POSTGRAD. MED. J. (1964), 40, 240

IT'S ONLY A CUT FINGERROBERT H. C. ROBINS, M.B., B.CHIR., F.R.C.S.

Orthopaedic Surgeon, Royal Cornwall Infirmary, Truro; Hunterian Professor, Royal College of Surgeons

MINOR injuries are of two sorts: those which areconsidered trivial by the patient and those whichare liable to be underestimated by the doctor(Fig. i). The former are indeed minor in allrespects: abrasions, tiny lacerations and pene-trating wounds, the importance of which lies in thedanger of infection. The others embrace all thoseinjuries not requiring admission to hospital andoften thought unworthy of the attention of aconsultant. Yet the penalties of failure can besevere, even after injury to a single digit, if in-fection, oedema or disuse should cripple the rest ofthe hand (Fig. 2); the potentialities for this existwherever the surgeon fails to distinguish betweenan incised wound and one caused by crushing(Fig. 3). In this article I shall discuss the manage-ment of patients whose treatment can be performedwithout the need for admission to hospital, butassuming that the proper facilities are available,including anxsthesia, asepsis and instrumentsappropriate for hand surgery (Fig. 4).Prevention of Infection

Sepsis rarely follows severe hand injuries whichreceive attention in a main operating theatre andin which the wound gets the treatment it deserves.Infections typically complicate trivial wounds andresult mainly from their neglect. By their nature,these injuries seldom come to hospital but, asdoctors, it is our duty to educate the public and,more particularly, nurses and first-aid workers infactories. Common sense and cleanliness are themain requirements. Common sense implies theability to distinguish a penetrating wound or onewhich requires suturing from a superficial cut orabrasion. The former needs hospital treatment,while the latter requires thorough cleansing and-the application of a simple sterile dressing.Antiseptics should be avoided. The removal ofsplinters and foreign bodies must be complete andif a piece is retained the patient should be referredto hospital. The question of tetanus prophylaxisis appropriate here. The value of serum is indoubt. I am of the opinion that all attention shouldbe paid to the wound and, if there is reason toquestion its contamination, that an antibioticshould be given and serum withheld. Patientswho have been immunized should receive a

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FIG. I.-Granulations growing froman untreated incised wound.

FIG. 2.-Finger stiffness following haematoma andinfection.

booster dose of toxoid, and those who have notshould be given their first, not with the idea ofimmediate protection, but in order to start a

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May 1964 ROBINS: It's Only a Cut Finger 241

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FIG. 4.-Routine set for minor hand surgery.

programme of active immunization. Leavingaside the possibility of tetanus, full antibioticcover should be given to all patients with signifi-

cant wounds which have been untreated for morethan 6 hours, especially those caused by crushing.Patients with crush injuries and lesions for which

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POSTGRADUATE MEDICAL JOURNAL

special treatment has been necessary, such astendon repair or skin grafting, should receive onelarge dose of crystalline penicillin by injection.Clean incised wounds of skin and subcutaneoustissue need no antibiotic at all, provided that theyhave had the proper local treatment.

Principles ofWound TreatmentThe first need is to ask the patient the cause of

the injury, when it occurred and what has hap-pened to the wound since. Wounds are causedby the cutting, tearing or crushing of tissues andthese distinctions apply as much to small injuriesof the fingers as to mutilating conditions. Incisedwounds may be expected to heal with minimalreaction and thus permit the suture of a tendon ordigital nerve if there is no other contraindication.Contused wounds have been partially devitalized;at best they are liable to delayed healing withaccompanying oedema and fibrosis, and at worst toactual sloughing of skin and subcutaneous tissue.In such circumstances repair of deep structures isnot only contraindicated but may be harmful.The time between accident and definitive treat-ment influences the risk of infection and delay inhealing, as does the application of strong chemicalsor meddlesome interference with the wound.The choice of anaesthetic depends on the

circumstances. Most of the procedures I shalldescribe can be performed under digital nerveblock, using I% Xylocaine solution; all can bedone under brachial plexus block which allowsthe use of a pneumatic tourniquet. Generalanaesthesia is often more convenient, particularlyin operations for skin replacement. A bloodlessfield can be obtained adequately by elevation ofthe arm and application of a pneumatic cuff. Itshould be used whenever wound exploration isnecessary or any deep structure is to be repaired,but not for skin grafting in any form.

Dressings should be simple. Fluffed dry gauzeis the most generally applicable, and petroleumjelly gauze next to the wound if adherence is likelyto be a problem. A light compression bandagemay be used and a protective plaster slab if it isnecessary to control the position of a part of thehand. Individual finger dressings with stockinetteapplied on a frame are very convenient, but caremust be taken to avoid a constricting turn at thebase of the digit. For the first few days only,elevation in a sling may be desirable, but from thebeginning the patient must be instructed inexercises for the shoulder and uninjured parts ofthe hand, and it must be clear that he understandsthem.

Superficial Wounds Without Skin LossClean incised wounds in the fingers do not need

to be excised. Simple cleansing is necessary andthe wound inspected for damage to deep structures.The skin is then sutured with fine monofilamentnylon or other suitable material and a simple drydressing applied.

