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Chapter 7A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles Partial-Hand Amputations: Surgical Principles
Elizabeth Anne Ouellette, M.D.
John A. McAuliffe, M.D.
Ronaldo Carneiro, M.D.
The primary goals of amputation surgery are preservation of length and useful sensibility, prevention of symptomatic neuromas and adjacent joint contracture, early prosthetic fitting where applicable, and prompt return of the patient to work or play. When the amputation is for a malignant tumor, the primary goal is to restore the best function possible in the context of preservation of life.
HAND FUNCTION
The primary objective of hand surgery is the restoration of function to an injured hand. It is therefore important that the basics of hand function and their evaluation be understood prior to repair or reconstruction.
There are a number of standard tests now used to assess hand function. These evaluate the musculoskeletal components, sensation, and functional capacity. An adequate method of evaluating function is necessary to assess the extent of the injury and the outcome of reconstructive efforts.
The musculoskeletal components are evaluated by measuring muscle strength and joint range of motion, while sensory function is evaluated through tactile sensitivity. Functional capacity is assessed by observing a patient's ability to manipulate objects and use the hand. The joint ranges of motion are important in assessing function; the impairment as a result of lost motion is well outlined in the American Medical Association Guides to the Evaluation of Permanent Impairment.8-11
Prehensile activities involve power and precision grips, which are evaluated by grip strength and, in the case of precision grips, by a movement profile as well. The hand grip dynamometer provides the most consistent measure of power grip strength. It is assessed by averaging three separate trials (Fig 7A-1.). There are three types of precision grip: tip, three-jaw chuck, and lateral-pinch grip. These involve the thumb and second and third fingers (Fig 7A-2.). Tip pinch is used in picking up objects such as paper clips, the three-jaw chuck in grasping objects more firmly, and lateral pinch in holding a key. These grip measurements are also most accurate when an average of three trials is made.
Evaluation of tactile sensitivity includes an examination of pressure thresholds, temperature, vibration, and two-point discrimination. Normal static two-point discrimination at the fingertips is approximately 6 mm. Moving two-point discrimination can also be used to test the mechanoreceptors in the hand.Normal values for moving two-point discrimination are slightly lower (4 mm) than those for static two-point discrimination measured in the same individual (Fig 7A-3.).
Pressure sensitivity can be evaluated by Semmes-Weinstein monofilaments. These are a graduated series of nylon filaments of decreasing diameter that are calibrated so that the force required to bend the filament after skin contact is diminished with each test until the patient is unable to feel the pressure applied. Pressure sensation does not correlate with two-point discrimination.
Point localization, tactile object recognition, and su-domotor function are also important in evaluating sensory defects. Point localization is the ability to accurately localize a point of stimulation of the skin. This test is performed by touching with a probe in one or two separate locations and asking the patient to identify those locations. Tactile object recognition, also known as tactile gnosis or stereognosis, is the ability to recognize an object placed in the hand. The time the patient takes to identify the object is also recorded. Su-domotor function is evaluated by the Ninhydriri sweat test or the wrinkle test. When a peripheral nerve is cut, innervation to the sweat glands is lost, and the skin becomes dry. The return of sudomotor function closely follows the return of tactile sensibility. The wrinkle test is performed by placing the hand in warm water (42° C) for 20 to 30 minutes. If the skin is denervated, it will not wrinkle.
In order to more fully evaluate functional activities of the hand, a number of tests have been devised that involve manipulating small objects or the performance of activities of daily living. The only objective measurement in these tests is the time it takes to perform the tasks. These tests are important because they require a combination of functions measured by all the previous methods, thus measuring the ability to execute certain tasks by the hand. At present, there are no better instruments to evaluate hand function as a whole.
FINGERTIP INJURIES
Fingertip injuries are very common in industry and also in children. The industrial worker, usually working with a circular saw, gets distracted, and the saw amputates the finger at the midnail area. Children have their fingertips amputated in doors that are forcefully slammed on the digit.
