My name is Kevin and on Sunday, August 15, 2016, I amputated my fingertip with the tablesaw. My fingertip is healed now, but I had an awful experience because I never got clear instruction in wound management, because of a lack of continuity of treatment from one doctor to the next.
So much depends on pure luck, who you get at the ER and can they, in time they have, tell you just what you need to succeed at the next ten to twenty weeks. Often, it is up to your family physician or whoever happens to be available to see you. For a musician, ‘good enough’ may not be good enough, so it is really up to you. Even specialists may not be the most up-to-date on wound management. The nurses, who do most of the bandaging, may know more.
I have found, as the patient, that my job is to bring out the best in my doctor by being a good patient, namely by doing what they say. There is no such thing as ‘too many questions’. Don’t assume you know anything, ask. And then, there is the “second opinion”. It never hurts to get a second opinon, they say.
My occupation is classical guitarist, and I may require further surgeries, which I hoped to avoid. However, I had the good luck to be seen by an ER doc who knew exactly what to do and say. She said, with my level of injury, I could expect the fingertip to grow back. So I hoped for the best. That is what you need, hope, so you will do what needs to be done for the next ten weeks to fourteen weeks. She also said I should see a specialist within 3-4 days, which is harder than it sounds.
The specialist for fingertip amputations is a surgeon. I asked my friend who is a MD, who worked at a major rehab hospital, and she said, “the treatment for fingertip amputation is the same as burn wound management”. And, she said, Shriner’s Hospital specializes in burns. But, if you go to Shriners, they will refer you to a hand surgeons. Unless there is something the sugeon can do for you, what you want, at this point, is a specialist in wound management. So try to stay focused on wound management, not surgery, is my advice: burn wound management. Remember, the treatment for fingertip amputation is the same as burn wound management. If you want to skip my story and read something really important, go to straight to Dr. Nelson’s Fingertip Amputations: Notes for Surgeons.
The goal of burn wound management is no scarring, no infection, and fastest healing. Treatment where the body heals itself is called “healing by secondary intention”. And the fastest (40% faster), easiest (fewest dressing changes) such wound management is called “moist healing”.
When it comes down to choosing which dressing to use, there are 21 different dressings I found, and they all come out about the same. The difference is some take longer. The studies don’t say which has the least scarring and best outcome, just how long. So it is up to you to reduce scaring. In this regard, (secondary intention) moist healing, is your friend.
Moist healing has been known for thousands of years, in which the wound is wrapped up in an occlusive (seals everything in) or semi-occulsive (breathes and passes moisture) dressing. The fingertip is sealed, kept moist, and allowed to heal in the body’s own juices. The body exudes what you need to heal, called “exudate” (it is white and is not pus.) Honey is and has been used, with its anti-bacterial properties. And it took me weeks to find all this out.
If you just had this injury, get the wound cleaned and debrided (loose tissue removed, if necessary). Then, all you need for moist healing is a product called Tegaderm. Seal it with Tegaderm, wrap it up in gauze, and leave it for five days ot even ten days. Moist healing has even been found to be effective in more severe injuries than just first-level fingertip amputation. If your doctor advises against moist healing, do not be afraid to ask why and do not be afraid to ask for a second opinion, is my advice.
The problem I had was they see so many of these, and they understand that you are stressed out and probably won’t remember anything they say. So they just tell you what they think you might remember, which is not much. Which is why you need is a plan. If have some to help you change s dre wound management, with a timetable, how often and when. Do not use anti-bacterial soap, iodine or hydrogen peroxide. And, there are nutritional things you can do to 1) stimulate the bodies production of growth hormone (stops after age 11) and, 2) promote good circulation. If this happened to you, you can skip my story and go straight to wound management and moist healing. This is what happened to me:
When I left the ER, they gave me a bag of dressings. As I left, a nurse said, “that doesn’t look like enough”. They were things I could not find at my local pharmacy when I ran out. That was my first hint.
And, after I left the ER, continuity of treatment stopped immediately, within 24 hours. From then on, I was seen by a series of doctors, surgeons, and PA’s, each of whom had a different idea of wound management, gave no written instructions, and used products I could not find in my local pharmacies.
On Monday, my PCP was too busy to see me right away, so I saw another nice physician in the office who offered to stitch it closed for me, which I declined. Putting stitches in a simple, first-level fingertip amputation which will grow back on it’s own is unnecessary. This is a common practice in some parts of the world that might be considered “barbaric”. But you don’t mention that to your doctor while they are working on you, if you want the best work, so I just said “No, thank you”.
