gms | German Medical Science

Objectives/Interrogation: The distal phalanx of fingers has a significant relevance in hand functionality and finger aesthetics. Therefore, it must be replanted in case of amputation. Microsurgical reimplantation is widely accepted as the technique which provides the best outcome. The main difficulties lie in the adequate anastomosis of the vessels due to the small calibre of the veins at this level and a high degree of vasospasm, especially in crush amputations.

Methods: PMO, male, 55 years old, suffered a serious traumatic injury to his left index and third fingers due to a crushing/cutting accident with a heavy metal sheet. The patient did not smoke and had a previous history of hypertension and angina pectoris (both were controlled with medication).

The index finger suffered a complete amputation at the level of the base of the nail plate and had bone exposition. The third finger suffered an incomplete amputation at the DIP joint level; nonetheless the deep flexor tendon was the only structure connected to the proximal portion of the finger. The fingertip was clearly ischemic.

The patient was quickly transferred to the operating room (8 hours of ischemia). In the index finger we proceeded with debridement, bone shaping and coverage with a volar advancement flap (Atasoy). In the third finger we opted to try to salvage the fingertip. First, we removed the remaining bone fragments and fused the middle and distal phalanx with 2 Kirshner wires. Then we repaired the extensor apparatus and the collateral nerves. After that we anastomosed the collateral ulnar artery and a central dorsal vein. At the end of the surgery, after tourniquet release, the fingertip was perfused. Finally, the skin was closed with few simple sutures and an occlusive dressing was applied.

Results and Conclusions: 6 months postoperatively the patient has complete range of motion in the MCP and PIP joints of the index and 3rd finger and a good sensitivity in both finger pulp (static 2-point discrimination of 4 and 5 mm, respectively). The patient is very happy with the functional and aesthetic result.

Conclusion: Fingertip traumatic amputations are always a difficult challenge to solve. Microsurgery reimplantation offers the best outcome possible. Two of the most important factors for its success seem to be the mechanism of injury and hot ischemia time. Prompt revascularization with a skilled microsurgical technique is the most effective treatment.