Annals of the Royal College of Surgeons of England (1991) vol. 73, 143-147
Amputations of the upper
limb
P S London MBE FRCS MFOM Honorary Consulting Surgeon The Birmingham Accident Hospital
Unlike amputations of the lower limb, most of those of the upper limb are the result of injury. This means that even if the surgeon does not have to perform an amputation he has to deal with one. Practical details will be largely confined to those operations that would be undertaken by surgeons of general competence or in training. More specialised methods of repair and reconstruction will be dealt with in more general terms. Amputations of the upper limb often occur at work and even though small they may greatly reduce the earning capacity of a young breadwinner-sometimes for psychological rather than physical reasons. The surgeon's task is to provide, as soon as possible, a stump that the patient will use. It is thus fair to suggest that amputation should be thought of not as an operation to remove something harmful or useless but as one to preserve as much of the patient as will be useful. A welljudged operation must be followed by the necessary efforts to restore the patient's confidence, upon which so much of a person's ability to work depends. It may also be necessary to overcome the reluctance to do so that is induced by the advice of lawyers and trade union officials.
Amputations proximal to the hand These are much fewer than amputations of the lower limb. My own experience over some 30 years is summarised in Table I.
Table I. Comparison of major amputations following injury of the upper and lower limbs Amputation
n
Above-elbow At elbow Below-elbow At wrist
2 1
Correspondence
Amputation
5
Hip Above-knee At knee Below-knee
2
Syme's
to: Mr P S
borough, Bucks MK17 ORF
The arm and forearm The favoured levels of amputation 20.5-25.5 cm below the acromion process and 15.5-18 cm below the tip of the olecranon process may not be possible. Shorter stumps can be satisfactory and the amputating surgeon may be well advised to consult a limb-fitting surgeon about this when time permits. However, it is a good general rule to aim to have a stump that heals promptly and will be comfortable. Length should not be preserved by using damaged skin or muscle, or bone without an adequate covering of soft tissue. Ideally, equal flaps should be used. In the forearm the scar should run across and not between the ends of the radius and ulna, but the precise position of the scar may have to be determined by what skin and muscle of adequate quality are available. If amputation can be carried out at the favoured level the muscles are sufficiently sinewy to be stitched firmly together, flexors to extensors, over the end(s) of the bone(s), but if a more proximal level has to be used, particularly in the arm, the muscles should be trimmed so as to come neatly together over the bone (Fig. 1). The advantages of myoplastic amputations for comfort, strength and controllability of the stump make them better than any other method. If suction drainage is used, a light dressing is sufficient. A good method is to place strips first of gauze and then of wool over the stitches and secure them with strips of 2.5 or 9 cm micropore tape or a covering of Hypafixg (Fig. 2). This dressing is then covered with a thin layer of wool and a firm crepe bandage that is secured by two U-shaped strips of Elastoplast® at right-angles to each
7~~~~~~~~~~~~~~~
n
I
5 18 1 18
1
London, The Ridings, Single-
bone.~~~~~~~~~~~~~~~~~~~~~~~~o Fiur
bone.
_. Trmmn toalwmsl_. ki
ob
lsdoe
144
P S London
Amputations of the hand Classifying these injuries is of no assistance to the surgeon who has to try and restore a useful extremity. Amputations of the digits are in some ways the most important of all partly because they are so numerous and partly because they may be regarded as minor surgery and left to inadequately trained or supervised junior staff when sound judgement and technical skill are needed.
Figure 2. Inner layers of a dressing for a stump.
other and held in place by an unstretched band round their top ends. Alternatively, the crepe bandage can be replaced by a tubular bandage of suitable size that is knotted at one end and pulled snugly into place before being secured with Elastoplast as already described. Because the loss of a hand can be a psychologically crippling experience, especially when it occurs at work, the idea of returning to work must be introduced very early on and the impetus of efforts to this end must be maintained. It is important to discuss this as soon as possible with the victim, the employers and others concerned with resettlement, and it can be of great advantage to the patient to meet someone who has made good after sustaining a similar amputation. This can be arranged through the local limb-fitting centre.
