|Year : 2023 | Volume
| Issue : 2 | Page : 186-189
Percutaneous hypodermic needling technique versus monofilament suture repair of partial finger amputation injuries – A comparative study
Ujjawal Pradhan1, Nobin Kumar Sharma1, Kushagra Sinha2, Jowas Dayal Rai1, Sunil Baliga1
1 Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Orthopaedics, Sri Krishna Medical College, Muzaffarpur, Bihar, India
|Date of Submission||10-Aug-2022|
|Date of Decision||16-Feb-2023|
|Date of Acceptance||27-Feb-2023|
|Date of Web Publication||3-May-2023|
Department of Orthopaedics, Sikkim Manipal Institute of Medical Sciences, Tadong, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
Context: Partial finger amputations are commonly encountered in the emergency room and are often inadequately treated. Aims: The aim of this study was to compare and evaluate the results of wound debridement, followed by primary wound closure with multiple percutaneous hypodermic needles versus closure with monofilament nonabsorbable sutures. Settings and Design: Comparative prospective study on the management of partial amputations of fingers was conducted in patients between 18 and 60 years at a tertiary care center. Subjects and Methods: We compared two different techniques of management of fingertip injuries. Group A comprised percutaneous hypodermic needling. Group B included suture technique using monofilament nonabsorbable suture. Patients not willing to participate, crush injuries, injuries involving more than 80% of digit circumference and digital arterial injury, complete amputation, and finger injuries with polytrauma were excluded from the study. Statistical Analysis Used: Data were analyzed using SPSS version 21. Results: The right hand (dominant side) was involved more commonly in both groups. Secondary procedures, infection rate, healing time, and the cost of the procedure from primary procedure to complete healing of the digit/s were all higher in Group B. Final appearance of the digit(s) based on skin color was better in Group A. Conclusion: Percutaneous hypodermic needling technique is a simple, novel technique which provides a better result in comparison to suture technique in terms of the requirement for secondary procedures, wound healing time, infection rate, cost of the overall procedure, and the final appearance of the digit on complete healing.
Keywords: Fingertip ischemia, marginal necrosis, nonabsorbable suture, partial finger amputation, percutaneous needling
|How to cite this article:|
Pradhan U, Sharma NK, Sinha K, Rai JD, Baliga S. Percutaneous hypodermic needling technique versus monofilament suture repair of partial finger amputation injuries – A comparative study. J Orthop Dis Traumatol 2023;6:186-9
|How to cite this URL:|
Pradhan U, Sharma NK, Sinha K, Rai JD, Baliga S. Percutaneous hypodermic needling technique versus monofilament suture repair of partial finger amputation injuries – A comparative study. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:186-9. Available from: https://jodt.org/text.asp?2023/6/2/186/375553
| Introduction|| |
Finger injuries are common hand injuries leading to significant impairment of hand function and disability. They are more commonly encountered in hospitals located near industrial areas. The fingertip is important for sensation due to the high concentration of sensory receptors. Therefore, restoration of sensation is the primary aim of treatment. Maintenance of digit length, restoration of the nail, and cosmesis are important, however, a painless fingertip with durable and sensate skin is vital for treatment outcome. These injuries are often not given the attention they deserve, given the importance of fingers for hand function.
| Subjects and Methods|| |
This was a comparative prospective study on the management of partial amputations of fingers managed by two different techniques. The first comprised percutaneous hypodermic needle to approximate the wound as well as to provide mechanical support to the injured digit. The other technique involved primary wound debridement and closure using monofilament nonabsorbable interrupted suture technique. This study was conducted in the department of orthopedics of a tertiary care center in the state of Sikkim, India, from December 2020 to December 2021 in patients attending emergency rooms with partial finger amputations.
A total of 21 patients were included in each group using simple random sampling method. The first patient in the series was assigned to one of the groups based on the toss of a coin. Every subsequent patient was assigned to the other group. Thus, all the even-numbered patients were included in one group and odd-numbered patients were included in the other group. Inclusion criteria were adult patients aged between 18 and 60 years with partial amputation of the digit involving more than 50% but <80% of the digit circumference with or without the involvement of the phalanges. Exclusion criteria were patient not willing to participate, crushed injuries, complete amputation, finger injuries with polytrauma, and injuries involving rupture of both the digital arteries.
Repair in both groups was done under a ring block using 2% lignocaine without adrenaline.
