- See:
-
Digit Reimplantation
-
Moberg Flap;
-
Tendon Injuries of the Thumb:
-
Second Toe Transfer:
-
Skin Grafts: for hand defects;
- Management of Acute Injuries:
-
amputations:
-
replantation:
- w/ amputations through the thumb IP joint, consider replantation and fusion;
-
amputation of the finger and hand:
- in contrast to amputations of a single finger, bone shortening and wound closure usually should not be considered for thumb soft tissue defects;
- in general, the thumb should never be shortened;
-
dorsal defects:
- subcutaneous axial flap should be raised from the dorsal aspect of the proximal phalanx of the index finger;
- tip amputations with more loss dorsally require a
V-Y advancement flap;
-
palmar tip amputations:
-
Moberg Flap
- w/ loss that is more palmar but less than two thirds of the pulp are ideal for a Moberg Flap:
-
Crossed Finger Flap:
- w/ more than 2/3 of volar pulp loss, crossed finger flap from the index finger is appropriate;
- in this case, the flap will hinge off the radial side of the index finger;
- reference:
- Radial innervated cross-finger flap from index to provide sensory pulp to injured thumb.
Gaul, J. S.:
J. Bone Joint Surg. 51A:1257, 1969.
- w/ loss that is palmar but is greater than 2/3 of the pulp should be treated with a neurovascular flap from the toe;
- Reconstructive Options for Established Injuries:
- level of injury:
- absence of thumb = 40% disability of hand as a whole;
- injury at IP joint;
- no reconstruction may be required but wrap around method may be considered;
- references:
Reconstruction of the thumb with a free wrap-around flap
- injury to proximal phalanx (intact MP joint);
-
w/ amputation distal to MP joint, only the long flexor and extensor are lost;
- whole great toe transfer,
2nd toe transfer, or wrap around may be considered;
- deepen thumb web by Z plasty;
- injury thru MP joint;
- great toe or 2nd toe transfer;
- injury thru metacarpal;
- proximal to the MP joint, the intrinsic insertions and progressively their muscle bellies
are destroyed which leaves only the APL functioning at the metacarpal base;
- pollicization or
2nd toe transfer (when indicated)
- w/ a distal metacarpal injury, consider great toe transfer w/ a small portion of MP joint;
- w/ more proximal metacarpal injury, use a 2nd toe transfer;
- injury at cmc level: pollicization;
- Specific Procedures:
-
digit reimplantation
-
toe to thumb transfer: (see:
second toe transfer):
- may be indicated to reconstruct the thumb after amputations from the level of the metcarpal base to the IP joint;
- procedure is also indicated w/ hands w/ multiple injuries & amputations
- first vs second toe transfer:
- usually the second toe is preferable in children and athletes, or in patients concerned about the appearance of the foot (such as women who wear sandles);
- transferred great toe has a better appearance than the second toe;
- great toe often has poor flexion ability where as second toe has poor extension ability;
- great toe may confer about 1/3 of normal strength (second toe confers on 15% of normal);
- w/ amputation is proximal to the MP joint:
- there will no thumb intrinsic function which will thus require a tendon transfer;
- transfered MP joint tends to hyperextend and therefore must be restrained by capsulodesis or arthrodesis;
- disadvantages:
- technically difficult procedure;
- vascular comprimise of hand may preclude the procedure;
- an adequate soft tissue cover (free of scar) is necessary prior to considering the procedure;
- most patients will require preoperative excision of scar and flap coverage and most patients will require at least one additional operation following the transfer;
- sensation recovery is slow and incomplete (75% of patients may expect 2 point of less than 10 mm at two years)
- cold tolerance remains a problem for most patients;
- references:
-
Free toe transfer for thumb and finger reconstruction in 300 cases.
-
Ideas and Innovations: Toe-to-Thumb Transfer: A New Technique.
- Reconstruction of the hand with microneurovascular toe-to-hand transfer. Lister, G. D., Kalisman, M., and Tsai, T. M.:
Plast. Reconstr. Surg. 71:372, 1983.
- Toe-to-hand transfer. Yoshimura, M.:
Plast. Reconstr. Surg. 66:74, 1980.
-
wrap around reconstruction:
- references:
-
Reconstruction of the thumb with a free wrap-around flap from the big toe and an iliac-bone graft.
-
Thumb reconstruction by the wrap-around method.
- Resurfacing of the donor defect after wrap around toe transfer with a free lateral forearm flap.
JY St Laurent and M. Lanzetta.
