CME

Posttraumatic Thumb Reconstruction

Arshad R. Muzaffar, M.D., James J. Chao, M.D., and Jeffrey B. Freidrich, M.D.
Seattle, Wash.; and San Diego, Calif.

Learning Objectives: After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the
thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb
reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction.

Background: The function of the thumb is flap, or a distant flap, to distraction osteo-
critical to overall hand function. Uniquely genesis, lengthening of the thumb ray,
endowed with anatomic features that allow spare parts from another injured digit in
circumduction and opposition, the thumb the acute setting for pollicization or hete-
enables activities of pinch, grasp, and fine rotopic replantation, and microvascular toe
manipulation that are essential in daily life. transfer.
Destruction of the thumb secondary to Results: Amputations in the distal third of
trauma represents a much more significant the thumb are generally well-tolerated. The
loss than would result from loss of any other primary reconstructive issues are the resto-
digit. Therefore, significant effort has been ration of a padded and sensate soft-tissue
focused on thumb reconstruction. Numer- cover, as well as aesthetic considerations.
ous techniques have been described, ranging First-web-space deepening will generally
from simple osteoplastic techniques to com- provide excellent results for amputations at
plex microsurgical procedures. With an ap- the distal half of the middle third. In the
preciation of the unique anatomic properties proximal half of the middle third, length-
of the thumb, the hand surgeon is better able ening of the thumb ray is generally re-
to understand the goals of thumb reconstruc- quired. Distraction lengthening of the first
tion and to develop an algorithm for thumb metacarpal is a useful and reliable tech-
reconstruction. With such an understanding, nique that provides up to 3 cm of length
an individualized reconstructive plan can be without requiring complex microsurgical
developed for each patient. methods. Spare parts from another injured
Methods: A great many options are avail- digit may be used in the acute setting for
able for posttraumatic thumb reconstruc- pollicization or heterotopic replantation.
tion. Optimal results are obtained by pur- Microvascular toe transfer is an excellent
suing an organized and logical approach to option for elective reconstruction. How-
reconstruction based upon the level of tis- ever, other options also are available and
sue loss. Reconstruction methods depend may be more appropriate in some cases.
on the location of the amputation and Less ideal options include the various types
range from homodigital and heterodigital of osteoplastic reconstruction.
flaps to partial-toe transfer or a great-toe Conclusions: The reconstruction of post-
wrap-around flap to first-web-space deep- traumatic thumb defects is a challenging and
ening using Z-plasties, a dorsal rotation rewarding surgical endeavor. The