Percutaneous needle group (Group A)
Wound was thoroughly washed with copious amount of normal saline, the wound margin was then approximated with multiple (10–15) hypodermic 24-gauge needles percutaneously, spanning the wound, and holding the distal end of the digit to the proximal end [Figure 1]. Fractured phalanges were addressed by passing a single 18-gauge needle from the tip of the digit across the fracture site. The involved limb as a whole was immobilized in functional position in a below elbow plaster of Paris (POP) slab extending from the digit tip to the mid-forearm.
|Figure 1: Percutaneous needle group (Group A) – Wound margins approximated with multiple hypodermic 24-gauge needle|
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Suture group (Group B)
Wound was thoroughly washed with copious amounts of normal saline and sutured with monofilament nonabsorbable 3-0 or 4-0 interrupted suture spanning the wound holding the distal end of the digit to the proximal end [Figure 2]. Fractured phalanges were addressed in the same manner as in Group A. The wound was then dressed with sterile gauze pieces and the limb was immobilized in POP slab as in Group A.
|Figure 2: Suture group (Group B) – Wound sutured with monofilament nonabsorbable 3-0 or 4-0 interrupted suture|
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After repair, patients were admitted in the orthopedic ward and started on intravenous ceftriaxone 1 g 12 h for a minimum of 5 days or continued in cases which showed signs of infections. Dressing was done on the 1st day after the procedure and on alternate days thereafter till the removal of the suture and needles. Clinical photographs were taken on each dressing.
The percutaneous needles and the sutures holding the skin edges were removed on the 10th day. Needle spanning the fractured phalanx was removed after 3 weeks. The injured digits in both groups were observed for signs of infection, marginal necrosis, and color changes of the distal end. Grossly infected digits were subjected to redebridement as and when required and observed for signs of resolution of infection. Digits with persistent infection and with ischemic changes were converted to complete amputation at the appropriate level and secondary stump closure was done on a later date. Patients were discharged after proper healing of the digit and called for follow-up on a weekly basis for 1 month to look for signs of occult infections, ischemia, and the appearance of the digit based on the color of the skin and for rehabilitation of the injured digit and hand as a whole. Final follow-up was done at 6 months.
Data were collected and tabulated. Information on patient demographics, side of injury, digit/s involved, mechanism of injury, the presence of phalangeal fractures, type of procedure, duration of the procedure, secondary procedures required (redebridement and complete amputation), infection, the appearance of the digit (skin color match/pigmented/depigmented), wound healing time, and the cost of each treatment method from the time of primary debridement to complete healing of the wound was processed and analyzed.
Written informed consent was obtained from every patient. Ethical clearance was obtained from the institutional ethics committee.
Data were coded and analyzed using Statistical Package for the Social Sciences. (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA). Descriptive statistics with cross-tabulation analysis were used for comparing the frequencies. An independent samples t-test was used to compare the mean and the P value between the two groups. P < 0.05 was considered statistically significant.
| Results|| |
In our study, the majority of the participants in both treatment groups were in the third and fourth decades. Right side (dominant hand) was involved more commonly in both the groups with the involvement of the digit/s as shown in [Table 1]. The mean duration of the procedure in Group A was 37.38 min (standard deviation [SD] 7.00 min) as compared to 40.24 (SD 7.32 min) min in Group B (P = 0.200) [Table 2]. The majority of the digit/s injuries were associated with fractures of the phalanges – 95% and 90%, respectively, in Group A and Group B. Secondary procedure was required in five patients in Group A in the form of redebridement due to poor skin condition, which was followed by repeating needling procedure after which the healing was uneventful. In contrast, 13 patients in Group B required secondary procedures for poor skin condition, marginal necrosis, infection, and delayed healing. This included eight cases of redebridement and five cases of complete amputation of the injured digit. This difference was statistically significant (P = 0.034) [Table 3]. Infection rate was higher in Group B (52%) versus 19% in Group A, which was statistically significant (P = 0.024) [Table 4]. Healing time was significantly shorter in Group A (24.43 days) compared to Group B (29.86 days) with a P = 0.011 [Table 5]. Cost of the entire treatment – from primary procedure to complete healing of the digit/s was also less in Group A (Indian Rupees (INR) 707.62 vs. INR 1268.1 in Group B), which was statistically significant (P = 0.007) [Table 6]. Final appearance of the digit/s based on skin color was also better in Group A and was statistically significant (P = 0.002) [Table 7].
| Discussion|| |
“Fingertip” is part of the digit which is distal to the insertion of the flexor and extensor tendons into the distal phalanx. The distal end of the digit is made of the nail complex and the glabrous pulp, which is abundantly supplied with blood vessels and nerve endings. The vascular supply of the finger in particular and the hand in general is abundant. The digital arteries course on both sides of each of the digits dorsal to the nerves and terminate at the level of the distal interphalangeal and anastomose distal to the flexor digitorum profundus insertion to form the distal transverse palmar arch. Multiple branches arise from this arch and supply the fingertip the size of which ranges between 0.85 and 1 mm.
