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AMPUTATION, FINGER

Introduction

Hand and finger injuries continue to be very common problems in emergency departments (ED) around the world. In the United States, finger amputations are very common in both the work environment1and in the home.2Finger amputations can be partial or complete. More than 90% involve the fingertip (pulp, fingernail, and/or distal phalanx) only and are treated and released in an ED.2Work-related amputations are prevalent in young males (>80%) with limited education beyond high school.1 Most work-related amputations occur during the regular work week, while using machines such as saws, punch presses, food and beverage machines, and printing presses.2,3 The industries where amputations are common include agriculture, forestry, fishing, manufacturing, and construction.1 Machinery guards and shields are frequently not used by injured workers.

Most amputations, whether they occur in the home or at the workplace, are treated by amputation revision (85%) rather than replantation (15%). In Japan, replantation is attempted in 29% of cases of digit amputation. This increased rate of replantation is based on the different cultural beliefs—primarily related to Confucius teachings—and because Japanese patients with amputations are stigmatized and avoided by some people.4

Definitions

The amputation of a finger is the loss of any part of the index, long, ring, or little finger digits.  The lost tissue may or may not include bone.1 The finger amputation can be partial or complete.2 With a partial amputation, there may be a skin bridge still connecting the distal part of the finger to the stump. In complete amputations, there is no visible connection between the amputated part and the stump. Amputations may also be defined by the level of the transection. For example, the amputation level may be through the fingertip and fingernail, through the distal phalanx, through the distal interphalangeal (DIP) joint, through the middle phalanx, through the proximal interphalangeal (PIP) joint, or through the proximal phalanx.

Related Anatomy

Obviously, complete amputation of a finger involves all the tissues in the amputated part. Therefore, a finger amputation involves the skin, veins, extensor tendons, bone, flexor tendons, digital nerves, and digital arteries.  How these structures are managed during revision amputation and microsurgical replant are outlined in this table.

 

Amputation

Replant

Bone
  • Shorten bone to allow for good soft tissue coverage of bone end
  • Debride bone ends and shorten proximal and/or distal to remove tension on microsurgical repairs. 
  • Do some type of ORIF for the bone
  • Debride bone ends and shorten proximal and/or distal to remove tension on microsurgical repairs.
  • Do some type of ORIF for the bone
  • Repair flexor tendons
Flexor tendons
  • Debride and allow ends to retract
  • Do not suture tendon over the end of bony stump
  • Repair flexor tendons
Extensor tendons
  • Debride damaged edge
  • Repair the extensor tendon
Digital arteries
  • Cauterize digital arteries at the stump level
  • Microsurgical repair
Digital nerves
  • Pull digital nerve endings distally, cut sharply and allow ends to retract in surrounding soft tissue
  • Microsurgical repair
Veins
  • Cauterize veins on the stump
  • Microsurgical repair
Skin
  • Maintain healthy viable skin for stump coverage
  • Maintain healthy viable skin for coverage of the circumferential wound.  Skin not always sutured following replant

Overall Incidence

  • Conn and colleagues reported that there are >30,000 non-work-related finger amputations annually in the U.S.2They also identified two high-risk groups: children aged <5 years and adults, usually male, aged >55 years.
    • Children often get a finger shut in a door, and adults are usually injured by power saws, snow blowers, and other machinery.
    • Fingers have been lost secondary to a cut, crush, bite, or burn.
    • Factors such as alcohol use, fatigue, decreased dexterity, and reflex time and medication use were cited as frequent secondary causes associated with these injuries.
  • Another study5used 3 years of data from the National Inpatient Sample of the Healthcare Cost and Utilization Project to identify 9,407 upper extremity amputations.5
    • Approximately 15% of these amputations underwent replantation; the mean cost of replantation was >$40,000.
  • In the U.S., amputations are very common in the workplace:
    • Amputation rates vary from 1.5 to 3.7 per 10,000 full-time workers per year.1
    • Single finger amputations occur 81% of the time, and multiple finger amputations in 14%.1
    • In North Carolina between 2004 and 2006, the amputation rate was 21.3 amputations per 1 million people. There was no correlation to increased numbers or immigrants.3

Related Injuries/Conditions

  • The majority of upper extremity amputations are secondary to traumatic injuries; however, amputations are also performed surgically to treat severe burns, neoplasms, and uncontrollable chronic infections.
  • Amputations are also the treatment-of-choice for subungual malignant melanomas.6
  • Congenital amputations are very rare; the Centers for Disease Control and Prevention estimates 4/10,000 babies are born with upper limb reductions.7

