Overview of Hand Amputation
Hand amputation, or removing a part or all of a hand, is a challenging medical procedure with significant impact on a person’s life and on the healthcare system. In the USA, more than 1.7 million people have had limbs removed, a figure that is expected to continue rising. Close to 70% of upper limb amputations, those involving the arms, occur below the elbow, and about 10% are on the hand or wrist.
In the past, removing a person’s hand was seen as a final option, performed only when everything else had failed. It was often seen as a crude procedure. However, now it is understood as a potentially beneficial surgery that can save a person’s life or their other limbs. The focus when amputating a hand is to keep as much of the limb as possible to retain some function, maximize the function of the remaining limb, and minimize side effects like phantom limb pain (pain that feels like it’s coming from a body part that’s no longer there) and neuroma formation (a growth or tumor of nerve tissue).
Anatomy and Physiology of Hand Amputation
Understanding the makeup of the hand and wrist is key when performing a hand amputation. The hand and wrist have many small parts that all work together.
Let’s start with the fingers, or ‘digits.’ Each finger (except for the thumb) has three parts or ‘phalanges:’ the proximal (closest to the hand), middle, and distal (furthest from the hand). These all bend at different joints. The thumb is a bit different – it doesn’t have a middle part and has its unique inner workings. All fingers end in a nail that overlays the nail bed of the distal phalanx. A mix of soft tissues helps stabilize the finger at these joints.
Inside our fingers, we have flexor tendons – this is what makes them bend. These tendons connect in two places, each responsible for bending at different parts of the finger. As they travel through the digit, they pass through a series of rings called ‘pulleys’ that guide the tendon. On the backside, there are extensor tendons that straighten our fingers. The thumb again differs here, having only one primary flexor and extensor tendon each.
Now let’s talk about the palm and wrist. The palm is made up of five ‘metacarpals’ and houses a number of different muscles. The wrist consists of eight small bones known as ‘carpals.’ These are arranged in two rows and connect with the forearm bones. Many ligaments (bands of soft tissue that connect bones to other bones) ensure that these bones interact properly. The flexor tendons of the finger travel through a structure called the ‘carpal tunnel’ as they pass into the palm and wrist. On the back of the wrist, the extensor tendons pass through a series of compartments.
Lastly, it’s vital to discuss the neurovascular structures, or the nerves and blood vessels in the hand. These are set up in a branching pattern, with the major nerves running deep within the hand and serving different functions. Blood supply for the hand comes from the radial and ulnar arteries. These form the ‘superficial and deep palmar arches’ which further branches into smaller arteries to supply the fingers.
Why do People Need Hand Amputation
A hand amputation, or the removal of part or all of a hand, might be needed due to a number of different health conditions and issues. These might include:
– Serious injuries that can’t be fixed by reattaching (or replanting) the hand.
– Dry or wet gangrene, which is a condition where tissue in your body dies because it’s not getting enough blood.
– Infections that cannot be controlled.
– Severe contractures or deformities that greatly affect the use of the hand. ‘Contracture’ means that your muscles, tendons, or other tissues get shorter or stiffer, making movement difficult.
– Frostbite, a condition where skin and the tissue under it freeze.
– Cancers found in the hand or a finger.
– Disease affecting the body’s blood vessels, especially if it’s related to end-stage kidney disease that needs dialysis (a treatment to filter and clean the blood).
– Poorly managed diabetes that leads to the formation of nonhealing ulcers or sores.
– Complex regional pain syndrome (a type of chronic pain condition) that doesn’t respond to other types of treatment.
– Previous attempts to replant the hand or finger that were unsuccessful.
When a Person Should Avoid Hand Amputation
The main reason why a doctor might choose not to amputate a hand is if there’s a good chance the hand or finger will work better if it’s not removed. In such cases, other treatments might be needed to ensure this better outcome.
Equipment used for Hand Amputation
When performing a hand or finger amputation, the type of equipment used can change depending on what the surgeon prefers and the specifics of the surgery itself. Nevertheless, a lot of the tools used in these surgeries are the same. Here’s a list of some of them:
Littler scissors: These are sharp, precision tools used for cutting tissue.
Adson forceps: This tool is like a tweezer but it has a more precise grip. They’re used to hold and adjust small pieces of tissue.
15-blade scalpel: This is a very sharp knife that doctors use to make the cuts during surgery.
Rongeur: This tool is used to cut and trim the bone.
Retractors, such as Ragnells: These tools are used to hold the skin and other tissues away from the area the surgeon is working on. This helps to create a clearer view and more space.