Fingertip injury can be in the form of complete amputation, incomplete amputation (wherein the part distal to the injury is held by some tissue), and crushed finger injuries.
There are many options available to the orthopedic, hand, and plastic surgeon in managing finger injuries. Simple, clean-cut injuries can be managed by primary debridement and closure with sutures. Complex finger injuries may even warrant full-thickness skin grafting from the hypothenar region, flap reconstruction, and even toe-to-finger and toe-to-thumb transfers in cases of amputations.
There are plenty of articles published in the literature on complete finger amputation and its management. However, partial or incomplete finger amputations are rather more common and more frequently encountered in the emergency room. Lack of literature and dilemma regarding the management of partial amputation poses a great dilemma to surgeons regarding its management.
Partial amputations are traditionally treated by wound debridement and primary or secondary closure using skin sutures, converting partial amputation to complete amputation in cases where the digit is severely crushed with very little tissue support with fracture phalanx. Most of the partial amputation in our center is managed with debridement and primary skin closure using monofilament nonabsorbable sutures. In our observation, the skin sutures cause undue tension at the wound margin impairing the vascular supply to already injured digit which may lead to margin necrosis and ischemia of the distal fingertip. Hence, in this study, we introduced a novel technique for dealing with partial finger amputation with multiple hypodermic needle techniques to primarily close and span the wound and compare its results with closure with monofilament interrupted sutures.
The majority of the participants in our study were between 20 and 40 years, indicating the working class of the population. Holm and Zachariae made similar observations in their study where the majority of the patients were in the manually active group (15–30) years. Right side was found to be more commonly involved in both study groups. Similar observation was made by Mohammed and Ahmed in their study, where the right hand was involved in 64.1% of the participants. In our study, the middle finger was injured more commonly in both groups, followed by the index finger. Multiple fingers were involved in 14% of the study sample in Group A, as compared with 10% in Group B. Brody et al. made similar observations where they found that the frequency of digit involvement was related directly to the length of the digit. Further studies by Moynihan, Tupper, and Miller supported this observation. The time taken for the primary procedure was similar in both two groups and was statistically insignificant (P > 0.05). We observed the procedure time depends on the number of digits involved, the severity of the injury, vascular injury, and wound contamination. However, in our observation, the needling technique was technically easy to perform. Secondary procedure was required less frequently in Group A compared to Group B, and the difference was statistically significant (P < 0.05). We observed that the needling technique was less invasive and caused minimal tension across the wound margins and hence fewer chances of marginal necrosis probably due to less compressive effect on the already impaired vascular supply of the digits compared to the suture technique. Suture technique invariably causes some amount of tension across the wound margin and this probably had compressive effect on the vascular supply of the digits. Statistically significant (P < 0.05) difference was noted with regard to infection rate, wound healing time, and the cost of the procedure (from the time of the primary procedure to complete healing of the wound) between the two groups with higher numbers of infection, longer healing time, and higher cost in Group B. We observed that a higher rate of marginal wound necrosis, ischemic changes in the digit distal to the wound, higher rate of the secondary procedure, and longer hospital stay in Group B were the contributing factors for these differences. The final appearance of the digit with regard to color difference in comparison to the surrounding normal areas was also statistically significant (P < 0.05) with larger number of hyper/hypopigmented digits in Group B. We noted that venous congestion impaired arterial supply secondary to compressive effect on the vasculature because of undue tension across the repair site was probably the reason.
| Conclusion|| |
Percutaneous hypodermic needling technique is a simple, novel technique for the management of partial finger amputation injuries which has very little effect on already impaired vascular supply of the digit and thus provides better results in comparison to suture technique in terms of the requirement for secondary procedures, wound healing time, infection rate, cost of the overall procedure, and the overall appearance of the digit on complete healing. Needling technique is technically less demanding with an easy learning curve– paramedics may also be trained in this procedure and can be performed with ease even in remote areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]