Amputations at the wrist Less than the complete carpus offers little functional advantage and may be discarded if this will facilitate closure of the skin, but the ability to pronate and supinate the forarm should be preserved whenever possible. This may mean that skin has to be provided in order to cover the distal part of the stump. If necessary, free flaps and neurovascular anastomoses can be used but simpler flaps may be satisfactory.
Reattachment of severed limbs To someone who has just lost a hand or more the fact that it could be reattached has obvious attractions, but it is only fair that the duration of recovery and the uncertainty of the final outcome should not be glossed over. Surprising though it may seem, patients may be fully capable of coherent thought and discussion and the surgeon should not hesitate to offer the patient the opportunity of making a well-informed choice between simple closure and what reattachment entails. It is fair to say that reattaching the severed part can greatly prolong
disability and sap morale.
Traumatic amputation of digits Most accidental amputations affect the tips of the three radial digits, which are the most used. If the stumps are to be used they must be comfortable and durable; to this end, it is not always advisable to save all viable tissue because this can result in a stump with a numb, tender or badly scarred tip. Length of stump The 'right' length of stump varies a good deal. In the case of the thumb, comfort is much more important than length. Even complete destruction of the thumb can allow such successful use of the hand as to persuade the patient to accept the loss; it is a sound principle not to disable a person, perhaps for months, by treating a condition that causes no more than tolerable inconvenience. In the case of the index finger, a stump with less than about 1' phalanges usually gets in the way; amputation through the metacarpal should be considered. Even short stumps of the middle and ring fingers are worth saving, but stumps that stick out when the fist is closed are a nuisance. The importance of the fifth ray for gripping firmly should be remembered; even a short but mobile stump of finger can add useful stability to the grip. It will readily be appreciated how important it is to discuss, whenever possible, what the patient requires of the hand not only at work but in hobbies and other pastimes.
Methods of closure Simple dressing. Simple dressing can be used for all amputations beyond the terminal phalanx; it has been advocated even when bone is exposed. Dressings should be changed as infrequently as possible; if the outer layer becomes dirty it may not be necessary to change the whole dressing.
Trimming and closure. Exposed bone is nibbled away to allow comfortable closure with flaps. Kutler's repair. A triangular flap of skin and pulp is fashioned on each side of the stump (Fig. 3a) and the two flaps are then stitched in place over the end of the bone (Fig. 3b).
Amputations of the upper limb
(a, i)
(a, ii)
(b, i)
(b, ii) Figure 3. Kutler's repair of a fingertip. The shaded areas are the triangular flaps with thick fatty pedicles that are cut from the sides and advanced to the tip of the stump.
Whichever method is used, exposed ends of nerves should be sought and cut short so that they will not heal into the scar. The 'best method' of closure varies with the circumstances; each has a place in the hands of the expert.
Split skin grafts. These can be used on fat or paratenon (after trimming the bone if necessary). Full-thickness skin grafts contain sensory end organs and can offer a better quality of sensibility; they may therefore be preferable to split-skin on the main working surface of the pulp. Flaps. Flaps from the palm or from other digits can yield a neat stump but they may result in a stiff finger or a tender donor area. If they are used the following considerations apply: 1 The digits concerned should be comfortably disposed with the flap free from tension. 2 Marked flexion or extension may be comfortable but prevent the return of full movements, particularly to short, stubby fingers and those of older persons. 3 Donor areas on pressure-bearing surfaces of the palm or digits may be intolerably sensitive. 4 A numb flap on the working surface, particularly of a finger tip, may render the stump useless. Local flaps. There are ingenious methods of moving intact skin about on the hand in order to maintain sensibility and conserve length but they require judgement and skill. Reconstruction This applies particularly to the severely injured hand. Much can be done to improve appearance and function, but the surgeon should remember the words of Sir Archibald McIndoe to the effect that it is not what you do to the injured hand that is important but what the patient does with what you have done to it. It is remarkable what
145
successful use a determined person will make of a much reduced remnant of hand. The essential requirements of the hand are to be able to hold, to release and to feel. For these purposes, the equivalent of a pair of forceps will suffice; it is not necessary for both jaws to move but it is desirable that both should retain or regain sensibility. These facts should be borne in mind when planning treatment, which should be guided by the following rules: 1 Try to visualise at the beginning a likely functional outcome and plan accordingly. 2 Treatment should be completed in as few stages as possible; one may suffice. 3 The most important first stage is to achieve prompt healing. 4 When several stages of treatment are necessary the patient should, if possible, be given an opportunity to make some use of the hand between operations.