J. Hand Surg. Vol 22-A. 1997. p 913-917.
-
lengthening:
- with distraction metacarpal lengthening up to a 105 per cent increase can be achieved over several weeks;
- alternatively, accept the distraction attained at surgery and insert a bone graft at the time;
- references:
- Thumb reconstruction after amputation at the MP joint by bone-lengthening.
Matev, I. B.: J. Bone Joint Surg. 52A:957, 1970.
- Thumb reconstruction after amputation at the interphalangeal joint by gradual lengthening of the proximal phalanx--A case report.
Matev, I. B.: Hand 11:302, 1979.
- The Gillies thumb lengthening operation.
Reid, D. A. C.: Hand 12:123, 1980.
- Thumb reconstruction through metacarpal bone lengthening.
Matev, I. B.: J. Hand Surg. 5:482, 1980.
-
phalangization:
- converts the metacarpal into a phalanx allowing increased space for grasp;
- muscle recession:
- first dorsal interosseous is recessed by releasing the portion which arises from the thumb metacarpal;
- reattach adductor insertion from the sesamoid at the MP joint to a point further proximal on the metacarpal shaft;
- deepening of the skin of the first web space:
- achieved w/ z-plasty (place on limb along the volar thenar crease, another along the ridge of the web space, and the last limb over the dorsum of the first metacarpal;
-
pollicization:
- indicated for proximal thumb metacarpal amputations;
- advantages:
- good appearance;
- potential for motion at all joints in the thumb;
- good sensibility;
- disadvantages:
- a ray is removed which narrows the hand;
- expect some loss in grip strength;
- most patients w/ require more than one operation (such as web space deepening, tendolysis, rotational osteotomy);
- flap comprimise:
- may arise from damage sustained at the original trauma;
- consider arteriogram to determine vascular anatomy;
- incomplete digit rotation / insufficient web space:
- may result from scarring on the radial side of the hand, in which case, patients should be managed w/ appropriate soft tissue transfer to eliminate scarring;
- inadequate first dorsal interosseous muscle:
- the first dorsal interosseous muscle will function as an opponens, and if it has been damaged, then a ring-FDS opponensplasty may be required;
- references:
- Thumb reconstruction by digital transposition.
Buck-Gramcko, D.:
Orthop. Clin. North Am. 8:329, 1977.
- Pollicization after traumatic amputation of the thumb.
Stern, P. J., and Lister, G. D.:
Clin. Orthop. 155:85, 1981.
Reconstruction of the thumb.
Reconstruction of the thumb with a free wrap-around flap
Per Primam thumb replantation for all patients with traumatic amputations.
One hundred eleven thumb amputations: replantation vs revision.
Survival factors in replantation and revascularization of the amputated thumb--10 years experience.
The choice of procedure following thumb amputation.
G. Lister.
CORR. Vol 195. p 45-51.
Transmetacarpal amputation of the index finger: A clinical assessment of hand strength and complications.
Murray, J. F., Carman, W., and MacKenzie, J. K.:
J. Hand Surg. 2:471, 1977.
Thumb reconstruction after amputation at the MP joint by bone-lengthening.
Matev, I. B.: J. Bone Joint Surg. 52A:957, 1970.
Thumb reconstruction after amputation at the interphalangeal joint by gradual lengthening
of the proximal phalanx--A case report.
Matev, I. B.:
Hand 11:302, 1979.
Thumb reconstruction through metacarpal bone lengthening.
Matev, I. B.:
J. Hand Surg. 5:482, 1980.
Adduction-flexion contracture of the thumb. Proceedings of the American Society for Surgery of the Hand.
Brown, P. W.:
J. Bone Joint Surg. 53A:809, 1971.
Adduction-flexion contracture of the thumb correction with dorsal rotation flap and release of contracture.
Brown, P. W.: Clin. Orthop. 88:161, 1972.
Dorsal pedicle flap for resurfacing a moderate thumb-index web contracture release.
Sandzen, S. C. Jr.:
J. Hand Surg. 7:21, 1982.
Thumb web contracture.
Mutz, S. B.: Hand 4:236, 1972.
Medical and surgical importance of the arterial blood supply of the thumb.
BJ Parks and RL Horner.
J. Hand Surg. Vol 3. p 383. 1978.
Arterial anatomy and clinical application of the dorsoulnar flap of the thumb.
F. Brunelli. et al.
J. Hand Surgery. Vol 24-A. No 4. July 1999. p 803.
