and subcutaneous tissue remains intact. Both neurovascular bundle, as well as bone and tendon, have been severed. The x-ray confirms the level of amputation with a bone level almost at the joint just proximal.

The physician discussed with the patient and his parents alternative treatments. While reimplantation of the finger could be attempted, the index finger is notorious for poor results following major trauma including stiffness, hyperthesia, and cold tolerance.

The physician preferred the alternative of index ray amputation. He carefully counseled the patient and his parents on the procedure. While this method would permanently remove the index finger and the appearance of the hand, in most experiences the patients usually develop excellent use of the middle finger for pinch and grip and have an acceptable functional result. The parents and patient were in agreement, but for additional peace of mind on the parents’ part, a consultation from another surgeon was given. The consulting physician was in complete agreement with his recommendation for ray amputation and would definitely advise against reimplatation of the index finger at this level. The patient and his family were again counseled on the procedure. The benefits of surgery as well as the possible risk and complications were explained. The agreement was made.

Operative Procedure

The patient was given a general anesthesia and right upper extremity prepped and draped it the usual manner with a tourniquet for hemostasis. A longitudinal incision was made dorsally after the remaining skin attachment of the distal finger was severed. Skin over the proximal phalanx was not in very good condition and there were some gaps. The incision was planned to take advantage of remaining skin in fashioning of flaps. Dissection was carried down through subcutaneous dorsally extensor tendons and were then divided proximally and metacarpal shaft exposed. Subposterial dissection exposed the metacarpal shaft and it was divided obliquely at the approximal level with a power saw. Subperisosteal dissection was continued with the proximal metacarpal graft with at towel hook. The interosseus and lumbrical tendons were divided at the extensor hood level and volar plate dissected free. Finally, the flexor tendons were placed under tendon and divided to retract proximally, completing the ray resection. Prior to this step the distal soft tissues had been thoroughly debridged and irrigated, the neurovascular bundles both identified distally and dissected out to the MP flexion crease. The digital arteries were now clamped and tied, with the digital nerves both gently dissected back proximal to the metacarpal head level, preserving branches to the volar skin as long as they were not under tension. The nerves were both ligated distally and gently turned up into the space previously occupied by the metacarpal head, and then were gently surtured into place on the interosseous muscle bellies providing maximum protection. Following through irrigation with a diluted Betadine solution, the periosteal sleeve from the metacarpal was closed dorsally and distally, further protecting the digital nerves. A small suction drain was placed in the periosteal sleeve prior to this step also. Skin closure was then begun proximally in the dorsal aspect and carried out distally, trimming skin flaps as the closure progressed to provide maximal skin and soft tissue padding without excessive dog ears. Good cosmetic closure resulted with extra padding on the volar aspect. Fluff dressing was applied and the patient left the operating room in satisfactory condition.

Literature & Conclusions

In a review of forty-one patients with index transmetacarpal amputation, Murray, Carman, and Mackenzie found hyperthesia interfering with function in 37.5 percent of the patients and in ten percent, disabling. Their conclusion was that the excessive mobilization of the radial digital nerve to the index finger was responsible for this, and in nine of the patients who had subsequent exploration, the symptoms were not relieved. Fisher and Goldner reported a similar problem in five patients. It is of interest that this complication usually appears six to eight weeks after surgery, although it may initially be relieved by a subsequent procedure, the symptoms may recur at approximately the same time interval. Twenty one of the thirty-four patients who had elective ray amputation in the series of Murray and colleagues complained of pain in the pre-existing stump before their transmetacarpal relieved of their symptoms following the procedure. This information is important in terms of advising the patient preoperatively as to the possibility of persistent postoperative symptoms.

6-8 weeks
The cosmetic appearance of an index ray amputation is highly acceptable.

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