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Authors : Dr. Mahinder Singh Chauhan, Dr. Shweta Saini, Dr. Ravi Shankar Yadav .
 

Abstract-

Hand is a body part which is of major importance. Along with functions like grasping and feeling, hands also have an esthetic impact and they can emphasize the beauty of a gesture or grace of a movement for communication, body language and social contact. Finger and partial finger amputations are some of the most frequently encountered forms of partial hand loss.Whether the traumatic loss of limb or finger is due to war, congenital malformations, systemic diseases (diabetes), an industrial, domestic or vehicular accident, amputation leaves the individual with a long lasting physical, psychological scar from the disfigurement.

This clinical report describes the fabrication of a silicone finger prosthesis for a 24 years old female patient with missing part of the index finger of the right hand after injury at work. This finger prosthesis offered psychological, functional and rehabilitative advantages for the patient restoring the natural appearance with the prosthesis. This prosthesis also eliminated the trauma generated by dysfunction and represented an efficient psychological therapy.
 

INTRODUCTION:

“Amputation” Derived from the Latin word “amputare” (to excise, to cut out) has been defined as the “removal of part or all of a body part enclosed by skin” (Medical Dictionary). Until the eighteenth century, a few physicians gave thought to the condition of the amputation stump for prosthetic appliance during the period 1846-1847.1 Amputation causes devastating physical, psychosocial and economic damage to an individual.2 There are various types of amputations some which are self-amputation, congenital amputation, and traumatic amputation which may result from a factory,farm, powdered tools or motor vehicle accidents,including industrial or environmental accidents, terrorist attacks and lack of public health which often leads to diabetic, gangrene and /infection. Whatever the indication of an amputation, the result is a limb stump.3

Beasley has noted that individuals who keep their hands inside pockets due to embarrassment over appearance are as functionally disabled as a forequarter amputee.4

Some of the most frequently encountered forms of partial hand loses are finger and partial finger amputations.5 When choosing a suitable treatment option some factors have to be considered the amount of tissue lost, the current condition of the bone, and involvement of other fingers.6 To evaluate the suitability of the amputated part of replantation is the primary goal of the treatment of traumatic amputation.7Prosthesis refers to artificial replacement of an absent part of the human body. A prosthesis can restore a “near-normal function” in the distal phalangeal amputation. The finger prosthesis requires an optimum retention for functions such as grasping, carrying and holding.8The most common methods of retaining a digital prosthesis are by vacuum effect on the stump, adhesive, use of a ring at the junction of prosthesis and stump9 and the use of osseointegrated implants with customized attachments.10, 11

The common method of prosthesis is replacing the lost finger by an artificial digit. Digital prosthesis fulfils all esthetic requirements, provides some functional gains, restoring movement for the patient and protecting the stump.12

The artificial digit is made of a silicone elastomer (chemical name- polysiloxane). These silicones can be rendered to match the skin color of the patient and give a more lifelike appearance. Most of silicones used for this purpose are Room temperature vulcanizing silicones (RTV) as they offer chemical inertness, flexibility and elasticity.13 This paper presents prosthetic rehabilitation of amputated right index finger with custom-made silicone prosthesis.
 

CASE REPORT:

A 24 year old female reported to the Department of Prosthodontics and Maxillofacial Prosthetics with chief complaint of partially missing right index finger. The patient revealed a history of having lost the digit in a traumatic injury caused by a mechanical lathe.

A complete hand examination was carried out that revealed a residual stump (1- 1.5 cm) which was asymptomatic with no signs of infection.
 
Figure 1. Amputed right index finger
 

Examination:

The case was discussed and a method to replace the finger was formulated. The treatment plan was then discussed with the patient. As the residual stump was not of appropriate length it was decided to include adjacent finger for additional retention (sleeve fabrication with respect to middle finger). As a part of protocol, and to ensure the patient’s willingness and co-operation, an informed consent was signed before beginning the treatment.
 