Differential Diagnosis

  • Traumatic amputation
  • Surgical amputation for tumor or infection control
  • Congenital amputation
ICD-10 Codes

  • AMPUTATION, FINGER

    Diagnostic Guide Name

    AMPUTATION, FINGER

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    TRANSPHALANGEAL; COMPLETE AMPUTATION    
    - INDEX S68.611_S68.610_ 
    - MIDDLE S68.613_S68.612_ 
    - RING S68.615_S68.614_ 
    - LITTLE S68.617_S68.616_ 
    TRANSPHALANGEAL; PARTIAL AMPUTATION    
    - INDEX S68.621_S68.620_ 
    - MIDDLE S68.623_S68.622_ 
    - RING S68.625_S68.624_ 
    - LITTLE S68.627_S68.626_ 
    METACARPOPHALANGEAL; COMPLETE    
    - INDEX S68.111_S68.110_ 
    - MIDDLE S68.113_S68.112_ 
    - RING S68.115_S68.114_ 
    - LITTLE S68.117_S68.116_ 
    METACARPOPHALANGEAL; PARTIAL    
    - INDEX S68.121_S68.120_ 
    - MIDDLE S68.123_S68.122_ 
    - RING S68.125_S68.124_ 
    - LITTLE S68.127_S68.126_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S68
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Finger Amputations
  • Finger amputations after revisions. Amputations secondary fireworks accident.
    Finger amputations after revisions. Amputations secondary fireworks accident.
  • Bilateral ring and little finger amputations from a high voltage electrical injury.
    Bilateral ring and little finger amputations from a high voltage electrical injury.
  • Left little finger crush avulsion amputation not suitable for replantation.
    Left little finger crush avulsion amputation not suitable for replantation.
  • Necrotic index and thumb tip after hypovolemic shock and a thromboses radial artery.
    Necrotic index and thumb tip after hypovolemic shock and a thromboses radial artery.
  • Necrotic fingers secondary to severe peripheral vascular prior to amputations .
    Necrotic fingers secondary to severe peripheral vascular prior to amputations .
Symptoms
History of traumatic amputation, surgical amputation, or birth defect causing a congenital amputation
Bandaged amputation stump
Amputated part frequently arrives with the patient
Typical History

The typical patient is a young, male worker aged 24-29 years who was working full time and injured during normal work hours. The worker will typically report he was using a press or a saw. There will likely be a history that verifies that the guards on the saw or shield on the press was not in use. The dominant hand will be slightly more likely to be the injured hand. The injured finger is likely to be the index or long finger and more often than not one finger will be amputated. If the patient is aged <5 years, the typical injury will be a crush injury of a finger caused by the finger being caught in a house or car door as it was being shut. If the patient is a homeowner, he will likely be aged >55 years. The amputation will be caused by a power tool like a table saw, skill saw, or lawnmower. Secondary factors may include: alcohol use, fatigue, decreased dexterity, decreased reflex time, and/or medication use.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
X-rays Finger Amputations
  • Amputation through distal phalanx at the base of the nail. Tip has a bulbous appearance but FDP tendon intact.
    Amputation through distal phalanx at the base of the nail. Tip has a bulbous appearance but FDP tendon intact.
  • Amputation long finger through middle phalanx. Central slip and FDS tendon intact.
    Amputation long finger through middle phalanx. Central slip and FDS tendon intact.
Treatment Options
Treatment Goals
  • Treatment goals for amputation revision include: (1) preserve stump length; (2) provide a stump with durable soft tissue coverage, intact sensation and minimal neuroma pain; (3) keep salvaged joints mobile; (4) minimize downtime with speedy return to work and vocational activities; (5) when appropriate, provide timely referrals for hand therapy and prosthetic fitting.3,8
  • Treatment goals for replantation of an amputated finger are similar: (1) save a functional finger by providing an intact, mobile, pain-free sensate digit; (2) minimize cold intolerance; (3) provide efficient post-operative care, rehabilitation, and early return to work and activities of daily living.5,8
Conservative
  • Usually limited to those that occur at the fingertip level and have little or no bone exposed; these distal amputations are ideal for nonoperative treatment with soaks and dressing change treatment.
  • These injuries can be treated with a small amount of bone resection if needed, followed by daily dressing changes.
  • This treatment allows for healing by secondary intent.
  • Typically, this treatment approach provides an excellent coverage and a very good cosmetic and functional result with nearly normal sensation.
  • Allowing an open amputation to heal without surgery by secondary intention may also be needed for amputations performed for infections.
Operative
  • The mainstay of surgical treatment for finger amputations remains amputation revision and closure of the amputation stump.
  • This treatment includes rongeuring back the protruding bone to shorten it if needed so that the soft tissues at this time can be sutured without excessive tension.
  • Revision also includes cauterizing the digital arteries and veins distally, gently pulling the digital nerves distally followed by resection of the distal nerve sharply and proximally so that the digital nerve can retract into the soft tissues of the stump.
  • This maneuver is performed to minimize neuroma symptoms.
  • If the amputation is at the level of the nail, then complete excision of the nail matrix on both sides of the nail fold is imperative to prevent the development of nail horns.
  • The angle of the amputation will dictate to a large extent which surgical options are available to revise and close the amputation stump.
    • For example, a fingertip amputation where the fingernail and the dorsal portion of the fingertip are intact while the pulp is amputated nearly to bone from the tip approximately to the distal edge of the DIP joint may be an excellent candidate for a thenar flap, especially in a young patient.
  • Other surgical techniques that have been used to maintain length and still provide adequate amputation stump coverage include:
    1. Split-thickness skin grafts9 

