PROCEDURE 3

Finger Amputations
Aviram M. Giladi and Kevin C. Chung

Indications
• Amputation does not indicate failure of salvage; rather, it is part of the treatment algo-
rithm for helping patients return to optimal function after extensive traumatic injuries.
• Injury that damages a digit to a degree that vascularity and function cannot be re-
stored (unsuccessful or unfeasible revascularization).
• Complete amputation of digit(s) that cannot successfully be replanted—either due
to degree of injury to the digit, or to the likely impairment that a poorly functioning
replanted digit would cause for the rest of the hand.
• Finger injury that substantially destroys structural and/or functional integrity beyond
ability to adequately reconstruct—this includes multisegment injuries, avulsions that
cause traction injury to the vessels and nerves, and loss of bone segment(s).
• Patient preference after substantial trauma to digit(s). For injuries in which the prog-
nosis for return of function is poor (joint destruction, need for extensive soft tissue
reconstruction, etc.), patients may prefer amputation to prolonged therapy with only
moderate return of function.
• Ischemic necrosis of the finger(s)
• Malignancy requiring adequate resection margins
• Goal is to preserve functional length with durable soft tissue coverage.
• For the thumb, it is important to preserve the carpometacarpal joint so that a toe
transfer remains an available option.
• In multidigit injuries, it is important to consider using tissues from a digit requiring
amputation to provide coverage for an adjacent digit or hand wound.
• Create soft tissue flaps for viable and potentially sensate coverage of other injured
sites.
• Use bone, tendon, vessel, or nerve for grafting in reconstruction of other injured digits. 

Clinical Examination
• Check perfusion of the finger, looking at capillary refill, color, and turgor (Fig. 3.1).
Note the color difference between the pink, vascularized finger (upper finger) and the
white devascularized finger (lower finger).
• Check that refill takes approximately 2 seconds. This is most easily done by compres-
sion and release at the nail bed if available (especially in patients with darker skin tone).
• If the finger feels soft and compressible, vascular inflow may have been lost result-
ing in this loss of turgor.

FIG. 3.1 

24
 PROCEDURE 3  Finger Amputations 25

• Evaluate sensation.
• Check response to sharp stimulus at fingertip—use a sterile needle to test sharp
sensation.
• Examine two-point discrimination (although often difficult in the recently injured
patient). Can be done using a premade device if available, or by opening up a
paper clip to the desired prong width. Can also gently press using the tips of
sharp iris scissors opened to various widths. The objective is to test at what width
between the two points the patient is able to distinguish two points from feeling
like one point of pressure.
• Examine the structural integrity of each involved finger—test the function of flexion
(superficialis and profundus) and extension against gravity and resistance. 

Imaging
• X-ray is generally the only modality used to evaluate traumatized digits when decid-
ing about structural integrity and potential for long-term function if salvaged. 

Surgical Anatomy
In general, revision finger amputations are done through the bony shaft, rather than at
joint level. Knowing the anatomy of the fingers is important for maintaining attach-
ments of flexor and extensor tendons if possible, as well as contouring bone appro-
priately for the revision stump (Fig. 3.2A and B).
For metacarpal amputations, one must decide between a transmetacarpal amputation
and a ray amputation.
• For border digits, one often can do a transmetacarpal (neck or shaft) amputation, with the
distal remaining bone cut at a 45-degree angle to preserve hand curvature and shape.
• For central digits, and for border digits in patients unhappy with hand function/ap-
pearance after border amputation, one often will do complete ray amputation with
removal of the metacarpal.
• For index and middle fingers, one must keep the metacarpal base to preserve the
extensor carpi radialis longus (ECRL)/extensor carpi radialis brevis (ECRB) attach-
ments (respectively).
Although some advocate leaving cartilage in place, it is our general practice to denude EXPOSURES PEARLS
cartilage at the amputation site. Denuding cartilage has remained standard teaching
• Peroxide soak/wash can be helpful in cleaning
in hand surgery; however, there is no clear evidence to support leaving the cartilage
off dried blood.
cap versus denuding it. • Use of a finger tourniquet facilitates operating
Identify the neurovascular bundles on radial and ulnar sides of digit. Ligate/cauterize in a dry field. An extra glove can be used if
the vessel for hemostasis and appropriately manage the nerve to prevent neuroma no prefabricated finger tourniquet option is
(discussed later) (Fig. 3.3). available (Fig. 3.5).
• Put a clamp on the finger tourniquet so
In a ray amputation, identify and protect the common (palmar) digital vessel and nerve
that the surgeon has a reminder to remove
so as not to injure inflow or sensation to the bordering digit (Fig. 3.4). the tourniquet after surgery. In the chaotic
The A1 pulley must be divided to identify the flexor tendons during transmetacarpal/ray environment of the emergency room, the
amputation (Fig. 3.4).  surgeon may forget the tourniquet is still on
without a reminder. In the anesthetized finger,
Positioning the patient may not feel tourniquet pain until it
is too late.
With an adequate digital block, a revision finger amputation can often be performed in the
emergency department or in a small procedure room rather than the operating room. 
EXPOSURES PITFALLS
Exposures
One should not stop active bleeding from the
Thoroughly clean the hand during examination and evaluation. This will aid in visu- injured finger before the examination has been
alization of skin color and perfusion, as well as the extent of deformity and soft performed, as tourniquet/pressure on the digital
tissue injury. Often, once the sensory examination has been completed, it is easi- bundles can potentially alter sensory examina-
est to place the digital block and then thoroughly clean the anesthetized finger(s) tion—attempt to use direct pressure on the bleed-
ing site if necessary.
(see Chapter 1). 
26 PROCEDURE 3  Finger Amputations

