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- A 32-year-old Thai female presented to the emergency department 4 hours after her right little finger was amputated when she fell off her motorcycle. - On examination, her right little finger distal phalanx was amputated with a sharp dissection and her vital signs were stable. - The diagnosis was a traumatic amputation of the distal phalanx of the right little finger. Debridement and stump closure were performed along with antibiotic treatment.
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- 2. Patient profile • ผู้ป่วยหญิงไทย อายุ 32 ปี ภูมิลาเนาจ.มหาสารคาม
- 3. Chief complaint • นิ้วก้อยขวาขาด 4 ชั่วโมงก่อนมาโรงพยาบาล
- 4. Present illness • 4 hr PTA ผู้ป่วยซ้อนรถจักรยานยนต์ล้มเอง ไม่สลบ จาเหตุการณ์ได้ มีแผลที่ นิ้วก้อยขวา นิ้วก้อยขวาขาด
- 5. Primary survey • Airway - can speak , not tender at posterior midline along C-spine, can flex & extend neck • Breathing - trachea in midline, clear, equal breath sound both lungs, CCT-neg • Circulation - BP 136/75 mmHg, PR 85 bpm, abdomen : no distension, soft, not tender, PCT-neg • Disability - E4V5M6, pupil 3 mm RTLBE • Exposure/Environment - amputated distal phalanx Rt. little finger
- 7. Diagnosis • Traumatic amputation distal phalanx Rt. little finger
- 8. Management • Debridement with stump closure • Antibiotic : dicloxacillin
- 9. Digital replantation • mechanism of traumatic amputation ▫ sharp dissection ▫ blunt dissection ▫ avulsion ▫ crush
- 10. Indication Absolute Relative • thumb at any level • multiple digits • children • individual digits distal to the insertion of flexor digitorum superficialis [FDS] (Zone I) • ring avulsion
- 11. Contraindication Absolute Relative • severe vascular disorder • mangled limb or crush injury • segmental amputation • single digit proximal to FDS insertion (Zone II) • medically unstable patient • disabling psychiatric illness • tissue contamination
- 12. Transport of amputated tissue • keep amputated tissue wrapped in moist gauze in lactate ringers solution • place in sealed plastic bag and place in ice water (avoid direct ice or dry ice) • wrap, cover and compress stump with moistened gauze
- 13. Time to replantation • warm ischemia time < 12 hours • cold ischemia time < 24 hours
- 14. Complication • Replantation failure ▫ most frequently cause within 12 hours is arterial thrombosis from persistent vasospasm • Stiffness ▫ replanted digits have 50% of total motion ▫ tenolysis is most common secondary surgery • Infection • Cold intolerance
- 15. Fingertip amputation • Treatment ▫ Nonoperative healing by secondary intention indications adults and children with no bone or tendon exposed with < 2cm of skin loss children with exposed bone
- 16. • Operation ▫ primary closure (revision amputation) Indication :finger amputation with exposed bone and the ability to rongeur bone proximally without compromising bony support to nail bed ▫ full thickness skin grafting from hypothenar region Indication :fingertip amputation with no exposed bone and > 2cm of tissue loss ▫ flap reconstruction Indication : exposed bone or tendon where rongeuring bone proximally is not an option
- 17. Flap technique