Epidemiology of Finger Amputations in the United States From 1997 to 2016

Partial hand and finger amputations in Sweden: an observational study of 6918 patients

BACKGROUND

We aimed to use open source data to understand the incidence, trends, and regional differences of finger and partial hand amputations on a national level in individuals aged 15 or older in Sweden.

METHODS

We analyzed 6,918 patients aged 15 and older who had experienced finger and partial hand amputations. Incidence rates, trends, and regional disparities were assessed using negative binomial regression models and Student's t-tests. Future trend prediction was performed using Poisson regression.

RESULTS

Finger amputations declined most, followed by partial hand and thumb amputations. Regional variations existed, with Stockholm having the lowest and Gotland highest incidence respectively. Overall, the incidence of finger, thumb and partial hand amputations in Sweden decreased slightly. Future trend analysis indicated decreasing incidence.

CONCLUSION

Although, lacking in definition, publicly available data can be used for monitoring of finger, thumb, and partial hand amputation incidence on a national level. Sex, age, and regional differences were observed, suggesting the need for targeted interventions to address disparities and mitigate the burden of finger and partial hand amputations on affected individuals.

Health Policy Implications of Digital Replantation

There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.

Psychosocial and functional impact of successful digital replantation - A cohort study of 36 patients with a median follow-up of 6 years

INTRODUCTION

This study aims to evaluate the long-term psychosocial and functional outcomes of successful digital replantation following traumatic amputation.

METHODS

Patients that underwent successful replantation (i.e. no secondary amputation following replantation) of one or more traumatically amputated digits between January 2009 and April 2019 were invited to participate in this study. In addition to a custom questionnaire on psychosocial and socioeconomic aspects of life, various Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires regarding global health, upper extremity function, and depressive symptoms were completed. Bivariate analyses were performed to identify significant associations between outcomes and explanatory variables.

RESULTS

Thirty-six patients were successfully enrolled and completed the questionnaires at a median follow-up of 6.1 years. The median PROMIS score for Upper Extremity Function (40.6) was considerably different from the score that is typically found in the general population (all PROMIS instruments are calibrated with a control group score of 50.0), but the median PROMIS scores for Global Health - Physical (49.0), Global Health - Mental (50.7), and Depression (45.6) were comparable to those among the general population. Dominant hand injury, a greater number of injured digits, higher age at the time of injury, and the need for neuropathic pain medication were associated with lower Upper Extremity Function scores (all p < 0.05). Additionally, the presence of neuroma was associated with negative changes in both household finances and mental well-being (p < 0.05).

CONCLUSIONS

At long-term follow-up, a majority of patients that underwent replantation of traumatically amputated digits seem to cope well based on psychosocial and functional outcomes. However, neuropathic pain and the presence of neuroma are strong negative factors. Specific attention to digital nerves at the time of surgery is crucial in the management of traumatic amputations.

Zone I Revision Finger Amputations Performed in the Emergency Department Compared With Those Performed in the Operating Room

Finger amputations are commonly encountered. These may be revised in the emergency department (ED) or the operating room (OR). Previous studies have demonstrated the cost-effectiveness associated with procedures performed in the ED. Patient outcomes have not been described. We retrospectively reviewed patients who presented to our level 1 trauma center with a traumatic partial or complete finger amputation through flexor tendon zone I. All were treated with revision amputation performed in either the ED or the OR between January 2012 and December 2017. A total of 172 patient charts were included. Ninety-three of the revision amputations were performed in the ED, while 79 were performed in the OR. There was no difference in age, race, sex, having a manual labor job, medical comorbidities, or mechanism of injury between the groups. Compared with procedures performed in the ED, procedures performed in the OR had a higher rate of delayed healing, a longer stay in the hospital, and a higher referral to therapy postoperatively. Length of follow-up and number of follow-up visits were not statistically different based on location of procedure. There was no difference in post-procedural infection rate or need for revision procedure between the groups. Our data support the efficacy of performing revision amputation procedures in the ED. Recorded patient complications and subsequent treatment after revision amputations performed in the ED vs the OR were comparable. Those performed in the ED potentially decrease the burden placed on the patient and the health care system. [Orthopedics. 2024;47(3):152-156.].