Planning calls for sound judgement on the part of the surgeon of first instance; his most valuable action may be to arrange for the necessary skill and experience to be made available, at another hospital if necessary. What matters nowadays is not how far away the nearest hand surgeon is but how long will elapse between injury and repair. If a severed part is kept cold it may be worth replacing after even 8-10 h. Methods of reconstruction Transposition and rotation flaps (Fig. 4a). A flap is raised and moved to its new situation. Because of the rules that govern the shapes of such flaps, the original defect may have to be enlarged in order to accept a viable flap. Transposing, as in Fig. 4b, requires a long dorsal flap (which retains its neurovascular bundles), but if it covers bare tendon and allows a useful finger to be retained it may be indicated. A particularly useful application of this principle is possible if a digit that is not worth saving can provide much needed skin for one that is. Advancement (Fig. 4c). Delicate dissection and moderate flexion of the digit can allow skin to be advanced from near the middle to its tip while retaining its neurovascular bundle(s).
Island flaps (Fig. 4d). A disc of skin that retains its neurovascular bundle can be moved from one digit to another. This can restore sensibility to an important fingertip, but sometimes tender neuromata develop around the edges of the implanted skin, and some patients find it difficult to come to terms with the fact that what feels like one finger is now part of another. Translation ofdigits. This is an extension of the concept of the island flap in that more or less of a digit, and perhaps some of its metacarpal, is moved to a new site while retaining its neurovascular bundles.
146
P S London
(b)
(c)
(a)
Figure 4. (a) Transposition flap. The dotted line represents the size of the defect after trimming of its ragged edges. (b) A dorsal flap transposed to fill a palmar defect. (c) Advancement of skin to the fingertip while retaining its neurovascular bundles. (d) Island flap. Skin transferred from the ring finger to a defect on the index after dissecting the neurovascular bundle back into the palm. A bed for the bundle has to be made in the index finger.
Free flaps. The development of microsurgical techniques has greatly extended the practicability of transferring skin and subcutaneous tissue or composite grafts to or within the hand. For the ordinary surgeon it is sufficient to know, firstly, that such techniques exist and, secondly, the telephone number of the nearest surgeon who can use them.
Reconstruction of digits. Previous methods of implanting bone and covering it with a flap of skin have taken on a new lease of life in that if it is not possible to move a digit to a new position in the hand microsurgical techniques now make it possible to provide a rigid projection with the sensible and well-nourished covering that makes it both useful and capable of surviving indefinitely.
Repair. Repair of tendons, blood vessels and nerves is often necessary but will not be dealt with here.
(d)
Reattachment of digits. Reattachment is most strongly indicated when several digits have been cut off leaving short stumps, but there are special cases in which it is justifiable to replace only a small part of one digit. Some patients are more concerned about appearance than use, even though it is remarkable what loss can be masked by the unselfconscious use of the hand and an unobtrusive position at rest. Formal amputation of digits This is necessary when it is decided that a recently injured digit cannot usefully be preserved or restored and that trimming of the stump will not suffice. It is also required when a diseased of a previously injured part has to be removed. One of the more difficult decisions for both the patient and the surgeon may be that, however well intentioned they may have been, attempts at conservation or reconstruction should be abandoned.
Amputations of the upper limb Dorsal and palmar flaps should be cut on the digits and whenever possible the palmar flap should cover the end of the stump. Racquet incisions should be used for amputations through metacarpals and they should be so placed that the scar will not lie where it will be pressed upon during ordinary use of the hand. After cutting the flaps, cut down to bone on the dorsum, clear it at the level of section and then cut through a metacarpal bone obliquely, but a phalanx transversely. Cutting forceps may be easier to use than a saw but they are liable to splinter the bone. They should, however, be used to remove the condyles of a phalanx when a digit is disarticulated. Pulling on the distal part with a hook in the marrow allows the tendons and nerves to be cut short and retract (Fig. 5). The palmar arteries should be ligated or coagulated before they retract. With young children it is advisable to bandage the whole hand and then encase it in plaster-of-Paris. In the interests of confidence and the return of function the dressing should first be reduced and then removed as soon as possible. Tender stumps The usual causes are adherent scars and nerves caught in the scar. These causes are amenable to surgical treatment by refashioning the stump or by freeing the nerve and either cutting it short or putting it out of harm's way, or by simply cutting the nerve proximal to the tender point. I have not found that tapping a 'neuroma' is successful. In other cases there is no identifiable cause in the stump and the mental attitude is responsible for the complaints.
