When Snow Blowers Attack: How to Use a Rongeur in Finger Amputations
Your patient in the Emergency Department has a Zone II or Zone III finger amputation which requires primary closure of the wound prior to discharge with appropriate outpatient follow up. However, a protruding piece of bone often prevents closure of the skin flap and requires trimming by using a rongeur. While this process is typically carried out by an orthopedic or hand surgical consultant, this post aims to introduce the use of a ronguer during management of finger amputation in the Emergency Department.
1. Treat these as open fractures, start IV antibiotics (often first-generation cephalosporins) and update tetanus immunization if the patient has not received a booster within 5 years.
2. Control hemorrhage with direct pressure. Of note, direct pressure may be painful, so gentle pressure at the base of the digit, effectively blocking the blood vessels is sufficient for bleeding control (until a digital block can be performed and direct pressure may be applied).
3. Assess the neurovascular status. Also assess for tendon involvement (flexor and extensor tendons of the hand). If there is tendon involvement, prompt referral to a hand surgeon is mandated (consult hand surgery if available; or follow-up within 5 days).
4. Anesthetize the finger with a digital block.
5. Irrigate the wound thoroughly. For irrigation, one may use a 60cc syringe with an 18-gauge angiocatheter sheath for proper pressure or use a 1000cc saline bag, cut the tip open and irrigate.
6. Next, re-examine the wound once it has been carefully irrigated. As shown, note the phalangeal bone protruding through the wound.
7. After irrigating, cover the wound with a sterile glove (you may dress the patient in a sterile gown for a larger field). To maintain a bloodless field, you may cut the tip off the glove for the finger of interest, then roll back that fingertip until the patient’s finger is visualized. This will function as a tourniquet, but remember to remove the tourniquet as soon as possible to prevent potential injury.
8. Next, use a rongeur bone cutter to slowly cutback the bone. To use the rongeur, grasp the two ends with one hand (like pliers), then cut through the exposed bone by taking small millimeter chips away from bone.
9. Continue cutting back the bone until you have enough soft tissue or skin over the bone through which to place a suture without overly stretching the skin.
10. Finally, use non-absorbable sutures to close the edges of skin and soft-tissue over the bone with simple interrupted stitches.
11. Apply antibiotic ointment and cover with dressing. Have the patient return in 24-48 hours for wound recheck, as well as with hand surgery within 1 week. Patients should be discharged with a course of antibiotics (for example, Keflex) effective against skin pathogens.
12. Consider splinting the finger if fractured or to allow for soft tissue rest.