The action taken for treatment is different depending on whether the patient brings the amputated part or not. If an adult brings the part and it is clean, the best treatment is the application of a full-thickness defatted skin graft taken from the part. If there are losses in the nailbed on the remaining finger, a full-thickness graft can be taken from the amputated part to restore the nail matrix of the remaining digit. In the case of the child, no defatting is done, and the clean amputated part is replaced in its proper position and sutured with as few sutures as possible in a circular manner so that revascularization may occur.
If the amputated part is not brought in or is dirty and therefore unusable, one must proceed with reconstruction. There are basically four modes of reconstructing the fingertip to avoid amputation of the distal phalanx. These are fat advancement and splitor full-thickness skin grafting, V-Y-plasty, cross-finger flaps, and distant flaps. These are well described in standard texts (Fig 7A-4. and Fig 7A-5.).
REPLANTATION: INDICATIONS AND RESULTS
Since the first report of successful reattachment of an amputated thumb by Komatsu and Tamai in 1968,advances in microsurgical technique and increased experience have made replantation routinely possible in microsurgical centers. At the level of the hand there is little or no muscle tissue to sustain anoxic damage, and successful replantation following cold ischemic times of over 30 hours has been reported.Virtually every individual in the continental United States can therefore be considered to be within range of a microsurgical center and thus a potential candidate for replantation. Although guidelines for consideration of replantation can be discussed preoperatively, often the ultimate decision must be made in the operating room. The referring physician must take care not to commit the replantation team to too much or too little in his discussions with the patient and family.
Generally accepted indications for replantation include the thumb, amputations of multiple digits, or those through the palm or near the wrist. In addition, virtually any amputation in a child should be replanted. Although the technical aspects of vascular repair are more difficult in children and success rates lower, the superior neurologic recovery exhibited, particularly by the young child, makes this effort worthwhile. Most patients report excellent levels of satisfaction with replanted thumbs. Significant stiffness at the interphalangeal and metacarpophalangeal joints does not hamper the thumb with an intact carpometacarpal articulation. Perhaps the most important reason for good function of the replanted thumb is that no completely satisfactory substitute for its function is available. This fact not only guarantees its use but also tends to maximize restoration of motion during the usual activities of daily living.
The same considerations also apply in the case of multiple digital replantations. Although the function of each individual digit may not be improved over that of a single digital replantation, the contribution of these fingers to overall hand function may be significant in the face of few or no remaining normal digits available for substitution. Certainly each additional digit in these cases, unless it is severely impaired, may add significantly to the width and strength of the hand.
Indications for replantation of a single digit, except the thumb, are more controversial. Replantations distal to the flexor superficialis insertion, i.e., middle phalanx, usually do well. They exhibit significantly better range of motion, approximately 80 degrees of proximal interphalangeal joint motion, than do replants at the metacarpal level. Digits replanted proximal to the flexor superficialis insertion have decidedly limited proximal interphalangeal joint motion that averages approximately 35 degrees. Scott and associates found the total active motion of replants through the proximal phalanx to be poor (averaging 120 degrees) in 84% of their patients. Joint stiffness combined with limited sensibility may seriously limit the use of a replanted digit when three normal digits are available for substitution. Even worse, the impaired function of the replanted finger may seriously jeopardize use of the entire hand. Causes of limited use may be decreased sensibility, pain, cold intolerance, and quadriga. The latter is a loss of full excursion in one profundus tendon that causes decreased motion in others due to their anatomic interconnections (Fig 7A-6.). For these reasons, many authors no longer recommend proximal replantation of single digits, except in the occasional patient in whom a full complement of digits is a professional necessity (e.g., a musician) or perhaps in children. Ring avulsion injuries are a specific subset of single-digit amputations whose care has been subject to debate. Although complete amputations by this mechanism were not recommended for replantation, it has since been demonstrated that the level of experience of the surgical team and liberal use of vein grafts are of far greater significance than are mechanisms of injury in predicting success.
Relative contraindications to replantation include associated life-threatening injury or the presence of systemic disease, particularly any that would affect the patient's vasculature or ability to withstand a prolonged surgical procedure. Factors pertaining to the injury itself, including severe crush or avulsion, gross contamination, the presence of injury at multiple levels, or excessive delay in treating the patient, may also make attempts at replantation inadvisable.