LINE OF SECTION.
---.-
Figure 5. Formal amputation of a digit.
147
My policy has been to offer an operation only when I believe that there is a surgically remediable cause for the symptoms, and I have done this even when the patient's reactions seemed excessive. If a surgically remediable cause is found and the appropriate steps to relieve it do not do so I do not operate again. Remnants of nail should be removed (which is more easily said than done) if they are troublesome or of unacceptable appearance: most are neither.
Return to work For all the patient's anxiety about returning to work in which the accident occurred, the surgeon's attitude should in many cases be one of robust confidence from the beginning. This is not to deny that a patient's anxiety may be fully justified by, for example, unsatisfactory working conditions, in which case the surgeon's outspoken confidence in the hand should be accompanied by steps designed to improve the working conditions. Much can be achieved by carefully designed occupational and physiotherapy. Another reason for reluctance to return to work is the advice that to do so as soon as is practicable is to risk a reduction in the amount of compensation that is being sought. These matters are not always easy to deal with and they can require a good deal of experience. Common errors by junior medical staff are to allow a dressing or a finger stall to be worn long after a stump has healed; failure to use remedial therapies early in order to restore the patient's readiness to use the stump, and failure to make the necessary arrangements with the employers or their medical advisers. Whenever possible the patient should not be discharged from medical supervision until he or she has returned to work. Prolonged absence from work may reflect the severity of the injury but all too often it is the result of poor surgical technique or judgement or of failure to make suitable contacts with the right persons, and sometimes for all of these reasons.
Amputations of the upper
limb
P S London MBE FRCS MFOM Honorary Consulting Surgeon The Birmingham Accident Hospital
Unlike amputations of the lower limb, most of those of the upper limb are the result of injury. This means that even if the surgeon does not have to perform an amputation he has to deal with one. Practical details will be largely confined to those operations that would be undertaken by surgeons of general competence or in training. More specialised methods of repair and reconstruction will be dealt with in more general terms. Amputations of the upper limb often occur at work and even though small they may greatly reduce the earning capacity of a young breadwinner-sometimes for psychological rather than physical reasons. The surgeon's task is to provide, as soon as possible, a stump that the patient will use. It is thus fair to suggest that amputation should be thought of not as an operation to remove something harmful or useless but as one to preserve as much of the patient as will be useful. A welljudged operation must be followed by the necessary efforts to restore the patient's confidence, upon which so much of a person's ability to work depends. It may also be necessary to overcome the reluctance to do so that is induced by the advice of lawyers and trade union officials.
Amputations proximal to the hand These are much fewer than amputations of the lower limb. My own experience over some 30 years is summarised in Table I.
