Bone Rongeur for Fingertip Amputation

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When there is a partial fingertip amputation with exposed bone you may need to use a rongeur to trim down the bone so skin can be closed over the top of it. After a digital block and finger tourniquet is applied, the bone is cut and the skin can be sutured over the remaining soft tissue. Here we see this procedure performed by Dr. Caleb Sunde and narrated by Dr. Jess Mason.

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Nicholas F. -

This is very cool (and doenst look particularly difficult) but is this really in our scope of practice? I wonder if there any complications if we would be raked over the coals for having done this ourselves intead of consulting/transferring.

Russell F. -

I think if you clipped too proximal you would have an issue however I can see doing this myself in consultation with a plastic or hand surgeon on the phone. My buddy is ortho and he does this all the time when the ER calls. With that being said if I have ortho in house I'd probably call them.

Dane O -

Awesome!

Jess Mason -

I think it really depends on your practice setting if this is something you need to do. Where I trained we called a hand surgeon. Where I work now, if we call a hand surgeon an EM intern covering hand surgery shows up! I have friends in some communities where this procedure is expected of the EM clinician. I think it just depends on where you practice.

Lars E., M.D. -

Thanks so much for posting this video. I'm want to give this a try. A number of these amputations I've seen are more proximal than the patient in the video. Do you have any recommendations as to how far proximal the injury can be and still be appropriate for the emergency physician to repair? Thank you.

Jess Mason -

I've read that if the amputation is <0.5 cm this is generally a safe range. Compare the amputated finger to the normal side to estimate. If more proximal than this I'd probably refer to a hand surgeon if that was possible. One of the concerns is the attachment point of the tendons onto the distal phalanx and not wanting to trip that.

Rick Pescatore -

Great video Jess! I've done a fair bit of rongeuring after making it a mission in residency. I'd like to add that finding/isolating the digital nerves, pulling them taut, and then snipping or bovie-ing as proximally as possible can help avoid the development of painful neuromas. Other than that, there's a few interesting pieces regarding distal finger amputations.

There's like a billion different classification schemes for hand/finger zones, but I think that standard flexor classification systems are fine. Anything beyond the distal middle phalanx seems to be well-within our wheelhouses as emergency physicians. There's not really any great data out there, but it's probably worth noting that where exposed bone is <=5mm, most of these things can be left to close by secondary intention and they do very well (Krauss et al, Hand 2014). That being said, I will often rongeur down where necessary to gain closure, as well as to smooth out any sharp pointy bits.

I 100% give these patients antibiotics, mainly because I'm a wimp, but there's weak evidence that they're not even necessary (Rubin et al, AJEM). Technically speaking, though, aren't these Gustilo III fractures almost by definition? That's what prompts me to (usually) give a dose of Ancef in the ED and then send them home with Keflex.

When all is said and done, I completely agree with your earlier statements that this is location- and context-dependent. There's certainly a difference between an 8 year old concert pianist and a 90 year old fireworks manufacturer!

Thanks again!

Jess Mason -

Thanks for your awesome comments and insight Rick.

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