They bandaged it and told me to change the dressing in three days. It was Tuesday so I said “On Friday?” and they said, “No, on Thursday. Or, in other words, not after three days but “in three days”. It seems like a simple thing, change the dressing in three days, not after three days. Seems funny now, but those were the only instructions I got, change the dressing in three days, on Thursday. Not on Friday, in three days.
And then, when I called the specialist, they were on vacation until September. Only, no one told me that the reason I had to wait was there was no one available in the office to see me. They only said to make an appointment in September. And then, it was not to see the specialist, the way the ER doc said, it was the surgeon’s Physician’s Assistant. And it was five weeks away, which is at the end of the eight week period when any intervention is possible. But it is important to see the specialist after any intervention is possible.
So, when I finally saw the P.A., they announced that they would not be giving me notes and proceeded to give me instructions. By now, I knew enough to bring a pad of paper and take notes and ask questions (hoping I would ask the right questions). And I received another bag of dressings, with more things that I ran out of and could not find in my local pharmacy. Wahoo!
And the P.A. put me on band-aids, said to run it under the shower in the morning and let it dry. Never checked my occupation, the wound was still exuding.
When I finally saw the surgeon, at week seven, the surgeon did not determine the date of the injury. I explained my concern with scarring from dessication (dead tissue from drying out) and scabbing, and they switched me from the dry dressing the P.A. put me on to Vaseline petroleum jelly to maintain moisture. The surgeon said I could expect a v-shaped fingertip from scarring, which was what I hoped to avoid.
So, if you are still reading this… Fingertip amputation is one of the most common ER cases. I am a classical guitarist and my hands are my life. But, by the time I saw the specialist, the eight-week period when anything could have been done to improve my outcome had passed. I recieved four different versions of wound management, within days. Looking back, I did everything wrong. Every possible thing, wrong. And now I have scarring and an uneven fingertip shape that may require further surgeries, if I have the patient to undergo another ten to fifteen week recovery. During this time, I found that obtaining continuity of treatment is impossible. Even with talking to the top surgeons in the field, th best in the world (no names), information on fingertip wound management is scattered and hard to find.
If you had this injury, I hope you get clear instructions for wound care at each stage of the healing process. Based on current, up-to-date knowledge and appropriate to your occupation.So you have the best possible outcome with the least scarring and further surgeries. So that you know what to expect and when..
There are things you can do such as nutrition (Argenine, 9 gr a day with fish oil, to stimulate production of growth hormones) and movement (don’t leave the spint on after work, keep moving). And what not to do — no bacterial soap, keep the tegaderm on longer than you think. The goal is the fastest healing with the least scarring. With good wound management, which is the simplest, really, you can the best finger shape, and without the agony of not knowing. In general, the body does the healing, called “secondary intention”. As my MD friend says, time is the greatest healer. [If you let it.]
The usual treatment for fingertip amputation is called “healing by secondary intention”, where the body regenerates the structure by itself. The fingertip is the only part of the body that will rebuild itself like this. The treatment for fingertip amputation is the same as for burns, in which the wound is sealed in a dressing and allowed to stew in its own juices. There are three stages of healing, which often overlap. Although there are many high-tech dressings, which offer good results, they are often not available over-the counter (OTC), or are very expensive, for some reason I don’t understand. The simplest is considered the best, because you will probably actually use it, and finish the full course of treatment, over many weeks. Remember, this takes time. If you quit a five week treatment after four weeks, what was the point?
The wound dressings you will mainly use for “moist healing” are found in the burn section, namely a “semi-occlusive film”. There are six types of dressings and this level breathes and allows moisture to pass (you can even wear it in the shower). There are several brand name products available: Tegaderm, Nexcare, and Stop & Shop ___ are commonly available.
These dressing depend on what is known as “moist healing”, where the wound is sealed and allowed to cook in its own juices. Moist healing has been known for thousands of years, whether wrapped in leaves, or sealed in honey.
In moist healing, the body produces a fluid called “exudate” which provides the environment for healing. It looks like pus, but it is not. By sealing the wound, the dressing is only changed every fourth or fifth day. Risk of infection is very low. Moist healing takes about 40% of the time of dry healing with minimal scarring.
There are three stages of wound healing, and your bandage may change as you go along. I’ll talk about that later. But if you just hurt yourself, ask your doctor about “moist healing”. Get the tegaderm, even if they gave you the gauze with petrolatum, Xeroform. The object is to minimize the frequency of dressing changes. Xerofrom is every day, Tegarderm is four to five to ten days. My ER doc gave me Xeroform, that doen’t mean I was supposed to leave it on. Had I known, I would have stopped on the way home for the Tegaderm. Or whatever.