Table I. Comparison of major amputations following injury of the upper and lower limbs Amputation
n
Above-elbow At elbow Below-elbow At wrist
2 1
Correspondence
Amputation
5
Hip Above-knee At knee Below-knee
2
Syme's
to: Mr P S
borough, Bucks MK17 ORF
The arm and forearm The favoured levels of amputation 20.5-25.5 cm below the acromion process and 15.5-18 cm below the tip of the olecranon process may not be possible. Shorter stumps can be satisfactory and the amputating surgeon may be well advised to consult a limb-fitting surgeon about this when time permits. However, it is a good general rule to aim to have a stump that heals promptly and will be comfortable. Length should not be preserved by using damaged skin or muscle, or bone without an adequate covering of soft tissue. Ideally, equal flaps should be used. In the forearm the scar should run across and not between the ends of the radius and ulna, but the precise position of the scar may have to be determined by what skin and muscle of adequate quality are available. If amputation can be carried out at the favoured level the muscles are sufficiently sinewy to be stitched firmly together, flexors to extensors, over the end(s) of the bone(s), but if a more proximal level has to be used, particularly in the arm, the muscles should be trimmed so as to come neatly together over the bone (Fig. 1). The advantages of myoplastic amputations for comfort, strength and controllability of the stump make them better than any other method. If suction drainage is used, a light dressing is sufficient. A good method is to place strips first of gauze and then of wool over the stitches and secure them with strips of 2.5 or 9 cm micropore tape or a covering of Hypafixg (Fig. 2). This dressing is then covered with a thin layer of wool and a firm crepe bandage that is secured by two U-shaped strips of Elastoplast® at right-angles to each
7~~~~~~~~~~~~~~~
n
I
5 18 1 18
1
London, The Ridings, Single-
bone.~~~~~~~~~~~~~~~~~~~~~~~~o Fiur
bone.
_. Trmmn toalwmsl_. ki
ob
lsdoe
144
P S London
Amputations of the hand Classifying these injuries is of no assistance to the surgeon who has to try and restore a useful extremity. Amputations of the digits are in some ways the most important of all partly because they are so numerous and partly because they may be regarded as minor surgery and left to inadequately trained or supervised junior staff when sound judgement and technical skill are needed.
Figure 2. Inner layers of a dressing for a stump.
other and held in place by an unstretched band round their top ends. Alternatively, the crepe bandage can be replaced by a tubular bandage of suitable size that is knotted at one end and pulled snugly into place before being secured with Elastoplast as already described. Because the loss of a hand can be a psychologically crippling experience, especially when it occurs at work, the idea of returning to work must be introduced very early on and the impetus of efforts to this end must be maintained. It is important to discuss this as soon as possible with the victim, the employers and others concerned with resettlement, and it can be of great advantage to the patient to meet someone who has made good after sustaining a similar amputation. This can be arranged through the local limb-fitting centre.
Amputations at the wrist Less than the complete carpus offers little functional advantage and may be discarded if this will facilitate closure of the skin, but the ability to pronate and supinate the forarm should be preserved whenever possible. This may mean that skin has to be provided in order to cover the distal part of the stump. If necessary, free flaps and neurovascular anastomoses can be used but simpler flaps may be satisfactory.
Reattachment of severed limbs To someone who has just lost a hand or more the fact that it could be reattached has obvious attractions, but it is only fair that the duration of recovery and the uncertainty of the final outcome should not be glossed over. Surprising though it may seem, patients may be fully capable of coherent thought and discussion and the surgeon should not hesitate to offer the patient the opportunity of making a well-informed choice between simple closure and what reattachment entails. It is fair to say that reattaching the severed part can greatly prolong
disability and sap morale.
Traumatic amputation of digits Most accidental amputations affect the tips of the three radial digits, which are the most used. If the stumps are to be used they must be comfortable and durable; to this end, it is not always advisable to save all viable tissue because this can result in a stump with a numb, tender or badly scarred tip. Length of stump The 'right' length of stump varies a good deal. In the case of the thumb, comfort is much more important than length. Even complete destruction of the thumb can allow such successful use of the hand as to persuade the patient to accept the loss; it is a sound principle not to disable a person, perhaps for months, by treating a condition that causes no more than tolerable inconvenience. In the case of the index finger, a stump with less than about 1' phalanges usually gets in the way; amputation through the metacarpal should be considered. Even short stumps of the middle and ring fingers are worth saving, but stumps that stick out when the fist is closed are a nuisance. The importance of the fifth ray for gripping firmly should be remembered; even a short but mobile stump of finger can add useful stability to the grip. It will readily be appreciated how important it is to discuss, whenever possible, what the patient requires of the hand not only at work but in hobbies and other pastimes.
Methods of closure Simple dressing. Simple dressing can be used for all amputations beyond the terminal phalanx; it has been advocated even when bone is exposed. Dressings should be changed as infrequently as possible; if the outer layer becomes dirty it may not be necessary to change the whole dressing.