Reconstruction of a Pediatric Distal Phalanx Amputation With Stacked Integra Dermal Substitute: A Case Report

Finger amputations in children present unique challenges and require special considerations compared to their adult counterparts. Maximizing length and preserving fingertip bulk and sensation is essential for maintaining a functional digit. Synthetic dermal substitutes have been recently used for soft tissue coverage for pediatric syndactyly as well as burn injuries; however, the literature discussing pediatric amputation cases with soft tissue damage proximal to the bony level is limited.In this case, we report a two-year-old patient who developed dry gangrene of her right index finger after multiple rabbit bites and underwent an amputation through the distal interphalangeal joint. Circumferential soft-tissue debridement proximal to the tip of the middle phalanx was required, leaving substantial exposed bone with no soft tissue envelope. We report our experience of single-stage stacking Integra dermal substitute directly onto the exposed bone to provide both finger bulk and soft tissue coverage.The patient displayed no functional limitations three years post-surgery.For instances when local or distant flap coverage may not be feasible, we present a novel technique to reconstruct, provide bulk, and preserve length in pediatric finger amputations. This case highlights that the utility of dermal substitutes is expanding and are providing more technical options.

Traumatic Finger Amputation in the U.S. Military

INTRODUCTION

Finger amputations can lead to loss of work time and suboptimal function, particularly in the active duty military. There is a paucity of epidemiologic and outcome data for these injuries. The purposes of this study are to define key demographic data pertaining to transphalangeal finger amputations in the U.S. Military and to assess epidemiological data to define risk factors for medical readiness following finger injuries.

MATERIALS AND METHODS

This was a retrospective review of the military electronic medical record of encounters between 2016 and 2019 with traumatic transphalangeal amputation ICD 10 codes S68.5 (thumb) and S68.6 (finger). Primary outcomes included median military occupational activity limitation length, ability to return to duty, and medical separation from the military.

RESULTS

A total of 235 patients were included in the final dataset. 221 (94.0%) of these service members were able to return to full duty, although 14 (6.0%) underwent medical separation from the military because of their finger injuries. The median limited duty timeline was 6 weeks. Significant risk factors identified that led to increased rates of medical separation were the use of tobacco (odds ratio [OR] of 5.53, 95% CI 1.21-25.29), junior enlisted status (OR of 5.51, 95% CI 1.67-18.17), and thumb or index finger involvement (OR of 3.50, 95% CI 1.13-10.83).

CONCLUSIONS

Within a physically high-demand population, traumatic finger amputation can limit duties and may lead to medical separation from service. Traumatic finger amputations are common and often require 6 weeks of restricted short-term disability, particularly in a tobacco-using, young, physically active cohort.

A Prospective Follow-up Study of Fingertip Amputation Treatment With Semi-occlusive Dressing

Background

The aim of this prospective cohort was to evaluate the conservative treatment of fingertip amputation with exposed bone, with a semi-occlusive dressing.

Methods

Ten patients with an amputation distal to the distal interphalangeal joint were treated via secondary healing under a semi-occlusive film dressing. We followed up the patients weekly until the fingertip had healed, then a final clinical visit at 6 months, and a patient-reported outcome assessment at 2 years after the injury.

Results

All 10 patients completed the 6-month clinical follow-up, and seven patients completed the final patient-rated outcome assessments at 2 years. There were no complications during the study period, all the patients were satisfied with the results, and all answered "fully agree" on choosing the same treatment method again in a similar injury.

Conclusion

Our results show that conservative treatment of fingertip amputation is feasible and can provide good results.

Finger prosthesis: A novel way to restore the form, function, and esthetics

Key Clinical Message

A well-customized prosthesis with a life-like esthetic and function are the primary determining factors for its acceptance and success. RTV silicones can prove to be very effective and useful in fabricating such prosthesis.

Abstract

Complete or partial finger amputations impact an individual's psychological and physical well-being and are considered the most frequently observed pattern of hand loss. A customized prosthesis offers the patient rehabilitative, functional, and psychological advantages. Retention is the key to the success of such prosthetic restoration. The present case report describes a novel technique that utilizes passive vacuum fit and mechanical retention to restore controlled function movements as a metal wire framework. The procedure was economical, most importantly, produced life-like anatomy of the missing digit and restored the function to some extent.