From the Division of Plastic Surgery, Department of Surgery, University of Washington, and the Department of Plastic Surgery, University
of California, San Diego. Received for publication September 1, 2003; revised January 19, 2005.
DOI: 10.1097/01.prs.0000182650.17230.2a
103e
104e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005
shorter fingers, allow the performance of the
value of a functioning thumb is immense, essential types of grip: the pad/side (key
and its reconstruction is worthy of consid- pinch) grip, the pulp-to-pulp pinch, the three-
erable effort. Despite the elegant recon- jawed chuck “baseball” grip, and the five-jawed
structive options available, the best results “cradle” grip.12
are obtained with replantation or revascu- The thumb is uniquely positioned at approx-
larization whenever possible. Finally, the imately 60 to 80 degrees to the plane of the
treatment plan always must be derived from metacarpal arch. It is antiposed, that is, ab-
a careful assessment of each patient’s post- ducted, slightly extended, and pronated. In
traumatic function and specific reconstruc- addition to its unique position, the key to the
tive needs. (Plast. Reconstr. Surg. 116: 103e, function of the thumb is its capacity for circum-
2005.) duction, a motion that occurs at the carpometa-
carpal joint.2,13
The function of the carpometacarpal joint is
paramount for optimal function of the thumb.
The significance of the thumb in its contri- This basilar joint provides the greatest degree
bution to overall hand function cannot be of mobility, but the least degree of stability of
overestimated. Indeed, the thumb contributes the articulations of the thumb. This pattern of
approximately 40 percent of hand function.1,2 mobility and stability is reversed distally in the
In the performance of prehensile functions, metacarpophalangeal and interphalangeal
the thumb is indispensable, as it allows for both joints.
precision and power grips.3,4 In addition, the In terms of its topography, the carpometa-
thumb is endowed with the unique capacity for carpal joint of the thumb is a biconcave saddle
circumduction and opposition through its ex- joint, or universal joint. This configuration per-
cursion out of the plane of the hand. Thus, mits motion about two axes: flexion/extension
reconstruction of the thumb after traumatic and abduction/adduction. In addition, the car-
amputations has been a subject of considerable pometacarpal joint affords approximately 10 to
importance to hand surgeons for many years. 20 degrees of rotation. Circumduction is thus
The level of sophistication of these reconstruc- made possible by the shape of the carpometa-
tive efforts has risen from that of cumbersome carpal articulation. With extension at the car-
pedicled toe-to-hand flaps to that of the ele- pometacarpal joint, there is a tendency toward
gant microsurgical reconstructions and pollici- supination of the thumb, while with flexion
zations that are performed today.5–11 In this there is usually some pronation of the thumb,
article, the pertinent anatomic features of the however, the degree of supination and prona-
thumb are discussed, followed by an algorith- tion can be controlled by the patient. If the
mic approach to thumb reconstruction accord- mobility of the thumb is impaired such that it
ing to the level of amputation. requires fixation in a position of function, it
should be fixed in 40-degree abduction, 15-
ANATOMIC CONSIDERATIONS degree extension, and 120-degree metacarpal
In evolutionary terms, the thumb is part of pronation.3,13 This position is preferred be-
the pentadactyl pattern of development that is cause it places the thumb in its natural op-
approximately 350 million years old, traced posed position.
back to the lobefin fish Eusthenopteron. The The stability of the carpometacarpal joint is
human thumb shares certain features with the provided by a complex set of ligaments. These
marsupial and placental species, including a ligaments counteract the tendency for dorsal/
first carpometacarpal saddle joint and the in- radial subluxation of the thumb with pinch
trinsic muscle cone of the thumb. However, and opposition functions. Although multiple
during its evolutionary development, the hu- ligaments have been defined,14 the primary lig-
man thumb has attained a number of unique aments include the anterior oblique, inter-
features: an independent long flexor of the metacarpal, ulnar collateral, dorsoradial, and
thumb interphalangeal joint, a broad and com- posterior oblique ligaments. The anterior
partmentalized volar pad, greater relative mass oblique ligament attaches to the trapezium
of the intrinsic musculature, and larger joint dorsum at its base, as well as the anteromedial
surfaces. These features, together with the de- metacarpal base. The dorsoradial ligament is
velopment of a relatively longer thumb and similar to a radial collateral ligament and at-
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 105e
taches to the radial sides of the metacarpal and duct, supinate, and balance the pronation
trapezium. The intermetacarpal ligament at- forces acting on the thumb ray.2,13
taches to the palmar bases of the first and
second metacarpals, and is instrumental in pre- GOALS OF RECONSTRUCTION
venting of radial subluxation of the thumb car- Certain key considerations must be ad-
pometacarpal joint. Of these, the anterior dressed to achieve a successful outcome in
oblique and intermetacarpal ligaments are the thumb reconstruction. These considerations
most important stabilizers of the carpometacar- include sensation, stability, length, mobility,
pal joint.14 position, and pain-free function. Additional
The metacarpophalangeal joint of the pertinent factors include strength, aesthetics,
thumb is a condyloid (rounded surface) and durability. The issue of stability versus mo-
“hinge” joint, which is similar to the other bility is a critical one: the other digits can com-
metacarpophalangeal joints in that it provides pensate for an immobile thumb, but not for an
mostly flexion/extension, but also a small unstable thumb.
amount of abduction/adduction. This joint is In assessing a candidate for thumb recon-
capable of approximately 5 degrees of exten- struction, it is critical to derive an individual-
sion, 100 degrees of flexion, and 0 to 20 de- ized treatment plan. Factors such as the pa-
grees of abduction/adduction. Compared with tient’s occupation and the importance of the
the carpometacarpal joint, the metacarpopha- aesthetic appearance of the thumb must be
langeal joint is more stable but less mobile. considered carefully. The amount of length
Indeed, stability of the metacarpophalangeal necessary for adequate function varies from
joint is essential for adequate function of the one patient to the next. For instance, providing
thumb in pinch and opposition; lack of motion length is paramount for patients who need to
at this joint is much better tolerated than in- perform fine motor or precision handling
stability. Stability of the metacarpophalangeal tasks, whereas other patients may do quite well
joint is provided by the collateral ligaments, with a shorter thumb. The surgeon must assess
volar plate, joint capsule, flexor, and extensor the patient’s current use pattern and func-
tendons, and the thenar musculature. The in- tional requirements before embarking upon a
terphalangeal joint of the thumb is a trochlear reconstructive pathway. Finally, it cannot be
(smooth surface) “hinge” joint that, overall, is overemphasized that, whenever possible, re-
similar to a finger interphalangeal joint. It is plantation or revascularization of the thumb
capable of approximately 15 to 20 degrees of should be performed, as the outcomes of this
extension and 80 degrees of flexion.2,13 treatment are superior to any secondary recon-
Both extrinsic and intrinsic musculotendi- struction (Fig. 1).2,15
nous units act upon the thumb ray. The extrin-
sic muscles include the flexor pollicis longus, RECONSTRUCTION BY LEVEL OF TISSUE LOSS
abductor pollicis longus, extensor pollicis bre- In deriving an algorithm for thumb recon-
vis, and extensor pollicis longus. The flexor struction, it is helpful to organize the various
pollicis longus travels via the carpal canal and surgical options according to the level of am-
is responsible for interphalangeal joint flexion. putation, i.e., the distal, middle, and proximal
The abductor pollicis longus has a dual func- thirds of the thumb ray.
tion in that it primarily abducts the thumb via
its insertion on the radial side of the metacar- Distal Third
pal base, but it also contributes to radial devi- The distal third of the thumb has been
ation of the wrist. Similarly, while the extensor termed the “compensated amputation zone.”16
pollicis longus provides interphalangeal joint Injuries at this level generally do not require
extension (and hyperextension), it is also a the replacement of length. Of course, the pa-
secondary thumb adductor. Pronation and op- tient’s occupation (i.e., the need for fine mo-
position is primarily a function of the intrinsic tor capability) and the patient’s level of con-
muscle cone of the thumb, which consists of cern for the aesthetic appearance of the thumb
the abductor pollicis brevis, the flexor pollicis must be considered when planning treatment.
brevis, and the opponens pollicis. In addition, In the distal third of the thumb, the soft-
the adductor pollicis and the first dorsal in- tissue requirements are analogous to those in
terosseous muscles are intrinsic muscles of the fingertip injuries. The requirements for recon-
hand that also insert upon the thumb to ad- struction are a sensate, durable, and padded
106e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

