Review Article Ray Resections of the Fingers: Indications ...€¦ · Philip E. Blazar, MD Mark T....

Review Article

Ray Resections of the Fingers:Indications, Techniques, andOutcomes

Abstract

Ray resection, which was pioneered by Bunnell in the 1920s, wasinitially performed as a salvage procedure for dysfunction of theproximal interphalangeal joint. Successful ray resection with or withoutanadjacent ray transfer canbeuseful for treatingvascular insufficiency,tumors, infection, trauma, recurrent Dupuytren contracture, andcongenital abnormalities of the hand. Indications, techniques, andoutcomes vary based on the digit and the number of digits resected.Compared with amputation at the proximal phalangeal level, a singleray resection has better cosmesis and similar function, resulting inimproved patient satisfaction. However, a 15% to 30% loss in grip andpinch strength has been reported. Today, ray resection results in goodcosmetic and functional outcomes when preservation of a functionaldigit is unattainable or when the presence of an abnormal,unreconstructable digit interferes with the overall hand function.

Anonfunctional digit that is lim-itedbypain, stiffness, insufficient

or excessive length, or lack of sensa-tionmay interferewithdaily activities.These functional limitations are usu-ally the result of trauma, malignancy,infection, congenital deformities, vas-cular insufficiency, or recurrent Du-puytren contractures (Figure 1). Rayresection of the finger is performed toreduce pain and improve function byremoving the finger using metacarpalresection. Here, we provide an over-view of the current issues concerningray resection in an effort to guide theorthopaedic surgeon with regard toappropriate patient selection, surgicaltechnique, and postoperative care foroptimal outcomes.

General Considerations

The one absolute indication for rayresection is ischemic necrosis involvingthemetacarpal.1 Severe dysfunction of

the proximal interphalangeal jointand amputations at the level of theproximal phalanx are also classic in-dications for ray resection.1-6 Someauthors argue that maintenance of themetacarpal head and the transversearch is important for grip stabilityand strength7 and advocate thatray resection should be reserved forextreme cases. Amputations per-formed distal to the proximal inter-phalangeal joint function wellwithout ray resection. However, a stiffobstructive finger, regardless of length,may result in decreased function anddexterity of the remainder of the handand, in some cases, a painful, repeat-edly traumatized useless digit.1,8,9 Theadvantages of ray resection are gapelimination, removal of a cumbersomeor painful digit, and better cosmesisin most cases.2-6,10-22,23 The dis-advantages of the procedure includedecreased grip and pinch strength,decreased palm width, and an

476 Journal of the American Academy of Orthopaedic Surgeons

Philip E. Blazar, MD

Mark T. Garon, MD

From the Department of OrthopedicSurgery, Brigham & Women’sHospital, Boston, MA (Dr. Blazar), andthe Department of OrthopaedicSurgery, Louisiana State UniversityHealth Sciences Center, Shreveport,LA (Dr. Garon).

Dr. Blazar or an immediate familymember serves as a paid consultantto Endo Pharmaceuticals and Smith &Nephew and has received research orinstitutional support from EndoPharmaceuticals. Neither Dr. Garonnor any immediate family member hasreceived anything of value from or hasstock or stock options held ina commercial company or institutionrelated directly or indirectly to thesubject of this article.

J Am Acad Orthop Surg 2015;23:476-484

http://dx.doi.org/10.5435/JAAOS-D-14-00056

Copyright 2015 by the AmericanAcademy of Orthopaedic Surgeons.

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

abnormal finger count.5,7,17,23 Manyauthors have described the importanceof hand width and grip strength tolaborers and have recommendedagainst ray resections in this pop-ulation,9,14,23 but others have reportedgood results even in these patients.6

The primary contraindication is anypsychological barrier to amputationbecause resection may lead to emo-tional distress.The decision to perform a proximal

phalangeal ray resection of the indexor little finger is difficult for both thepatient and the surgeon. In thetrauma setting, many resections areperformed as a secondary procedureafter the patient’s condition has sta-bilized. This allows the patient timeto decide whether the function andcosmesis of the injured digit areacceptable, thereby obviating theneed for further surgery; if resectionis desired, the injured digit serves asa good source of tissue for handreconstruction.24 The major disad-vantage to secondary resection isthat the patient requires more timeoff work.2,3,10-12

