INTRODUCTION
A fingertip amputation is defined as any amputation
of the soft tissue, nail or bony element distal
to the dorsal and volar skin creases at the distal
interphalangeal joint and insertions of long flexor
and extensor tendons of a finger or thumb [1].
Fingertip amputations are the most common
type of amputation injury in the upper extremity.
These injuries are either seen in the emergency
room or in an office setting. These lesions are very
frequent and require precise wound care for optimal
results. Treatment of fingertip injuries is a continuous
focus of controversy among hand and orthopedic
surgeons [2].
Goals of treatment should include minimization
of pain, optimization of healing time, preservation
of sensibility and length, prevention of painful
neuromas, avoidance or limiting of nail deformity,
minimization of time lost from work, and provision
of an acceptable cosmetic appearance [1].
The treatment of fingertip amputations is controversial
and so, many treatment options are available.
These treatment options are either conservative
management or surgical treatment.
Despite ongoing publications of new flaps for
fingertip reconstruction, there is a paucity of evidence
to support improved healing and function
in a surgically reconstructed fingertip compared
to conservative wound management [3].
Previously, authors advocated that defects >1cm
should be closed with local flaps. However, recently,
authors reported that healing by secondary
intention with dressing changes is one of the best
options for a tip amputation without exposed bone
and will be most applicable for wounds with skin
loss of 1.5cm or less; healing will occur by reepithelialization
over 3 to 4 weeks with return of
normal sensation and two-point discrimination. If
there is additional loss of subcutaneous tissue of
similar size, it may take 1 to 2 months to heal by
secondary intention [4].
Some have expanded the application of the
conservative management to include larger wounds
up to 2-3cm2 can heal by secondary intention
without bone, tendon or neurovascular structures
exposure, this is at the expense of longer healing
time [5].
In this study we will evaluate the functional
and aesthetic outcome of conservative management
of fingertip amputations of variable defect sizes
and the expanded application to include defects
³2-3cm2 even with exposed bone of variable
lengths, surrounded by soft tissue at any side of
its circumference, but not skeletonized.
PATIENTS AND METHODS
This prospective study was approved by the
Research Ethical Committee of Faculty of Medicine,
Fayoum University and conducted on 20
patients presented to the Emergency Department
of Fayoum University Hospital, complaining of
fingertip amputations, in the period from March
2018 to May 2019.
All ages were included in the study, patients
with isolated fingertip amputation, not associated
with other trauma and fingertip amputations within
24 hours of injury were also included.
Multi-trauma patient, diabetic uncontrolled
patients with polyneuropathy, defects with skeletonized
bone, not surrounded by soft tissues at any
side of its circumference and fingertip amputations
with exposed tendon were excluded from the study.
On admission, adequate history taking, thorough
physical examination and X-rays were taken to
exclude associated hand injury.
Daily simple non adherent dressing, paraffinimpregnated
gauze, with an ointment initially for
debridement then for healing was used.
We have measured the defect surface area,
length of bone exposed, length of bone trimmed.
We used pinch gauge, finger goniometer, caliper
and compass to measure pinch tip strength, distal
phalanx range of motion and 2 point discrimination
distance, respectively.
188 Vol. 44, No. 1 / Functional & Aesthetic Evaluation of Expanded Applications
We have evaluated sensibility, tenderness, cold
intolerance, development of neuroma and disability.
Aesthetic outcome, healing time and time off
work were also noted.
Follow-up period was at least 9 months after
healing occur.
Data was expressed as mean ± Standard Deviation
(SD) or number (%).
The p-value £0.05 was considered the cut-off
value for significance.
RESULTS
The mean age was (33±17.3) years old. The
patients were 16 males (80%) and 4 females (20%).
95% of patients had crushed amputation, the left
hand was affected in 70% of patients, the middle
finger is the most affected finger (35%) followed
by the thumb (20%).
The mean surface area of amputated fingertips
was (3.9±1.6) cm2, all cases had bone exposed
with mean length of (4.1±1.6) mm, 10% of them
had been trimmed with mean length of trimming
was (2.5±0.71) mm. The mean healing time was
(36.4±5.8) days and mean time off work was (11.6±
7.6) days.
As regards sensibility 30% complain numbness,
35% had hyper-sensibility, and 35% show normal
sensibility.