FIG. 1. Thumb replantation with an excellent functional result. (Above) Traumatic

amputation of thumb at metacarpophalangeal level. (Below) Result 6 months after
replantation.

distal thumb. These requirements may be met the flap base.17 Additionally, if a conventional
with either homodigital or heterodigital flaps. Moberg flap will only permit closure with
Homodigital flaps may include local flaps or excessive flexion of the interphalangeal
palmar advancement flaps such as the Moberg joint, the flap can be converted to an island
flap. The V-Y advancement flap can be used for flap by making a proximal releasing incision,
very distal thumb-tip injuries. The Moberg flap while preserving the neurovascular bundles.
has proven to be most useful in distal, palmar The donor site can then be covered by a skin
amputations, and can be advanced between 1 graft. Alternatively, heterodigital flaps such
and 1.5 cm. Z-plasties can be incorporated into as cross-finger flaps, neurovascular island
the midaxial incisions to facilitate advance- flaps, and innervated cross-finger flaps also
ment and closure, as can Burow’s triangles at may be useful in certain cases.15,18,19 (Figs. 2
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 107e
through 4). It should be noted that while more complex reconstructive methods may be
Figure 2 shows a volar cross-finger flap, the required for proximal defects in the middle
dorsal cross-finger flap is more commonly third.
described.
Distal Middle Third
Middle Third Conceptually, reconstruction of defects in
The middle third of the thumb ray spans the distal middle third of the thumb requires a
from the interphalangeal joint to just proximal relative lengthening of the thumb metacarpal
to the metacarpophalangeal joint and is di- and residual proximal phalanx. This relative
vided into a distal half and a proximal half for lengthening is termed “phalangization.” In ad-
the purposes of reconstruction. Significantly dition to thumb loss, the other factor that ne-