These are sometimes complicated by chronic fissures and decreased sensation

  •  
    1. Volar "V-Y" advancement flaps10
    2. Lateral "V-Y” advancement flaps11
    3. Volar Moberg type advancement flaps12
    4. Cross-finger and reverse cross-finger flaps13
    5. Thenar flaps14
    6. Island flaps15-17
    7. Antegrade and retrograde advancement flaps
    8. Ray amputations18,19
Treatment Photos and Diagrams
Amputations and Complications
  • Long finger amputation complicated by a painful inclusion cyst (arrow).
    Long finger amputation complicated by a painful inclusion cyst (arrow).
CPT Codes for Treatment Options

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Common Procedure Name
Amputation revision
CPT Description
Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure
CPT Code Number
26951
Common Procedure Name
Pollicization of digit
CPT Description
Pollicization of digit
CPT Code Number
26550
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Hand Therapy
  • For amputations that are allowed to heal by secondary intention, the hand therapist is an excellent resource to teach the patient proper techniques for soaking the amputated stump and performing daily dressing changes.
  • A hand therapist can also help patients recovering from a thumb amputation in the following ways:
    1. Instruct on how to maintain active range of motion (ROM) in the salvage joint(s)
    2. Decrease finger edema by massage and stump wrapping
    3. Minimize neuroma symptoms by desensitization techniques
    4. Teach prosthetic use and care when appropriate
Complications
  • Symptomatic neuroma and diminished stump sensation20
  • Psychological trauma, time off from work and job change or loss1
  • Wound complications such as infections
  • Bone overgrowth at stump end
  • Loss of ROM in the finger remaining joints
  • Contractures in the joints of the amputated finger
  • Phantom limb sensation and pain
  • Replant failure and need for secondary amputation revision
  • Cold intolerance from the amputated stump or replanted finger
  • Fingernail deformity and nail horns8
  • Lumbrical-plus finger development and digital amputations, particularly those amputations occurring at the middle phalanx level; occurs especially in amputations of the middle finger
Outcomes
  • Whether finger amputation should be treated with revision or replantation remains controversial.21-23
  • Finger replantation procedures achieve an average 86% survival rate of the distal part.20   Guillotine amputations do better than crush type injuries.8,23
  • Active range of motion usually is greater after finger replantation.
  • Finger replantation is usually associated an excellent cosmetic result; however, paresthesias and cold intolerance are present after amputation revision and after successful replantation surgery.21Pain can be a posttraumatic complaint in both groups.
  • Amputation revision remains a straightforward procedure that is frequently done without hospitalization; rehabilitation and time lost from work is usually shorter for amputation revision surgery than for replantation.
  • Despite this, lost time from work, lost jobs and placement in alternative work remain occurrences that workers often experience after a finger amputation.1
  • Pulp atrophy and nail deformity occur after replantation surgery at rates of 14% and 24%, respectively.23Finger sensation was often acceptable even without nerve repairs.23However, finger replantation remains a more financially costly procedure than does amputation revision, both for the healthcare system and the patient.22
YouTube Video
Replantation and Microsurgery
Key Educational Points
  • Fingertip amputations that involved no bone or minimal bone can be managed effectively by minimal debridement and bone shortening followed by dressing change therapy. This treatment allows stump healing by secondary intention.
  • Amputations to the PIP and DIP joints that are not amenable to replantation should be revised by removing the cartilage and some bone from the middle or proximal phalanx head to provide a stump that is not overly bulbous and covered without tension on the skin.
  • Amputation in the long (middle) finger through the middle phalanx can be complicated by the development of a lumbrical-plus finger deformity (ie, the PIP joint extends as the patient attempts to flex the finger with the amputation).
  • All revision amputations have neuromas, and all replanted fingers have either neuroma incontinuity or neuroma if the nerves were not repaired.
  • Symptomatic amputation neuromas are complex problems with no simple answer.  Centro-central union of the digital nerves and the stump may decrease these annoying and troublesome symptoms.24
  • Patients with elective and traumatic amputations should be advised early about phantom sensations and/or phantom pain. These patients should be advised to ignore these disrupted perceptions that are caused by the damaged nerve endings sending the brain corrupted messages that are perceived as pain or the feeling that the amputated finger is still present.
References