The ultimate question to be answered is whether the replanted part will function in a manner that will surpass amputation. Although the strictly medical issues involved in making such a decision are complex enough, the physician must also consider and discuss with the patient the psychological and economic implications of the available options. It must be remembered that the functional results of digit salvage in the presence of injury to multiple tissues at the same level are not enhanced by our ability to re-establish circulation.
Once the decision for replantation has been made, survival rates in most recent series approach 80% to 90% or greater at all levels. The major factors influencing survival are age of the patient and experience of the surgeon. Early complications requiring reoperation are related to vascular occlusion in up to 40% of cases. Somewhat fewer than half of the digits requiring early reoperation are salvageable. Infection is a rare occurrence following replantation in the hand. The occurrence of postoperative hemorrhage reported in various series ranges from rare to nearly 50% of cases. The severity of this complication is difficult to quantify, and the incidence of bleeding significant enough to require reoperation is not reported. Postoperative heparinization seems to be associated with higher rates of hemorrhagic complications, and the current tendency of most surgeons is to routinely heparinize only those patients with severe crush or avulsion injuries in whom the risk of thrombosis is greatest. Leeches may also be of benefit if there is difficulty with venous drainage.
Recovery of sensation following replantation is slightly poorer than that of digital neurorrhaphy in lacerations involving fingers. If nerve repair is delayed or requires the use of grafts, recovery of sensation is not as good as with primary repair. In general, virtually all patients develop protective sensation, while two thirds regain measurable two-point discrimination. Approximately half will exhibit two-point discrimination of 10 mm or less. Gelberman and colleagues have shown a correlation between the return of sensation and restoration of digital vascularity on a quantitative basis.
Other late complications include malunion or nonunion, with an incidence of less than 5% in most series, and the almost universal presence of cold intolerance. Urbaniak states that this problem usually resolves spontaneously in the year or two following replantation, although it may remain indefinitely as a minor problem in colder climates.
Secondary operations are performed on 15% to almost 50% of patients, with tenolysis and release of joint contracture being the most common procedures. Very few patients require late secondary reamputation.Virtually all patients express satisfaction regarding replantation, with few stating that they would have preferred amputation.
An appreciation of the patient's ability to integrate the function of the replanted digit or digits with that of the remainder of the hand is difficult to achieve and even more difficult to quantify. Data regarding return to work do give some indication of fairly normal functional use, and the ability to do so is of obvious economic, social, and personal significance to the patient. Early return to work should be considered a priority of rehabilitation.
THE THUMB
The thumb is required for both power and precision grip. In order to achieve this, adequate length and sensation must be present as well as stability and the ability to oppose the other fingers.
Loss of the thumb at the level of the metacarpophalangeal joint constitutes a 40% loss of function of the hand and 36% loss of function of the entire upper limb. There is still controversy over exactly how much length must be lost before there is a significant impairment. For example, disarticulation through the interphalangeal joint of the thumb is rated as a 20% impairment of the hand. Whatever the amputation level, the patient must have an adequate residuum for pinch and grip to be restored.
Once adequate length has been achieved, the sensation of the thumb must be considered. The thumb is involved in tactile perception and two-point stereognosis. Without adequate sensation, it is difficult to recognize an object and localize its position in the hand. In order for function to occur, the thumb must have at least protective sensation.
The ability to oppose the thumb and index finger is necessary for grasping and pinching. This motion occurs at the carpometacarpal joint of the thumb. If this joint is destroyed or unstable, it can be fused with the thumb in full opposition, with resultant loss of function. This position enables the fingers to brace objects against the thumb, which serves as a post. Motion at the interphalangeal or metacarpophalangeal joint is not an absolute necessity for normal thumb function.
Replantation has become a reliable surgical procedure as microvascular surgical techniques have improved. Restoration of thumb function by replantation has been reliable and well documented. This should be the first consideration when examining a thumb amputation. Only after replantation is not successful or found to be not feasible should other reconstructive procedures be considered.