Resections are classified as thumb,border, or central, and each categoryis treated differently. Incisions for rayresections vary, but recreating the

web space is paramount.11,14 Also,avoiding placement of the incisionon the ulnar border of the palmprevents a painful scar on a weight-bearing portion of the hand. Becausethe thumb allows for opposition andis crucial to overall hand function,indications for ray resection of thisdigit are typically limited, and sur-gical reconstruction is preferred.Surgical reconstruction of the thumbis beyond the scope of this article.A racquet or V-shaped incision can

be used for the border digits (Figures2 and 3). A web space–preservingincision pioneered by Plasschaertand Hage25 may be used for a centralray resection, with good results re-ported (Figure 4). Most authorsagree with extending the proximalaspect of the incision using a Brunnerzig-zag incision to prevent thedevelopment of contractures.11,15,25

Resection of the central digits isunique in that it may result in diffi-culty with small objects fallingthrough the persistent gap3,6,8,11,14-16,18-26 (Figure 5). Thus, centraldigits are treated with resection and

soft-tissue imbrication, bony trans-position, carpal wedge resections, ortotal metacarpal resections to closepalmar gaps (Figure 6). Border re-sections are performed withouttransposition. Following single rayresection of the fingers, grip andpinch strength can be expected to be70% to 85% of the strength of theuninvolved hand.1,2,4,7-11,14-16,18-22,24

Patients are generally satisfied withthe outcomes of ray resection,given the improved dexterity andgood functional and cosmeticoutcomes.

Preoperative Evaluation

A detailed history and physicalexamination is performed, takinginto account patient age, hand dom-inance, occupation, medical co-morbidities, patient concerns aboutoutcome and amputations, anyfunctional limitations, prior surgeries,and any history of injury to orpathology of the hand. The focusedphysical examination includes inspec-tion for any wounds or scars;

Figure 1

Preoperative photograph of the handdemonstrating an infected indexfinger. The finger was later treatedwith resection.

Figure 2

Photographs of the dorsal (A) and volar (B) aspects of the hand demonstratingthe markings for a racquet- or V-shaped incision for resection of the little finger.

Philip E. Blazar, MD, and Mark T. Garon, MD

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palpation of any fluctuance or masses;and detailed sensory, range-of-motion(ROM), and motor examinations. Athorough vascular examination is

conducted, as well, including assess-ment of pulses; anAllen test for radial,ulnar, and digital arteries; andaDoppler evaluation of digital vessels.

Radiography of the affected hand isalso indicated. Additional studies,such as MRI, ultrasonography, andarteriography,maybeused toevaluatemasses or vascular insufficiency.

Indications

Indications for border ray resection aretrauma that involves the index andlittle fingers, malignancy confined toone of the border metacarpals, infec-tion, congenital deformities, vascularinsufficiency, and recurrentDupuytrencontracture involving the borderdigits.1-7,10,12,13,23 Although the in-dications for central ray resection aresimilar to those for border ray resec-tion, having a dysfunctional centralfinger is arguably more problematicfor the patient because it is harder to“avoid” the obstructive central digit inday-to-day activities.2,3,8-11,14-23,25-28

Ray Resection of the Indexand Little Fingers

Surgical TechniquesFor resection of the index finger,a skin incision should be used thatallows for wound closure withouttension or excess integument whilepreventing contractures.1,7,23,29 Thedigital neurovascular bundles andbranches of the superficial radialnerve are identified. The digital ar-teries and veins are ligated and cut,and the nerves are isolated andtransected sharply. The extensortendons of the index finger (ie,extensor digitorum communis,extensor indicis proprius) are iso-lated. The tendons are transected,and the cut ends are allowed toretract proximally after division ofthe junctura tendinea. The indexfinger metacarpal is then exposed ina subperiosteal fashion. In resectionsof the border fingers, the metacarpalis partially removed with an osteot-omy; the bone is cut obliquely 2 cm

Figure 3

Photographs of the dorsal (A) and volar (B) aspects of the hand demonstratingthe markings for a racquet- or V-shaped incision for resection of the index finger.

Figure 4

Photographs of the dorsal (A) and volar (B) aspects of the hand demonstratingthe markings for an incision described by Plasschaert and Hage25 for resectionof the long finger.

