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A simple plastic procedure of the fingers for conserving bony tissue and forming a soft tissue pad
A SIMPLE PLASTIC PROCEDURE OF THE FINGERS FOR CONSERVING BONY TISSUE AND FORMING A SOFT TISSUE PAD EDWIN DEJONGH, M.D. DETROIT, MICHIGAN
T
HIS procedure is to move a section of paImar surface skin to the amputated end of the finger. It has been sug-
axis of the finger, the operation chance for success.
has a good
PROCEDURE
FIG. I. Drawing illustrates line of incision forming palmar skin section.
gested that this method has appeared in the literature. The writer has been unable to find it. In America’s Iarge industria1 pIants, amputation is approaching a rarity. In the smaIIer jobbing shops, where safety departments are Iess efficient, this injury is stiI1 sadIy common. The writer has had rather discouraging results with the free graft in industry. NeedIess to say, a11 digit amputations wiI1 not submit to this pIastic operation. GeneraIIy speaking, an amputation through a nai1, if the proxima1 part of the nai1 or its bed, remains and if the transverse Iine of amputation is not too obhque with the long 346
On admission to the pIant hospita1 the base of the finger is cIeansed with benzine, green soap, aIcoho1 and mercresin, care being taken not to get any of these into the open wound. Then I per cent novocaine is injected at the base of the finger, about 2 to 2% cc. in each side, using care to get enough near the dorsa1 aspect of the finger. RareIy is more than a tota of 5 cc. required. Following this the Iesion is scrubbed with greensoap as is the remainder of the finger. This is foIIowed by aIcoho1 and mercresin after which the arm, hand and finger are draped. The wound is debrided. The end of the remaining part of the dista1 phaIanx is trimmed and the edges rounded and smoothed. OccasionalIy, the paImar edge may have to be trimmed back further than the extensor edge. This, of course, is determined by the dkbridement necessary. In some cases a smaI1 section of remaining dista1 phaIanx may have to be removed. Next a transverse incision is made on the palmar surface about 3is to x inch, (6 to 7 mm.), proxima1 and paraIIe1 to the edge of the amputation. The incision is extended from the midIatera1 point on one side to the same point on the other side. (Fig. I .) The depth of the incision is not diffIcuIt to determine. It is carried down through the layers of the skin and just into the areoIar tissue. A transverse section or strip of skin is free to be moved over the end though it is stiI1 attached on both its Iateral ends. Under-cutting is not necessary. AI1 that now remains to be done is to move the section distaIward and dorsaIIy so it covers the end of the finger. This is
NEW SERIESVOL. LVII, No. z
DeJongh-Procedure
easiIy done with three, rareIy more, linen sutures. The sutures are passed through the nail or its bed, and through the skin section
for Fingers
AmericanJournalof Surgery
347
the tip of the finger. The pad was not as thick as usua1 due to lack of depth of the transverse paImar surface incision. However, it did not
FIG. 4. FIG. 3. FIG. 2. FIG. 2. Left second linger of Mr. T. M. on August 25, 1941, about five minutes after traumatic amputation. Fro. 3. Left second finger of Mr. T. M. on September 26. Note difficuIty in determining scar left by moving skin section. FIG. 4. Left second finger of Mr. T. M. on September 26. Note small lateral distal fragment of old nai1 remaining.
near the distaI edge and drawn up tight under the nai1 or to the bed. The denuded area just proxima1 to the proxima1 edge of the skin section granulates in we11 and rapidIy. The smaI1 scar formed, though it is on the ffexor surface, is not tender and has caused no inconvenience. A Vaseline gauze dressing covers the entire finger. The first dressing is done in five days and the sutures are removed about the eighth or ninth dav. If removed too soon, the skin section wiI1 move toward its origina position. The nail usuaIIy sIoughs and a new one forms. The new nai1 wiI1 be shorter than its fellow and predecessor but wiII bear a proportional ength to its finger. The average heaIing time is twenty to twenty-five days with the disabiIity depending on the patient and the abiIity of the department to place him for the first four to six postoperative days. One possibIe faiIure out of twenty eight cases was noted: J. W., a nineteen-year old female, factory worker, was operated upon in the manner described. However, in addition, a free spIit thickness graft was taken from the thigh and sutured on the denuded area. The graft did not take. The donor area heaIed as usual and required onty steriIe Vaseline gauze dressings. After the graft sIoughed the denuded area heaIed as usua1. Three weeks after her discharge, she returned, compIaining of pain at
appear to be unduly thin. There was no evidence of an amputation neuroma. The patient was asked to give the finger a tria1 for some time, perhaps a month, and return to the cIinic if she stiI1 had diffrcuIty. She has not been seen since. The remaining twenty-seven patients heaIed rapidly. The final results were similar to those shown in Figures 2, 3 and 4. Patients are eager to avoid Ioss of appreciabIe finger Iength and Ioss of the nail. The cosmetic resuIt is happily accepted. There seems to be evidence that grafting the denuded area is of no vaIue in improving the hna1 resuIt or in decreasing the heaIing time. Th e writer prefers not to graft. The risk to the operation is no greater than that invoIved in any nerve bIocking procedure and the same precautions should be observed. In case of a faiIure the finger can be amputated and cIosed with a palmar flap. CONCLUSIONS
A bone conserving pIastic procedure is presented which is simpIe and requires no specia1 ski11 or instruments. Disability is not Iong. There is little, if any, risk; and the final resuIt is a good finger functionally and cosmetically.
