III.

PATHOPHYSIOLOGY

Definition An amputation is the removal of an extremity or appendage from the body. Amputations in the upper extremity can occur as a result of trauma, or they can be performed in the treatment of congenital or acquired conditions. Predisposing Factor: Age(10 y.o) Lifestyle Gender (F) Precipitating Factor: Laceration of the distal second digit right hand through a knife

Tissues, Nail bed and Blood vessels were cut/lacerated (Dorsal Metacarpal Vein) Inadequate perforation of oxygen since supply of blood is cut off

Severe Bleeding; Redness Subungal Hematoma; Pain

Piece of tissue has been severely damaged, or has been separated for a long period resulted to destruction of tissues of the lacerated part of the finger; diminished sensation of nerve endings Surgery: Amputation of the distal second digit right hand Removal of distal 2nd digit right hand, sutured and fixed

Necrotic Tissue

Complications: Infection Quadriga or profundus tendon blockage

An amputation is the removal of an extremity or appendage from the body. Amputations in the upper extremity can occur as a result of trauma, or they can be performed in the treatment of congenital or acquired conditions. Although successful replantation represents a technical triumph to the surgeon, the patient's best interests should direct the treatment of amputations. The goals involved in the treatment of amputations of the upper extremity include the following: (1) preservation of the functional length, (2) durable coverage, (3) preservation of useful sensibility, (4) prevention of symptomatic neuromas, (5) prevention of adjacent joint contractures, (6) early return to work, and (7) early prosthetic fitting.1,2 These goals apply differently to different levels of amputation. Amputations can result from traumatic injury involving a variety of machines, they can be self-inflicted, or they may be required after traumatic events, such as electrical burns or frostbite. In addition, elective amputations may be indicated for tumor extirpation, vascular insufficiency, infection, or congenital malformation. - Surgical Technique for Amputation of the Distal Phalanx: - indications: - amputation and shortening of the digit may be indicated when there is less then 5 mm of sterile matrix, since nail adherence will be losed; - nail bed: - because the nail matrix extends considerably proximal to skin fold, extensive dissection may be necessary to remove it completely; - w/ transverse amputations, create distal midlateral incisions on both sides of the digit, to allow easier access to nerves, the phalanx, and to allow easier flap closure; - shorten and contour bone for primary closure; - insertions of flexor and extensor tendons on most proximal portion of the distal phalanx should be left intact if possible; - if flexor and extensor insertions cannot be left intact, then the distal phalanx should be disarticulated; - in this case, the flexor and extensor tendons are placed under traction, transected, and are allow to retract; - a ronguer can be used to contour the volar condyles of the middle phalanx; - digital nerves are transected as proximally as possible; - volar skin flap is created & wound is closed dorsally; - inorder to avoid a club deformity, place the initial suture centrally, and then draw the palmar skin proximally over the dorsal stump; - incise the overlapping portion of the dorsal skin (which typically extends 45 deg from the central stitch); - the resulting scar resembles an inverted horseshoe; - complications: - can occur after amputation of the distal phalanx if the lumbrical

muscle is not released (along w/ release of the FDP); - the result is that the FDP becomes a paradoxical extensor of the PIP joint, since the FDP can now act only thru the lumbrical's insertion into the lateral band (which coarse dorsally into the triangular ligament); Digital amputations In performing digital amputations, provide a mobile, stable, painless stump with the least interference from the remaining tendon and joint function to provide the most useful amputation stump. When possible, use volar skin for the stump coverage because it provides skin that is thicker and more sensate than dorsal skin4 There are several local options for tissue rearrangement of volar skin over the amputation stump. These include fillet flaps, volar V-Y flaps, bilateral V-Y flaps, and homodigital island flaps.5 "Dog ears" in the acute traumatic amputation often should be left to eliminate tension and to prevent compromising the blood flow to the remaining flaps achieving closure; these dog ears disappear over time. If the wound is small, it can be allowed to heal spontaneously by contraction and epithelialization. Wounds smaller than 1 cm can heal spontaneously in a reasonable amount of time. Larger wounds may require a skin graft to heal quicker. Split-thickness grafts can be used for the benefit of wound contraction to result in a smaller area on the tip, which is not normal pulp. Regarding the treatment of the bone in a digital amputation, the bone under the stump end must be smooth. Remaining bone chips and devitalized bone should be removed. The bone at the stump end can be smoothed by using a rongeur and file. Bone length is not as important as a stump with mobile nonsensitive coverage. The bone of the distal phalanx must be of adequate length to support the nail bed and nail growth.6,7,8,9 With digital amputations involving the thumb, length is important. The articular cartilage can be preserved when the amputation occurs at the level of the interphalangeal joint. This articular cartilage can provide a shock pad for trauma and potentially causes less pain under than skin than the bone edges. Whitaker et al clinically evaluated the preservation of the articular cartilage with digital amputations and found a better outcome when the cartilage was left on the stump end.10 The protruding condyles and anterior aspect of the phalanx may be trimmed to provide a less bulbous stump. In addressing the nerve at the stump end, it is important to avoid neuroma formation in this location. The nerve end should be in a position away from the stump end or an anticipated point-of-contact pressure. To minimize the risk of neuroma formation at the stump end, traction neurectomy of the

