The

Kutler Finger-Tip

Method

of Repair

of

Amputations*
FISHER, M.D.t, ROANOKE, VIRGINIA

BY

RICHARD

H.

In
I

1947

Kutler

described

a method

of repair

after

finger-tip

anmputationms. procedure for time proper recognition.

have repair

used it for fifteen years arid have found of this type of injury, yet this procedure Description
Time finmger tip is anesthetized by

it a most helpful has not received

of
a digital

Procedure
nerve block at the proxinmal phalanmx.

Ts-o
tip

per cent plain mieedle ; a rubber-band

is

Xylocaine tourniquet the

the

anesthesia is applied edges of soft

one the on too either large, apex

is preferred around the tissue

on of side each each each of the side

and is given with a No. 27 proximal phalanx ; the finger bone

of flap

debrided,
triangular through in the flaps

arid
flaps

uneven
are skin, not with line be

and
side

are
the directed

trinmnmed
finger,

(Fig.
by

1, a).
arid one-

Two incisinmg

developed,

simarply

proxinmally approximmmtitely

cenmtered The

mid-lateral should

finger. measuring

FIG.

l)rocednrre a, Time inneven edges of the anmplntnited finger I ip are (lellrided and sm(s)tiied: b, the Shari) corners of the ampnntated phalanx are rounded to provide a nornmmal comitonrr amm(l to i)reVent inmpimmgement (npoli the pulp (If the flaps as they are snnture(l together; e, the tnanigular flaps nue developed by incising the skimi as shown in the diagram; d, the flaps are mobilized by Insing small plnistic scissors at the apex, dividing jnrst the amount of pnnlp necessary, while traction is applied at the base (If the flap with a skin hook, to permit displacenmemni of the flap distally over the tip of the i)halanX e, the two flaps are sintured togethen:f, the flaps are snnt mired to the remaining nailbed; g, some (If the pulp usirally has to be excised before o)mpleting the closnrre ; anal h, t he conpleted closnnme is showmm.
of I lie
*

I )iagran

Flea(1 at

he Ammnnnal )Jeeting

of

the

American Lewis-(.ale

Society Clinmic,

for

Snnrgery

of

the

Ilamid, 24007.

Chicago,

Illin

mis, Januai-y

1 I )epai-t
V(IL 49-A, NO.

2 1 , 11)66. nmemit ()f Or) hopaedic

2, MAR(H 11)67

Snnrgery,

Iloanoke,

\irginia

317

315

It.

H.

FISHER

FIG.

2-A
ii) annpnrtation vitii

Fig.
proxin)ately

2-A : A fimmger-t
()nuil-httlf
(If

apthe

Fig.
photograph imail -ith

2-B:

iwo

years

mmailbed reniaining. follilwiilg the sinmgery,

the

sl)O%.s aim essemmt good al)I)earinn(e.

ally

normal

length

FIG.

2-B

FIG.

3-A
sustained flaps a typical sharp amputation to

FIG.

3-B
finger with a bmntehen

Fig. knife, Fig.

3-A: 3-B

This : Fine

hoirsewife triangular

her

an-c developed.

Fn;.
Fig. Fig, 3-C : The 3-i ): lime
corner

3-C
of t he phalanx apiearance
is

FIG. rotrinded.
of

3-D

end-view

the

closure.

KUTLEIt

REPAIR

OF FINGER-TIP

AMPUTATIONS

319

The

side

view

of the

closure.

The

restnlt.

(lutmnter

of

arm inicim

in

length

aimd

the

base

about

the

same

length

or slightly

less.