Ray Resections of the Fingers: Indications, Techniques, and Outcomes



from the base from proximalto distal and radial to ulnar7,9

(Figure 7). The insertions of theflexor carpi radialis and extensorcarpi radialis longus must be pro-tected during the osteotomy.1,7,26

Although an osteotomy of the base ofthe metacarpal is preferred to pre-serve ligamentous and tendinous in-sertions at the base,2 in the rare caseof malignancy or when a soft-tissuedefect is present, removal of the entiremetacarpal may be beneficial.When disarticulation is used, the in-

sertions of the wrist extensors or flex-ors are subperiosteally dissected,transferred, tenodesed, or allowed toscar in place; the remaining attach-ments prevent retraction.8,15,19 Addi-tionally, protection of the radial arteryas it wraps around the base of thesecond metacarpal is important.12

Volarly, the flexor tendons of theindex finger (ie, the flexor digitorumprofundus and flexor digitorum su-perficialis) are transected proximal tothe lumbrical muscles to allow forretraction without causing intrinsictightness. Transection proximally alsoallows the tendons to retract proximalto the carpal tunnel to decrease carpaltunnel congestion and scarring.23

Historically, the insertion of thefirst dorsal interosseous muscle wastransferred to the proximal phalanxof the long finger to prevent scissor-ing and ulnar translation of the re-maining lesser digits.1,7 This transferhas fallen out of favor, given the lackof benefits and because the musclewas often transferred to the extensorhood, causing intrinsic overpull.28

The extensor indicis proprius andflexor digitorum superficialis of theindex finger have also been trans-ferred to the long finger in anattempt to improve the independentfunction of the long finger, but re-sults have been discouraging giventhe lack of functional benefit andincreased number of rotational de-formities reported.7,8,23,24 Tendontransfers done in conjunction withray resection are of historical interestonly and should not be performed.Preservation of the radial digital

neurovascular bundle to the longfinger is important to preventdecreased perfusion and sensation,which could interfere with keypinch maneuvers.29 To prevent neu-roma and hyperesthesia, surgeonshave used suture ligature, proximal

transection, intraneural alcohol,buried nerve ends, silicone caps,avoidance of excessive mobilization,and end-to end repair of nerves2,7,11,23,30 (Figure 8). However, notechnique has been shown to reduceneuroma formation. Transectedradial and ulnar digital nerves can berepaired by suturing the nervestogether end to end. Gorkisch et al30

performed this technique using aninterposed autograft from one of theinjured digital nerves to prevent thepartially regenerated axon ends fromresting beneath the anastomosis.Compared with resection of the

index finger, some technical differencesexist when the procedure in the littlefinger is performed. The metacarpal ofthe little finger is cut from proximal todistal and ulnar to radial to prevent anulnar spike, and the flexor and exten-sor tendons and the ulnar artery andnerve are protected9,13 (Figure 9). Theosteotomies are performed in thisfashion to prevent bony prominenceover the radial or ulnar border of thepalm in index and small finger re-sections, respectively. Historically, theabductor digiti quinti insertion hasbeen transferred to the proximal

Figure 5

Preoperative photograph of the handdemonstrating a palmar gap resultingfrom amputation of the ring finger.

Figure 6

Postoperative photograph of the dorsal (A) and volar (B) aspects of the handdemonstrating the gap closure after a central digit resection with soft-tissueimbrication.


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phalanx of the ring finger to allowabduction of the ring finger andprevent scissoring of the fingers inflexion.6,29 Tendon transfers of theinterossei, flexor digitorum profundus,flexor digitorum superficialis, andhypothenar muscles have no clinicalbenefit and may lead to further dys-function of the hand; therefore, thesetransfers are of historical interest onlyand should not be performed in rou-tine ray resections.1,6-8,23,26,28

Postoperative Care andRehabilitationThepatient’s finger is immobilized ina bulky soft dressing or protectivesplint, with the hand placed in theintrinsic-plus position. A drain maybe placed at the discretion of thesurgeon. The splint is removed 2 to 7days postoperatively, and a woundcheck is performed. Active ROMis encouraged to decrease post-operative stiffness. In border rayresection, the patient may be allowedto progress to unrestricted motionafter the wound has healed.1,5,7,13,23

