finger and thumb amputations are unfortunately common. Replantation
of amputations at any level from shoulder to fingertip pulp is technically
possible and has been performed for years. Replantation is a considerable
undertaking, more so for the patient than for the surgeon, because it usually
involves a prolonged recovery period, often multiple operations, intensive
therapy and when complete, it is realistic to expect only partial recovery
of range of motion and sensation. If replantation is a consideration, a
regional center performing replantation surgery should be contacted to
confirm with the receiving surgeon that referral for replantation is appropriate
and that such services will be available. Replantation obviously does not
take precedence over potentially life-threatening injuries, and particularly
in a blunt trauma scenario such as a motor vehicle accident, the drama
of the amputation should not be allowe d to curtail thorough evaluation
for other more dangerous injuries.
If replantation is not performed, amputation wounds may require skeletal shortening for simple primary closure. Skeletal shortening should be avoided in the digits if possible, for a relatively small loss of length may critically change the functional outcome of the digit. Fingertip amputation is the most common situation to test the knowledge and ingenuity of the surgeon. Pure soft tissue fingertip defects measuring 1 cm in diameter or less may be treated with dressing changes, allowing the wound to heal by secondary intent. If the defect extends to the distal nail bed, the scar will come to lie beneath the fingernail and may not be visible. Larger defects or those in which bone is exposed require flap cover. Many flaps have been described for fingertip cover. The three most common and useful regional flaps for fingertip cover are the central V-Y palmar advancement flap, the thenar flap, and the dorsal cross finger fla p (Fig. 21). The three most common and useful regional flaps for thumb tip cover are the Moberg palmar advancement flap, dorsal cross finger flap from the index finger, and neurovascular island flap (Fig. 22a) (Fig. 22b) (Fig. 22c) (Fig. 22d).