There are many ways to sever a finger— Maybe your partner threw a vodka bottle at you with
extreme force... Maybe you were engaged in an innocent game of fruit ninja with friends…
B1: fruit ninja
No matter how it happened. Keep the tip– and I’ll tell you how we can reattach it.
Intro music
It came to light in the Heard v Depp trial that Amber threw a vodka bottle with enough force
to crush and sever the tip of Johnny’s finger. Here’s a photo of the aftermath
B2: what happened
The landslide of finger chopping media that followed in the wake of this event reminded
me of an incident I encountered earlier in my career as a surgeon, where a man had his thumb
and first two fingers amputated by a machete below the level of the proximal interphalangeal joint.
Right around here [show finger to camera]. So when I heard the words
“amputated finger,” my brain was flooded with images of a more severe amputation and the
subsequent replantation procedure in which I took part. Now, there is no doubt that Johnny’s injury
would have been very painful and traumatic– but his injury was very lucky in comparison to some
of the digit amputations that we see in the ER, especially considering it occurred due to
crushing force against the corner of a bartop. Crushing force amputations are typically worse,
because they leave us with less viable tissue to be used in the replantation procedure.
B3: bar top corner
Had his hand been positioned so that a little bit more of the fingers extended over the edge
of the bar, the injury could have been much more severe. And in my opinion,
the headlines that read [insert photo of headline] were a classic case of Hollywood hyperbole.
Today in order to learn how to reattach a finger, we’ll compare Johnny’s injury to the first
replantation procedure that I took part in. At the time, I was working in plastics at a hospital near
Gatineau, Quebec. It was winter at the time when a patient came into the emergency department with a
cleanly amputated thumb and first two fingers. He and his friends had been involved in a brawl
outside a nightclub. When reinforcements showed up for the opposing group, they were outnumbered and
decided to run away. Our patient knew he’d been struck in the hand, but hadn’t seen any weapons
and it wasn’t until he noticed blood dripping down his arm that he realised that three of his
fingers were missing. Someone had been swinging a machete in a fist fight. Then came the pain…
When I heard about Johnny and Amber, that’s immediately where my brain went. Can you imagine
Amber Heard wielding a machete? But no, it was a vodka bottle and a countertop. One thing is
for sure– she must have thrown that bottle with a whole lot of force. It takes a lot of force to
sever a digit by crushing it against something– her adrenaline must have really been pumping.
As was Johnny’s adrenaline:
B4: Adrenaline “Honestly at first I didn’t feel the pain…”
Many years ago while a resident, my patient recounted a similar experience. Contrary
to popular belief adrenaline isn’t actually a pain killer, it diverts
an individual’s concentration from the pain to something else,
giving them the feeling that the felt pain doesn't exist. When the stressful situation has subsided
and you’re say sitting in a car the pain comes rushing back and suddenly you’re saying:
BX: Overlay Chris’ face on someone in a car– “Can we turn around? I forgot my fingers at the club…”
Now I sincerely hope you never find yourself in a situation like this,
but if you do, Kieram Litchfield of ‘Medic 101 for Civilians on TikTok’ has some helpful tips.
B5: what not to do…
Back in Ottawa, our patient broke several of these rules in his race to save his fingers.
First of all, it was winter in Canada and his fingers were strewn across the ice cold ground
– which essentially amounts to being
in the freezer – before they were collected by him and his friends.
They then put the fingers in a plastic bag while they raced to the emergency department.
The Charms centre for hand and reconstructive microsurgery in Singapore echos Kieram’s
sentiments– “DO NOT PLACE THE AMPUTATED HAND OR FINGER PART IN DIRECT CONTACT
WITH ICE OR ICE WATER! It MUST NOT be placed in the freezer!”
Sub zero temperatures may damage the blood vessels and tissues in the finger causing freezer burn and
rendering them less viable for reconnection. It is however beneficial to keep the digit refrigerated
to preserve the flesh as long as possible, especially if there is a delay in your arrival at
a hospital. When reattaching tissue, we’re working in a window of approximately 24 hours, though
the sooner surgery can be performed the better our chances at success. We aim for 6-12 hours
for our best shot at success. Luckily, unlike my patient, Johnny had a doctor on a texting basis–
B6: texted the doc
Meaning that he would have received professional stepwise instructions
immediately following the injury, saving as much time as possible.
