Treatment of Toe-Tip Amputation in Children. Presentation of a New Technique with Occlusive Dressing and Review of the Literature

Unlike the fingertip amputation, the toe-tip amputation is an injury that so far has been neglected in the literature. Although injuries to the big toe are described in childhood [1], unlike finger injuries, there is no established classification model for injuries of toetip. However, for orientation the most widespread Allen classification for fingertip injuries (Fig.9) [7] can be used. This classification distinguishes between type I (no involvement of the nail bed), type II (no bony involvement), type III (bony involvement distal to the lunula) and type IV (injury to the lunula and further proximal).

One reason for the neglect of toe tip injuries in the literature may be the lower functional and cosmetic importance of the toes compared to the fingers. Nevertheless, the big toe plays an important role in the function of the foot [8]. Furthermore, patients with posttraumatic reduced toe length are aware of and bothered by the deformity [6,9]]. In addition, the surgical covering of substance injuries on the toe tips is a surgical challenge [5].

Treatment with a semi-occlusive bandage has been described many times for partial amputation of the distal phalanx of the fingers [2-4]. The dressing protects the wound from drying out, so that epidermal cells use the moist wound exudate directly for migration, which leads to faster epithelialization. In addition, the bandage acts as protective wall to the outside world, preserving the pH value, immunoglobulin concentration, temperature and humidity and at the same time allowing an influx of oxygen. All of this leads to faster epithelialization of the wound. The indication for semi-occlusive treatment can be made up to Allen type IV injuries [2].

Applied to the big toe, the case described is a type III injury according to Allen. In retrospect, the initial attempt to fix the subtotally amputated tip of the toe under anesthesia led to an unnecessary delay in healing of 17 days. Anesthesia and antibiotic therapy could also have been avoided if conservative therapy had been carried out initially. It is possible, that an immediate start of therapy would have led to even faster healing.

Transferring the knowledge about the treatment of fingertip injuries to the toes, caution is advised.   The longer distance between the heart and toes, also noticeable in the significantly higher incidence of PAD on the lower extremities [10], as well as the higher mechanical stress to which the feet are exposed in everyday life compared to the hands, forbid a one on one transfer of treatmentalgorithms. The good end result achieved in this case should, however, give reason to consider semi-occlusive treatment for toe tip amputations up to the lunula as a therapeutic option.

Ethics statement: This case report is a retrospective report of the treatment of a single patient. An approval of an ethics committee was not required for the treatment and was not obtained afterwards.

Ethics approval: As this is a retrospective presentation of performed therapy in consent with the fully informed patients parents, the ethics committee advised that no ethical approval was needed.