The nerve and artery should be separated. Any transection of a nerve will result in a neuroma. The goal of nerve management during amputation is to place the nerve stump in a well-padded area away from the surgical scar. This can be accomplished by placing gentle traction on the nerve, sharply transecting it, and allowing it to retract proximally under healthy soft tissue with minimal mechanical contact. The artery should be cauterized and allowed to retract proximally away from the surgical scar.

As a general rule, both flexor and extensor tendons are pulled distally, transected, and allowed to retract proximally. The extensors will retract much less than the flexors due to attachments to other structures (i.e., lateral bands, sagittal bands, and adjacent extensor tendons via juncturae). They should never be pulled distally, or sutured together to
act as a source for coverage of exposed bone, as this will prevent the normal excursion of both tendons and compromise the function of the remaining digits.

Bone ends should be trimmed and smoothed so that there are no sharp areas or spikes, which may be sensitive or tender following healing. When the amputation is through the joint and cartilage is present, the condyles are trimmed, creating a smooth, rounded contour. Often, the central portion of the cartilaginous surface can be left in place, creating a smooth tip.

The goal of soft tissue coverage should be to provide well-padded coverage of the amputation stump without tension on the skin closure. This can be completed with local soft tissue flaps or regional flaps, if necessary to preserve functional length. Skin grafts over exposed bone are not durable and often tender when the patient attempts to touch the end of the injured finger.

Amputations through the thumb require special consideration because of the importance of the pinch, grasp, and gripping activities. The maintenance of length is also important. Amputations involving the distal phalanx will typically result in a functional thumb. Effort should be undertaken to provide durable sensate soft tissue coverage with the liberal use of flaps. In addition, greater efforts should be taken to replant a thumb when possible. Amputations proximal to the IP joint should be managed so that future reconstructive options are available.

Local soft tissue coverage can often be obtained by the use of a Moberg flap. This involves making midaxial incisions on the radial and ulnar aspects of the thumb, and elevating the volar skin containing both neurovascular bundles. The flap is then advanced distally, allowing closure of wounds up to 2 cm in length. This technique involves flexion of the IP joint requiring therapy to regain extension and some patients may be left with an IP joint flexion contracture. Slight further advancement can be obtained with a transverse skin incision at the level of the MP joint flexion crease. This creates a proximal defect, which typically is skin grafted. Alternatively, it can be left to heal secondarily, but this increases the risk of development of a contracture. This technique is reliable in the thumb due to the independent dorsal blood supply, but poses a risk in the fingers, as dorsal skin necrosis may occur.

Amputations of the distal phalanx can often be managed by trimming the bone below the soft tissue, so it is not exposed and covering with local flaps or allowing healing by secondary intention. If the amputation is proximal to the lunula of the nail, there in no advantage to trying to maintain the nail, and the nail matrix can be ablated at the time of amputation revision. The maintenance of the DIP joint is advantageous if the FDP and terminal extensor tendon insertions are intact. This will allow for greater grip strength and better overall hand function. If the tendon insertions cannot be maintained, amputation can be completed at the level of the DIP joint, as there is no advantage in maintaining a small remnant of the distal phalanx.

Amputations though the DIP joint are managed by rounding the condyles, removing the volar plate, and providing a smooth contour to the middle phalangeal head. Alternatively, there may be some merit in maintaining the volar plate and suturing the FDP tendon to the volar plate. This will maintain the proper length and tension on the FDP, increasing the power grip, and decreasing the chance of developing a lumbrical plus finger.