Trimming and closure. Exposed bone is nibbled away to allow comfortable closure with flaps. Kutler's repair. A triangular flap of skin and pulp is fashioned on each side of the stump (Fig. 3a) and the two flaps are then stitched in place over the end of the bone (Fig. 3b).
Amputations of the upper limb
(a, i)
(a, ii)
(b, i)
(b, ii) Figure 3. Kutler's repair of a fingertip. The shaded areas are the triangular flaps with thick fatty pedicles that are cut from the sides and advanced to the tip of the stump.
Whichever method is used, exposed ends of nerves should be sought and cut short so that they will not heal into the scar. The 'best method' of closure varies with the circumstances; each has a place in the hands of the expert.
Split skin grafts. These can be used on fat or paratenon (after trimming the bone if necessary). Full-thickness skin grafts contain sensory end organs and can offer a better quality of sensibility; they may therefore be preferable to split-skin on the main working surface of the pulp. Flaps. Flaps from the palm or from other digits can yield a neat stump but they may result in a stiff finger or a tender donor area. If they are used the following considerations apply: 1 The digits concerned should be comfortably disposed with the flap free from tension. 2 Marked flexion or extension may be comfortable but prevent the return of full movements, particularly to short, stubby fingers and those of older persons. 3 Donor areas on pressure-bearing surfaces of the palm or digits may be intolerably sensitive. 4 A numb flap on the working surface, particularly of a finger tip, may render the stump useless. Local flaps. There are ingenious methods of moving intact skin about on the hand in order to maintain sensibility and conserve length but they require judgement and skill. Reconstruction This applies particularly to the severely injured hand. Much can be done to improve appearance and function, but the surgeon should remember the words of Sir Archibald McIndoe to the effect that it is not what you do to the injured hand that is important but what the patient does with what you have done to it. It is remarkable what
145
successful use a determined person will make of a much reduced remnant of hand. The essential requirements of the hand are to be able to hold, to release and to feel. For these purposes, the equivalent of a pair of forceps will suffice; it is not necessary for both jaws to move but it is desirable that both should retain or regain sensibility. These facts should be borne in mind when planning treatment, which should be guided by the following rules: 1 Try to visualise at the beginning a likely functional outcome and plan accordingly. 2 Treatment should be completed in as few stages as possible; one may suffice. 3 The most important first stage is to achieve prompt healing. 4 When several stages of treatment are necessary the patient should, if possible, be given an opportunity to make some use of the hand between operations.
Planning calls for sound judgement on the part of the surgeon of first instance; his most valuable action may be to arrange for the necessary skill and experience to be made available, at another hospital if necessary. What matters nowadays is not how far away the nearest hand surgeon is but how long will elapse between injury and repair. If a severed part is kept cold it may be worth replacing after even 8-10 h. Methods of reconstruction Transposition and rotation flaps (Fig. 4a). A flap is raised and moved to its new situation. Because of the rules that govern the shapes of such flaps, the original defect may have to be enlarged in order to accept a viable flap. Transposing, as in Fig. 4b, requires a long dorsal flap (which retains its neurovascular bundles), but if it covers bare tendon and allows a useful finger to be retained it may be indicated. A particularly useful application of this principle is possible if a digit that is not worth saving can provide much needed skin for one that is. Advancement (Fig. 4c). Delicate dissection and moderate flexion of the digit can allow skin to be advanced from near the middle to its tip while retaining its neurovascular bundle(s).
Island flaps (Fig. 4d). A disc of skin that retains its neurovascular bundle can be moved from one digit to another. This can restore sensibility to an important fingertip, but sometimes tender neuromata develop around the edges of the implanted skin, and some patients find it difficult to come to terms with the fact that what feels like one finger is now part of another. Translation ofdigits. This is an extension of the concept of the island flap in that more or less of a digit, and perhaps some of its metacarpal, is moved to a new site while retaining its neurovascular bundles.
146
P S London
(b)
(c)
(a)
Figure 4. (a) Transposition flap. The dotted line represents the size of the defect after trimming of its ragged edges. (b) A dorsal flap transposed to fill a palmar defect. (c) Advancement of skin to the fingertip while retaining its neurovascular bundles. (d) Island flap. Skin transferred from the ring finger to a defect on the index after dissecting the neurovascular bundle back into the palm. A bed for the bundle has to be made in the index finger.