Bactericidal Activity of Silver-Doped Chitosan Coatings via Electrophoretic Deposition on Ti6Al4V Additively Manufactured Substrates

Prosthetic reconstruction can serve as a feasible alternative, delivering both functional and aesthetic benefits to individuals with hand and finger injuries, frequent causes of emergency room visits. Implant-related infections pose significant challenges in arthroplasty and osteosynthesis procedures, contributing to surgical failures. As a potential solution to this challenge, this study developed a new class of silver (Ag)-doped chitosan (CS) coatings via electrophoretic deposition (EPD) on osseointegrated prostheses for infection therapy. These coatings were successfully applied to additively manufactured Ti6Al4V ELI samples. In the initial phase, the feasibility of the composite coating was assessed using the Thermogravimetric Analysis (TGA) and Attenuated Total Reflection (ATR) techniques. The optimized structures exhibited impressive water uptake in the range of 300-360%. Codeposition with an antibacterial agent proved effective, and scanning electron microscopy (SEM) was used to examine the coating morphology. Biologically, CS coatings demonstrated cytocompatibility when in direct contact with a fibroblast cell line (L929) after 72 h. When exposed to the Staphylococcus epidermidis strain (ATCC 12228), these coatings inhibited bacterial growth and biofilm formation within 24 h. These findings underscore the significant potential of this approach for various applications, including endoprostheses like hip implants, internal medical devices, and transcutaneous prostheses such as osseointegrated limb prosthetics for upper and lower extremities.

Traumatic Amputations Treated in US Emergency Departments: A Review of the NEISS Database

BACKGROUND

Trauma is the second most common cause of limb loss in the United States (US), second only to vascular disease. The aim of this study was to evaluate the demographics and commercial products associated with traumatic amputations in the United States.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was analyzed from 2012 to 2021 to identify patients presenting to the Emergency Department (ED) with the diagnosis of amputation. Additional variables included patient demographics, body part amputated, commercial products associated with amputation, and ED treatment disposition.

RESULTS

A total of 7323 patients diagnosed with amputation were identified in the NEISS database. Amputations were most frequent in the 0-5 years age group, followed by 51-55 years. More males than females suffered an amputation during the study period (77% vs 22%). Most patients were Caucasian. Fingers were most frequently amputated (91%), followed by toes (5%). Most injuries occurred in the home (56%). The top commercial product behind these traumatic amputations was doors (18%), followed by bench or table saws (14%) and power lawn mowers (6%). Over 70% of patients were able to be treated and released from the ED, while 22% required hospitalization and 5% were transferred to another facility.

DISCUSSION

Traumatic amputations can cause significant injuries. A better understanding of the incidence and mechanisms behind traumatic amputations may help with injury prevention. Pediatric patients had a high incidence of traumatic amputations, which warrants further research and dedication to injury prevention in this vulnerable group.

A biomechanical study of osseointegrated patient-matched additively manufactured implant for treatment of thumb amputees

Thumb amputations leads to 50 % loss in hand functionality. To date, silicone vacuum prosthesis and autologous transplantation are the most adopted treatment solutions: nevertheless, vacuum prostheses lack in stability and cause skin issue and surgical treatment is not always accepted by patients. Osseointegrated implants were demonstrated to enhance stability, restore osseoperception and increase the time of prosthesis use. Thumb amputations present varying stump sizes: a standard size implant cannot address specificity of each patient, while a patient matched solution can meet surgeon requirements, by geometrical features of implant. The fixture presented in the current paper is the first additively manufactured patient matched osseointegrated implant for the treatment of thumb amputees. The current work aims to verify and validate a predictive finite element model (FEM) for mechanical strength of the presented fixture. FEM was demonstrated to correctly evaluate the mechanical strength of patient matched device. Minimum strength requirements were calculated in different core diameters: FEM were experimentally validated. Safety factor of 1.5 was guaranteed. Finally, considerations on performance of the prototype were carried out by means of insertion tests in Sawbones and axial pull-out force assessment. Cadaver tests to evaluate the entire procedure and production process are ongoing.

Outcomes of Composite Grafts for Pediatric Fingertip Amputations: A Systematic Review

Introduction  The aim of this study was to explore the outcomes of composite grafts in fingertip amputations in children as well as the contributing factors that may affect outcomes. Methods  Literature search was conducted across six databases in March 2022 to select studies on the use of composite grafts on fingertip amputations in the pediatric population. Results  Twelve articles with 735 composite grafts were identified for review. Most fingertip injuries occurred in the less than 5-year age group and were due to crush type injuries. In studies that reported "complete" graft take as a separate outcome measure, 17.3% of fingertips with this result were observed. In the studies that reported "complete" and "partial" graft take together as an outcome measure, 81.6% of fingertips achieved this outcome. A lower proportion of failed graft take was observed in more distal fingertip amputations. Infection (3.8%) and nail abnormalities (3.4%) were the most common complications following composite grafting. Conclusion  Composite grafting can be considered as a useful method of treatment in this population. Clinicians should be aware of the potential complications following this method of treatment such as infection and nail abnormalities. More proximal fingertip amputations may warrant other surgical interventions (beyond Level II on the modified Ishikawa/Ishikawa classification). Significant heterogeneity was observed within the studies, mainly due to lack of standardization in assessment and reporting of outcomes.