Thumb reconstruction requires assessment of the patient's age, sex, occupation, hand dominance, and the remaining structure and functional status of the injured hand. The level of amputation in the thumb determines which procedures should be considered.
Amputation of the Distal Phalanx of the Thumb
The functional impairment of amputation at this level is minimal. Primary goals are skeletal stability and adequate pain-free skin coverage with good sensation. There are numerous techniques that will maintain length and provide sensation.
For losses of soft tissue dorsally but minimal loss from the distal phalanx, healing by secondary intention or skin graft is possible. If these do not provide adequate coverage, then lateral triangular advancement flaps or pedicle flaps may be used to gain coverage.
When the soft-tissue loss is greater and there is digital nerve damage, other procedures may be necessary to preserve length and maintain good sensation. These consist of palmar advancement flaps, cross-finger flaps, and neurovascular island flaps.
Amputation Through the Midproximal Phalanx and Mid-distal Phalanx of the Thumb
At these levels of amputation, the functional impairment is caused by loss of length, which affects pinch and grip strength. The carpometacarpal joint is usually uninvolved, thus giving the thumb good rotation and mobility. The goals are to restore length and sensibility.
A free toe transfer satisfies all the requirements of reconstruction at this level. When this is unacceptable to the patient, there are other reconstructive procedures such as "phalangization" of the first metacarpal, which results in a deepened first web space that can improve grip and pinch.
The web space procedures available include Z-plas-ties, both simple and four flap, and dorsal rotational or remote pedicle flaps. These are best performed when the underlying soft tissues are minimally scarred and there is good joint mobility.
When there are contractures of the muscles and scarring with loss of mobility, then a pedicle from uninjured tissue must be utilized. This can be obtained by cross-arm flap, free flap, or reverse radial artery flap coverage into the web space. By deepening the web space and releasing contracted tissue, the thumb is effectively lengthened (Fig 7A-7., Fig 7A-8., Fig 7A-9.).
Disarticulation at the Metacarpophalangeal Joint of the Thumb
At this level, the thumb is unable to perform any of its normal functions. Restoration of length, stability, sensation, and mobility are required. Lengthening the residuum by 2 cm may improve function dramatically.
Procedures that have been used to gain length and sensibility at this level are pollicization, transfer replantation of salvaged injured digits to the thumb position, toe-to-hand transfers, metacarpal lengthening, bone grafting with tubed pedicle flaps, and composite radial forearm island flaps.
Sensation must be achieved for these techniques to restore useful function. For this reason, bone grafting with flap coverage is considered a less-satisfactory alternative. Two thirds of the first metacarpal with good skin coverage must be present before contemplating metacarpal lengthening. Pollicization and transfer of free tissue offer the best chances to restore thumb function (Fig 7A-10.).
Amputation Through the Proximal Third of the First Metacarpal of the Thumb
This injury represents a complete loss of the thumb and subtotal or total loss of the first metacarpal with resultant loss of mobility through the carpometacarpal joint. Reconstructive options are essentially limited to pollicization and island or free digit transfers. If the carpometacarpal joint is intact due to a residual portion of metacarpal, a digit transfer to the thumb can be performed with minimal loss of mobility. If the entire first metacarpal is absent, the finger should be transferred with its metacarpophalangeal joint to preserve some motion.
Toe-to-thumb transfer is best when there are other mutilated fingers. This is the only technique capable of restoring function when only metacarpals are remaining after amputation.
RAY AMPUTATIONS
These amputations are rarely performed emergently. They are usually part of the reconstruction of a hand in which an amputation has occurred traumatically or in which an amputation is necessary for a tumor, infection, or failed replantation. If function is severely impaired secondary to the injury and especially if the function of adjacent digits is impaired, the removal of the entire ray should be considered in an effort to improve function of the hand as a whole.
