Notes From the Medical Director Partial-Hand Amputations by Douglas G. Smith, MD We routinely call upon our we’re smart, but because we have thumbs hands to perform a huge so we can make coffee.” Surgically, we can do some really extraor- number of tasks. As noted in dinary things when the thumb is severely the introductory article of injured. We’re much more likely to do sal- vage surgery, such as bone and skin grafts, our series on upper-limb and flaps, in hopes of saving at least part of amputation, recovery and the thumb and its function. Sometimes, if the thumb can’t be saved, surgeons rehabilitation, we ask our will take the person’s index finger hands to perform everything and relocate it to the thumb area so from the delicate and intricate that it, hopefully, will restore some function. Alternatively, even the to the strenuous and forceful. second toe can be transferred up to the thumb position. The trans- Our hands demonstrate the architectural planted toe is sometimes referred concepts of form and function. In surgically to as a “thoe.” treating hand injuries, we often balance Some people might ask, “Why function with cosmesis (appearance). wouldn’t you perform a thumb When the hand is badly injured or subject transplant from a donor, rather than to disease and requires amputation surgery, removing a toe? After all, kidney, heart our goal is to both restore as much function and lung transplants are done all the time.” as possible and consider what can be done study, published last November in the While taking a toe from the same individual to minimize the appearance of the loss. journal Pediatrics, that nearly 92 percent of to replace a thumb may seem unnecessary Until one experiences a severe hand 102,257 amputations among children and in this day and age of donor transplants, injury or partial-hand amputation, we rarely adolescents involved one or more fingers. it allows the person to avoid the issues of consider the tremendous contribution of Among children, finger and hand injuries tissue rejection and medication. I believe our hands to body image. In most cultures, usually involve doors. Adult finger and hand that the lifelong impact of medications used our hands and face are what we present first injuries are often the result of accidents with to suppress rejection is vastly understated to the world about ourselves. An injury to industrial or home power tools. in typical discussions concerning organ and the hand that requires amputation involves tissue transplantation. more than just physical loss; it’s also a pro- The Amazing Thumb found loss of a part of ourselves. It’s a loss of One of the things we learn as far back as The Fingers our presentation to others. elementary school is the vital importance The fingers, digits two through five, are It should come as no surprise that the of our thumbs. The thumb enables most of located on our hands to work uniquely hands are the primary site for amputation the hand’s function. If you lose your thumb, with digit number one: the thumb. These injuries, since we use them so often and it’s really devastating. The thumb, many say, strong, slender extensions are also known in so many ways. The exact number of is one of the key things that enabled us to as the index finger (the one closest to the amputations involving all or part of the hand evolve to become the creative, designing thumb), middle finger, ring finger and small that occur each year is difficult to determine and constructive human beings that we are. finger (sometimes referred to as the pinkie). because most researchers track only major Being from Seattle, I love this quote by pho- Our fingers can come into contact with the upper-limb amputations (those above the tographer and humorist Flash Rosenberg: “I thumb in various ways to fit the task, be it wrist). But we know from a 12-year national believe humans get a lot done, not because in tip-to-tip pinch, side-to-side pinch or key 56 inMotion Volume 17, Issue 1 January/February 2007 Notes From the Medical Director pinch (the way your thumb and index finger of your hand (the part with fingers four and damaged digit, the uninjured, neighboring hold a key). The fingers work in concert five) gives you to turn the knob? Without tendons are now free to move over their full with the thumb and palm to give our hands the ring finger, pinkie, or both, you lose an excursion. Removing the “anchor effect” maximum dexterity and strength, creating incredible amount of strength for gripping from the damaged digit results in restoration grip patterns too numerous to count. and rotating the hand. of fuller motion and strength in the unin- When I speak to students who are train- jured digits. ing to become medical professionals, I’m Losing One Can Weaken See for yourself how restricting the always interested in how they’ll answer the Others movement of the tendons of two fingers the question: “If you had to lose a finger, Many people have asked me, “I’ve lost affects the flexibility and dexterity of the which one would you give up?” Almost all one finger and damaged another, but other two. Press your ring and little fingers people say they’d give up the fourth or fifth the remaining two don’t work quite right back a bit, as if you were trying to fold them finger. (Nobody ever says the thumb.) But, anymore. Why have the uninjured fingers back to touch the top of your wrist. (Not interestingly, the digit that is functionally lost some motion and strength?” The loss too hard or too far, though. We don’t want replaced most readily is the index finger. The or damage of a finger impacts the others you to hurt yourself!) Now, with those two middle finger can do everything the index in subtle ways. The tendons that flex and fingers pushed back, try to make a fist with finger does, and do it very well. Also, the extend our fingers have a great deal of the other two fingers. Very difficult, isn’t it? space caused by the loss of an index finger “excursion” (meaning they travel long This demonstrates how restrictions on the is less noticeable than the loss of other distances), but they don’t work totally tendons of some fingers greatly impact the fingers since there’s already a gap between independently of each other. If one or other digits. the index finger and the thumb. Losing the two fingers are damaged, the subsequent middle and/or ring finger leaves a gap that scarring of their tendons can limit some of Sensitivities is quite noticeable and makes it difficult to the uninjured tendons. This “tethering” of Two long-term problems with all partial- hold some objects or pick up things, such the tendons for the injured digit can create hand amputations, whether palm, finger as coins. the very real perception that the uninjured or fingertip level, are hypersensitivity and The loss of the fourth or fifth finger results fingers no longer have their full motion and in a frustrating loss of grip strength and hand strength. power. Try the doorknob test: Grasp a door- Surgically, the solution sometimes is to knob and turn it to open the door. See how remove the scarred tendons of the damaged much strength and leverage the ulnar side fingers. By releasing the constriction in the To support the ACA or to become a member, call 1-888/267-5669 59 Notes From the Medical Director intolerance to cold. Our fingers have so nondominant hand? We all use our hands in many nerves that injury can result in our work; how will amputation and surgical hypersensitivity, where the slightest pressure modification affect what we do for a living results in severe pain. Also, some people and how we do it? with partial-hand amputation can’t go out Changes brought about by partial-hand in the cold without their hand “freezing up” amputation can result in a fairly noticeable and becoming stiff or completely immobile. defect, but attempts can be made to mini- Intolerance to cold is common after finger mize the appearance of loss. For example, or partial-hand amputation but usually after loss of the fifth finger, the surgeon may improves over time. When these two prob- elect to keep the palm as wide as possible lems persist, treatment involves desensitiza- to preserve hand strength, giving the person tion therapy and, occasionally, medication. a broader surface for grip and torque. This Unfortunately, medications aren’t always as amputation site is very obvious, with an successful as we would like. abrupt step-off and contour change (Figure I’ve also had some patients tell me of 1). But if the surgeon chooses to surgically their experiences with chilblains, an itching, narrow the palm by removing all but the burning sensation resulting from exposure base of the fifth metacarpal, then the loss to moist cold. This chronic condition can isn’t so obvious (Figure 2). However, when cause discomfort when temperatures drop, working outside in the cold. Others move to we surgically taper the amputation site, the limiting some people’s outdoor activities. warmer regions in search of relief. hand looks more contoured, but there is no Some people must change professions doubt that the hand is weaker. because chilblains prevents them from Surgical Decision-Making Knowledge of the factors that balance As a surgeon, performing amputations function and appearance plays a role in the on the hand involves a balance between difficult decisions concerning reconstruction functional needs and appearance.