digital nerve should be performed bilaterally for each digital amputation. The nerve is longitudinally distracted in the distal direction and then transected to allow for proximal retraction, leaving the nerve end 1-1.5 cm from the fingertip. Preservation of a tendon insertion improves the active mobility and function of an amputation stump. Therefore, when possible, tendon insertions should be preserved. However, the amputation level is often proximal to the tendon insertion. The flexor digitorum profundus tendon should never be sutured over the bone end or to the extensor because this can result in the quadriga effect. The quadriga effect results in less excursion of the adjacent normal fingers because of the common profundus muscle from which all the profundus tendons originate. The amputated finger, which has a tighter profundus tendon, reaches the palm before the other fingers do and results in a weaker grip. Another complication of tendon imbalance is the lumbrical plus posture, which is the paradoxical extension of the involved finger's proximal interphalangeal joint with attempted flexion. This occurs when the profundus tendon is allowed to retract proximally, resulting in a pull on the lumbrical muscle as it originates from the profundus. The lumbricals contribute to metacarpophalangeal joint flexion and interphalangeal joint extension. This proximal pulling of the profundus pulls the lumbrical tighter to extend the interphalangeal joints paradoxically with attempted flexion.11 However, lumbrical plus posture after amputations of the distal interphalangeal joint is rare. Also, adhesions can result; therefore, early motion of the amputated finger is recommended. The digital arteries should be identified and ligated with small-caliber sutures or be cauterized. The visible veins can be cauterized as well. Then, the skin is loosely approximated to make sure there is no tension on the skin edges. If there is tension on the skin, the bone may be shortened or local flaps can be used. When amputations are at the level of the distal phalanx, preservation of the profundus insertion is critical. An intact profundus improves functional contribution of the amputated finger and improves grip strength by providing active flexion at the distal interphalangeal joints in conjunction with the other fingers. Preservation of enough bone to support normal nail growth is perhaps the most crucial predictor of functional length with amputations at this level. Amputations at the level of the distal interphalangeal joint can be closed over the articular surface of the middle phalanx. Local flaps can be used to provide soft tissue for closure over the middle phalanx, if needed. The volar V-Y flap is the standard local flap option for injuries at this level. The volar V-

Y flap is fashioned with the apex of the V at the proximal interphalangeal crease. When amputations are through the middle phalanx, preserving the flexor digitorum superficialis insertion, which inserts on the middle third of the middle phalanx, is desirable. Amputations proximal to the superficialis insertion leave the amputated finger without active motion control at the proximal interphalangeal joint level and only with active motion at the metacarpophalangeal level. Amputations at the proximal interphalangeal joint can be closed over the articular surface of the proximal phalanx as can those at the distal interphalangeal joint. Amputations at this level can still actively flex at the metacarpophalangeal joint through the action of the intrinsic muscles. If the amputation is near the metacarpophalangeal joint, especially in the long and ring fingers, dropping small objects because of the defect can be addressed with a finger prosthesis or ray amputation, with or without transposition. Pain following amputation may be caused by inadequate soft-tissue coverage of the residuum or pain of neural origin due either to frank neuroma or pain syndromes such as reflex sympathetic dystrophy. Painful amputations due to adherent or excessive scarring, poor padding, or protuberant bone are much more common in the digits than at the metacarpal level. These are usually the result of an injudicious attempt to save length at all costs.
Quadriga or profundus tendon blockage may limit motion of adjacent unaffected digits following amputation. The three ulnar profundus tendons arise from a common muscle belly and are further interconnected in the palm by the bipennate origins of the ulnar two lumbricals. Scarring of these tendons within the amputated digit or in the palm may limit excursion of the adjacent digits. Early and full active motion of the intact fingers postoperatively usually prevents this complication. Once present, surgical correction by release of the adherent profundus tendon is quite successful.