OutcomesKarle et al4 compared the outcomes ofray resection (58 patients) and proxi-mal phalanx amputation (12 patients)

of the index finger. The authorsfound that patients treated with rayresection were more satisfied withthe cosmetic result and had lesspain than did the patients treatedwith proximal phalanx amputation.However, patients in the resectiongroup also had lower Disabilities ofArm, Shoulder, and Hand scores(Part B), decreased ROM, decreasedsensation, and slightly weaker gripand pinch strength.In a study of 14 ray resections

of border digits (8 index, 6 little),Melikyan et al10 reported a 19% (P.0.05) decrease in grip strength in theindex finger group and a 16% (P .0.05) decrease in grip strength in thelittle finger group compared with thegrip strength of the contralateral hand.Three-point pinch was also decreasedby 15% in the index finger group andby 24% in the little finger group. Palmwidth is also a concern becausedecreased palm width may lead todifficulty with grasp. Melikyan et al10

reported that little finger resectionswere associated with a 6% decreasein palm width, whereas index fingerresections had a 3% decrease.Several studies have reported

a decrease of 15% to 30% in three-point pinch and grip strength com-paredwith the unaffected hand.2,4,7,10

In a study of hand strength andcomplications following resection ofthe index finger in 41 patients,Murray et al7 reported a 50% loss ofpronation strength and a 20%decrease in supination strength withindex finger resections. With regardto the function of the affected handcompared with that of the contralat-eral hand, patients who underwentborder ray resection performed wellon the Purdue Pegboard andMinnesota Rate of Manipulationtests. Functional outcomes followingresection of the index finger arefavorable because of the transfer oftasks to the long finger.1,2,7,10 Mostpatients are able to return to thesame occupation and leisure activ-ities at an average of 10 weeks

Figure 8

Intraoperative photograph of thehand demonstrating the digitalnerves buried in the interossei.

Figure 9

Photograph of a Sawbones model(Pacific Research Laboratories) ofthe hand demonstrating resection ofthe little finger.

Figure 7

A, Intraoperative photograph of the hand demonstrating index finger resectionwith removal of the metacarpal in a retrograde fashion after subperiostealexposure of the metacarpal. B, Photograph of a Sawbones model (PacificResearch Laboratories) of the hand demonstrating resection of the index finger.




postoperatively.10 Although somestudies have demonstrated good painrelief following the procedure,4

Murray et al7 found that 59% ofpatients had hyperesthesia and coldintolerance and 37% had limitedfunction. Before the resection, 34patients had pain, and only 3 werepain free postoperatively. Most of thehypersensitivity was in the first webspace and involved the superficialradial nerve, despite the cut endsbeing buried in the interossei. Someauthors have advocated the use ofend-to-end nerve repair after ampu-tation to reduce neuroma formationin this highly sensitive area.1,11,30

Gorkisch et al30 resected 20 indexfingers and performed end-to-endrepair of the sensory nerves, result-ing in one neuroma caused by repairfailure. Even with weakness in gripand pinch strength and the highincidence of hypersensitivity and coldintolerance, patients are typicallysatisfied with the outcomes after rayresection.1,2,4-7,10,23

Ray Resections of the Longand Ring Fingers

Surgical TechniquesRay resection of the long or ring fingermay be performed with or withoutbony transposition of the adjacentindex or little finger metacarpals. Thebony transposition can be performedvia metacarpal osteotomy, carpome-tacarpal disarticulation, or intercarpalosteotomy.10,11,14-16,18 Althoughresection with deep transverse inter-carpal ligament repair is an option,advocates argue that transpositionallows better control of rotation,angulation, gap closure, and digitlength.8,9,11,14,16,18,21,26,27 The dis-advantages of transposition includethe risk of implant infection andprominence, malunion, nonunion,wide web space, stump protrusion,and extensor tendon adherence.8,11

Proponents of soft-tissue imbrication

report good functional results andweb space closure without the risks ofnonunion, device irritation, or tendonadhesions.8,14,15,19 Closure of theweb space with soft-tissue imbrica-tion is less technically demandingthan transposition, with satisfactoryresults reported.15,18,19

The incision pioneered byPlasschaert and Hage25 is preferredfor accurate reconstruction of theweb space (Figure 4). As in resectionof the border digits, the extensortendons are transected proximallyand allowed to retract to preventcarpal tunnel congestion.16,23 Thedigital vessels are ligated and thedigital nerves are repaired end-to-endor buried in the interossei to preventneuroma formation.11,14,30 The sub-periosteally exposed metacarpal maybe partially removed via osteotomyor may be disarticulated from thecarpus (ie, ring finger). Althoughsatisfactory results can be achievedwith both techniques, disarticulationof the ring finger may allow fortranslation of the little finger at thelevel of the carpometacarpal joints toclose the large web space; however,this may increase the risk of angula-tion and malrotation.26