FIG. 2. Distal soft-tissue reconstruction with cross-finger flap. (Above) Dorsal and
volar views of thumb amputation. (Below) Planning of cross-finger flap.
108e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005
techniques are available to deepen the first
web space and widen the thumb-index interval.
These techniques include Z-plasties (simple,
four-flap, or five-flap), dorsal rotation flaps,
remote pedicle flaps, regional flaps, and free
flaps. Four key factors determine which of
these techniques will be most appropriate for
each individual case: the residual thumb
length, the amount of first web space contrac-
ture, the mobility of the first metacarpal, and
the condition of the skin and muscles of the
thumb.2,15
The Z-plasty is a standard technique of tissue
rearrangement in plastic surgery that is well-
suited to deepening of the first web space.
While a simple Z-plasty may be used, the four-
flap Z-plasty is generally preferred. Successful
use of the Z-plasty requires that at least half of
the proximal phalanx of the thumb remains.
In addition, the skin must be minimally
scarred; the first metacarpal must be mobile;
and, there must be no contractures of the in-
trinsic muscles (Fig. 5). Even without contrac-
ture of the intrinsic muscles, one must some-
times release the adductor fascia and part of
FIG. 3. Insetting of flap.
the intrinsic muscles to get the desired amount
of web-space deepening.
When the soft-tissue injury involves the skin
and musculature of the first web space, with
development of an adduction contracture of
the first metacarpal, a dorsal rotation flap from
the hand can be used. This technique involves
phalangization of the first metacarpal, with re-
lease of any restraining skin, muscle, scar, or
capsular adhesions in a sequential fashion.
Then, good quality, sensate skin is rotated into
the web space from the dorsum of the hand.
The donor site is skin grafted and the first and
second metacarpals are held in an abducted
posture with K-wires or an external fixator.
When these techniques are not possible or
desirable, other techniques are available. The
reverse radial forearm flap and the posterior
interosseous flap are regional flaps that pro-
vide thin and supple skin from an adjacent
donor site. Barring this, free tissue transfer,
such as a lateral arm flap, may be necessary to
resurface the first web space. In addition to
FIG. 4. Four months postoperatively.
phalangization, distraction osteogenesis can be
used for amputations at the distal middle third
cessitates phalangization is some degree of level. Further discussion of distraction osteo-
contracture of the first web space. Essentially, genesis follows in the section regarding proxi-
phalangization involves deepening the web mal middle third amputations.
space and releasing any tethering structures In general, all of the techniques used for
between the thumb and index rays. Various reconstruction at this level require postopera-
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 109e

FIG. 5. Four-flap Z-plasty for deepening of first web space in a case of congenital thumb
hypoplasia. (Above) Design of four-flap Z-plasty. (Below) First web space is deepened after flap
transposition.

tive splinting of the first web space. For severe length by phalangization and web-space deep-
contractures, this may be necessary for at least ening is usually not adequate. In most cases, an
2 to 3 months. If K-wires or external fixators absolute increase in length is required. This
are used, these may be removed at 4 to 6 weeks may be achieved by applying the concept of
postoperatively. “spare parts surgery,” whereby another injured
digit may be transferred onto the residual
thumb stump. Alternatively, distraction osteo-
Proximal Middle Third genesis may be used to lengthen the first meta-
Tissue loss in the proximal half of the middle carpal. Finally, the refinement of microsurgery
third of the thumb ray requires somewhat has made possible the toe-to-thumb transfer,
more complex reconstructive methods. At this which will be discussed in the section on prox-
level, simply providing a relative increase in imal third defects.
110e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

FIG. 6. Pollicization of the stump of an injured index finger with deletion of the remainder of the index ray to reconstruct
thumb length and deepen the first web space. Preoperative view of right hand.

FIG. 7. Preoperative markings.