Hand and Finger Amputated Injuries
Now clean cuts with a knife, saw or you know machete, can be reattached with higher rate
of success than injuries where the finger has been crushed or pulled off forcefully.
B7: “I was looking directly at my bone, all these bones up here were…”
And while Johnny’s finger was definitely crushed,
there is really only one bone at the tip of the finger– attached one end to the rest of
the finger by the Distal Interphalangeal Joint. If the injury occurred above the level of this joint
(towards the tip), we’re talking about a complex fracture repair, but an increased likelihood of
retaining joint, ligament, and tendon function. Looks gruesome, but Johnny is still in good
shape. Part of the reason that clean cuts yield better replantation success rates is because they
are less likely to destroy these tissues, joint capsules or bone. So by chance, Johnny seems to
have avoided catastrophic joint and tendon damage, and only the very tip of his finger was crushed.
Similarly in Ottawa, although my patient's fingers had been completely severed,
his chances of undergoing a successful reattachment surgery were enhanced
by very luckily located clean cuts and relatively quick trip to the hospital.
Typically, finger reattachment or replantation surgery involves fixing the bone,
repairing cut tendons and microsurgical repair of cut blood vessels and nerves.
Each of these procedures in isolation are things we do all the time in the operating room,
but done all at once and across multiple amputation sites is no small
task. When faced with multiple replantations, a surgeon must be strategic about the order
of the surgeries to be performed, beginning with the digits or digits that will restore
the most function. Without the thumb, anything approaching regular function becomes difficult
– but you may be surprised to learn that I would then begin work on the middle finger
which can perform all the duties of the index finger if necessary. That doesn’t mean we won’t
try to save all your fingers, but in the operating room, difficult decisions must sometimes be made.
First in a replantation procedure, the amputation site is thoroughly cleaned and any damaged tissue
removed. This may mean shortening the exposed ends of the bone ever so slightly so that they rest
cleanly against each other while healing. Bone grafts (from the patient's own body or from tissue
banks) may be used if the bone has suffered too much damage or considerable bone loss. From there,
the bone may be treated like any broken bone, and repaired with pins, wires, plates or screws. With
the bone held in place, the other tissues around it will have a chance to heal– In Johnny’s case,
the bone repair at the tip of his finger may have been all that was necessary before suturing into
place the soft tissue and skin. But given the distal location of the fracture, it is quite
possible that the fractured tuft of bone was excised to improve the likelihood of closing
the wound. As we will soon see, the location of his injury helped him skip a few steps.
After the bone, the surgery proceeds in sequential order: flexor tendons, digital arteries, digital
nerves, extensor tendons, dorsal veins, and skin. If there has been prolonged ischemia time,
the arteries can be repaired earlier in the sequence. But what about the muscles?
Well, muscle repair may not be necessary in digit replantation. Let’s take a closer look.
Due to the location of their injuries, Johnny and my patient in Ottawa avoided direct injury
to most of the muscles of the hand. Fingers do not actually contain muscles (other than
arrector pili - which is a tiny muscle at the base of a hair follicle that attaches
to dermal tissue below it and activates when the body is cold, making your hairs
stand on end). The larger muscles that move the finger joints are in the palm and forearm and
connect to the corresponding tendons there. Had the injuries occurred a few centimetres closer to
the palm of the hand, the intrinsic musculature of our patient’s hand would have been at risk.
The intrinsic muscles of the hand originate within the wrist and hand and are responsible
for fine motor movement of the hand. Each finger has 6 muscles controlling its movement: three
are intrinsic muscles and three are extrinsic muscles. The extrinsic muscles reside further
away from the site of injury in the wrist and the forearm. The index and little finger have an extra
extrinsic extensor. With no major muscle damage, both Johnny and our patient dodged a bullet.