Digital Nerve Management and Neuroma Prevention in Hand Amputations

BACKGROUND

Hand and digit amputations represent a relatively common injury affecting an active patient population. Neuroma formation following amputation at the level of the digital nerve can cause significant disability and lead to revision surgery. One method for managing digital nerves in primary and revision partial hand amputations is to perform interdigital end-to-end nerve coaptations to prevent neuroma formation.

METHODS

All patients with an amputation at the level of the common or proper digital nerves that had appropriate follow-up at our institution from 2010 to 2020 were included. Common or proper digital nerves were managed with either traction neurectomy or digital end-to-end neurorrhaphy. The primary outcome was the development of a neuroma. Secondary outcomes included revision surgery, complications, and visual analog pain scores.

RESULTS

A total of 289 nerves in 54 patients underwent hand or digital amputation in the study period. Thirteen hands with 78 nerves (27%) underwent direct end-to-end coaptation with a postoperative neuroma incidence of 12.8% compared with 22.7% in the 211 nerves that did not have a coaptation performed. Significantly fewer patients reported persistent pain if an end-to-end coaptation was performed (0% vs. 11.8%, P < .01). The prevalence of depression and workers compensation status was significantly higher in in patients with symptomatic neuromas than in patients without symptomatic neuromas (P < .01).

CONCLUSIONS

Digital nerve end-to-end neurorrhaphy is a method for neuroma prevention in partial hand amputations that results in decreased residual hand pain without increase complications. Depression and worker's compensations status were significantly associated with symptomatic neuroma formation.

Functional improvement by body-powered 3D-printed prosthesis in patients with finger amputation: Two case reports

RATIONALE

The most common upper limb amputations are finger amputations, resulting in functional limitations that lead to problems with activities of daily living or job loss. For many years, prosthetic options for finger amputations have been limited to passive prostheses. In many countries including South Korea, body-powered finger prostheses have rarely been prescribed due to high cost, lack of experience of physicians and prosthetists, low interest and no coverage by insurance benefits. We report 2 cases of work-related finger amputations in patients who received body-powered 3D-printed finger prostheses.

PATIENT CONCERNS AND DIAGNOSIS

Patient 1 was a 25-year-old woman with second and third finger amputations at the proximal interphalangeal level. Patient 2 was a 26-year-old man who sustained a second finger amputation at proximal interphalangeal level.

INTERVENTIONS

We created body-powered 3D-printed finger prostheses that mimicked distal interphalangeal joint motion through patient-driven metacarpophalangeal joint motion using a string connected to a wrist strap and a linkage system. The source code "Knick Finger" was downloaded from e-NABLE.

OUTCOMES

After 1 month of prosthesis training, both patients were satisfied with the prostheses and showed improved performance in patient-derived goals of cooking (patient 1) and typing on a computer (patient 2).

LESSONS

Over the past decade, significant advances have been made in 3D-printed prosthetics owing to their light weight, low cost, on-site fabrication, and easy customization. Although there are still several limitations in the general application of 3D-printed finger prostheses, our study suggests that for patients with finger amputations, body-powered 3D-printed finger prostheses have high potential as an additional prosthetic option to the existing passive cosmetic prostheses.

Osseointegrated Metallic Implants for Finger Amputees: A Review of the Literature

Digital trauma amputations and digital agenesis strongly affect the functionality and aesthetic appearance of the hand. Autologous reconstruction is the gold standard of treatment. Unfortunately, microsurgical options and transplantation procedures are not possible for patients who present contraindications or refuse to undergo transplantation from the toe (e.g. toe‐to‐thumb transplantation). To address these issues, osseointegrated finger prostheses are a promising alternative. The functional assessments registered during follow‐up confirmed the promising outcomes of osseointegrated prostheses in the treatment of hand finger amputees. This review outlines (a) a detailed analysis of osseointegrated finger metallic components of the implants, (b) the surgical procedures suggested in the literature, and (c) the functional assessments and promising outcomes that demonstrate the potential of these medical osseointegrated devices in the treatment of finger amputees.

Trauma workload during COVID19 lockdown: an analysis of incidence in 4 million people

BACKGROUND

Aim of this study is to report the trauma workload during COVID19 lockdown in a region of four million people and to compare it with the same period in 2019.