Each

flap

is further

the

volar

developed pulp, as shown

with thumb

by incisinmg the skimm deeper toward the nail in Figure 1 , c. The flap of pulp tissue should
forceps or henmostats, as this could impair its

bed
hot

and

toward
A just it can the be

be pinched

01- clammmped

vascularity.

smmmall skin light

hook
of

is l)laced
at ally the the apex tip of the

mi the
direction.

pulp

toward
flap

the

base
to

of the
free the or

flap
flap base

and
to

used
divide

to apply

tenmsionm

in a distal

A pair finger toward (Fig. the

of snmall necessary
1,

scissors

is used

ttnmmoummt

pulp toward

of each pulp

so that

nioi)ihized sttn_y,
flap. 1)1111)

of the

d).

It is not
margin

desirable, of the

nor
of each

is it necestriangular

to

divide

distal

Usually
riced

not
to suture

nmorc
theni

thtmn i)efore

50 per

cent
(Fig.

of the
1,

thickness

proxinmal

part

of the

be severed the sharp rounded they

sutured on each to of the the
gtmuze

it is possible

finger reslmape
nionnmmal fltips

arid

together

to move each flap toward the e). It is very important to round

distal phalanx

tip of the off and to

the

corners (Fig. 1, b) of the amputated tuft arid to avoid pressure omi the together.
00000

to simulate

pedicles two
then

of the

two

triangular

aS

are sutured
interrupted to the side tninm sonic

The nail
tip

bases
sutures

of the
and

with
flap

three
are

dcrnmalone

small flaps are approxinmated the dorsal nmarginis of each 1,f). with
prior

renmainming
firmger

or nail
which
can

bed (Fig.

(Fig. be closed 1, g)
1,

This
to

leaves
suturing

fish-nmouth It is usually the

using

defects miecessary portion After

oimitnment

of the of has

sutures.

the pulp

excess to the
conmpleted

pulp triangular

volar
an

skin
closure

of the

been

(Fig.

flaps. Ii), a dressing arid

to by

is applied,

folloed

by
to

sterile
seal the

fluff
tissues

cottorm
prior

arm elastic
the the renmoval surgeon.

bandage
of the

which rubber-

is

tipplied
This 1)anid

snugly.
bandage tenmds tourniquet, a responsibility always assunmed

Results
A statistical l)atients of the
test for commtoured l)attelnms.

armalysis
treated
was

of the of the
attempted;

end later

results
and

has
were

not
riot

been

feasible,

since
in the

most
record

of the
roonm

were

as out

patielmts

cross-indexed

imospital.
senisitivity

In sonic so snmall
the nmost patients

cases,
however,

Mobergs the
the results been

nilmhydrin area
have barely

inmpregniated tip
quite

paper is so sweat
as

at the for the and

been

of the study

filmger of the

arid
Froni

that

this

test

is riot

effective appearance,

standpoirmt, the scars

satisfactory,

the
beeni

fingers
tender.

have
In

had

arm essentially
I)tttienits

Imornmal
have

there

has
and

been
have

good
nmot

senmsationi.

perceptible

In sonme definite and

Von..

of the

repairs length

by the

Kutler growth

method of the

there nail

has after

appeared the repair

to be a very (Figs. 2-A

increase 2-B).

iii the

of the

49-A.

NO.

2,

MARCH

1967

320

H.

H.

FISHER

FIG.

4-A
t I

FIG.

4.-B with 30 per cemnt witim

(

Fig. 4-A : A jagge(1 aml)( nt at 0 )I n ( f mnailbed reniaimniing. Fig. 4-B : Three years aft er iepaln,
the miornial left thunmil.

he

ip of the

t humb
O!i

of a mechanic compares

)f

h#{248}
of

he thumbnail

t he right

favon-ably

I hat

Fr;.
Fig. Fig. of
t

4-C
-ll( )Ws good (0111 onrr bows no l)ereI)tihle le:tnly evi(lemlt of t he
s(11rs

FIG.

4-I)
ridges amid furrowa.

4-( : Flie 4.-I ): The

finger-I

side

era!

view view
are

hmnmh hind the

t

tip. normal

appearing

he

ii) skimi

Fn;. Fig. Fig.