Figure 2. Wax mould
 

Fabrication:

The fabrication of the prosthesis consisted of the fabrication of the wax pattern followed by laboratory procedures to fabricate it into silicone rubber prosthesis.
 
Figure 3. Impression of residual stump on right index finger and normal left index, middle and ring finger


Making of Impression: The patient hands were lubricated with petroleum jelly to prevent the impression material from sticking to the amputed site. Two big wax moulds were used for making the impressions of the right and left index, middle and ring finger using irreversible hydrocolloid impression material. The patient was instructed to keep the hands in normal resting position along with fingers apart, without stretching.

Preparation of Models: The impressions were then poured in dental stone (Pankaj Enterprises) using vibrator to avoid voids and the working casts of both hands were retrieved.
 
Figure 4. Model of amputed index finger Figure 5. Wax pattern


Wax Pattern Fabrication and Try in: The impression was poured in molten wax (modelling wax) and after cooling, the wax pattern was retrieved. The necessary modifications were made at chair side. The wax try in was done in the patient finger. During try in stage,the fit, stability and seating of the wax pattern were evaluated along with the shape and size of the pattern.

Nail bed Preparation:An undercut was created beneath the cuticle margin that would function to retain the prefabricated artificial nail within the wax pattern. The nail was shaped according to the nail of the natural fingers.

Flasking and Dewaxing: Putty wash technique was used to make impression of amputed stump and was poured in dental stone. The pattern was transferred on the model and flasked to enhance the accuracy at the stage of shade matching such that the dorsal and the palmer aspects of the finger were separable, separating medium is applied between the two pours. After dewaxing,the mould is allowed to cool.

Colour Matching:Shade matching was done using natural daylight. The best time for this procedure was between 11 am to 1 pm.The room temperature vulcanising silicone(M P SAI Mumbai) was used to match intrinsically with the dorsal and palmer surface of finger. It is essential to carry out this procedure in front of the patient so as to gain approval.

Packing of Mould:Cyanoacrylate was painted to the artificial nail .Vaseline was applied to the mould. Mould was packed with silicone. The material was allowed to bench cured overnight.

Finishing of Prosthesis:Once the final prosthesis was retrieved, theflash was trimmed using a sharp blade.

Fitting and Instructions:Slight extrinsic staining was done for exact matching of the shade. Though the fit of the prosthesis was quite satisfactory adhesive has been applied to enhance retention.

Patient was demonstrated about the use and maintenance of the prosthesis. Patient was instructed not to expose the prosthesis to high temperatures, and sunlight.
 
Figure 6. After dewaxing Figure 7. Final prosthesis
 

DISCUSSION:

The amputation of one or more fingers of the hand, as the consequence of trauma or congenital absence of one or more phalanges, carries a serious reduction of hand function and social dysfunction for the patient.Currently many traumatically amputed digits can be saved by microsurgical replantation or osseointegrated digital prosthesis.The osseointegrated digital prosthesis is an alternate technique for patients with short stump on which a standard digital prosthesis attaches securely by means of an osseointegrated implant placed on intramedullary canal of residual bone of the amputed digit.14

In a study by Manurangsee et al, acrylic resin prostheses were fabricated and firmly attached to the abutments using hexagonal magnetic suprastructure system.15

Lundborget al, rehabilitated 3 patients with traumatic thumb amputations with implant retained silicone thumb prosthesis.16In some cases, however reconstruction is contraindicated or patient economic conditions preclude such treatment options. Prosthetic replacement of fingers can be satisfactory in patients who have at least 1.5 cm of residual stump. Prostheses for the upper limb have been broadly classified as functional and aesthetic. The patient may be treated with the surgical or non-surgical approach. As the patient was not willing to bear any expenses, a non-surgical method of rehabilitation was carried out. Aesthetic prosthesis has been defined as passive devices aimed at restoring normal appearance of the hand. It has also been stated that every case may not be indicated for rehabilitation by an aesthetic prosthesis.17