Controversy also exists with regardto what should be done with the in-terossei attached to the resected cen-tral digit. Some authors advocate theremoval of the interossei to facilitateclosure of the web space;9,18 otherssuggest repairing the periosteum ofthe resected metacarpal, leaving theinterossei in place.15,19 When disar-ticulation or osteotomy of the centraldigits is performed, the deep motorbranch of the ulnar nerve must beprotected, along with the deep pal-mar arch.13 The surgeon may elect toachieve web space closure withrepair of the deep transverse inter-metacarpal ligament and dorsaldermodesis15 or transposition.11,14

When a metacarpal osteotomy isperformed, the metacarpal is cuttransversely 2 cm from the articulation

with the carpus; this allows bothadequate fixation of the osteotomysite and preservation of the extensorcarpi radialis brevis insertion on thelong finger and takes advantageof the superior union rates of themetaphysis.9,14,27 The appropriateborder ray is then cut, as described.A second transverse cut is made aftermeasuring to allow for alterations inlength.11,18 The donor metacarpal isthen transferred to the neighboringresidual metacarpal base en bloc,allowing preservation of the nativedigital neurovascular bundles, ten-dons, and intercarpal ligaments.11,14

A T-plate is commonly used for os-teosynthesis, but Kirschner wirestabilization also has been per-formed successfully with a step-cutosteotomy11,17,18 (Figure 10). Bonegraft from the metacarpal base of theborder digit or a bone plug may bepacked into the osteotomy site toenhance union rates with minimalmorbidity.11,17

Repair of the deep transverse inter-metacarpal ligament is performedafter bony stabilization. During resec-tion of the long finger, the adductorpollicis origin may be transferred tothe transposed index finger to preserveadduction of the thumb.11,14,18 This iscommonly performed by sub-periosteal elevation of the origin of theadductor off the long finger andplacement of a braided suture to tagthe origin. The adductor is thentransferred to the transposed indexfinger with soft-tissue imbrication,14

through drill holes,11 or with a sutureanchor or anchors. No consensus ex-ists on whether the transfer of theadductor pollicis is necessary.8 Car-roll8 suggested that subperiosteal ele-vation without repair allows scarringof the adductor into a functionalposition.Finally, transposition may be per-

formed by intercarpal osteotomy, asoriginally described by Le Viet.20

After the resected metacarpal isremoved by disarticulation, the


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incision is extended proximally toexpose the carpal bones. It is crucialthat the wedge resection be plannedusing the angle of divergencebetween the resected metacarpal andthe transposed metacarpal, which istypically 7� to 10�. Once the os-teotomy is marked on the respectivecarpal bone and checked, it is per-formed with an osteotome or oscil-lating saw. The dorsal cortex isremoved, and the remainder of thecarpal wedge is subperiosteally dis-sected volarly and removed, withcare taken to prevent damage to theneurovascular structures volar to thecarpus. When a wedge osteotomy forlong finger resections is performed,the wedge is taken out of the capitateonly. For a ring finger resection,wedge osteotomy and arthrodesis ofboth the capitate and hamate isperformed. Once the wedge of boneis removed, closure of the resultinggap brings the metacarpals closertogether. Removal or supplementa-tion of the dorsal or volar portion ofthe osteotomy site can help correctrotation and angulation. Once theresection is satisfactory, osteosyn-thesis can be performed successfullyby using internal fixation withscrews or by placing a suture in theperiosteum, along with repair of the

deep transverse intermetacarpal lig-ament16,20 (Figure 11). After thedeep layers are closed, excess skin isremoved and the wound is closed;the rotation in both flexion andextension with the wrist is checkedwith the tenodesis test.15,19

Postoperative Care andRehabilitationDrains are inserted at the discretionof the surgeon. The patient’s hand isplaced in a soft dressing or immobi-lized in the intrinsic-plus position. Awound check is performed 2 to 7 dayspostoperatively. Early active ROM isencouraged to prevent extensor tendonadhesions and stiffness. If an extensorlag is noted on the postoperativeexamination, a dynamic splint may beused for 2 weeks.11,14 When internalfixation of the intercarpal osteotomy isperformed with suture, the newlytransposed digit may be buddy tapedto the more radial digit to ensuremaintenance of the web space. If bonytransposition is performed, unre-stricted motion is allowed when thepain is minimal at the osteotomy siteor radiographic union is noted.2,11 Ifsoft-tissue transposition is performed,unrestricted motion is allowed at 8 to12 weeks postoperatively.15