Lacerated and contused wounds require carefulhandling in order to avoid inflicting furtherdamage. Excision, in the true sense of the word,is unnecessary but devitalized tissue and foreignmaterial must be removed. Skin closure should beas precise as possible, provided that there is notension. Where a flap of skin is based distally, itshould be thinned by removal of fatty tissue beforesuture.

Superficial Wounds With Skin LossLoss of skin demands immediate replacement

by grafting. The special problem of amputationof the tip of the finger will be considered later.Elsewhere in the hand, and notably on the sides ofthe digits, small areas of skin loss are adequatelytreated by free split skin grafts. These mayconveniently be taken from the volar aspect of theforearm after the donor area has been demarcatedby infiltration with local analgesic. (For cosmeticreasons, women should be offered the alternativeof the thigh). It is always wise to suture the graftin its position. Five days after operation is areasonable time to perform the first dressing, butthere are occasions when it should be done sooner,particularly if there is a chance of haematoma,while in other instances it may be left for a week ormore.

Injuries Around the NailSubungual hzematoma is a painful condition,

easily relieved by trephining the nail for itsrelease. Contact with the red-hot end of a paperclip is effective. Radiographs should be taken toexclude a fracture of the terminal phalanx,though this will not affect the treatment.More extensive injuries are usually caused by

crushing and if the nail fold is crushed, somedeformity of the nail is likely to ensue. There areno special features about treatment except thatthe nail should not be sacrificed needlessly,because it acts as a natural protection during thehealing phase, even if shed later. If the nail isdislocated, however, there is little virtue inpreserving it and it should be removed at theoutset.

Penetrating Wounds and Foreign BodiesThe history here is important. Penetrating

wounds caused by inorganic materials, such asglass and metal, may be treated conservativelyunless they are contaminated or a deep structurehas been divided. In contrast, wounds caused by

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May 1964 ROBINS: It's Only a Cut Finger 243

organic materials, such as wooden splinters orbones, should be explored. The same principleapplies to foreign bodies. Organic foreign bodiesmust not be allowed to remain because of the riskof infection, including tetanus. By contrast glass,fragments of needles or air gun pellets may oftenbe left for elective removal later. Foreign bodiesin the hand may be very difficult to find andcasualty officers are liable to embark on their searchwith insufficient forethought and preparation. Inthe case of radio-opaque objects, films should betaken in two planes. Glass will be visible only if itcontains lead.

Amputations of The Finger TipIf the result of treatment of a traumatic amputa-

tion is a painful and tender end to the finger or anunstable scar, the method chosen has failed. Thepoint which I mean to emphasize is this:-Length is important, but the quality of the stumpis more so. The typical problem is loss of skin anda variable amount of pulp, the level of amputationpassing through the terminal phalanx or the pulpdistal to it. If the direction is oblique and in adorsal direction, so that the main loss of tissueinvolves the nail and underlying structures, it isusually best to make a formal amputation throughthe distal phalanx removing nail bed and fold(Fig. 5). The volar skin flap will then give idealcover; being the proper local skin and havingnormal sensibility, it will stand up to the stressesof hard manual work. Such a procedure isadvisable in all instances when local skin flaps canbe fashioned without undue shortening of thedigit. It may also be best for unskilled labourerseven when significant shortening is needed to getsatisfactory closure, and especially in elderlypatients where rapid healing is important to offsetthe danger of finger stiffness.

This will leave a large group of cases whichneed skin cover by grafting. A split skin graftseldom gives satisfactory permanent cover to thefinger tip unless the defect is superficial and likelyto be protected by the new nail as it grows. It is,however, a valuable technique as a temporaryexpedient in, for instance, a patient who comeslate for treatment after an injury at sea; definitivesurgery can then be deferred until primary healinghas been achieved and the danger of sepsis passed.The usual alternatives are a full thickness graft

or a flap from elsewhere in the hand. Neither ofthese will develop more than protective sensibility,but a flap gives a more handsome cosmetic resultand better durability. Against a flap are the factsthat it means two operations, a longer disabilityperiod, admission to hospital for a few days if thepatient does not live near enough to attend daily,and a decided risk of finger stiffness ifthe operation

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FIG. 6.--Two fingers treated by full thickness grafts.

is not skilfully performed or the selection ofpatient has been misjudged. An advantage of afree graft is its tendency to contract and thereforeto pull towards itself the marginal and normal skinof the volar pad to which it was sutured; thusthe final grafted area several months later will besmaller than the original defect. Moreover it

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(c)FIG. 7.-(a) Level of amputation. (b) Thenar flap in situ. (c) Result, showing restoration of the pad of the finger

and healed donor area.