Oscillating bone saw: Surgeons use this tool to cut through bones. It moves back and forth very quickly, which allows it to cut smoothly.
Needle driver: This is a tool that holds the needle while the surgeon is stitching up the wound.
Sutures: These are the threads used by the surgeon to stitch the wound closed. They come in different sizes (such as 4-0 or 5-0 nylon, 4-0 vicryl, 4-0 or 5-0 chromic, 2-0 silk).
Suture scissors: These scissors are used to cut the sutures to the right length.
Tourniquet: This is a device that’s wrapped around the arm above the hand being operated on. It stops the blood flow and allows the surgeon to work without a lot of bleeding. The size of the tourniquet will depend on the surgery (18-inch or larger as needed).
Bipolar electrocautery: This tool uses electricity to cut or seal blood vessels, which helps reduce bleeding.
Suction with a neuro tip: This tool sucks away vital fluids produced during surgery. The neuro tip is particularly helpful in delicate and precise surgical procedures.
Irrigation (normal saline): This is a salt water solution that is frequently used to clean the area during surgery.
Mini C-arm: This device provides real-time X-ray images during the operation, allowing the surgeon to make sure everything is going as planned.
Dressing supplies: These are used to cover and protect the surgical area after the operation.
Who is needed to perform Hand Amputation?
If you need a hand amputation, various healthcare professionals will take care of you. The main doctor, often called a surgeon, could be a specialist in bones (an orthopedist), a skin and reconstruction expert (a plastic surgeon), or sometimes, a blood vessel expert (a vascular surgeon). These surgeons have additional training specifically for hand and arm surgeries. No matter their specific specialty, the surgeon will take care of your needs from before the operation to after it’s completed.
Other healthcare professionals will also assist at different stages of your treatment. Here’s how it typically works:
Before Surgery – Doctors specializing in emergencies, general health, or infections, may first discover the issue with your hand that requires amputation. These doctors may then ask a surgeon to evaluate your situation further.
During Surgery – An anesthesiologist, who is a doctor that specializes in making sure you don’t feel pain during an operation, will give you medicine to make you sleepy and numb. Another healthcare worker may help the surgeon by holding your hand and arm in the right position during the operation.
After Surgery – Members of the wound care team will recommend specific coverings that can help your surgery site heal better. Hand therapists will also be key in helping you adapt your life after the operation. They will show you how to use the remainder of your arm, and they can help you adjust your daily routines. Depending on where the amputation was done, you may also see a prosthetist, a specialist who can create and fit artificial body parts (prosthetics). They can assist you in obtaining and learning to use an artificial hand or arm if you need one.
Preparing for Hand Amputation
Before a doctor carries out a hand amputation, they will collect a detailed medical history and perform a careful check-up. It is important to know if the patient uses tobacco, steroids, medicines that suppress the immune system, or blood thinners, because these can impact how well wounds heal and increase the risk of infections after the procedure. If the patient has diabetes, the doctor will want to know their recent blood sugar control levels as poor control can also lead to delayed wound healing and infections. The doctor will also ask about any other health condition that could potentially worsen due to amputation, such as gout and rheumatoid arthritis.
Next, the doctor will examine the entire arm, paying close attention to signs of infection, and assess how well the arm is moving. They will check the quality of the tissue around the area where the hand is to be amputated to plan exactly where to make the cut and how much of the arm needs to be removed. If the doctor has doubts about the health of any tissue and if the amputation is not an emergency, they might wait to see exactly which tissue is healthy and which is not.
Imaging studies like X-rays or MRI scans are usually done before the surgery. These pictures of the hand, wrist, and forearm help the doctor understand the condition better and look for signs of bone infection or other problems. If there is a concern about blood flow to the hand, a special kind of ultrasound might be done. All these steps are to ensure that the decision to amputate, and how much of the hand or arm to remove, is the best one under the current circumstances.
How is Hand Amputation performed
There are three main types of hand amputation surgeries: primary digital amputation, revision amputation, and wrist disarticulation. These procedures aim to maintain as much length as possible, cover the remaining part with skin that can feel, prevent painful nerve growths, and preserve function in the hand. Here’s a simplified explanation of each procedure:
Primary Digital Amputation
This procedure is done when a finger cannot be saved. The procedures begin with making the patient comfortable, usually lying flat, and applying a device to the upper part of the arm to minimize blood flow to the area during surgery. Then the type of anesthesia chosen by the surgery and anesthesia teams is administered. The area is then cleaned and prepped for surgery.