DIP joint Terminal tendon

Lateral band
Middle phalanx
Central slip
PIP joint

Proximal phalanx
Sagittal bands

MP joint

Juncturae tendineae

Extensor tendon

FDP

FDS

FIG. 3.2 
 PROCEDURE 3  Finger Amputations 27

Palmar digital
arteries
and nerves

Superficial
palmar arch

FIG. 3.3 

Flexor tendon

Palmar digital
arteries A1 pulley
and nerves

Superficial
palmar arch

FIG. 3.4 
28 PROCEDURE 3  Finger Amputations

STEP 1 PEARLS Procedure: Revision Amputation

• Allow adequate time for the block to set in. It
is often easiest to place the block early, even Step 1: Set Up for the Procedure: Thoroughly Clean, Anesthetize,
before thorough cleaning, so the block has and Place Tourniquet
time to set in. • After the injury, the surgical site is often bloody and dirty from manual labor at the
• If possible, mark any areas of clearly nonviable time of the injury. Cleaning with peroxide can help clear away blood and grime.
soft tissue before placing the tourniquet.
• For most posttraumatic revision amputations, the only required anesthesia is a digital
block (see Chapter 1). After the sensory examination is completed, the block can be
placed to facilitate more thorough cleaning and functional testing.
STEP 1 PITFALLS • Mark out the areas of clearly nonviable skin.
Be sure the tourniquet is tight enough to prevent • Use a finger tourniquet for hemostasis, placed at the base of the finger after ad-
any arterial inflow—if tourniquet is somewhat lax equately anesthetized (Fig. 3.5).
(especially if using a makeshift tourniquet, e.g., • If finger amputation is performed in the operating room under anesthesia, one can
rubber glove) then congestion and backflow bleed-
ing will make the procedure more difficult. use a standard arm tourniquet. Use the standard tourniquet for transmetacarpal/ray
amputation. 

Step 2: Confirm Viability of Skin and Debride Away Any Clearly Non-
viable Tissue
• Devitalized skin should be sharply excised (scalpel preferable).
• Even under tourniquet, the transition to healthier, more viable tissue can be seen.
• In general, all skin and soft tissue proximal to laceration sites should be pre-
served even if traumatized, unless it is clearly no longer viable. This extra soft
STEP 2 PEARLS tissue length will be needed to provide adequate durable coverage over the bony
Attempt to preserve volar skin to cover distal bone. stump.
This will move the scar to a noncontact surface, • Bone will need to be resected proximal to the injury site to provide adequate soft
and likely will improve sensation of the stump tissue to close over the bone. This tissue therefore must be dissected off of the
(Fig. 3.6). bone with minimal injury to preserve viability.
• With sharp scissors or elevator directly on the phalanx, elevate the soft tissue
envelope off of the bone.
STEP 2 PITFALLS
• If the flexor or extensor tendon remains attached to the distal bone segment that
Caution overresection—adequate length and will be excised, pull on the tendon and divide as proximally as possible and al-
thickness of soft tissue flaps is required to cover low to retract into the palm. This prevents the tendon from being tethered distally,
over the distal bony stump.
which could restrict tendon excursion of the other fingers. 

Step 3: Identify and Treat the Neurovascular Bundles

• Bundles are identified along volar region of radial and ulnar borders of the injured
digit.
• If soft tissue connections remain between the distal segment and the remaining
digit, the neurovascular bundles may be in that soft tissue. Closely examine before
transecting these soft tissue connections.
• In the finger, the nerve is volar to the artery; in the palm, artery is volar to nerve.
• In amputated digits, confirm arterial end of each digital vessel is coagulated or ligated.

