Mr Ryan and Dr Murray are from the Department of Kinesiology, and Mr Fullmer is from the Department of Athletics, Mesa State College, Grand Junction, Colo.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Robert E. Ryan, MA, ATC, CSCS, Athletic Training Education Program, Department of Kinesiology, Mesa State College, 1100 North Ave, Grand Junction, CO 81501; e-mail: email@example.com.
Participation in sport can result in injuries such as avulsions and amputations of the digits.1,2 Sports such as rodeo, rock climbing, and water skiing have high rates of avulsions and amputations because of rope entanglement.3 Other sports, particularly those with object-manipulation skills (eg, basketball, softball), have more contusions, dislocations, and fractures to the digits. Generally, these injuries respond well to conservative treatment (eg, ice, rest, immobilization) and are typically not a major health concern. However, a digital fracture, dislocation, or avulsion can result in the need for surgical repair,1 and in extreme cases, surgical amputation. We present the case of a collegiate American football player who experienced a severely dislocated finger during full-contact practice, resulting in surgical amputation. The case is important because athletic trainers need to understand that injuries such as these can occur and that proper counseling of an athlete is necessary to ensure that an informed decision regarding the proper treatment is made.
A 22-year-old male collegiate American football player (height = 188 cm [6’2”], weight = 128.36 kg [283 lbs]) participated in full-contact practice. Following a play, he noticed that his right hand felt “funny.” He went to the sideline to see the certified athletic trainer. When he took off his practice glove, he saw that his fifth finger was deformed. The certified athletic trainer observed an open dislocation of the proximal interphalangeal joint in the fifth finger of the athlete’s right-hand. The wound was covered in a sterile gauze and immobilized with an ice pack and elastic wrap. The athlete was taken immediately to the local hospital emergency department for further evaluation.
On physical examination, the patient was alert and had normal vital signs and no distress other than moderate pain in his right hand. Visual inspection of the hand showed an obvious deformity of the fifth finger at the proximal interphalangeal joint, with apparent complete disruption of the supportive tissues; radiographs revealed no bone fractures (Figure 1). The gross findings of the examination revealed that the right, fifth finger demonstrated ulnar and dorsal dislocation of the proximal interphalangeal joint, with a 2-cm palmar and radial laceration. A bayonet apposition of the middle phalanx on the proximal phalanx and a complete disruption of the radial and ulnar collateral ligaments, as well as the volar plate, were present.
Figure 1. Initial Injury in the Hospital Emergency Department (A) and Radiograph of the Affected Hand Showing the Dislocated Phalanges (B).
After consultation with the athlete and the athlete’s parents by the athletic training staff and the attending physician, the athlete elected to proceed with amputation of the right, fifth finger at the proximal interphalangeal joint in lieu of an open reduction and internal fixation. The athlete was taken to the operating department and general anesthesia was administered. The mid and distal phalanges of the fifth digit were amputated, and the distal end of the bone was covered with a dorsal-to-palmer skin flap. A bulky, sterile dressing was applied, and an intravenous antibiotic therapy was initiated. The athlete was released from the hospital the following morning. A follow-up visit was completed 2 days later, as the athlete wanted to return to competition the next day. The athlete was disallowed a return to activities because of wound drainage, but he did return to full practice 8 days postsurgery with a customized, protective cast. He started in a varsity game 11 days postsurgery. Three weeks postsurgery, his sutures were removed. He continued full participation for the remainder of the season while wearing a protective device during practices and games. At 60 days postsurgery, he no longer needed the protective device and was released to unrestricted activity; he had no further complications (Figure 2).
Figure 2. The Affected Hand 60 Days Postsurgery.