4-l

Fn;.

5 mmornial

4-I : Fhis nie(hammi( st ated ! hat he 5 : The l)amldage incorporates onily t he t 0 nmosl occupatiomis at ant early date.

able
t

to
t

ip

of

he

nnse t he thnnnib mi a nearly finger, thnns perniitting t

he p:itiemmt

to

fashnom. met nnmu

Comments Timis j)rocedume of the fingel

does
miot

shorten

the

amputtited

finiger

tip

further.

Actutilly,

time.

length

is inncnctised

slightly

by coveninmg
TIlE

the
JOURNAL

tip

of the
OF BONE

Phalamix
AND JO!NT

with

local

SURGERY

KUTLER

REPAIR

OF

FINGER-TIP

AMPUTATIONS

321 has been 3-E, and and

fingernail, to can cover be dolme

l)edicle
procedure

flaps
also

in which
restores

some to the able

(Figs. be

of the women to use

4-A, used 4-B, for be twenty

neurovascular
to 3-A, the

supply
finger tip,

preserved.
which has
.

The
been Patients and

a good

contour

a result

)articularly
whose without This occasions operation out-patient usually This juries. Also Perimaps
cOlmmpared

pleasing
activities
require

(Figs.
use

3-B,

3-C,
fingers,

3-D,
such

3-F)

considerable

of their

as piano

players

immechanics,

have
coniplaints nmethod a finger takes

been
carm joint no

their
4-C,

fingers
4-D,

in their aimd 4-E).

proximal advancing to

professions
to the the flaps and

occupations
anmd on it. as The an

anmmputations by minutes

can than

salvaged

more

perform

procedure.

The
of

dressing within pedicle

of

is nmot cumbersome a few days. transfers is also

amputations of

(Fig. adaptable
the fingers

5), and

the

patient toe

is in-

able

to returni
after

technmique

to work island
types

to sinmilar
and toes

unusual most other

a single when

triangular

flap
the with two secondary

nmay

be helpful
important procedures, require operations,

in reconstructing
advantage such the use nmore as

the
of this a cross-finger

danmaged
technique flap

part.
is its and anmd simplicity a palniar

flap. as
im-

These well as

procedures

of adjacent cumbersome

normal

and

uninvolved
prolonged

tissue,

dressings,

immobilization.

Complications
Complications colmmpronmised covered
nmoving were

imave by skirm the and

riot pulp

been and tissue

significant. the except exposed for

Adjacent wounded a very small

normal tissues area.

structures are Before

are imnmediately I began

not re-

procedure

with

the
iimstanmces

corners the
period.

of the
the

distal
resulting

phalanx
tip

and
of the

the
finger

technique
was not

was
as

perfected,
pliable

there

mm which

as desired.

In

sonme

cases

triangular
However,

flaps
found.
granulation

appeared beneath the

tissue

dark

or even case,

black necrotic
at

in the skin,

inimediate pink arid

postoperative

superficial
was present

viable
was
riot

epitheliunm
achieved

was
and

usually
some

In arm occasional nmot rmecessitated

of

However,
rmo significant occurred to

this

delayed
infectiorms.

healing

has

complete skin coverage the tip of the finger. revision and there have been finmger tip has not

Hypersensitivity

the

reconstructed

nmy knowledge. Summary

The
amputated

Kutler
firmger

procedure
tip.

is a simple, tissue
results

effective its
most

surgical neurovascular

method supply
from both

to
the

repair is used
cosmetic

an to

Local
and the

with
are

own

cover

the

finger

tip,

satisfactory

and

the

functional

standpoint. References

1. KUTLER,
1947.

WILLIAm: WILLIAM

A New
: Personal

Method

for Finger

Tip

Amputation.

J. Am.

iIed.

Assn.,

133

: 29-30,

2. K UTLEnI,

communication.

VOL.

49-A,

NO.

2,

MARCH

1967