Nutrition & Circulation
In children, the fingertip regrowth is usually complete. However, in adults, who stop producing growth hormone after age 11, nutrition becomes a factor in tissue regeneration. In order to stimulate the pancreas to produce growth hormone, taking L-Arginine amino acid has been shown effective at stimulating growth hormone production. The amount is 9 grams a day. Walmart carries Arginine. A nine-gram dose would be 18 x 500 mg. capsules. Further, adding fish oil makes it more effective.
Another other factor you can do something about is circulation. Mainly, tight bandages should be avoided, and the hand should not be immobilized, but kept active. While a splint seems like a good idea, the finger should be worked and stiffness avoided.
Further, as a guitarist, I take 5000 mg of Biotin daily for nail growth. The dermatologist who I see suggested it, although there isn’t much in the literature. So there is that possibility. And vitamin E is also important for healing, so take that. You’ll figure it out.
What I found
The fingertip is a complex structure which includes the pad, the bone, and the fingernail. The injury may be to one or all of these.
Fingertip amputations can be managed by surgical or nonsurgical measures. There is a wide variety of management strategies ranging from close observation and wound care, to complicated reconstruction procedures. Good results are reported from many of these procedures. 15 There are no absolute indications for surgical or nonsurgical treatment for these injuries. The pros and cons of surgical and nonsurgical treatments are considered on a patient-by-patient basis.
A preschool-age child with a transverse fingertip amputation will be well-served with composite grafting or healing by secondary intention. However, the same injury in a manual laborer who cannot be away from work for 4–6 weeks for healing may be better treated with a V-Y flap in the emergency department, followed by suture removal in 2 weeks and return to work if the wounds are satisfactorily healed.
The most useful way to classify these injuries is with a simple description of the level of amputation, obliquity (angle) of the wound, nail bed involvement (is the half-moon still showing), and whether bone is exposed in the injury.
Fingertip Amputations: Nonsurgical Treatment
Nonsurgical treatment for fingertip injuries is usually reserved for those without exposed bone. 16 Studies have shown good outcomes following semi-occlusive dressing changes and healing by secondary intention even when the distal phalanx (fingertip bone) is exposed. 17, 18 Many different types of semi-occlusive, nonadherent dressings such as Tegaderm (film, 3M), Xeroform (gauze with petrolatum), and Adaptic (Systagenix, from the UK) have been used for conservative management of fingertip injuries with excellent results. 17-24
The frequency of dressing changes has also been studied in depth. Recommendations range from once weekly dressing changes to 3-times-daily soaks, with no difference in the universally good results. Good sensation, acceptable appearance, and satisfactory function are expected outcomes of healing by secondary intention with regular supervised dressing changes. Patient counseling is of utmost importance if nonsurgical treatment is chosen. Four to 6 weeks of dressing changes, and waiting for wound healing can be psychologically difficult for patients and for parents of children with fingertip injuries. Frequent reassurance of the expected good result is needed.
Nonsurgical treatment for most fingertip injuries without exposed bone is often recommended. There are no absolute cut-offs for the amount of tissue loss that necessitates surgical intervention. Lemmon et al recommended consideration for operative intervention for defects larger than 1.5 cm2. 25 In general, amputations with the moon of the nail remaining can expect a full recovery.
Nonsurgical treatment begins with a thorough débridement in the emergency room or office in which the wound is cleaned. For pain while cleaning the wound, a digital block is performed with a 50:50 mix of 1% lidocaine: 0.25% bupivacaine (both without epinephrine). A finger tourniquet may be used if needed. Irrigation with 3000 ml of normal saline is generally sufficient along with gentle mechanical débridement with moist gauze. An 18 gauge needle and syringe may be used to irrigate into small crevices. Nail bed repairs are performed as needed and the nail plate is replaced as previously described. In the ER and at my PCP, they preferred Xeroform, for the semiocclusive, nonadherent dressing. Gauze is placed over that and 1 inch rolled gauze is used to make a loose tubular dressing.
Finally the finger is protected with an aluminum orthosis (splint). The patient receives oral antibiotics, depending on if the wound is heavily contaminated. For pain, low-potency narcotics are prescribed and acetaminophen at regular intervals (if no contraindications) is recommended. The extremity is elevated to heart level as much as possible.
Five to 7 days after injury, the dressing is changed, and the wound is inspected for further demarcation. Another débridement is performed if needed. The dressing is replaced and weekly dressing changes are performed in the office until good granulation tissue is present. You may be expected to perform dressing changes at home, and you should have someone to help you with this.
At this point the patient is transitioned to home dressing changes with biweekly office visits until the wound is healed. The patient should be followed every 3 months thereafter until the nail plate is fully grown to monitor for any residual deformity.