The surgery starts by making a circular cut around the affected finger. The cut is carefully deepened, revealing the structures below the skin. Then a deeper cut is made to free the tendons and nerves from the surrounding tissue. Extreme care is taken with the nerves to prevent the formation of painful nerve growths.
The bone is then cut using a special bone-cutting tool. If possible, the cut is made in such a way as to preserve the joint closest to the wrist. If the condition requires a more drastic cut, then the joint closest to the wrist is completely separated. Then the removed digit might be sent for further examination.
Next, the remaining flaps of skin are brought together to cover the remaining part of the finger. The skin is stitched together using special thread. If it’s not possible to bring the skin together, skin grafting or other techniques might be used. Lastly, a protective dressing and splint might be applied.
After the surgery, patients are instructed to keep their hand elevated and avoid lifting activities to control swelling. They are also monitored for healing, which usually takes 2 to 3 weeks. Once healing is confirmed, therapy is started to restore the motion and strength of the hand.
Revision (Digital) Amputation
This type of amputation is done if a finger has been severely damaged and cannot be reattached. It’s done to revise the damaged part and ensure its proper healing. The procedure is often carried out in the emergency room. The process is very similar to a primary digital amputation and follows the same postoperative procedures.
Wrist Disarticulation
This is an amputation that occurs at the wrist and is done in patients with severe hand damage. This procedure will be outlined in a separate section.
Possible Complications of Hand Amputation
After having a hand amputated, a person may experience a variety of problems. Some of these complications are common after many different types of upper arm surgeries, while others are more unique to limb removal operations.
Some people may feel a “phantom limb,” where it feels like the amputated hand is still there. This tingling sensation is not usually painful, and it’s fairly common. Usually, just reassuring the person is enough treatment.
“Phantom pain” is different. It’s a sort neuropathic pain that feels sharp, crushing, burning, or cramping, and it’s in the part of the arm where the hand used to be. This can be treated with medications, nerve blocking injections, botulinum toxin therapy (which is related to Botox), techniques that modify the brain’s response to nerve signals, or in some cases surgery.
Another possible problem is when a neuroma forms. A neuroma is a painful lump that can develop where a nerve was cut during the amputation. This risk can be lessened depending on how the surgery is done. If a neuroma does form, it can be treated with medications, certain forms of therapy, or, if necessary, more surgery.
As with any operation, there’s a risk of infection after hand amputation. This could hinder wound healing, create an abscess, or lead to osteomyelitis, which is an infection in the bone. Antibiotics and good wound care can reduce this risk.
Edema — or swelling — can happen in the days and weeks after surgery. This might cause more pain and affect wound healing. Making sure to keep the arm elevated can help lower swelling, and once the wound has healed, compression bandages and massage can further reduce swelling.
Wound dehiscence, where the wound comes apart, or delayed wound healing can also occur. This might be due to the infection, swelling, continued bleeding, or health factors like diabetes, weak blood vessels, use of immunosuppressive drugs and steroids, and smoking. Taking care of the wound and maybe more minor operations can help the wound heal.
If the surgeons use a flap of tissue to close the wound, it could die before it heals. This could be caused vasospasm, which is a narrowing blood vessels leading to a blood clot at the site of connection. Prompt treatment can lower the risk of more surgery.
The person might have limited movement in the joints closest to the amputation, because of swelling, not using the joint, or the arm being held still for a long time. If the amputation was close to the wrist, the person might also struggle to turn their hand palm-up or palm-down.
Finally, losing a limb can also have a psychological impact. A person may feel emotional distress, may prefer to be alone, and may struggle to fulfill their usual roles in life. Counsellors can provide a lot of help with these issues.
What Else Should I Know About Hand Amputation?
Hand amputations, or the medical process of removing a part of the hand, can significantly affect a person’s life, both in terms of how their hands function and how they look. A hand has three main parts that help us perform different tasks. These include the thumb, which allows us to grasp things; the index and middle fingers, which help us pinch or hold small items; and the ring and small fingers, which assist us to grip larger objects.
If any part of your hand is amputated, you may find it harder to do these tasks. This can affect the way you physically interact with the world, and it can also impact your mental and emotional wellbeing. Your social life could also be affected. And there’s also the aesthetic aspect – losing a part of your hand could make you feel self-conscious about how you look.
That’s why the doctors pay careful attention before, during, and after the surgery. They plan thoroughly to ensure the best possible outcome, use the most appropriate surgical techniques during the operation, and make sure that the follow-up care after the surgery is meticulous. This all helps to minimize the impact of the amputation and to help you get the best possible quality of life.