OutcomesOpinions vary on whether to trans-pose the neighboring digit after a cen-tral ray resection, and no consensushas been reached.10,11,14-16,18-22 Soft-tissue imbrication of the deep trans-verse intermetacarpal ligament is aneasier option and does not have theinherent risks of nonunion or bonymalalignment associated with os-teotomy.7,11 However, scissoring ofthe adjacent digits and discrepanciesin digit length and rotation are moreprevalent with soft-tissue repair.7,11,16

Metacarpal osteotomies may allowrotation and length correction, butthey have an inherent risk ofmalunion and nonunion and must berigidly fixed.11,17 There is also noconsensus as to whether the entirering finger metacarpal should be re-sected to eliminate a painful stump orif a stump should be retained to pre-serve tendinous insertions.4,8,16,19,22

Intercarpal osteotomies do notallow for length adjustments; how-ever, rotational and angular correc-tions may be made.16,20,21 Levy22

described the long-term results of rayresection and soft-tissue imbricationwithout transposition performed ina patient with traumatic avulsion ofthe ring finger. The patient wasa surgeonwhowas also an avid tennisplayer. Although the patient was

Figure 10

Photographs of Sawbones models (Pacific Research Laboratories) of little fingertransposition (A) after ring finger resection using a step-cut osteotomy withKirschner wire osteosynthesis, and index finger transposition (B) for resection ofthe long finger using a T-plate for osteosynthesis.

Figure 11

Photograph of a Sawbones model(Pacific Research Laboratories) ofthe hand demonstrating intercarpalosteotomy after ring finger resection.




satisfied with the result, he reportedthat coins slipped through the gap inhis hand.As with ray resection of border

fingers, strength of the central fingersafter ray resection has been heavilystudied. A decrease in grip, key pinch,and three-point pinch strength of atleast 20% to 30% (even as much as50% in some cases) can be expectedafter central ray resection, with orwithout transposition.2,3,8-11,14

ROM following ray resection hasalso been examined because of con-cerns about extensor tendon adhe-sions. In a study of 19 patients whounderwent ray transposition for lossof a central digit, Colen et al14 re-ported that the transposed fingershad average ROMs of 77.6� for themetacarpophalangeal joint, 87.6� forthe proximal interphalangeal joint,and 80.8� for the distal interpha-langeal joint. In a study of 10 pa-tients treated with metacarpaltransposition plate osteosynthesisafter resection of the long finger,Hanel and Lederman11 reported thatno patient had decreased ROM, andone patient had increased ROM inthe transposed finger. Steichen andIdler15 reported similar results fol-lowing ray resection; ROM wasgood even without transposition.Because of its association with

grasp, palm width following rayresection of the long finger has alsobeen studied. Nuzumlali et al3 andPeacock9 showed decreased palmarvolume and width and decreasedhand circumference associated withray resection. Melikyan et al10 foundthat total palm width after resectionof a central finger was decreasedby 7%.Barring injury to the remaining

nerves during resection, post-operative sensation has been uni-formly acceptable,2,11 but pain tendsto be a problem after resection, withapproximately 50% of patients re-porting some pain and up to 10%claiming severe pain in one series.15

Pain can be caused by neuromaformation, implant irritation, non-union, or a prominent metacarpalstump.8,11 Cold intolerance is alsoa problem. Steichen and Idler15 re-ported that 4 of 13 patients whounderwent central ray resectionwithout bony transposition reportedcold intolerance.Patients treated with resection

without transposition tend to returnto work at approximately 10 weekspostoperatively, with most patientsreturning to the same job.2,11,15

