Independence Day is a distant memory, summer lawnmowers are finally falling silent, and many of us are finally enjoying a low point for distal finger injuries. It will be short-lived, though, before the snowblowers of winter and celebratory explosives of New Year's Eve drive patients back to our doors, clutching their bloody stumps while a helpful family member screams admonitions of “I told you so!”
This injury is a nearly-universal frustrating experience for patients, of course, but also for emergency physicians across the country. Where hand surgery specialists are readily available, consultation seems to sometimes result in insistence that their services are not emergently necessary. In more austere practice conditions, disposition questions can be almost paralyzing—can these patients be properly managed from the emergency department, or do they require transfer to a higher level of care?
It's a complex consideration. The injuries are relatively unremarkable, but functional and aesthetic concerns, as well as medicolegal reservations, often drive a more conservative approach to the patient with a distal finger amputation. Unfortunately, collated data suggest that this hesitancy may be associated with marked resource utilization without increased benefit to our patients. The majority of patients with finger amputations transported by helicopter to a Level I receiving center underwent simple revision and were discharged. (J Hand Surg Am 2010;35:936.)
A number of classification systems exist to describe zones of the finger, but nearly all injuries distal to the distal interphalangeal joint, with or without bony involvement, can be managed safely and effectively in the emergency department with conservative therapy and outpatient referral to specialty care. Treatment should begin by providing a digital block. Most physicians are familiar with lidocaine infiltration in a ring distribution, but a single volar injection of bupivacaine likely provides similar or superior anesthesia without the need for multiple injections. (Emerg Med J 2010;27:533.)
A needle is inserted on the volar side at the proximal digital crease and 2-3 cc of anesthetic is injected at the point of minimal resistance, infiltrating the digital sheath. (Can J Plast Surg 2003;11:33; http://bit.ly/2Mrkcev.) Tetanus status should be updated, but data from small randomized trials suggest that the risk of infection is abundantly low, although prophylactic antibiotics are commonly administered. (Am J Emerg Med 2015;33:645.) It is my practice to order the customary cefazolin.
A Penrose drain, IV tourniquet, or cut glove can be used to create a hemostatic field. Crushed, grossly contaminated, or devitalized tissue generally should be debrided, and extensive and meticulous wound care, cleansing, and irrigation are the rule. Once the wound has been cleaned and irrigated to my satisfaction, I repeat the procedure, particularly where bone is visible. The wound can be explored further on a sterile field with adequate lighting. Where bone protrudes beyond surrounding fat or tissue, the bone can be rongeured back with millimeter bites until closure can confidently be completed, and the digital nerves should be isolated and transected as proximally as possible to help limit the development of painful neuromas. (Iowa Orthop J 2011;31:110; J Plast Reconstr Aesthet Surg 2013;66:1330.)
Cutting back the bone may be deferred to maximize length maintenance and minimize disability in cases where hand surgery follow-up can be assured within 72 hours and there is minimal (<5 mm) protrusion beyond a sterile matrix. (J Am Acad Orthop Surg 1996;4:84.) The wound can be left to heal by secondary intention, and compelling clinical experience shows that these patients will heal well with near-normal sensation, minimal cold intolerance, and high rates of aesthetic satisfaction. (Hand [NY]. 2014;9:282; http://bit.ly/2nF0f5U.)
A variety of closure techniques have been described where bone is visible or has been rongeured back, though simple fishmouth closure with anticipated revision at follow-up is likely the best option for the emergency physician. The palmar skin should be brought over the bone and sutured to dorsal skin to maximize functionality after healing. I favor petrolatum dressings and tube gauze for ideal bandaging, but routine wound care with nearly any nonabsorbable dressing should be sufficient. Discharge with strict wound care instructions, a strong consideration for antibiotics, and a durable follow-up plan can obviate the need for emergency resource utilization or low-value transfer.
The overwhelming majority of patients presenting with amputations near the distal interphalangeal joint can be managed without difficulty by emergency physicians. Revision amputation and conservative management can be accomplished with good patient outcomes and no significant rate of adverse events. Involvement of specialty services when available is certainly reasonable and may be necessary where patient or department factors dictate, but the natural history of these injuries should be reassuring where consultation is undesirable or unavailable.
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