FINGER AND EXTREMITY AMPUTATIONS

Amputations are divided into two groups as total and partial amputations. The organ (finger, hand or arm) is completely separated from the body in total amputations and the amputated part shall be immediately sutured to its place as all vessels are severed. Continuity of the organ with the body continues in partial amputations and only a part is cut. If vessels are stable, as vitality of the damaged part continues, transportation of the patient to the hospital is less important than those with total amputations. The most important factor for success of the surgical treatment is to transmit the patient and the part to the facility as soon as possible in both circumstances. Replantation is called to suture the severed organ on its place. To suture the organ on it place is not possible in all circumstances. General condition of the patient, status of the severed part, transportation period of the patient to a health facility, current technical options are factors that are effective to perform the procedure.

The priority in severe injuries that damages other systems of the patient such as in traffic accidents is to focus on the vital risk. If there is a vital risk in the patient or replantation may cause a vital risk, this procedure should not be done.

If the damage is much in the severed organ due to contusion or fragmentation, replantation may not be performed. The rate of success in amputations with sharp cutters such as knife, chopper is higher than amputations by pulling due to compression under press or tripping.

Additional conditions such as smoking, diabetes, heart diseases, blood pressure diseases effects the treatment adversely. Also, success may be less in old patients than young and middle age patients.

Severed part should be sutured on its place within 2 hours in ideal conditions. When amputation level reaches to the finger tip, this period may increase up to 6-12 hours, if amputated part is stored in suitable conditions. As specified above, the patient should be immediately transported to the hospital. As the amputation level approaches to the end, due to small vessels to be sutured; quality of the technical equipment and experience in microsurgery become more important. On the other hand, functional results are better when the severed part is treated properly in end level amputations.

Replantation and after period requires perseverance both for the patient and the surgeon. While a replantation procedure may last for 2-14 hours according to the severance level, if severed part is more than one (4-5 fingers or severance of both arms) this period may increase. Recovery period also may vary between 2 months and 2 years according to the level of severance. Also further operations may be required to provide function after the severed part is kept alive.

It should be remembered that, replantation process may not be performed in every health centre. Patients should apply to a microsurgery centre where special microsurgery tools and operation microscope exists with a microsurgery and hand surgery specialist. Unfortunately, such centers are not many either in Istanbul or in Turkey.

DUPUYTREN`S DISEASE

It is abnormal thickening of the fascia which is just under the palmar skin and protects the passing tendon, nerve and vessel structures. Fascia thickening starts from palm and extends to the fingers. In advanced terms of the disease, distortion through the palm and some hardness called nodules arise. (Figure 1)

This disease may be also seen in the sole and penis.

It is usually observed in men over 40. While observation frequency is more in diabetic patients, relationship with other occupational diseases is not proven. It may affect all fingers as well as frequent in small and middle finger.

Swelling and bending increase are seen in the examination. Cord shaped thickened indurations related with swellings are handled in the palm. Distortion due to cord pulling occurs in finger in advanced terms of the disease. Both hands are affected in most patients. If the disease starts in the early age, it progresses more serious.

Palmar nodules formed due to dupuytren`s disease are typically painless. The disease is first noticed with disability to put the palm on flat surfaces. When distortion increases more and more, difficulty in some movements such as hand washing, hand shaking, wearing gloves, holding something etc. occurs. Progress rate changes from patient to patient.

If functions of the patient in the initial term are not affected, the patient is followed. If there is no distortion on fingers, existence of nodules does not require the surgery. Steroid injection on nodules may decrease the progress rate of the disease in these cases. In cases that fingers distort 70 degrees and over, surgery is considered. The purpose for surgery is to remove hardened fascia extending to the palm and fingers by protecting the vessel and nerve structures. Deficiencies that may arise in the skin cover after removal of the hardened bands are solved by skin grafts taken from other parts of the body. Brace application after the surgery and physical treatment are very important in terms of success of the treatment.

Source: dupuytren's disease