METHODS

The regional register for A&E admissions and hospitalizations has been reviewed in order to compare the number of A&D admission, the triage colour codes rates, aetiology of trauma, number of patients hospitalized for trauma, number of fractures that required surgery, type of fractures and injuries and mean patients' age.

RESULTS

During lockdown 7314 patients were admitted in A&E, while 22,508 patients were admitted in 2019. In 2020 and 2019 triage codes were respectively distributed as follows: red code 0.1% vs 0.2%, yellow code 8.9% vs 6.3%, green code 84% vs 84.7% and white code 6% vs 8.8%. (p = 0.042). The number of hospitalized patients for trauma was 670 in 2020, while in 2019 was 1774 (p = 0.02). The most common fracture that required surgery was femur fracture (409 in 2020 vs 635 in 2019); fracture subtype distribution and mean age of the patients were significantly different in the two groups (respectively p < 0.01 and p = 0.02).

CONCLUSIONS

One month of lockdown showed a 68% decrease in the number of A&E visits and a 74% decrease of fractures that required surgery. Femur fracture showed the lowest decrease moving from 635 to 409 units but increasing their incidence rate (42 to 61%).

Pulp De-epithelialization for Venous Outflow Augmentation after Digital Replantation

Traumatic amputation injuries account for a substantial portion of emergency department visits. This includes digital amputations that may be considered for replantation. Following surgery, venous congestion is the most common cause of replant failure. To address this, several methods have been proposed to augment venous outflow. In this article, a simple and straightforward method that can be utilized to establish or augment venous outflow in cases of venous insufficiency is described. This method entails de-epithelization of the replanted digit pulp skin with use of postoperative anticoagulation. The area can be further expanded or stimulated to increase bleeding as needed and is allowed to heal by secondary intention. This method allows for reliable venous outflow with relative ease of implementation.

Geospatial Inefficiencies Associated With Digital Replantations at High-Volume Centers and Optimal Allocation Model for Centralization of Replantations

PURPOSE

Digit replantation can improve dexterity, functionality, patient satisfaction, and pain following amputation, but rates continue to fall nationally. This study aimed to describe the effects of travel time and distance as barriers to high-volume hospitals, identify geospatial inefficiencies in the presentation of patients to replantation care, and provide an optimal allocation model in which cases are redistributed to select centers to reduce geospatial redundancies and optimize outcomes.

METHODS

We reviewed the California Office of Statewide Health Planning and Development hospital discharge database to identify cases of digital amputation and determine outcomes of replantation. Using residential zip codes, risk- and reliability-adjusted multivariable logistic regression was used to assess the relationship of hospital volume and travel time on replantation success. Geospatial analysis assessed the travel burden of patients as they presented for care, and optimal allocation modeling was used to create a model of centralization.

RESULTS

We identified 5,503 patients during the study period; 1,060 underwent replantation with an overall success rate of 70.2%. Ninety-three hospitals were found to perform replantations, of which only 4 were identified as high-volume hospitals. Patients routinely traveled farther to reach high-volume hospitals, and decreasing the travel time predicted a 15% increase in odds of replantation at a low-volume center. Twenty-one percent of patients presented to a low-volume hospital when a high-volume hospital was closer, and differencein payer type and race/ethnicity existed between those who presented to the closest center compared to those who bypassed high-volume centers. The optimal allocation modeling allocated all cases into 8 centers, which increased the median annual volume from 1 case to 9.6 cases and decreased patient travel time.

CONCLUSIONS

Travel burden and geospatial inefficiencies serve as barriers to high-quality and high-volume replantation services. Optimized allocation of digital replantation cases into high-quality centers can decrease travel times, increase annual volumes, and potentially improve replantation outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Management of Pediatric Distal Fingertip Injuries: A Systematic Literature Review

Background:

Nail bed and fingertip injuries are the commonest hand injuries in children and can lead to profound functional and cosmetic impairments if not appropriately managed. Fingertip injuries can present with subungual hematomas, simple or stellate lacerations, crush, or avulsion injuries, often with associated fractures or tip amputations. The fundamentals of managing nail bed injuries concern restoring the form and function of a painless fingertip. However, there are controversies surrounding the optimal management of each of these injuries, which has led to nonuniformity of clinical practice.

Methods:

The PubMed database was searched from March 2001 to March 2019, using a combination of MeSH terms and keywords. Studies evaluating children (<18 years of age) and the fingertip (defined as distal to the distal interphalangeal joint) were included following screening by the authors.

Results and Conclusion:

The evidence base for the diverse clinical management strategies currently employed for fingertip injuries in the pediatric population is limited. Further studies yielding level I data in this field are warranted.