FIG. 3.5 
 PROCEDURE 3  Finger Amputations 29

• In amputated digits, the nerve should be placed on traction (Fig. 3.7) and then STEP 3 PEARLS
transected with sharp scissors so it can retract proximally away from the scar site.
If the nerve does not adequately retract after trans-
Nerves trapped in the sutured skin cause debilitating pain, whereas a nerve retracted section, attempt to tunnel the nerve end into soft
into the palm shields the nerve end from contact. tissue or potentially into bone to prevent pain-
• In metacarpal-level amputations, management of the primary neurovascular bundles ful neuroma. All nerves will form a neuroma, but
is a more delicate matter, as the common branches in the palm also feed the adja- nerves trapped in contact areas and not buried
cent digits and therefore must be preserved (Fig. 3.8). The blue arrow indicates the may cause painful neuromas.
common branch in the palm.
• Identifying the digital nerve distally in the finger can aid in finding it proximally in
the intermetacarpal space. Putting traction on the digital nerve in the finger can STEP 3 PITFALLS
help identify the branch-point in the webspace or the common nerve in the palm, If controlling bleeding from the digital artery is dif-
showing a safe transection point for the nerve to the finger being amputated ficult before tourniquet placement, use pressure to
• When approaching the metacarpal, approach over the bone and peel soft tissue control the bleeding rather than trying to control
bleeding before isolating the nerve.
off to either side, protecting the neurovascular bundles. 

FIG. 3.6 

FIG. 3.7 

FIG. 3.8 
30 PROCEDURE 3  Finger Amputations

FIG. 3.9 

Step 4: Perform the Bony Amputation Based on Level of Injury and

Available Soft Tissue
• Level of amputation is determined by available soft tissue.
• After trauma to multiple digits, one may need to use soft tissue from one digit to
cover wounds on neighboring digits or the hand (Fig. 3.9A–C).
• Level of amputation also can be guided by level of fracture or bony injury.
• In the fingers, perform amputation through phalangeal shaft if possible.
•  If possible, aim to preserve the attachments of flexor digitorum superficialis
(FDS), flexor digitorum profundus (FDP), and extensor digitorum communis (EDC)
­tendons (see Fig. 3.3).
• If amputation occurs through the joint, then denude the cartilage along the distal
aspect of the remaining phalanx.
• Contour the distal bone (Fig. 3.10).
• For digits, do not leave sharp edges, and avoid leaving flared/boxy distal aspect
just proximal to the joint.
• For metacarpals, angle distal osteotomy of border digits to be approximately 45
STEP 4 PEARLS
degrees angled toward the hand, providing natural curved contour to match the
Attempt to trim any bony spicules or radial/ulnar rest of the hand (Fig. 3.11).
prominence to avoid leaving the stump with abnor- • For ray amputations, leave the base of index and middle finger metacarpals to
mally wide or prominent edges.
preserve the insertion of ECRL/ERCB. 
 PROCEDURE 3  Finger Amputations 31

FIG. 3.10 

FIG. 3.11 

Step 5: Close the Skin Flaps Over the Distal Bone STEP 5 PEARLS
• No buried sutures are needed. Place interrupted nylons in the skin (Fig. 3.10). If there is a question of viability of remaining soft
• Do not suture the flexor tendon to the extensor tendon or tack the tendons down as tissues, examine again in approximately 48 hours
this can substantially limit function of the hand. to determine whether additional debridement is
• Consider loosely closing the skin flaps to allow drainage of any contaminated fluid as required or if it can be treated with local wound
care.
the wounds heal (rather than tight closure of all wound margins).
• In children, consider closing with chromic suture that does not need removal, as
compliance with suture removal may be a challenge.  STEP 5 PITFALLS

Procedure: Elective Amputation (Transmetacarpal or Ray • Suturing the flexor tendon to the extensor
tendon, or otherwise tethering the flexor
Amputation) tendon to the finger during closure, risks
If performing transmetacarpal or ray amputations to remove nonfunctional digit after developing quadregia.
revision finger amputation or for ischemia/malignancy, consider these additional • Avoid volar-based wound closure if possible,
steps. as this risks painful scars on the functional
surface of remaining fingers (Fig. 3.12).
Step 1
The base/metacarpophalangeal joint of the finger to be amputated should be marked
with a curvilinear teardrop-shaped incision on the volar aspect, and a Y-shaped in-
cision more proximal over the metacarpal on the dorsal aspect (Fig. 3.13Aand B ). 
32 PROCEDURE 3  Finger Amputations

FIG. 3.12 

FIG. 3.13 

Step 2
• Start with volar incision, and identify the digital neurovascular bundles to the finger
(Fig. 3.14).
• After identifying a nerve, place on slight traction and see if it pulls in the webspace;
if there is a tethering in the webspace, this is the proper digital nerve and it can be
transected. If not, one may have the common digital nerve and need to explore
further so as not to damage sensation of the adjacent digit.
• Identify the A1 pulley, divide it, and transect the flexor tendons to the digit. 