Free flaps. The development of microsurgical techniques has greatly extended the practicability of transferring skin and subcutaneous tissue or composite grafts to or within the hand. For the ordinary surgeon it is sufficient to know, firstly, that such techniques exist and, secondly, the telephone number of the nearest surgeon who can use them.
Reconstruction of digits. Previous methods of implanting bone and covering it with a flap of skin have taken on a new lease of life in that if it is not possible to move a digit to a new position in the hand microsurgical techniques now make it possible to provide a rigid projection with the sensible and well-nourished covering that makes it both useful and capable of surviving indefinitely.
Repair. Repair of tendons, blood vessels and nerves is often necessary but will not be dealt with here.
(d)
Reattachment of digits. Reattachment is most strongly indicated when several digits have been cut off leaving short stumps, but there are special cases in which it is justifiable to replace only a small part of one digit. Some patients are more concerned about appearance than use, even though it is remarkable what loss can be masked by the unselfconscious use of the hand and an unobtrusive position at rest. Formal amputation of digits This is necessary when it is decided that a recently injured digit cannot usefully be preserved or restored and that trimming of the stump will not suffice. It is also required when a diseased of a previously injured part has to be removed. One of the more difficult decisions for both the patient and the surgeon may be that, however well intentioned they may have been, attempts at conservation or reconstruction should be abandoned.
Amputations of the upper limb Dorsal and palmar flaps should be cut on the digits and whenever possible the palmar flap should cover the end of the stump. Racquet incisions should be used for amputations through metacarpals and they should be so placed that the scar will not lie where it will be pressed upon during ordinary use of the hand. After cutting the flaps, cut down to bone on the dorsum, clear it at the level of section and then cut through a metacarpal bone obliquely, but a phalanx transversely. Cutting forceps may be easier to use than a saw but they are liable to splinter the bone. They should, however, be used to remove the condyles of a phalanx when a digit is disarticulated. Pulling on the distal part with a hook in the marrow allows the tendons and nerves to be cut short and retract (Fig. 5). The palmar arteries should be ligated or coagulated before they retract. With young children it is advisable to bandage the whole hand and then encase it in plaster-of-Paris. In the interests of confidence and the return of function the dressing should first be reduced and then removed as soon as possible. Tender stumps The usual causes are adherent scars and nerves caught in the scar. These causes are amenable to surgical treatment by refashioning the stump or by freeing the nerve and either cutting it short or putting it out of harm's way, or by simply cutting the nerve proximal to the tender point. I have not found that tapping a 'neuroma' is successful. In other cases there is no identifiable cause in the stump and the mental attitude is responsible for the complaints.
LINE OF SECTION.
---.-
Figure 5. Formal amputation of a digit.
147
My policy has been to offer an operation only when I believe that there is a surgically remediable cause for the symptoms, and I have done this even when the patient's reactions seemed excessive. If a surgically remediable cause is found and the appropriate steps to relieve it do not do so I do not operate again. Remnants of nail should be removed (which is more easily said than done) if they are troublesome or of unacceptable appearance: most are neither.
Return to work For all the patient's anxiety about returning to work in which the accident occurred, the surgeon's attitude should in many cases be one of robust confidence from the beginning. This is not to deny that a patient's anxiety may be fully justified by, for example, unsatisfactory working conditions, in which case the surgeon's outspoken confidence in the hand should be accompanied by steps designed to improve the working conditions. Much can be achieved by carefully designed occupational and physiotherapy. Another reason for reluctance to return to work is the advice that to do so as soon as is practicable is to risk a reduction in the amount of compensation that is being sought. These matters are not always easy to deal with and they can require a good deal of experience. Common errors by junior medical staff are to allow a dressing or a finger stall to be worn long after a stump has healed; failure to use remedial therapies early in order to restore the patient's readiness to use the stump, and failure to make the necessary arrangements with the employers or their medical advisers. Whenever possible the patient should not be discharged from medical supervision until he or she has returned to work. Prolonged absence from work may reflect the severity of the injury but all too often it is the result of poor surgical technique or judgement or of failure to make suitable contacts with the right persons, and sometimes for all of these reasons.