New and Cited Articles

  1. Boyle, D, Parker, D, Larson, C, et al. Nature, incidence, and cause of work-related amputations in Minnesota. Am J Ind Med 2000;37(5):542-50.PMID: 10723048
  2. Conn, JM, Annest, JL, Ryan, GW, et al. Non-work-related finger amputations in the United States, 2001-2002. Ann Emerg Med 2005;45(6):630-5. PMID: 15940097  
  3. Gavrilova, N, Harijan, A, Schiro, S, et al. Patterns of finger amputation and replantation in the setting of a rapidly growing immigrant population. Ann Plast Surg 2010;64(5):534-6. PMID: 20395810
  4. Shauver, MJ, Nishizuka, T, Hirata, H, et al. Traumatic Finger Amputation Treatment Preference among Hand Surgeons in the United States and Japan. Plast Reconstr Surg 2016;137(4):1193-202. PMID: 27018674
  5. Friedrich, JB, Poppler, LH, Mack, CD, et al. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am 2011;36(11):1835-40. PMID: 21975098
  6. Martin, DE, English, JC and Goitz, RJ. Subungual malignant melanoma. J Hand Surg Am 2011;36(4):704-7. PMID: 21277700
  7. Upper and lower limb reduction defects. Centers for Disease Control and Prevention2018-4-20 retrieved 2018-09-12.
  8. Jebson PL, Louis DS, Bagg M. Amputations. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery 6thEdition, Philadelphia. Elsevier Churchill Livingstone, 2010.
  9. Moynihan, FJ. Long-term results of split-skin grafting in finger-tip injuries. Br Med J1961;2(5255):802-6. PMID: 13773383
  10. Atasoy, E, Ioakimidis, E, Kasdan, ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am 1970;52(5):921-6.PMID: 4920906
  11. Kuyler, W. A new method for fingertip amputation. JAMA 1947;133(1):29. PMID: 20277556
  12. Snow, JW. The use of a volar flap for repair of fingertip amputations: a preliminary report. Plast Reconstr Surg 1967;40(2):163-8. PMID: 5340493
  13. Johnson, RK and Iverson, RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am 1971;53(5):913-9.PMID: 4934075
  14. Smith, RJ and Albin, R. Thenar "H-flap" for fingertip injuries. J Trauma 1976;16(10):778-81. PMID: 792463
  15. Foucher, G and Khouri, RK. Digital reconstruction with island flaps. Clin Plast Surg 1997;24(1):1-32. PMID: 9211025
  16. Germann, G, Rudolf, KD, Levin, SL, et al. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am 2017;42(4):274-284.PMID: 28372640
  17. Henry, M and Stutz, C. Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries. J Hand Surg Am 2006;31(7):1220-5. PMID: 16945731
  18. Carroll, RE. Transposition of the index finger to replace the middle finger. Clin Orthop1959;15:27-34. PMID: 13807969
  19. Peimer, CA, Wheeler, DR, Barrett, A, et al. Hand function following single ray amputation. J Hand Surg Am 1999;24(6):1245-8. PMID: 10584948
  20. Pierrie, SN, Gaston, RG and Loeffler, BJ. Current Concepts in Upper-Extremity Amputation. J Hand Surg Am 2018;43(7):657-667. PMID: 29871787
  21. Hattori, Y, Doi, K, Ikeda, K, et al. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg Am 2006;31(5):811-8. PMID: 16713848
  22. Sears, ED, Shin, R, Prosser, LA, et al. Economic analysis of revision amputation and replantation treatment of finger amputation injuries. Plast Reconstr Surg 2014;133(4):827-40.PMID: 24352209
  23. Sebastin, SJ and Chung, KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011;128(3):723-37. PMID: 21572379
  24. Belcher, HJ and Pandya, AN. Centro-central union for the prevention of neuroma formation after finger amputation. J Hand Surg Br 2000;25(2):154-9. PMID: 11062573
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