The initial patient evaluation should be guided by the nature of the injury and should first ensure a hemodynamically stable patient following an appropriate trauma evaluation. If paramedics in the field consult the provider, the recommendation should be for a clean dressing to the hand to minimize ongoing contamination and blood loss. Direct pressure can be held over point of bleeding and, except in extreme cases or major arterial injury, the use of tourniquets in the field should be discouraged. In addition to significant tourniquet pain, prolonged upper extremity tourniquet use can expose the patient to the risk of compressive neuropathy, hemodynamic instability following lactic acid production in the ischemic limb, and the potential for additional tissue or limb loss. The part itself should be placed in moistened gauze in a plastic bag, preferably on ice. If this is not possible, simply wrapping the amputated digit in saline-soaked gauze will help to cool it. The part should not be directly placed within the ice, and dry ice should never be utilized, both of which can cause severe thermal injury to the part. Additionally, tetanus booster should be updated and antibiotics administered. Intravenous pain medications should be used as necessary.

Upon presentation, the amputated part and injured hand should have radiographs obtained to determine the presence of any residual foreign bodies and define the quality of the bone fragments (Fig. 4.2). In some crush or high-energy injuries, severe fracture comminution will guide the operative plan and patient discussion towards aggressive shortening or immediate arthrodesis. If replantation is agreed upon, the amputated part should precede the patient to the operating room. This will give the surgeon a valuable chance to carefully examine the part and begin preparation for replantation prior to the start of anesthesia. This will have the added benefit of decreasing the overall ischemia time. The amputated digit should be cooled, with whatever is available, throughout this process.

Time to return to work or the ability to return to the same occupation postoperatively should be strongly weighed and discussed with the patient when considering revision amputation verses replantation. A linear relationship between an increasingly proximal level of injury and a decrease in the likelihood of the patient’s return to their pre-injury job should be expected and discussed. This finding was based on a review of 111 thumb amputations where more proximal amputations up to the level of the thumb metacarpophalangeal joint had the lowest rates of return to work with nearly 50 % of patients reporting that they were unable to return to work. Revision amputation through the proximal phalanx or metacarpal will give the patient a diminished ability to grasp large objects and to perform fine motor tasks such as buttoning a shirt [10].

The first step in any amputation is a thorough debridement and irrigation of the injury site and amputated part. Following an amputation, particulate matter or organic debris can be deposited throughout and beneath various structures. Failure to recognize foreign contamination and thoroughly remove this debris may result in early infection with subsequent vascular thrombosis and loss of the replanted part [11]. If a small, viable dorsal skin bridge remains intact following a near-complete amputation, this bridge should be preserved as small veins may be present within this segment that will provide some element of venous outflow. Midlateral incisions on the amputated part can allow for exploration of the volar structures, including the flexor sheath and neurovascular bundles. Again, this can be performed on the back table prior to arrival of the patient in the operating room. The ulnar and radial neurovascular bundles should be identified, and the quality of the digital arterial and nerves should be inspected. Additionally, any dorsal veins should be identified and dissected. As the veins are in the superficial subcutaneous tissue, the dorsal skin should be sharply dissected off of the extensor tendon as one unit, including the dorsal veins. The veins can then be carefully identified by bleeding at the edge of the skin and dissected from the underlying subcutaneous tissue. One should be mindful to avoid aggressive trimming of vessel and nerve ends in the initial “tagging” stage. Prolonged operative time and the frequent handling of vessels can create a desiccated, crushed vessel end that needs secondary debridement and trimming. In this way, the vessel has been shortened twice and may increase the level of difficulty for primary anastomosis or vein grafting. The final trimming of the end of the vessel or the nerve, then, should be saved until immediately prior to anastomosis or coaptation.