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Chapter 15
Partial Hand Amputation: Surgical Management
Edward A. Athanasian, MD Mark Edward Puhaindran, MBBS (Singapore), MMED (Surg), MRCS (Edin)
Abstract
Keywords: double ray amputation; partial hand amputation; ray
amputation; single ray amputation
Introduction
Amputations of fingers or portions of the
hand may be required in the treatment
of traumatic injury, infection, and tumor. Each patient has a unique clinical
scenario, and treatment should be individualized to that patient and the injury
or condition. A well-performed amputation may maximize patient function
and appearance. This in turn may have a
major effect on the patient’s self-perception, socialization, and work capacity.
Single Ray Amputation
General Considerations
Single ray amputation is most commonly done for the treatment of traumatic
injuries, malignant bone and soft-tissue
tumors, and, less frequently, infection.
Deficits produced by trauma can be limited to the affected digit or can extend
more proximally into the metacarpus or
the hand. Similarly, the surgical deficits
that remain as a result of the oncologic
requirements of resection are sometimes
unique and must be taken into consideration in surgical planning for definitive
amputation and reconstruction. The status of the soft tissues and the need for
coverage also must be considered. Fillet
flaps and “spare parts” from distal amputated parts or adjacent digits can be
extremely helpful in achieving wound
closure or coverage.
Index and small finger ray amputations are done by transecting the base
of the metacarpal distal to the extensor carpi radialis and extensor carpi
ulnaris, respectively. The middle ray is
most commonly transected at the base
of the metacarpal, with or without index ray amputation.2 The ring finger
ray is most commonly disarticulated at
the carpometacarpal articulation, with
the anticipation that the small finger ray
base will migrate to the midline over
time. Intermetacarpal ligament repair
or reconstruction is critical to reduce
the gap between digits produced by central ray amputation and will improve
cosmesis. The authors of this chapter
prefer a middle ray amputation without
transposition. Intermetacarpal ligament
repair or reconstruction will provide a
satisfactory appearance and avoids the
risk of contamination of adjacent rays
when the procedure is done because of
malignancy.
1
Outcome Considerations
When possible, it is imperative that
the functional and cosmetic deficits
produced by ray amputation be carefully reviewed with the patient before
the surgical procedure. Emotional and
psychological considerations should be
addressed and expectations defined.
Pictures demonstrating the anticipated
result and or appearance are helpful.
Speaking to or meeting with an individual who had a ray amputation can be
extremely beneficial. In some instances,
psychological counseling is appropriate.
Neuroma at the transection site of
the digital nerves is expected after all
procedures. Most commonly, these
neuromas are not particularly uncomfortable, with the exception of the index
ray where painful neuromas occur in
approximately 70% of patients. There
is no commonly accepted treatment
method to reduce the risk of a painful
digital neuroma after a ray amputation.
Ligation, implantation of the nerve into
muscle and bone, and pretreatment with
local anesthetic have been advocated.
Painful neuromas may require secondary procedures, including proximal
transection and burial or cryoablation.
Grip strength is diminished by approximately 30% after ray amputation,
although there can be great variations.
The routine reduction of grip strength
should be discussed in advance with patients to provide realistic expectations.
Patients commonly adapt well to this
deficit.
The appearance of the hand after a
well-done elective ray amputation can
be excellent. Patients should be reassured preoperatively that the deficit of
a single ray is not routinely noticed in
3
2,3
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
203
Section 2: Upper Limb
human interactions, unless fingers are
counted.
Preferred Techniques of
This Chapter’s Authors
Index Ray Amputation
In an index ray amputation, the dorsal incision is made and the flaps are
elevated. The incision may be longitudinal (preferred) or a long V-flap. The
extensor tendons are then transected,
and interosseous muscles are mobilized
extraperiosteally. Bone transection is
performed distal to the insertion of the
flexor carpi radialis.
For the volar incision, additional skin
is taken radially when possible to facilitate closure. The V-incision is incorporated with a volar Bruner incision, which
may need to be trimmed at final closure.
Digital vessels are identified proximally,
cauterized, and then transected. Digital nerves are identified, anesthetized
with a local anesthetic, and transected.
Flexor tendons are then transected, and
the intermetacarpal ligament between
the index ray and the middle finger ray
is transected. The ray is rotated, and
the remaining intrinsic musculature is
transected. Skin is closed using nylon
suture with attention to the distal radial
flap first, followed by dorsal and palmar
closures (Figure 1).
