The second consideration is to provide at least two opposable fingers. Amputation of the fingers can be classified as a metacarpal hand (loss of all digits), loss of radial (index ± middle ± ring) or ulnar (little ± ring ± middle) digits, loss of alternate fingers (index and ring; middle and little), or other combinations, such as loss of central (middle and/or ring) digits or loss of both radial and ulnar digits. A metacarpal hand requires restoration of at least two functional digits [6]. Wei et al. found grip strength to be greater when replanting digits to the ulnar stumps of the hand. In contrast, if the patient requires better dexterity for more delicate work, digits are best reconstructed on the radial side of the hand. A compromise position is to reconstruct middle and ring fingers. This provides some degree of power grip, an adequate first web space, as well as precision grip [6, 16].

Replantation of multiple radial or ulnar digit amputations should start from adjacent to an uninjured finger to avoid a mid-hand gap. This principle also governs reconstruction of amputations of alternate digits, where reestablishing three contiguous fingers is the priority. If this is not possible, ray amputation of the intervening amputated digit should be considered [17]. Management of other rare amputation combinations should prioritize reconstruction of the central rays in the first instance (middle and ring fingers). This is reflected in the higher percentage of middle (77.3 %) and ring finger (78.9 %) reconstructions undertaken than for index (40 %) and little finger (21.4 %) in our series (unpublished). In summary, the vast majority of multiple amputations can be managed by reconstructing digits in the following order: middle, ring or index, index or ring, followed by the little finger (Fig. 10.2).

The third consideration is management of any associated hand injury. When the amputated digit is judged unsuitable for replantation, it should be borne in mind that the remnant can be used for “spare parts” to reconstruct other injuries within the hand. Useful components may include skin, soft tissue, nail bed, nerve, vessel, bone, joint, and tendon [17, 18]. It may even be possible to design a small free flap or vascularized joint transfer to improve function (Fig. 10.3).

When all possible functional requirements are met, an attempt should be made to restore the normal length sequence of the digits. This can improve the overall cosmetic appearance of the hand that many patients appreciate.