Report on Hands from Doctors Demystify, August 2012
CONTENTS
Doctors Demystify happenings
Journal article review: Fingertip injuries. Does treatment method matter?
Writing tips from the pros
DOCTORS DEMYSTIFY HAPPENNGS
2013 Face-to-Face Courses
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Miami, FL February 17-19, 2013 (Presidents’ Day Weekend)
Santa Monica, CA August 9-11, 2013
Doctors Demystify the Whys and Hows of Hand Surgery
Los Angeles, CA Saturday, January 26, 2013
In 30+ major cities on Saturdays thereafter
JOURNAL ARTICLE REVIEW
Fingertip injuries. Does Treatment Method Matter?
What do you say to the unhappy patient with a fingertip amputation?
Fingertip amputations are common and usually result in permanent changes in function and appearance. Does the method of treatment affect the outcome?
Investigators from the Netherlands retrospectively reviewed 53 patients with 59 fingertip amputations at an average of 4.5 years after injury. They noted the level of amputation
(Allen II: pulp and partial sterile matrix; Allen III: pulp and partial sterile matrix and partial distal phalanx; Allen IV: pulp and partial distal phalanx loss through the germinal matrix). They categorized the treatments into reconstruction (graft or flap coverage), bone shortening (trimming distal phalanx and closing skin primarily), or conservative
(bandage with or without ointment).
The investigators then rated the results both subjectively and objectively. Subjective measures were cold intolerance using an established scale, nail deformity (hook, split, hypertrophy, spike, absence), and aesthetics (rated independently by the patient and a surgeon). Objective measures were grip strength; key, three-point, and tip pinch strengths; range of motion; sensibility with S-W monofilaments and moving 2-point discrimination; and time off work.
In the reconstructive group, numbers of fingers in the Allen II, III, and IV categories were
4, 14, and 7 respectively. In the shortening group, numbers of fingers in the II, III, and IV

categories were 0, 12, and 11 respectively. In the conservative group, numbers of fingers in the same Allen categories were 2, 9, and 0.
Grip strength did not differ according to treatment received. Neither did any form of pinch strength. Sensibility, both with S-W monofilaments and with moving 2PD, was statistically equivalent in all 3 treatment groups. For all groups combined, active DIP joint motion was diminished 22% on average, and passive was diminished 18% on average. Again, there was no statistical difference in motion with respect to treatment received. Time off work for the reconstructive, shortening, and conservative groups averaged 40, 50, and 55 days respectively, but these differences were not statistically significant.
Eighty-five percent of fingertips had some cold intolerance, with a trend toward less cold intolerance in the ones with bone shortening and primary closure; but again, the differences were not statistically different. Ninety percent of injured fingers had some nail distortion, typically a hook nail, but the method of treatment did not affect the final nail appearance.
Study strengths include the length of follow-up and the collection of quantitative results where possible. The major limitations are the relative small numbers of amputations studies and the uncontrolled variable of surgeon/patient choice for treatment rendered.
The authors (3 plastic surgeons, 1 traumatologist, 1 physiatrist) expressed surprise with the results. Despite hand surgery texts and journals demonstrating multiple fancy methods of reconstructing tip amputations, the injuries in this study with graft/flap coverage fared no better than bone shortening with primary closure or than with benign neglect to allow for secondary healing.
What is the message for hand therapists? Understandably, these patients are typically not happy with their result, especially early on. They wonder if they received appropriate treatment. While you are desensitizing and mobilizing these fingers and educating these patients about wound healing and readying them for a return to full activity, you can say with considerable certainty that the result would not have been particularly different even if they had gone to the other hospital, had to wait less time, seen a different doctor, or had better insurance.
How to Write Better
I am presenting an Instructional Course at the Hand Society annual meeting next month in Chicago. The topic is how to get a manuscript published. Some of the information has broader applications. Here are some of the wizards who I will quote:
Literature is the art of writing something that will be read twice; journalism what will be grasped at once. Cyril Connolly, critic and editor (1903-1974)

One should aim not at being possible to understand, but at being impossible to misunderstand. Quintilain
Short words are best, and old words when short are best of all. Winston Churchill
Easy reading from hard writing. CE Montague
Brevity in writing is the best insurance for its perusal. R Virchow
Quarrel with the need for every paragraph, every sentence, every word. AE Flatt
Sit down and put down everything that comes into your head and then you're a writer. But an author is one who can judge his own stuff's worth, without pity, and destroy most of it. Colette, writer (1873-1954)
To improve your writing, change every instance of ‘very’ to ‘damn’, then the editor will cross it out and your writing is as it should be. Mark Twain
Best wishes,
Roy A. Meals, MD
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