Step 3
Cut down to bone, and elevate whatever volar soft tissues are tethered to bone, protect-
ing soft tissues on either side of the metacarpal. 

Step 4
• Turn to the dorsal side, make the Y incision overlying the bone.
• Cut down, divide the extensor tendon to that digit, and continue down to bone be-
fore using elevator to lift interosseous muscles off the metacarpal.
• Again, mobilize soft tissues to each side, protecting the neurovascular bundles,
and avoid unnecessary trauma to the muscles and intermetacarpal ligaments. 
 PROCEDURE 3  Finger Amputations 33

FIG. 3.14 

FIG. 3.15 

A B

FIG. 3.16 

Step 5
• Divide the transmetacarpal ligaments, preserving as much length as possible.
• Use saw to cut through metacarpal and remove the finger and metacarpal (see
Step 4: Revision Amputation for additional information about the bony cut). 

Step 6
• Use 2-0 Ethibond (or other braided suture of choice) to bring transmetacarpal liga-
ments together and close down the open space (Figs. 3.15 and 3.16A and B ).
• Be cautious not to overtighten this suture because it can pull in the adjacent fin-
gers and they can end up crossing over each other.
• One can use buried absorbable suture to loosely bring soft tissues together, close
down dead space, and cover the permanent suture.
• Close overlying soft tissue with interrupted nylon suture (Fig. 3.17A and B ). 
34 PROCEDURE 3  Finger Amputations

FIG. 3.17 

Postoperative Care and Expected Outcomes

• Often the patient with finger amputations is discharged with only a soft dressing un-
less other more proximal injuries are also identified.
• After 48 hours, begin standard wound care with gentle cleansing and dressing
changes (our preference is Xeroform daily or bacitracin twice a day).
• With dressings in place, we encourage wrapping and elevation to control edema.
• Once the wounds heal, patients are cleared to return to activities gradually. It is often
a much more rapid recovery than if complex reconstruction was performed.
• After metacarpal-level amputations, we often will place patient in intrinsic-plus volar
splint while healing to prevent collapse of border metacarpals and abnormal remain-
ing finger cascade.

See Video 3.1, Revision Amputation and Treatment of Painful Neuroma, on Expert
Consult.com.

EVIDENCE
Blazar PE, Garon MT. Ray resections of the fingers: indications, techniques, and outcomes. J Am Acad
Orthop Surg 2015;23:476–84.
Review of ray amputation. Major negative outcome reported is 15% to 30% loss of grip and pinch
strength, otherwise patients with overall high satisfaction and successful long-term function.
Chow SP, Ng C. Hand function after digital amputation. J Hand Surg Br 1993;18:125–8.
This article is a review of outcomes after finger amputations. Power grip and key pinch returned to
70% of unaffected side by 1 year. Multiple finger amputation injuries resulted in weaker grip and key
pinch. Twenty-five percent of patients had to change jobs and 20% expressed concerns regarding
the appearance of their injured hand.
Wang K, Sears ED, Shauver MJ, Chung KC. A systematic review of outcomes of revision amputation
treatment for fingertip amputations. Hand (NY) 2013;8:139–45.
This article is a review of outcomes after revision amputation for fingertip injuries. The authors
reviewed 38 studies, and concluded that near-normal sensation could be restored with satisfactory
motion. Return to work took an average of 7 weeks.
Whitaker LA, Graham 3rd WP, Riser WH, Kilgore E. Retaining the articular cartilage in finger joint ampu-
tations. Plast Reconstr Surg 1972;49:542–7.
This article presents an experiment in cats that evaluated disarticulation amputation vs. cartilage
removal at distal amputation site. Inflammation and remodeling occurred more quickly in the disar-
ticulation model with longer recovery time in cases where the cartilage had been denuded.
 PROCEDURE 3  Finger Amputations 35

Yuan F, McGlinn EP, Giladi AM, Chung KC. A systematic review of outcomes after revision amputation
for treatment of traumatic finger amputation. Plast Reconstr Surg 2015;136:99–113.
This is a systematic review of treatment for revision amputation injuries. The mean static two-point
discrimination was 5 mm, with total active motion 93% of normal (slightly better after revision ampu-
tation compared with local flap coverage). Seventy-seven percent of patients report cold intolerance.
Ninety-one percent reported satisfactory or good/excellent overall function regardless of treatment.