One of the most difficult complications of a severe open upper extremity injury is the failure to amputate. If amputation is a consideration, the best time to amputate is at the first operation. Faced with a mangled upper extremity, many patients are pessimistic about salvage, but when they return from the operating room and see that their hand is "still there", they are given hope that may be entirely unfounded. Once started on this road of reconstruction, many patients are unable to consent to amputation later, even after many operations, chronic pain and an extremity of which is more a burden than an asset. Faced with a mangled upper extremity, it may be helpful for the surgeon to ask himself or herself: "If this were a complete amputation, would it be worth the effort to replant?" or "If this survives, will the final result be better than a prosthesis? If the answer is no, primary amputation should be strongly considered. In complex wounds with poor wound definition, mixed viability, and those for which the source of distal vascular supply is uncertain but for which the final outcome is likely to be better than a prosthesis, a conservative approach is reasonable. Wound healing is unpredictable in these indeterminate wounds, and efforts at radical debridement and complex reconstruction are more likely to fail or have serious complications. A conservative approach gives wounds the opportunity to heal while minimizing additional risk to the patient. Principles of conservative management include minimal debridement, no additional incisions, percutaneous fracture reduction, early active and passive motion, repeated debridement, and skin grafts. Obviously, expectations are less: such an approach gives greater likelihood for stiffness and poor function but also lessens the chances for major iatrogenic complications. Conservative management should be considered when the anticipated margins of radical debridement are not clear or if debridement itself may precipitate an unsalvageable situation.
Partial Finger Amputation