If a finger is severed: what to do in the first hour

An accident with a saw, a door or a machine leaves little time to think, and it is in those minutes that it is decided whether the finger can be replanted or not. It is worth knowing this before you need it.

The essential part fits in one sentence: a finger kept properly cold can be replanted many hours later; kept badly, it is lost in a few.

The four steps

1. The person first. Cover the wound with a clean cloth and press to stop the bleeding. Raise the hand. Do not apply a tourniquet unless the bleeding will not stop with firm, sustained pressure.
2. Wrap the severed part in gauze moistened with saline. If there is no saline, clean water will do to moisten the gauze — not to submerge it.
3. Put it in a plastic bag and seal it. Properly sealed.
4. Place that bag on ice. The bag on the ice, never the finger touching the ice.

Then to a hospital with microsurgical capability, immediately. Not to just any emergency department: ring ahead and ask whether they have microsurgery before setting off, because an extra transfer costs hours the finger does not have.

What destroys the finger

Three mistakes, all three common, all three irreversible:

• Ice in direct contact. It freezes the tissue and damages it beyond recovery. Cold preserves; ice against the skin kills.
• Submerging it in water — or alcohol, or saline — during the journey. The tissue macerates and stops being replantable.
• Leaving it dry at room temperature, or wrapped in paper. The useful hours fall away sharply.

Gauze with saline, sealed bag, ice on the outside. If only one sentence stays with you, let it be that one.

And even if the finger looks destroyed, take it anyway. It is not for you to decide whether it is of use: sometimes it is not replanted whole but provides skin, bone, tendon or a nerve that saves the function of what remains.

What a replantation is

Microsurgery means repairing vessels and nerves one or two millimetres across under a microscope, with sutures finer than a hair. A replantation takes between three and ten hours, demands a trained team, a theatre available urgently and several days in hospital.

The first days of post-operative monitoring matter as much as the surgery itself: circulation in the segment is checked hour by hour, and if it fails you go back to theatre.

Replanting is not always best

This needs saying because it surprises people. A replanted finger can end up stiff, numb and painful, and get in the way more than it helps. In some cases — particularly crush or avulsion injuries, or a single finger on an otherwise healthy hand — a well-performed amputation gives better function than a stiff replantation.

That decision is taken at the time, with the injury in front of you, and explained to the family. A surgeon raising it is not being dismissive: it is judgement.

What is not promised

A replanted segment is not promised to work as it did before. Partial movement and partial sensation are the usual outcome, and in many cases the hand ends up functional but different. The rehabilitation afterwards lasts months and counts as much as the surgery.

What does change the outcome, and lies entirely in the hands of whoever is there when it happens, are those four steps in the first hour.