But again, the man in Quebec suffered a complete amputation at the proximal phalanx of his thumb,
first and second fingers. Thus after reattaching the bone, we had to repair the flexor and extensor
tendons in all three fingers. The surgeon must locate the ends of the severed tendons
and suture them back together. Inside the hands, tendons are taught chords,
that once cut, tend to recoil towards their connection site. So in reality,
this portion of the surgery may require the surgeon to cut deeper into your hand
to find the severed tendons. And again here, the surgeon may graft tendon material onto
the injured segments if there has been too much damage and the ends no longer connect.
He was lucky that his fingers were cut between the interphalangeal joints of the thumb
and between the interphalangeal and metacarpophalangeal joints (aka
the knuckles) of his first and second finger in a straight segment of bone. Damage to the joints
can complicate a replantation surgery and impair the movement of those joints. When the joint has
suffered extreme damage, it is possible to replace the PIP and MP joints in the hand, though these
may need to be performed as a secondary procedure once the initial healing process is complete.
A case report of total finger joint replacement arthroplasty after traumatic amputation
Looking again at the location of Johnny’s injury, it is possible, but not certain
that he suffered a flexor tendon or joint injury (both of which would have complicated
the replantation procedure). He claims that his bone was showing at the time of injury–
and as we can see, this is possible without him sustaining any injury to the tendon as
the tip of the distal phalanx extends beyond the flexor tendon insertion point. This would be the
greatest complication I can see from the injury he describes since all major nerves, blood vessels,
joints and all other tendons were sufficiently out of harm's way. Lots of blood, yes… But we’re
talking about a relatively small amount of flesh that could be cleaned and sutured back
into place without disrupting the major function of the digit. Good aim, Amber. Or wait, bad aim?
B8: Arthritis?
Johnny did mention arthritis and loss of function at the joint and tip of his finger.
This could mean that the fracture line from the end of the distal phalanx
extended in a longitudinal manner toward the distal interphalangeal joint.
This could compromise the function of the distal interphalangeal joint
if there was disruption of the articular surface of the interphalangeal joint.
Loss of congruence at the joint surface would result in abnormal forces across the joint and
eventual degeneration of the joint resulting in degenerative arthritis and loss of joint function.
Typically in order for a replanted finger to regain sufficient function, the severed nerves
must be carefully repaired. The nerves in the region will either be reconnected if enough viable
tissue remains or supplemented with a nerve graft if the ends no longer connect. The ulnar, radial
and median nerves originate in the shoulder and travel down the arm to the hand and each of these
nerves has both sensory and motor components. The radial and medial nerves were of special interest
to our patient as they provide sensation to the thumb, index and middle finger (radial nerve via
the back of the hand and corresponding fingers and the medial nerve through the palm and front side).
Perhaps the nerve endings at the tip of Johnny’s finger were injured beyond repair?
The blood vessels of the hand travel alongside the nerves and supply blood to the fingers. Like these
nerves these must be reconnected (and are supplemented with tissue graft when necessary)
so that the healing tissues may be supplied with blood. The radial artery,
where pulse is measured, travels across the front of the wrist on the thumb side and arcs
up into the palm of the hand via the palmar arch. Again, our patient’s injuries avoided
the most vital of the blood vessels in the hand and during the surgery we had only
to repair the blood vessels that extend up into the fingers. And by comparison,
Johnny would have suffered injury to only the tips of the blood vessel supplying his middle finger.
Whether it be a triple replantation such as this,
or the tip of your middle finger, our goal as surgeons is to restore as much function
as possible. But the reimplanted digits will not function as they did before the trauma,
and even if the initial surgery is successful complications may occur in the days that follow.
Patients typically remain in the hospital for 2-5 days as they are monitored for clotting, ischemia
(a condition where blood flow and thus oxygen is reduced in a part of the body), and infection.
From there, the patient will undergo a long and onerous road to recovery with extensive
physiotherapy. As I say to many of my patients, surgery is only 5-10% of the solution. The
remainder comes from persistence, dedication, and a crap tonne of physiotherapy. Best get to work.
At the end of the day, both Johnny and my patient in Ottawa were lucky.
A crushing impact further down the finger may have left Johnny with a much more difficult repair
and less functional result. And although three of my patients fingers were severed,
they were severed in a way that left them viable for replantation.
As for me? I’m happy to have both hands in tact.
Outro