Earlier, various materials such as acrylic resins and polyvinyl chloride were used to fabricate a finger prosthesis but were rejected because of suboptimal appearance and lack of stain resistance.18 Acrylic resins are uncomfortable because of lack of flexibility, although they are cheaper. The overall durability and resistance of silicone is superior to any other material currently available for finger restorations with the functional benefit of the gentle, constant pressure applied by the elastomer helping to desensitize and protect the injured tip. Over time, scar tissue contained within the silicone prosthesis becomes more pliant and comfortable. Thinness of the silicone prosthesis allows good sensibility through it.

A lubricant should be used to lubricate the skin to facilitate donning and doffing of the prosthesis.

Jean Pillet19 enumerated the essential characteristics of a prosthesis are that it should be of high quality both technically and aesthetically, resemble the digit of contralateral hand, skin must correspond to the natural skin in all details and match the colour as appropriately as possible, should not be effected by climatic variations, heat resistant and must not be stained by ordinary materials. Prosthesis must be cleaned easily and should not irritate the skin.
 

CONCLUSION:

The custom-made finger prosthesis is esthetically acceptable and comfortable for use in patients with amputated fingers, resulting in psychological improvement and personality. An esthetic and retentive prosthesis are the primary determinant factors in the successful prosthetic restoration of a finger. There are many methods of retention such as implant and adhesives. An alternate method using both suction and vacuum was attempted and found to be quite successful. Such restorations are successful when finger prostheses are individually sculpted and coloured in situ.

A convenient and affordable method of prosthetic rehabilitation of an amputed finger with room temperature vulcanising silicone material has been presented. The custom made glove type finger prosthesis is esthetically acceptable and comfortable in patients with amputed fingers. Patient was highly satisfied with this prosthesis in terms of retention, function and esthetics. The morale of the patient was also boosted to a great extent.

The loss of all or part of a finger has a negative impact on the physical and psychological well-being of an individual. An esthetic and retentive prosthesis are the primary determinant factors in the successful prosthetic restoration of a finger. For most patients, the aesthetic appearance of an amputated finger plays a more important role than function. With the advancement in skill, technology and materials available today, the rehabilitation of an amputated finger is no more aesthetically challenging. When fabricated with immense care, they can be made life- like. A well fabricated aesthetic prosthesis can help in providing the patients with psychological support.
 

REFERENCES:

  1. Shanmuganathan N, Maheswari U, and Jibran AH.Aethetic Finger Prosthesis.
  2. Parkes CM. Psycho-social transitions: Comparison between reactions to loss of a limb and loss of a spouse. British Journal of Psychiatry 1975;127:204-210.
  3. Fassler PR. Fingertip injuries: evaluation and treatment. J Am AcadOrthopSurg 1996;4(1):84-92.
  4. Beasley RW. General consideration in managing upper limb amputations. OrthopClin North Am 1981:12(4);743-749.
  5. Pillet J. The Aesthetic hand prosthesis. Orthop Clinics in North Amer 1981;12;961-70.
  6. Aydin C, Karakoca S, Yilmaz H. Implant-retained digital prostheses with custom-designed attachments: A clinical report. Journal of Prosthetic Dentistry 2007;97:191-95.
  7. Boulas HJ Amputations of the fingers and Hand: Indications for replantation. J Am Acad Ortho Surg 1998;6:100-105.
  8. Pereira BP, Kour AK, Leow EL, Pho RWH. Benefits and use of digital prostheses. Journal of Hand Surgery 1996;21:222-228.
  9. Scolozzi P, Jaques B. Treatment of midfacial defects using prostheses supported by ITI dental implants. PlastReconstrSurg 2004;114(6):1395-1404.
  10. Lundborg G, Branemark PI, Rosen B. Osseointegrated thumb prostheses: a concept for fixation of digit prosthetic devices. J Hand Surg Am 1996; 21(2):216-221.

More references are availabe on request.

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