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May 1964 ROBINS: It's Only a Cut Finger 245

sometimes happens that sufficient local skin isavailable to cover the exposed bone and a freegraft will then close what remains.The technique of full thickness skin grafting is

fist to prepare the affected finger, to take a patternof the defect cut in glove rubber or sterile foil, thento map this out on the donor area, cut the graftand suture it to the defect. In preparing thefinger, minimal excision is performed, removingonly such tissue as is contaminated or devitalized.Haemostasis must be meticulous and can beachieved by pressure with hot moist packs. Whilewaiting for the field to become dry the graft istaken. The most convenient donor area is thebend of the elbow, because after removing thegraft, the defect can be closed by transverse suturein the line of the skin crease. In cutting the graft,the skin is lifted at its margin with a fine hook andgreat care taken to remove every trace of fat fromits under-surface. Fixation to the end of thefinger is important and fine atraumatic suturesshould-be used. Four can be left long enough totie a small pressure dressing on top. The graft isinspected after five days and thereafter as neces-sary. The period off work for a manual worker islikely to be 6 to 8 weeks (Fig. 6).

For selected patients, a skin flap provides thebest method of repair. The donor site may be thethenar eminence, adjacent digit (cross-finger flap)or, in the case of the thumb, the radial side of theproximal segment of the index finger. In raisinga thenar flap (Fig. 7) it is important to judge thecorrect site accurately by flexing the affected fingerin its natural direction and choosing the area ofskin which comes into contact with the amputatedtip. In cutting the flap some subcutaneous tissue isusually left behind as a bed for a small free graft(either split skin or full thickness) which is suturedto the edges of the defect. The thenar flap issutured to the margins of the amputation woundand a small dressing interposed between the bridgeof the flap and the free graft beneath. Strapping ora plaster cast should be used to maintain the fingerin its correct position and to prevent too muchtension on the flap. Dressings require changingabout every fourth day and the flap may be detachedafter two weeks; healing should be complete inanother fortnight. Failure-loss of the graft,painful donor area or finger stiffness-may be dueto wrong selection of patients, incorrect siting ofthe flap, positioning of the finger too flexed or tooextended (the flap should be at right angles to thethenar skin), or detachment too early or too late.The principle of a cross-finger flap is exactly

the same. The donor area is the lateral aspect anddorsum of the middle segment of an adjacentfinger. It must be large enough to cover the defectand still allow for a short bridge and its length

FIG. 8.-Figure-of-eight suture. (After Bunnell).

should not exceed one and one-third times itsbreadth. On no account may its base extend infront of the mid-lateral line, and a covering ofparatenon must be left on the extensor tendon.The flap is rotated through I80 degrees in orderto suture it to the defect; split skin graft coversthe donor area and extends on to the bridge betweenthe two fingers. A plaster cast is used to maintainthe position and a window is cut in it to observethe vascularity of the flap which should be readyfor detachment after a fortnight.Digital Nerve Injuries

Examination for sensory loss is essential in allpatients with injuries of the hand. A divideddigital nerve in an incised wound is suited toprimary repair, though some extension of thewound may be necessary. Two fine atraumaticsutures are passed through the perineurium, carebeing taken to ensure that the ends of the nerve arein their correct rotational relationship. Afterclosure of the skin the finger is splinted in midflexion to relieve the suture line of tension.

In contused and contaminated wounds, nosutures should be inserted but it is worth laying thedivided nerve with its ends approximated, becausea reasonable degree of natural recovery sometimesensues.

Flexor Tendon InjuriesThese should not be submitted to surgical

repair as an out-patient. If, on exploration of awound, the flexor tendon is found to be intact butits sheath to be open, penicillin solution should beinstilled into its lumen.

Extensor Tendon InjuriesExtensor tendons may be considered for

primary repair in clean, incised wounds. Admissionto hospital is not necessary if the lesion is situatedat a level where the proximal end is not likely tohave retracted far and therefore can be foundwithout much extension of the wound of injury.In practice, this means from the metacarpal headsdistally.

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The diagnosis, though usually obvious, is notinfrequently missed. Over the metacarpo-phalangeal joint, division of the extensor tendoncauses dropping of the whole finger; over themiddle phalanx or terminal joint it gives theappearance of a mallet finger. Where the proximalphalanx and inter-phalangeal joint is concernedonly the middle slip of the tendon is likely to beaffected, so that there is loss of extension at thisjoint while the distal one may show active extension.

In the situations discussed, and this appliesalso if a joint has been opened, a figure-of-eightwire suture is generally applicable, becauseretraction is not a serious problem and the tendonis approaching flat in section. Moreover, there islittle subcutaneous tissue to act as a cushion andthe absence of buried suture material is animportant advantage.The technique is simple. The tendon and skin

are incorporated in a figure-of-eight manner(Fig. 8), so that the ends of the former are auto-

matically approximated as the suture is tied.Three sutures are usually needed and they shouldall be inserted before the first is tied. They areleft in position for three weeks, during which timethe digit is splinted in the extended position.Conclusion

All these operations require precise technique,and if they are applied without due regaid forbasic principles of asepsis and surgical skill theywill bring disrepute. I do not suggest that they aresuited to indiscriminate use in casualty depart-ments, but I do believe that this is the standardwhich should be aimed at in out-patient accidentwork, and if that is achieved the treatment of theseinjuries will contribute to an ideal basic surgicaltraining.

Figures i, 2, 3, 4, 5, 6 and 8 are reproduced bypermission from 'Injuries and Infections of the Hand'(Edward Arnold, London).

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