Middle Finger Ray Amputation
A middle finger ray amputation is similar to an index ray amputation. The
proximal metacarpal is transected at the
base of the diaphysis distal to the carpometacarpal ligaments. After removal
of the ray, the intermetacarpal ligament
is repaired using nonabsorbable suture
or reconstructed using the A-1 pulley
of the index and middle ray (Figure 2).
Ring Finger Ray Amputation
Ring finger ray amputation is similar
to a middle finger ray amputation with
the exception of routine disarticulation
of the base of the ring finger metacarpal
from the carpometacarpal joint. This
requires transection of the intermetacarpal ligaments. Care must be taken to
avoid injury to the deep palmar arch and
deep motor branch of the ulnar nerve,
which are palmar to the base of the
ring finger metacarpal and thus easily
injured. Intermetacarpal ligament repair
or reconstruction is important for cosmesis. Over time, the base of the small
finger metacarpal migrates radially to
help reduce the defect produced by ring
finger ray amputation (Figure 3).
Small Finger Amputation
Small finger ray amputation is entirely
analogous to index ray amputation with
similar incisions and skin flaps. Care
must be taken to plan the ulnar-sided
skin flap to facilitate closure. The bone
is transected distal to the insertion of
the extensor carpi ulnaris (Figure 4).
Alternative Surgical Techniques
Transposition of the index ray to the
base of the middle ray is a well- accepted
reconstruction technique after middle
ray amputation. This broadens the first
web space slightly and can reduce the
tendency for index ray pronation after
intermetacarpal ligament repair or reconstruction when transposition is not
done. This procedure requires osteotomy of the index metacarpal base
and open reduction and internal fixation of the index metacarpal diaphysis
to the middle finger metacarpal base.
Additional surgical time and risks of
malrotation, nonunion, hardware removal, and theoretic expansion of the
field of contamination (in the setting
of malignant tumor resection) must be
taken into consideration if transposition
is being considered.
Rehabilitation
Bulky, soft compressive bandages are applied at the time of surgery. Digit range
of motion is encouraged to the extent
allowed by the level of pain, particularly
metacarpophalangeal flexion and proximal interphalangeal joint extension.
Supervised digit range of motion should
be initiated between the first and second
postoperative weeks. Sutures remain in
place for 2 to 3 weeks. Recovery of range
of motion should be the early emphasis
of therapy. At week 6, strengthening is
initiated. Palmar wound desensitization
may be required in the first 3 months,
after which incision-site sensitivity typically decreases. Full activity is allowed at
3 months, with continued improvement
in strength and function expected for
more than 1 year after surgery. Routine
discussion of psychological well-being
is incorporated into early postoperative
physician visits.
Managing Complications The management of complications should be
considered at the time of surgery. Digit alignment in extension and flexion
must be critically assessed after intermetacarpal ligament repair and, particularly, reconstruction. It is possible to
pronate radial-sided digits and supinate
ulnar-sided digits during this repair. If
done, this will affect appearance and
could impair function.
Digital nerves form neuroma after
transection. Care must be taken at surgery to handle nerves gently; crushing
and electrocautery should be avoided. If
a painful neuroma develops postoperatively, medical management may be beneficial. Pain management consultation
should be considered. For recalcitrant
neuromas, more proximal transection
can be performed with neuroma burial
or cryoablation. Good results are possible in some patients.
Nonunion or malrotation after digit
transposition will require additional intervention in the form of bone grafting
or surgical correction of rotation.
Double Ray Amputation
General Considerations
Double ray amputation may be required
for patients with major hand trauma,
those with large tumors involving single rays that encroach on the adjacent
ray, or in patients in whom a tumor is
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 15: Partial Hand Amputation: Surgical Management
A, Clinical photograph of a liposarcoma involving the rst web space. B, Axial MRI
needed for vascular repair or grafting
if indicated.
Outcome Considerations
Double ray amputation causes a much
greater deficit in appearance compared
with single ray amputation. This deficit is more commonly noted in routine
interpersonal interactions and has a
located in the space between individual rays. Radiosensitive lesions, such
as soft-tissue sarcomas, may be treated
with preoperative radiation in an attempt to reduce the size of the tumor.
If adequate size reduction is achieved,
it may be possible to convert a planned
double ray amputation into a single ray
amputation.
Figure 1
showing the lesi on extending from the thumb metacarpal radially to the middle nger metacarpal
ulnarly. The palmar barrier is the adductor pollicis. The dorsal disease fungating through the skin.