T
HIS procedure is to move a section of paImar surface skin to the amputated end of the finger. It has been sug-
axis of the finger, the operation chance for success.
has a good
PROCEDURE
FIG. I. Drawing illustrates line of incision forming palmar skin section.
gested that this method has appeared in the literature. The writer has been unable to find it. In America’s Iarge industria1 pIants, amputation is approaching a rarity. In the smaIIer jobbing shops, where safety departments are Iess efficient, this injury is stiI1 sadIy common. The writer has had rather discouraging results with the free graft in industry. NeedIess to say, a11 digit amputations wiI1 not submit to this pIastic operation. GeneraIIy speaking, an amputation through a nai1, if the proxima1 part of the nai1 or its bed, remains and if the transverse Iine of amputation is not too obhque with the long 346
On admission to the pIant hospita1 the base of the finger is cIeansed with benzine, green soap, aIcoho1 and mercresin, care being taken not to get any of these into the open wound. Then I per cent novocaine is injected at the base of the finger, about 2 to 2% cc. in each side, using care to get enough near the dorsa1 aspect of the finger. RareIy is more than a tota of 5 cc. required. Following this the Iesion is scrubbed with greensoap as is the remainder of the finger. This is foIIowed by aIcoho1 and mercresin after which the arm, hand and finger are draped. The wound is debrided. The end of the remaining part of the dista1 phaIanx is trimmed and the edges rounded and smoothed. OccasionalIy, the paImar edge may have to be trimmed back further than the extensor edge. This, of course, is determined by the dkbridement necessary. In some cases a smaI1 section of remaining dista1 phaIanx may have to be removed. Next a transverse incision is made on the palmar surface about 3is to x inch, (6 to 7 mm.), proxima1 and paraIIe1 to the edge of the amputation. The incision is extended from the midIatera1 point on one side to the same point on the other side. (Fig. I .) The depth of the incision is not diffIcuIt to determine. It is carried down through the layers of the skin and just into the areoIar tissue. A transverse section or strip of skin is free to be moved over the end though it is stiI1 attached on both its Iateral ends. Under-cutting is not necessary. AI1 that now remains to be done is to move the section distaIward and dorsaIIy so it covers the end of the finger. This is
NEW SERIESVOL. LVII, No. z
DeJongh-Procedure
easiIy done with three, rareIy more, linen sutures. The sutures are passed through the nail or its bed, and through the skin section
for Fingers
AmericanJournalof Surgery
347
the tip of the finger. The pad was not as thick as usua1 due to lack of depth of the transverse paImar surface incision. However, it did not
FIG. 4. FIG. 3. FIG. 2. FIG. 2. Left second linger of Mr. T. M. on August 25, 1941, about five minutes after traumatic amputation. Fro. 3. Left second finger of Mr. T. M. on September 26. Note difficuIty in determining scar left by moving skin section. FIG. 4. Left second finger of Mr. T. M. on September 26. Note small lateral distal fragment of old nai1 remaining.
near the distaI edge and drawn up tight under the nai1 or to the bed. The denuded area just proxima1 to the proxima1 edge of the skin section granulates in we11 and rapidIy. The smaI1 scar formed, though it is on the ffexor surface, is not tender and has caused no inconvenience. A Vaseline gauze dressing covers the entire finger. The first dressing is done in five days and the sutures are removed about the eighth or ninth dav. If removed too soon, the skin section wiI1 move toward its origina position. The nail usuaIIy sIoughs and a new one forms. The new nai1 wiI1 be shorter than its fellow and predecessor but wiII bear a proportional ength to its finger. The average heaIing time is twenty to twenty-five days with the disabiIity depending on the patient and the abiIity of the department to place him for the first four to six postoperative days. One possibIe faiIure out of twenty eight cases was noted: J. W., a nineteen-year old female, factory worker, was operated upon in the manner described. However, in addition, a free spIit thickness graft was taken from the thigh and sutured on the denuded area. The graft did not take. The donor area heaIed as usual and required onty steriIe Vaseline gauze dressings. After the graft sIoughed the denuded area heaIed as usua1. Three weeks after her discharge, she returned, compIaining of pain at
appear to be unduly thin. There was no evidence of an amputation neuroma. The patient was asked to give the finger a tria1 for some time, perhaps a month, and return to the cIinic if she stiI1 had diffrcuIty. She has not been seen since. The remaining twenty-seven patients heaIed rapidly. The final results were similar to those shown in Figures 2, 3 and 4. Patients are eager to avoid Ioss of appreciabIe finger Iength and Ioss of the nail. The cosmetic resuIt is happily accepted. There seems to be evidence that grafting the denuded area is of no vaIue in improving the hna1 resuIt or in decreasing the heaIing time. Th e writer prefers not to graft. The risk to the operation is no greater than that invoIved in any nerve bIocking procedure and the same precautions should be observed. In case of a faiIure the finger can be amputated and cIosed with a palmar flap. CONCLUSIONS
A bone conserving pIastic procedure is presented which is simpIe and requires no specia1 ski11 or instruments. Disability is not Iong. There is little, if any, risk; and the final resuIt is a good finger functionally and cosmetically.