As regards two point discrimination in the
corresponding healthy fingertip, the mean distance
was (4.7±1.5) mm, versus (8.6±2.5) mm in amputated
fingertip with a statistical significance difference
with p-value <0.05 in two points discrimination
in healthy and amputated fingertips.
The mean pinch tip strength was (2.18±1) kg
versus (3.5±1.6) kg in contralateral normal fingertip.
There is statistical significance difference with
p-value <0.05 in pinch tip strength in contralateral
healthy and amputated fingertip.
The mean degree of joint flexion was (124.5±
15.8)º and mean degree of joint extension was
(11.5±4.3)º. The mean normal degree of active
flexion of the DIP joint in the normal contralateral
finger was (118.5º), range from (105º-140º), the
mean normal degree of active extension of the DIP
joint in the normal contralateral finger was (10.75º),
range from (5º-20º).
Egypt, J. Plast. Reconstr. Surg., January 2020 189
There was no tenderness, cold intolerance,
joint stiffness, neuroma or disability in all patients.
45% of patients had hook nail deformity, followed
by 10% complained amputated nail and nail
bed, and 5% had short nail, versus 40% show
normal nail with no deformity.
50% of patients expressed good aesthetic results,
40% of patients had accepted aesthetic results, and
10% had poor aesthetic results.
Fig. (1): Before and 9 months after conservative treatment of amputated right thumb finger tip.
Fig. (2): Before and 10 months after conservative treatment of amputated left index finger tip.
190 Vol. 44, No. 1 / Functional & Aesthetic Evaluation of Expanded Applications
Fig. (4): Before and 9 months after conservative treatment of amputated right ring finger tip.
Fig. (3): Before and 9 months after conservative treatment of amputated left index finger tip.
Egypt, J. Plast. Reconstr. Surg., January 2020 191
DISCUSSION
Fingertip amputations are among the most common
traumatic injuries that present for acute care.
The fingertip is a specialized structure that permits
fine motor activity and precise sensation and contributes
to hand aesthetics [6].
A reasonable treatment strategy for a fingertip
amputation should consider both cosmetic and
functional outcome. The conservative approach
requires no surgical skill, has a low risk for complications,
and is likely to result in a sensate, nontender,
and cosmetically appealing finger [7].
In the literatures, no clear definition of fingertip
and thumb tip defects can be found, mostly the
defects are defined as small or large, but there are
classifications that describe the involved structures
as the nail, pulp, or bone [8].
Champagne et al., in a systematic review found
that healing by secondary intention is a preferred
treatment for many authors, because it provides
the best possible functional and cosmetic result,
with minimal risk of iatrogenic complications [7].
We have evaluated the functional and aesthetic
outcome because it is challengeable to treat a wider
defects of fingertip amputations with exposed bone
conservatively with only simple dressing changes.
Fingertip amputations with skeletonized bone,
except if the patient preferred trimming and conservative
management over surgical reconstruction,
were excluded from the study; because we felt that
in this situation no soft tissue to creep and cover
it.
We meant with skeletonized bone, not surrounded
by soft tissues at any side of its circumference.
Surface area calculated as the longest length
head-to-toe and longest width side-to-side, perpendicular
to length. Keast et al., reported that research
indicates that this method in wound measurement
is indeed the more valid and reliable method compared
with other ruler-based methods [9].
The mean surface area of amputated fingertip
was (3.9±1.6) cm2. In the contrary, in the literatures,
no clear definition of fingertip and thumb tip defects
can be found, mostly the defects are defined as
small or large,and the litratures who mentioned
the defet size in conservative management of fingertip
amputations were <1cm2, >1cm2, <1.5cm2
and the expanded application was for defect size
>1.5cm2 [3].
A study conducted by Ipsen et al., included
defects more than 1cm2 in adults and more than
0.5cm2 in children, with no tendon or joint exposed.
Amer's study in 2008, the mean surface area
of the defect was 1.6cm2 (range 0.5-2.2cm2) [10,11].
Weichman and his colleagues reported that
average defect size allowed to heal by secondary
intention was 1.75cm2, all without exposed bone
[12].
Some have expanded the application of the
conservative management to include larger wounds
up to 2-3cm can heal by secondary intention without
bone, tendon or neurovascular structures exposure
[5].