C through J, Surgical photographs. C, The dorsal incision incorporates skin resection at the area
of the fungating lesion, with a plan for an index llet ap. D, The volar incision incorporates a llet
ap incision. The volar wrist veins are marked for a possible donor graft. E, A llet ap is raised, and
the radial disse ction includes thumb m etacarpal perios teum. F, Palmar disse ction is done palmar to
the adductor pollicis to allow adequate resection margin. The thumb is rotated radially to facilitate
exposure. G and H, Dorsal views of the rotated thumb, llet ap, and resection specimen. I, Volar
appearance of the hand after closure, medial collateral ligament repair, and pinning. J, Dorsal appearance of the hand, with closure facilitated with a llet ap.
The preoperative physical examination should include the Allen test
to confirm patency of the arterial arch
and adequate perfusion of the digit. It
is imperative to determine the patency of the superficial arch before double ray amputation when resection of
the superficial vascular arch is being
considered. Microsurgical capability is
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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Section 2: Upper Limb
be prepared to perform microsurgical
repair or reconstruction of the arch if
there is inadequate blood flow to the
remaining digits. Flexor tendons and
intrinsic muscle transection are needed
to complete the amputation. Closure is
performed using local flaps, a fillet flap,
or (occasionally) distant coverage such
as a radial forearm flap or a free flap.
Rehabilitation
Rehabilitation after double ray amputation of the hand is nearly identical
to that for single ray amputation. The
cosmetic deficit produced by double
ray amputation is substantial. A passive prosthesis may be considered to
improve appearance if this is important
to the patient.
Figure 2
proximal phalanx tumor that required ray amputation. Surgical photographs of the volar incision
(C) and the dorsal incision (D).
greater effect on a patient’s perception
of his or her appearance.
Function after double ray amputation is also more severely affected than
after single ray amputation. In one series
of double ray amputation done to treat
sarcomas, grip strength was reduced
approximately 75%.4 Resection of the
deep motor branch of the ulnar nerve,
if required, also impairs thumb function
and manual dexterity.
A, Illustration of a middle nger ray amputation. B, Clinical photograph of a large
flaps may be used for ulnar double ray
4,5
amputation. A large radial index flap
will facilitate closure in radial-sided
double ray amputation of the index and
middle fingers (Figures 5 and 6).
Dorsal dissection is usually done
first after completion of the dissection
of any fillet flap. Extensor tendons are
transected. Interosseous muscle that can
be spared is dissected from the metacarpal to be resected at both the radial and ulnar aspects of the respective
Preferred Techniques of
This Chapter’s Authors
In double ray amputation, incision
placement is usually dictated by the location and the extent of the tumor or the
traumatic injury. Routine consideration
of the use of a fillet flap of uninjured or
uncontaminated digit tissue should be
incorporated into the surgical plan to
facilitate coverage, if needed. If there is
adequate tissue, ulnar- or palmar-based
metacarpals. Metacarpal transection of
both rays is done distal to the insertion
of radial-sided wrist flexors and extensors at the index ray and ulnar-sided
wrist flexors and extensors at the small
finger ray.
Palmar dissection is determined
by the extent of the lesion or trauma.
The superficial palmar arch should
be spared when possible. If this arch
must be resected, the surgeon should
Managing Complications
Complications after double ray amputation are similar to those after single ray
amputation. Double ray amputation for
malignant bone and soft-tissue tumors
is typically done for very large lesions.
The extent of the resection may require
extensive reconstruction, including tendon and bone reconstruction or repair.
Complications are more frequent when
radiation is used, which is common in
the treatment of soft-tissue sarcomas of
the hand.6 Tendon excursion problems
are more common after double ray amputation than single ray amputation and
may require subsequent tenolysis.
Transmetacarpal
Amputation
Elective transmetacarpal amputation is
rarely performed. Even large distal tumors can be resected with either double
ray amputation or triple ray amputation.
Preoperative radiation or chemotherapy
is often effective in decreasing tumor size
to allow hand-sparing surgical options at
definitive treatment. If all four digit rays
are contaminated by tumor, it is likely
that there will be extension of tumor into
the carpal tunnel. In this setting, a more
proximal level amputation is indicated.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 15: Partial Hand Amputation: Surgical Management
A, Axial MRI of a synovial sar-
Transmetacarpal amputation may
be appropriate to treat some traumatic
injuries. Every effort should be made to
replant the amputated part, unless contraindicated. In severe crush injuries, it
may not be possible to replant multiple
digits. In this setting, the focus should
be on soft-tissue coverage, with consideration of a subsequent, staged toe-to-hand
transfer to allow thumb-to-toe pinch.
Figure 3
coma treated with a ring nger ray amputation and a middle nger metacarpal resection.