Each ray resection has its own special considerations for preventing complications such as painful neuromas, closing the gap created between rays, and minimizing cosmetic deformities. Index ray resection has two complications associated with it that need attention (Fig 7A-11.). The first is debilitating pain occurring from excessive mobilization of the radial digital nerve when performing the amputation. This complication appears in the first 8 weeks following surgery, and reoperation is not usually successful. The second complication is an intrinsic-plus deformity of the long finger resulting from transfer of the first dorsal interosseous muscle to the second in an attempt to improve pinch strength of the long finger. This procedure is not necessary, and the resultant deformity will further hinder hand function.
When performing a long-ray resection, there may be difficulty in closing the space between the ring and index rays (Fig 7A-12. and Fig 7A-13.). A soft-tissue closure of the gap by using the deep intervolar plate ligaments can be performed with minimal rotational deformity of the fingers as a result. Transfering the index metacarpal to the base of the long-finger metacarpal is another acceptable method of reducing the gap and gives an excellent functional and cosmetic result.
Ring-ray resections are similar to those of the long ray but usually close the remaining gap more easily (Fig 7A-14.). If there is difficulty in reducing the space, the fifth metacarpal base can be allowed to slide radially if the entire base of the fourth metacarpal is excised. The fifth metacarpal can also be transposed to the base of the remaining fourth metacarpal after amputation, but this is rarely necessary.
Fifth-ray resections require that the base of the fifth metacarpal be left because of the insertion of the extensor carpi ulnaris (Fig 7A-15.). The hypothenar muscles are used to provide padding over the base but are not reattached to the fourth interosseous muscle tendon because this too can cause an intrinsic-plus deformity and loss of function.
Amputations Proximal to the Digital Tips
These amputations by definition involve bone of the fingers. Function can be preserved by shortening or maintaining length, depending on the anatomic situation. Flap coverage similar to those used in fingertip injuries may be used to preserve length. If this is unnecessary, then bone trimming and primary wound closure can be performed (Fig 7A-16.).
It is not necessary to remove articular cartilage in amputations through the interphalangeal joints. In fact, there is evidence that the inflammatory response to amputation is less when the cartilage is left intact. The condyles should be trimmed so that they are not prominent. Both the tendon and the digital nerves should be found and transected so that clean edges may retract proximally. The flexor and extensor tendons should not be sewn to each other because the excursion of these tendons would be limited, thus limiting range of motion of the amputated finger and adjacent fingers. The most significant complication of amputation at the distal interphalangeal joint is the lumbrical-plus finger. This is caused by the flexor digitorum profundus retracting proximally after transection. As it retracts, the lumbrical muscle is pulled into a more taut position. When flexion at the metacarpophalangeal and proximal interphalangeal joints is attempted while making a fist, the involved finger's proximal phalangeal joint is seen to paradoxically extend. Tension of the unrestrained flexor digitorum profundus tendon is transmitted through the lumbrical to the dorsal hood mechanism to produce this effect. This complication can be alleviated by releasing the lumbrical from its origin on the flexor digitorium profundus tendon in the palm. It is unnecessary to perform this at the time of the amputation since few fingers amputated at the distal interphalangeal joint develop this complication.
An amputation through the middle phalanx distal to the flexor digitorum sublimis tendon insertion is a functional one. When flexion control of the remaining middle phalanx is lost, disarticulation at the proximal interphalangeal joint is recommended. The proximal interphalangeal joint should be approached in a fashion similar to the distal interphalangeal joint.
When amputation through the proximal phalanx occurs in the long and ring fingers, a ray resection should be considered in an effort to improve function. The space left in the center of the hand cannot be compensated for except by closing the gap with a ray resection or with a prosthesis (see Chapter 7C).
RECONSTRUCTION
Following single or multiple digital amputations in which replantation is not feasible, attention is focused on reconstruction of the remaining hand so that a prosthesis can be worn. In addition, preservation of the general function of the hand has to be considered fundamental to reconstruction.
In the case where the patient has retained a "basic" hand including the thumb and at least one of the digits, consideration has to be given to the space between them. Is that space adequate? Is there a painful neuroma in the midpalmar area that would inhibit function? Is there adequate skin coverage? Is there good sensation?