In our thesis, all cases had bone exposed with
mean length of (4.1±1.6) mm, 10% of them had
been trimmed with mean length of trimming was
(2.5±0.71) mm.
Only 2 cases had been trimmed; the 1st one
was 4mm exposed bone, we trimmed 3mm, left
1mm. It was skeletonized, one case only in our
study, and patient refused flap coverage and preferred
conservative management.
The 2nd one was with 5mm exposed bone, 2mm
trimmed, 3mm left, it was a sharp bony spicule in
agreement with Champagne et al., previously discussed
in our review.
In the rest of cases, no more trimming were
done; to avoid shortening and we felt that soft
tissue around will creep.
In the contrary, most literatures of conservative
management of fingertip amputations agreed on
that conservative without bone exposed, some
treated conservatively with exposed bone in children
only Allen treated conservatively in adult
with exposed bone and minimal trimming done,
but did not mention how much bone exposed and
how much he trimmed [13].
Some authors classified the defect >1.5cm2
with bone exposed as a candidate for semi occlusive
dressing [14,15].
About bone trimming, some mentioned only
1-2mm [6]. Some did not mention, and reported to
trim the bone until leave soft tissue cover >3mm
and trim the nail bed 2mm proximal to the bone
in order to avoid hook nail deformity [16].
Some mentioned trimming only for sharp specules
1-3mm [7].
In our thesis, we measured the amount of bone
exposed and length of trimming.
Only 15% of our patients had nail bed lacerations.
We had repaired them in order to avoid nail
deformity, this was with agreement with Lee et al.
[17].
In this study, 20% associated distal phalangeal
fractures, 1 angulated and in place, other comminuted
and the remaining 2 were fissure fractures.
As reported by Yeo et al., we prescribed analgesia
and protection with a suitable cap or aluminium
splint for 2-3 weeks. Repair of the nail bed was
enough to stabilizes the fractures [18].
The mean pinch tip strength of our patients
was (2.18±1) kg. Compared to the mean pinch tip
strength in the contralateral healthy fingertip was
(3.5±1.6) kg. This may be due to initial hypersensitivity
and more proximal amputations.
In our study, there was no statistically significant
difference with p-value >0.05 in tip pinch in different
gender and side of lesion.
On the other hand there was statistically significant
difference with p-value <0.05 in tip pinch in
healthy and amputated fingertip with low mean
among amputated finger.
In contrast, most studies reported no change in
pinch grip strength except in the very proximal
fingertip injuries [13,19].
In agreement with them, proximal injuries,
Allen III and IV, were 90% of our cases, showed
apparent decrease in pinch tip strength.
The mean healing time was (36.4±5.8) days.
The most commonly reported mean time to complete
healing using conservative wound care alone
was 4 weeks, small defects (<1cm) with no bone
involvement were frequently healed within 2 weeks
[20].
The mean healing time reported by Ipsen was
25 days defect was >1cm2 no exposed bone. Lee
et al., the mean healing time was 32 days e defect
size <1cm with exposed bone [3].
Amer, reported that healing time was 29 days
(range 21 to 45 days) in fingertip amputations of
mean defect sizes 1.6cm2 without exposed bone
[11,21].
Healing time, in literatures used the semi occlusive
dressing, was as follows: Mennen and Wise
in a series of 200 fingertip amputations found a
192 Vol. 44, No. 1 / Functional & Aesthetic Evaluation of Expanded Applications
healing time ranging from 20 to 30 days and good
functional recovery. Hoigné et al., in 2014, the
treatment duration with an average of 6.5 weeks
may seem relatively long. The same type of injury
treated with the same method by Quell et al., in
1998 had a treatment period of 49 days and Richter
in 2010 described a duration of 6 weeks. This is
a remarkable consistency between the three studies.
In our study, 45% of patients had hook nail
deformity, followed by 10% complained of amputated
finger nail and nailbed, and 5% had short
nail, versus 40% show normal nail with no deformity.
Patients who had hook nail deformity were 9
patients. Only 2 of them exposed for bone trimming,
the remaining 7 patients underwent no trimming.
This is may be due to the wound contraction
occurs with 2ry healing, some of cases were proximal
and we didn't excise the nail bed proximal to
the exposed bone in other cases.
According to literatures, the main residual
deformity with secondary healing is the hook nail
or parrot beak deformity, which occurs mainly in
the most proximal injuries [13,20].