Spare parts. The digits that are most com- the proximal half of the middle third might be
monly injured, in addition to the thumb, are the accomplished by either pollicization of the
index and middle fingers. Reconstruction of stump of an adjacent injured digit or by micro-
the thumb with a nonreplantable amputation in vascular transfer of an amputated digit acutely.
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 111e
Pollicization of the stump of an adjacent to its proximal interphalangeal joint such that
injured digit (typically the index finger) allows orthotopic replantation is impossible or ill-
the simultaneous lengthening of the thumb advised. In such a case, the amputated part can
and removal of a useless and potentially ob- be shortened and transferred with microsurgical
structive stump (Figs. 6 through 8). The technique to the thumb.21
amount of metacarpal that is transferred may Other situations in which spare parts surgery
be varied with the level of thumb loss, and the has been considered for thumb reconstruction in
remainder of the donor ray may be deleted. the proximal half of the middle third include the
The technique of pollicization has been well transfer of a nonfunctional digit on the contralat-
described by various authors in both trauma eral hand and even the transfer of normal digits,
and congenital absence of the thumb.6,7,8,20 although this is a highly controversial approach
Conceptually, pollicization involves four basic that we believe should be avoided.21 A case exam-
principles: 1) transposition of the digit on its ple in which spare parts surgery was used is
neurovascular pedicle; 2) skeletal realignment; shown in Figures 9 through 12.
3) muscular stabilization; and 4) appropriate Distraction lengthening. Distraction lengthen-
incisional design. ing of the first metacarpal can also be used to
The transposed finger undergoes four move- reconstruct thumb amputations at this level.22
ments that must be precisely controlled. The This technique is ideal when the injury is at the
first of these is shortening, as we have de- metacarpophalangeal joint and is usually com-
scribed. The second is rotation of the index bined with phalangization techniques. Up to
finger of approximately 120 to 140 degrees 3.0 to 3.5 cm in length may be gained by dis-
about its long axis. Thirdly, the transposed traction osteogenesis of the first metacarpal.
digit should be placed in 15 degrees of radial (Figs. 13 through 16)
abduction. Finally, the transposed digit also The prerequisite conditions that must be
should be placed in 35 degrees of palmar present for successful distraction lengthening
abduction.8,20 include the presence of at least two-thirds of
In the acute setting, microvascular transfer of the first metacarpal, good skin cover with sen-
an amputated digit onto the thumb stump may sation, and a compliant patient.22,23 Distraction
be an excellent option. The transferred digit typ- lengthening in the hand follows the principles
ically has sustained severe damage at or proximal originally defined by Ilizarov:24

FIG. 8. Postoperative views.

112e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

FIG. 9. Use of the spare-parts concept to reconstruct the thumb in this blast
injury. Preoperative view.

FIG. 10. Preoperative views of blast injury.

1. Maximum preservation of extraosseous months of immobilization. Some authors, how-

and medullary blood supply, ever, bone graft all distraction-lengthening
2. Stable external fixation, defects.23 The main complications related to
3. Delay before distraction, this technique involve pin migration or loosen-
4. One mm per day rate of distraction, and ing and pin-tract infections.
5. A period of stable neutral fixation after Osteoplastic reconstruction. Osteoplastic tech-
distraction with physiologic use. niques are based on the original description of
There is some question as to when a bone combining a nonvascularized bone graft with a
graft is necessary to fill the gap created by tubed pedicle flap to add length to the thumb.
distraction lengthening versus allowing the gap However, such reconstructions generally exhib-
to be filled by the regenerate. No definitive ited poor sensation and were subject to signif-
data exist regarding this question in the hand; icant bony resorption over time.15 The results of
however, it is apparent that the age of the osteoplastic reconstructions were significantly
patient is an important consideration in this improved with the introduction of the neuro-
regard. In general, bone grafting has been rec- vascular island flap for sensation.19,25
ommended in patients who are 25 years of age Osteoplastic reconstruction is useful when
and older with a gap of 3 cm or in patients who the amputation is at the distal metacarpal level
have failed distraction osteogenesis after 5 and a functional carpometacarpal joint and
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 113e

FIG. 11. Operative procedures.