If a contracture exists, that area should be reconstructed with a long-lasting, soft piece of skin, ideally a distant free flap with sensation.
If the patient presents with a thumb and no other digit, reconstruction of an opposing finger is a priority. A toe with its neurovascular bundle may be transferred from the foot to the hand to provide an opposing digit. The ideal timing for this procedure is at least 6 months from the original injury so that the patient has time to mature his scars and to develop significant contractures so that more skin can be included with the transferred toe if additional skin is needed for contracture release.
When coverage must include subcutaneous tissue and sensation, potential donor procedures are the free lateral arm flap and the radial artery fasciocutaneous flap. The free lateral arm flap has a very good cushion of fat and fascia and also has a sensory nerve that can be sutured to the recipient nerve. This is also true for the radial artery flap, where the superficial radial nerve can provide innervation. These flaps are capable of withstanding the use of a prosthesis very nicely. Other donor sites are available but do not provide as good a sensory component as these flaps (see Fig 7A-10.).
COMPLICATIONS
Numerous complications can occur following amputation in the hand. Although much has been written concerning solutions to these problems, particularly the painful neuroma, few authors have attempted to examine their true nature and incidence. The incidence of complications varies considerably in published reports, depending somewhat upon how diligently they are sought. The reported need for reoperation following amputation ranges from 2% to 25%.
The largest number of complications involve the presence of pain and is therefore at least partially subjective in nature. The patient's attempt to come to terms with an amputation involves a complex and interrelated series of physical, psychological, emotional, aesthetic, economic, and cultural adaptations. To say that well-motivated amputees do better may be trite, but it is also quite true. A review of surgeons with amputations involving the hand revealed few of these complications, a high level of acceptance, and almost universal return to preamputation activities.
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. Although maintenance of length is of concern, such residua seriously jeopardize function of the entire hand. Tension-free closure with appropriate shortening or tissue transposition should be performed initially. Late treatment of such a problem is usually best managed by more proximal amputation, although occasionally local flap coverage may be considered for specific indications.
The incidence of painful neuroma following amputation in the hand has been reported to range from less than 1% to 25% or greater. The number of treatments proposed to prevent or manage a painful neuroma is large. Occasionally, nonoperative methods such as desensitization, transcutaneous nerve stimulation, or neural blockade may prove to be curative, but an established painful neuroma often requires a surgical solution. Tupper and Booth have reported a 71% overall success rate with simple excision of the neuroma when the nerve end was allowed to retract under cover of more proximal unscarred and well-padded tissue. Other authors have had significantly less success with this technique. Transposition of the intact neuroma to a better-padded, preferably dorsal location seems to provide the most consistent and significant long-term relief of pain. The most promising new technique that may be considered when adequate local soft-tissue for transposition is not present is that of centrocentral nerve union, whereby two proximal nerve ends are joined with intervening graft.
Nail deformity following amputation at or near the level of the germinal matrix is generally best treated by ablation of the remaining perionychium and skin graft coverage. Deformity more distal in the nail may be treated similarly; however, reconstruction with grafts of sterile or germinal matrix may be considered. The hooked nail resulting from the loss of distal phalangeal support is exceptionally difficult to treat, with resorption of distally located bone grafts and recurrence of deformity being the norm.
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.
Paradoxical extension of the proximal interphalangeal joint during attempted flexion due to retraction of the divided profundus tendon and its associated lumbrical origin is rarely encountered clinically. Interconnections of the profundus tendons in the palm and the relatively greater strength of the flexor system make this "lumbri-cal-plus" deformity uncommon. When encountered, division of the lumbrical tendon is curative. Median nerve compression following retraction of the profundus tendon and its lumbrical into the carpal tunnnel is another rare complication.
Cold intolerance following amputation is quite common, although this usually resolves over time without treatment. The dysvascular residuum, which is painful, nonfunctional, and prone to repeated trauma and ulceration, is generally best treated by more proximal amputation. Occasionally, pharmacologic treatment or local sympathectomy by excision of vessel adventitia may prove effective, although long-term benefits are uncertain.
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Chapter 7A - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
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