Radiographic evidence of trans-position healing appears at 4 to 12weeks postoperatively, and patientsmay return to work at 3 to 15weeks—sooner for those with a lessdemanding occupation, later in thesetting of secondary amputation andworkers’ compensation involve-ment.2,11 Peimer et al2 retrospec-tively reviewed 25 patients treatedwith primary (,2 weeks) and sec-ondary single ray resections; 14 hadresections involving the dominanthand. The authors performed re-sections and metacarpal trans-position in 18 border and 7 centraldigits. Time to return to work was 9weeks for the primary resectiongroup and 16 weeks for the sec-ondary group. Although 21 of 25patients returned to work, thoseinvolved in workers’ compensation/litigation performed poorly infunctional testing.2 Overall, moststudies report good functionalresults using a variety of mea-sures.10,15 However, Peimer et al2

demonstrated a 12% and 24%decrease in gross hand function andfine finger dexterity, respectively,using the Minnesota Rate ofManipulation test and timedgrooved pegboard test.Cosmesis tends to be considered

favorable after the procedure, andmost patients are pleased with theresults.3,15,19 Nuzumlali et al3 com-pared the outcomes of patientstreated with ray resection or proxi-

mal phalanx amputation for anavulsion injury of the ring finger.The authors found that patients whounderwent resection were satisfiedwith the cosmetic and functionaloutcomes, whereas the patientstreated with proximal phalanxamputation without ray resectionconsidered the cosmetic outcomeunacceptable and noted that smallobjects fell through the injured hand.No patients in the amputation groupdesired a ray resection because theywere happy with a normal fingercount, and only one wore a cosmeticprosthesis. The authors concludedthat choosing between amputationand ray resection should be left to thepatient, but ray resection should beavoided in patients who requirestrong key and chuck pinchfunction.3

Hanel and Lederman11 concludedthat successful reconstruction oflong finger resection must addressthe following: web-space closure,malrotation, hand symmetry, rigidosteosynthesis, and end-to-endrepair of the digital nerves. Ingeneral, patients who underwentcentral ray resections were able topreserve hand function and returnto work; they were also satisfiedwith the surgical outcome regard-less whether a transposition wasperformed.2-4,10,11,14-16,18-22

Summary

Ray resection of the index or littlefinger is usually performed by meta-carpal resection, leaving the meta-carpal base intact. Tendon transfershave failed to show functional bene-fits and lead to further complications.Resection of the long or ring fingerinvolves partial or complete rayresection with soft-tissue imbricationor transposition of the border digitvia metacarpal osteotomy or inter-carpal osteotomy. Advocates oftransposition report better correctionof digit length, rotation, and closure


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of gaps, whereas others report satis-factory results and a decreased risk ofcomplications with soft-tissue imbri-cation. Burying the sensory nerves inthe interossei or end-to-end repairmay help decrease the high rate ofhyperesthesia and neuroma, but thishas not been clinically proven. Dex-terity, function, patient satisfaction,and cosmetic results of ray resectionare generally as good as or better thanthose of amputations at the proximalphalanx. However, a 15% to 30%loss of pinch and grip strength asso-ciated with resection should be ex-pected. Thus, ray resection should beused with caution in patients whorequire strong grasp and pinchstrength.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, references2-4, 7, 10, 11, and 14 are level IIIstudies. References 1, 5, 6, 8, 9, 12,13, 15-21, 24-28, and 30 are level IVstudies. References 22 and 23 arelevel V expert opinion.

1. Mahoney JH, Phalen GS, Frackelton WH:Amputation of the index ray. Surgery 1947;21(6):911-918.

2. Peimer CA, Wheeler DR, Barrett A,Goldschmidt PG: Hand function followingsingle ray amputation. J Hand Surg Am1999;24(6):1245-1248.

3. Nuzumlali E, Orhun E, Oztürk K,Cepel S, Polatkan S: Results of rayresection and amputation for ringavulsion injuries at the proximalinterphalangeal joint. J Hand Surg Br2003;28(6):578-581.

4. Karle B, Wittemann M, Germann G:Functional outcome and quality of life after

ray amputation versus amputation throughthe proximal phalanx of the index finger[German]. Handchir Mikrochir Plast Chir2002;34(1):30-35.

5. Segret J, Barbary S, Pétry D, Dautel G:Primary ray resection as an alternative tomicrosurgical replantation in themanagement of ring finger avulsion[French]. Chir Main 2008;27(5):202-207.

6. Gottlieb O: Metacarpal amputation: Theproblem of the four-finger hand. Acta ChirScand Suppl 1965;343:132-142.

7. Murray JF, Carman W, MacKenzie JK:Transmetacarpal amputation of the indexfinger: A clinical assessment of handstrength and complications. J Hand SurgAm 1977;2(6):471-481.

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Review Article Ray Resections of the Fingers: Indications ...€¦ · Philip E. Blazar, MD Mark T....

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