B through G, Surgical photographs of the ring
nger amputation. The plans for the volar incision with a llet ap (B) and dorsal incision with
a llet ap (C) are mar ked on the hand. D, Dorsal
dissection. E, The defect after the ray amputation with a llet ap. The specimen has been
disarticulated. Dorsal (F) and palmar (G) views
of the hand after intermetacarpal ligament repair and wound closure.
Thumb Amputation
General Considerations
The thumb accounts for approximately
50% of hand function. A minimum requirement of thumb function is a stable
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
207
Section 2: Upper Limb
Figure 4
marked on the hand. C, The llet ap is raised. D, The fth ray is resected. Palmar (E) and dorsal (F) views of the hand after closure.
post against which objects can be held.
Function is improved if sensation is
present or motion is possible.
Traumatic amputation of the thumb
is considered a strong indication for replantation if possible. Success of thumb
replantation may be limited in the setting of avulsion-type injuries.
Given the devastating effects of proximal level amputation of the thumb, there
has been recent increased emphasis
on thumb-sparing procedures when a
sensate terminal thumb can be reconstructed.
amputated at the metacarpophalangeal
joint, proximal reconstruction options
include toe-to-thumb transfer, index pollicization, and use of a passive prosthesis.
Interphalangeal Thumb
Disarticulation
Interphalangeal thumb disarticulation
is commonly done in the setting of
Surgical photographs of a fth ray amputation with a harvest llet ap. The planned dorsal incision (A) and palmar incision (B) are
7,8
If the entire thumb must be
melanoma, squamous cell carcinoma,
and, less frequently, trauma. Two coverage options are generally considered.
Volar-based flaps and fish-mouth incisions both yield excellent results.
Interphalangeal joint disarticulation is very well tolerated. Although
the thumb is shortened, this rarely
affects general functions such as gripping large objects, and there is only a
small decrease in dexterity. Patients
compensate well for any change in
sensation. Patients rely more heavily
on the combination of visual and tactile sensations when handling small
objects than do those with an intact
thumb.
amputation, and prosthetic use has not
been required.
Interphalangeal amputation coverage
is often dictated by the extent of trauma
or tumor. The use of a large volar flap
is preferred when possible (Figure 7).
If there is excessive palmar skin loss or
contamination, fish-mouth–type incisions are used.
A transverse incision is marked dorsally, often in line with the distal extensor crease. A palmar flap is marked
with longitudinal extensions from the
dorsal transverse incision, which will
allow inclusion of the digital arteries and
nerves in the volar flap. The dorsal incision is made first. Large dorsal veins are
cauterized. The extensor mechanism is
Preferred Techniques of
transected. The collateral ligaments are
transected proximally from the proxi-
In the experience of this chapter’s
authors, thumb lengthening has not
been necessary after interphalangeal
mal phalanx. The volar flap is elevated
superficial to the flexor tendon sheath.
The flexor tendon is transected at the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
208
Chapter 15: Partial Hand Amputation: Surgical Management
A, Illustration showing a planned index and middle ray resection for a malignant
extending into the interphalangeal joint
or for more proximal level trauma.
Postoperative Care and Rehabilitation
A soft, bulky, lightly compressive thumb
spica bandage is applied after surgery.
Sutures are removed after 2 weeks.
level of the interphalangeal joint. The
volar plate is transected, and the amputation is completed. Closure is performed using 5-0 nylon suture, with
great care to approximate the volar flap
without excessive tension, which may
compromise blood flow.
Figure 5
neoplasm. Axial (B) and coronal (C) MRIs demonstrating the extent of the malignant neoplasm.
D through J, Photographs of the double ray amputation. The planned dorsal incision (D) and volar
incision (E) are drawn on th e hand. The hand after d orsal (F) and palmar (G) dissec tion. The resec ted
specimen is removed (H). Dorsal (I) and palmar (J) views of the hand after closure.
Alternative Surgical Techniques
Aesthetic appearance is superior with a
fish-mouth closure; however, sensation
and padding are superior with a volar
flap. More proximal level amputation
through the distal portion of the proximal phalanx may be required for tumors
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
209
Section 2: Upper Limb
analysis. Toe-to-thumb transfer in the
setting of a positive margin will have
a disease-dependent risk of local recurrence and might necessitate amputation of the transferred part.9 If
toe-to-thumb transfer is anticipated, it
is wise to plan the soft-tissue flaps in
advance so that additional uninjured,
uncontaminated tissue can be spared
at the time of disarticulation. This will
facilitate subsequent closure at the time
of reconstruction.
Index pollicization in children for
congenital deformity often has an excellent final appearance. A pollicized index
finger in an adult retains the appearance
of a rotated index finger and does not
have the same aesthetic result as seen in
a child. Toe-to-thumb transfer is often
preferred.