Hand injuries are common in sporting activities, especially in American football.4 Generally, these injuries are not very serious, and conservative treatment (eg, ice, rest, immobilization) results in an uneventful, positive outcome with no long-term negative effects. American football is not known to be as risky for serious digital injuries (eg, avulsions, amputations) as are sports that potentially involve rope entanglements (eg, rodeo, rock climbing). However, our case is a perfect example that these types of serious injuries sometimes occur and is reminiscent of a similar incident that occurred to Ronnie Lott, a Hall-of-Fame American football player.5
Although certified athletic trainers are aware that serious injury to the digits can result in a number of sports, the occurrence of catastrophic (ie, loss of appendage) digital injuries is less frequent and, therefore, generally less expected. Nonetheless, when these injuries occur, the certified athletic trainer must be prepared to help counsel the injured athlete to make the proper choice specific to his or her situation.
Certified athletic trainers often work with highly motivated athletes who are more concerned with athletic participation because they are “caught up in the moment” more than they are with the long-term health consequences of their decisions. In our case, the athlete’s fifth finger was severely damaged. His finger could have been surgically repaired—although the outcome of the surgery was uncertain and his finger would have had functional deficits—but he would have missed playing for the remainder of the season. Our athlete’s initial response was, “Cut it off.” However, a faster return-to-play rationale is not a valid reason to make such a drastic choice as amputation, and one must look at the both the short- and long-term ramifications of any injury to decide on a prudent course of action.
For this athlete, the use of the finger would have been compromised. The range of motion and sensation of the digit would have been impaired, thus reducing mechanical function, and the digit would have been susceptible to long-term pain and arthritis. The athletic training staff and the attending physician emphasized that such a decision should be based on the athlete’s long-term health and not on the return-to-play status. Thus, the following criteria were considered for the athlete to decide whether amputation was the proper treatment6:
- The only absolute indication for amputation is irreversible ischemia in a diseased or traumatized limb.
- Amputation may be the treatment of choice for infection control, removal of tumors, or orthopedic conditions in which the individual would be more functional without the affected body part or with a prosthesis.
After much consultation and consideration, our athlete decided to have the injured phalanges amputated because he wanted to reduce the long-term health repercussions of the injury. Although a return-to-play motive was considered in his reasoning, it would not have been an acceptable criterion for deciding to have the surgery. The considerable media coverage of this injury emphasized the return-to-play desire of the athlete, but the decision to amputate was reached only after a thorough evaluation of the long-term repercussions.
Implications for Clinical Practice
When counseling an athlete or patient regarding possible amputation following a severe avulsion injury or fracture, use of the extremity is the most important consideration. The future goals of the individual, as well as function, mobility, and potential for arthritis, need to be assessed.
Avulsions and amputations related to sports injuries can occur. Sports that involve using ropes have higher incidence rates of avulsions and amputations than do other sports, but injuries to the hand and digits are common in American football. Some digital injuries can jeopardize the appendage, and amputation can become a valid option. Many athletes are motivated to return to play as quickly as possible, but that motivating factor should not be considered a valid reason for choosing amputation. Certified athletic trainers must take extra care to provide the necessary counseling to affected athletes so that a proper, informed choice is made.
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- Jakubietz RG, Jakubietz MG, Gruenert JG. Digital amputation caused by climbing-rope entanglement. Wilderness Environ Med. 2006;16:178–179. doi:10.1580/PR10-05 [CrossRef]
- Bieber EJ, Wood MB, Cooney WP, Amadio PC. Thumb avulsion: Results of replantation/revascularization. J Hand Surg Am. 1987;12:786–790.
- Dick R, Ferrara MS, Agel J, Courson R, Marshall SW, Hanley MJ, Reifsteck F. Descriptive epidemiology of collegiate men’s football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004. J Athl Train. 2007;42:202–210.
- Falkner D. Passion play. Sporting News. 1994. http://findarticles.com/p/articles/mi_m1208/is_n17_v218/ai_15833407/. Accessed August 25, 2010.
- Canale ST, Beaty JH. Campbell’s Operative Othopedics. Philadelphia, PA: Mosby; 2008.