April 16, 2014
The benefit of a simple reattachment in patients not candidates for microvascular reimplantation.
Treatment Options for Damaged Fingertips
Treatment options for freshly damaged fingertips that are completely detached range from noninvasive wound cleansing, simple bandaging and observation, to shortening the end of the finger or thumb and closing the wound directly over it, with the in-between option of possibly placing the reattached end in a subcutaneous pocket for rotation flap coverage, etc.
The Goal of Fingertip Damage Treatment
The goal is to end up with the best looking, pain-free, sensitive-for-touch finger or thumb and, if at all possible, with a normal-appearing fingernail. The nail itself provides great sensory feedback to the brain from vibration, etc. when touching objects.
Literature on Fingertip Amputation
The majority of the medical literature has focused on microvascular reattachment rather than salvage the amputated part if the level of amputation is at or beyond the distal interphalangeal joint (DIP).
The largest series I am aware of reported in the medical literature is from the Annals of Plastic Surgery, Vol. 50, No. 3, March 2003, pages 299-303 (Heisten, JB, and Cook, PA)- “The factors affecting composite graft survival in digital tip amputations.” This plastic surgery group had about a 90% follow up rate of 66 digits from 62 patients- ultimately 57 digit tip amputations in 53 patients. In the 57 injured digits for which there was adequate follow up (three months or more), 53% survived completely while 32% had partial survival and only 16% no survival meaning that the tissue would have to have been trimmed off/discarded resulting in a slightly shorter fingertip.
In assessing these for the site of amputation, i.e. DP zone one, the amputations occurring between the DIP joint and the nail fold had a 43% chance of surviving while the DP two level amputation from distal to the nail fold had a 60% overall survival rate. This is summarized as a complete survival and, in fact, the absolute no survival was only about 16%. Among non-smoking patients and non-diabetic patients, 58% with crush-type amputations survival vs. 81% survival when the amputation was guillotine or avulsion-type, i.e. presumed less tissue damage.
A report by Fufa, D, et al, reported in JBJS (Am), 95-a, No. 3, December 4, 2013, “Digit Reimplantation: Experience of two U.S. Academic level one trauma centers,” arrived at the same conclusion with regard to tobacco use in patients with reimplantation of digits, those who smoke vs. those who don’t smoke.
For the purpose of this study, the only factor that seemed to make a difference in survival in this specific group of patients was whether or not the patient was a smoker. Age, alcohol, etc. did not seem to factor in. Based on this careful outcome analysis, the doctors recommended reattachment of amputated fingertip beyond the DIP joint in non-smokers pointing out that even when not successful in the small percentage the grafts would act a biological dressing with minimal risk until subsequent treatment would be performed once the fate of the fingertip had been determined. They went on to state, “This gives the patient the best chance of retaining a cosmetically pleasing, full length finger that potentially will provide excellent function.”
Conclusion: Smoking and Fingertip Wound Healing
I don’t have the large numbers to analyze because follow up is hard to maintain with this type of patient coming into emergency rooms. This parallels my experience in preserving the length of many digits in patients who are not good candidates for microvascular reimplantation with severe injury to their fingertips. Once again, the deleterious effects of smoking can affect wound healing and survival of tissue as highlighted.