Figure 6
for a soft-tissue tumor. B through D, Surgical photographs of the amputation. B, The volar incision
with a llet ap is marked on the hand. C, The ulnar double ray is resected with a ring llet ap. The
resection incorporated the exor tendons to ring nger. D, Appearance of the hand after tendon
reconstruction and direct closure using dorsal skin.
Physical therapy begins with rangeof-motion and wound desensitization
exercises. Activities are restricted for
approximately 6 weeks and are then resumed as tolerated. Therapy can be very
A, Illustration showing a planned ring and small nger ulnar double ray amputatio n
Metacarpophalangeal
Disarticulation
When there is no other alternative, amputation at the metacarpophalangeal
joint may be required.
helpful in improving manual dexterity
and the development of compensatory and adaptive techniques to facilitate
function.
Outcome Considerations
Metacarpophalangeal disarticulation of
the thumb will result in a major func-
tional deficit. Despite this deficit, some
Managing Complications
Wound desensitization exercises supervised by a therapist are effective
in reducing wound sensitivity, which
tends to gradually lessen over time.
Neuroma- related symptoms and phantom pain are possible but are extremely
uncommon after thumb interphalangeal
disarticulation.
patient will choose to have no recon-
structive procedures and will adapt
and compensate as best as possible. If
a toe-to-thumb reconstruction is being
considered, it is best to stage the re-
construction after amputation done for
malignant bone or soft-tissue tumors
so that negative resection margins can
be confirmed by definitive pathological
Preferred Techniques of
is Chapter’s Authors
Incisions are planned with the reconstructive procedure in mind. Fishmouth flaps are used, with longer flaps,
when possible, if a toe-to-thumb transfer
is anticipated.
The dorsal incision is made distal
to the joint. Large veins are cauterized.
Extensor tendons and sensory nerves
are transected. The dorsal capsule is incised, and the collateral ligaments are
transected. If a toe-to-thumb transfer
is anticipated, larger remnants are left
to allow ligament reconstruction and
retain metacarpophalangeal joint stability after reconstruction. The volar flap
incision is made. Digital nerves are identified, anesthetized with bupivacaine
hydrochloride and transected. Digital
arteries are cauterized and transected.
The flexor pollicis longus and the volar
plate are transected, and the amputation
is completed. The wound is closed with
5-0 nylon suture.
Alternative Surgical Techniques
When a toe-to-thumb transfer is anticipated, nerves and vessels are tagged to
facilitate identification at reconstruction.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
210
Chapter 15: Partial Hand Amputation: Surgical Management
Figure 7
eral (B) and palmar (C) views of the planned amputation and volar ap drawn on the thumb. Dorsal (D) and lateral (E) views of the thumb after the
interphalangeal disarticulation and closure.
Vessels are ligated with hemoclips, and
nerves and vessels are transected more
distally.
Osseointegrated implants for the
thumb have been described.10 After
amputation, a titanium peg is implanted into the distal metacarpal. After
skin maturation, a passive prosthesis
can be readily attached to the thumb
metacarpal.
Postoperative Care and Rehabilitation
After surgery the hand is bandaged and
the digits are kept free. Digit range of
motion is encouraged. Sutures are removed after 2 weeks. Therapy can be
beneficial for first web space stretching
to avoid adduction contractures. A passive rigid prosthesis may be considered.
Photographs of a thumb interphalangeal disarticulation with volar ap closure. A, Subungual melanoma of the thumb is shown. Lat-
Summary
Partial hand amputations may be performed to treat patients after traumatic
injury, infection, or malignant bone
References
1. Talbot SG, Mehrara BJ, Disa JJ, et al:
So-tissue coverage of the hand
following sarcoma resection. Plast
and soft-tissue tumors. When possible, the functional and cosmetic deficits of the planned procedure should
be discussed with the patient prior to
surgery. Surgical considerations will
depend on the etiology, the extent of
the surgery (such as single ray, double
ray, or thumb amputation), the status
of soft-tissues, and the general health
of the patient. To obtain optimal outcomes, the surgeon should be familiar
with established and alternative surgical techniques.
Medline DOI
2. Steichen JB, Idler RS: Results of
central ray resection without bony
transposition. J Hand Surg Am
1986;11(4):466-474. Medline DOI
3. Puhaindran ME, Healey JH, Athanasian EA: Single ray amputation
for tumors of the hand. Clin Orthop
Medline DOI
4. Puhaindran ME, Athanasian
EA: Double ray amputation for
tumors of the hand. Clin Orthop
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