As regards sensibility 35% show normal sensibility,
while 35% had hyper-sensibility and 30%
complained of numbness.
Altered sensibility, hypersensitivity and numbness,
usually occurs early after healing but is
usually transient. It may be due to the relatively
larger defect surface area (3.9±1.6) cm2. It may
improve within 12 months after healing. Amer in
2008, hypersensitivity was noticed in 12 fingers
(35.3%) after 3 months. After 12 months no hypersensitivity
was noticed in any fingertip [11,21].
Ipsen et al., noticed numbness in (36%) of his
cases [10].
In our study, patients had neither cold intolerance
nor tenderness, even in cases with highest
length of exposed bone. This may be due to the
adequate soft tissue and glabrous skin pulled over
the exposed bone in the process of 2ry intension.
Patients were asked according to the Cold Intolerance
Symptom Severity (CISS) questionnaire,
and did not complain from any symptom related
to low temperature, such as during cold weather
[22].
In the contrary, Amer et al., reported that cold
intolerance was detected in 9 fingertips (27.3%)
after 3 months and only in 2 fingers (6.1%) after
one year [21].
Egypt, J. Plast. Reconstr. Surg., January 2020 193
Many literatures reported that the highest incidence
of cold intolerance was 86% at 2 months,
but all reports showed a decreasing incidence with
time. Cold intolerance frequently resolved by 1
year and caused disability in only a small minority
of patients. Ipsen et al., noticed that the main later
complaints were intolerance of cold in (36%) of
cases [3].
Cold intolerance tends to be low in conservative
management of fingertip amputations but more
common in proximal injuries.
In the current study, the mean time off work
was (11.6±7.6) days. This was a relatively shorter
period than other literatures, because we have
encouraged early return to work, provided keeping
the wound away from any injurious things or dirt.
The patients were lost more time off work justify
this because of fear from them to use their affected
digits.
Allen reported that the mean time off work was
18 for distal amputations and 26 for proximal. Lee
et al., reported 30 days time off work [3].
Weichman et al., followed 100 fingertips prospectively.
Sixty-four percent of patients healed
secondarily, 18% underwent operative intervention,
and 18% were lost to follow-up. Patients requiring
surgery were more likely to have a larger defect
and exposed bone. They also had a longer average
return to work time (4.33 weeks) when compared
with the secondary healing group (2.98 weeks)
[12].
Assessing the aesthetic result is a crude, subjective
assessment and determined according to
the patient's own culture and standards.
In our study 50% had been satisfied and expressed
their aesthetic results as good, 40% of
patients were acceptable, and 10% had poor aesthetic
results. Patients justify their acceptable and
poor aesthetic results, because of hook nail deformity.
In agreement with our results, residual nail
deformity was the usual cause of aesthetic dissatisfaction
in systematic review of 1592 fingertip
amputation [3].
Douglas in 1972 reported good aesthetic outcome
and accompanying restoration of some of
the length and thickness of the pulp of 29 children
treated conservatively. Small defect size without
bone exposed in children may justify his results
[7].
Amer reported good cosmetic outcome in 26
fingertips (76.47%) out of 34 cases. A relatively
small defect size without bone exposed may justify
his results [11].
In our thesis, neither of cases showed neuroma,
nor disability. Although neuroma-type problems
can occur with secondary healing, they are rare
[3].
Hoigné et al., reported that only one patient
developed a clinically diagnosed neuroma, which
was treated with desensitization program [22].
Conclusion:
Conservative management of fingertip amputations
using repeated dressings is an effective,
simple and good option for treatment of fingertip
amputations with bone exposure of variable lengths
up to (4.1±1.6) mm, even with relatively larger
surface area of the defect, up to (3.9±1.6) cm2,
provided that presence of adequate soft tissue
around and the bone not skeletonized.
The functional outcome was good, as there
were no tenderness, cold intolerance, neuroma or
disability. Although longer healing time, time off
work was generally acceptable.
There were statistically significant difference
with p-value <0.05 in pinch tip strength and two
point discrimination distance in healthy and amputated
fingertips.
Hook nail deformity was the only cause of poor
aesthetic results. However, conservative management
of fingertip amputations using simple daily
dressings provides good and acceptable results
outweigh the poor results.
View on SCiNiTO