FIG. 12. Postoperative result, with a functional pincer-type hand.

intrinsic muscle cone are present. In addition, composite radial forearm flap in combination
this method may be the best option if the other with a neurovascular island flap. This proce-
fingers are either normal or too badly dam- dure has the advantage of being a single-stage
aged for transfer and if toe transfer or distrac- operation with less bony resorption since the
tion lengthening are not possible. bone is vascularized.27
Modern osteoplastic reconstructions gener- Despite these recent advances, osteoplastic
ally require two stages, with an iliac crest bone reconstructions are still characterized by a
graft and groin flap performed at the first stage number of problems. Typically, these methods
and a neurovascular island flap at the second provide relatively poor sensation. Unless vascu-
stage.2,15 A single-stage iliac crest bone graft larized bone is used, resorption is common.
combined with a free dorsalis pedis flap has Moreover, the resulting thumb is usually bulky
been described by Doi.26 Also, Foucher has and has a poor aesthetic appearance. Most os-
described a single-stage procedure using a teoplastic methods require multiple operative
114e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

FIG. 13. Use of distraction osteogenesis to lengthen the injured thumb. Preoperative views of bilateral hand crush injury.

FIG. 14. Postoperative view.

stages and do not provide any mobility. Finally, Pollicization. Pollicization was originally de-
all of these techniques create some degree of scribed by Gosset in 19496 and Hilgenfeldt in
donor-site morbidity.15 1950,7 and later by Littler (1953),8 who subse-
Microvascular toe transfers of various types, quently applied the technique to reconstruction
such as the wraparound flap,11,28 offer a tre- of congenital thumb hypoplasia.29 Transfer of the
mendous flexibility and adaptability in recon- index or ring finger is preferred, although trans-
struction of proximal middle third and proxi- fer of the other fingers also has been reported.30
mal third amputations. These techniques will Pollicization is a single-stage operation that pro-
be discussed in detail below. vides nearly normal sensation and vascularity im-
mediately, with some functional joint motion
Proximal Third (Figs. 17 through 21). This technique is ideal for
Amputations of the thumb at this level gener- reconstructing defects proximal to the metacar-
ally require the addition of at least 5 cm of pophalangeal joint. Ideally, four normal fingers
length.15 Reconstruction of the thumb in the should be present.
proximal third should, at the very least, provide a The surgeon must decide which finger to
stable and sensate post for pinch and opposition. transfer. If available, the first choice should
Mobility of the reconstructed thumb is a second- always be an injured but sensate finger. If this is
ary consideration. Transfer of an available in- not possible, the index finger is the accepted
jured digit (i.e., the index finger) is an appealing standard digit for transfer in pollicization. Pol-
and useful reconstructive option. However, when licization of the index finger is easier and safer
this option is not available, only two good alter- compared with transfer of the other digits: no
natives remain: pollicization of a normal digit or crossover of vessels, nerves, or tendons is re-
microvascular toe transfer. quired, and the middle finger spontaneously
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 115e

FIG. 15. Radiographs of left thumb distraction.

FIG. 16. Distractors in situ.

substitutes for the transferred index finger. finger is not available. Additional advantages of
Moreover, pollicization of the index finger al- using the ring finger rather than the middle
lows deepening of the first web space via exci- finger are that the ring finger is shorter, the
sion of the excess index metacarpal. No palmar adductor pollicis origin on the middle finger is
scars are necessary. The origin of the adductor undisturbed, and the middle finger spontane-
pollicis is preserved. Finally, the aesthetic ap- ously substitutes for the index finger.
pearance of the pollicized index finger is bet- The distal phalanx of the pollicized digit
ter than that of the other digits, as there is no may be retained or discarded. The advantage
void at the donor site.8,30 of retaining the distal phalanx is the presence
Pollicization of the middle finger is associ- of the nail. However, when the distal phalanx is
ated with the problems of rotation and over- retained, the size of the fingertip does not
riding of the index and ring fingers. To avoid match that of the thumb distal phalanx. More-
this, it is recommended to transfer the index over, two flexor tendons are present with re-
onto the third metacarpal when pollicizing the dundant tendon lengths. Finally, it may be dif-
middle finger.30 Given these problems, transfer ficult to suture the thumb intrinsics to the
of the ring finger is preferred when the index tendons of the index intrinsics.30 Ultimately,
116e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

FIG. 17. Pollicization of the index finger in a case of congenital thumb hypoplasia. Preoperative markings.

FIG. 18. Immediate postoperative views.

whether to retain or discard the distal phalanx don is to create a juncture with the remaining
depends upon the surgeon’s preference. extensor pollicis longus tendon. The adductor
Technically, pollicization requires mobiliz- pollicis is reattached to the first volar interosse-
ing the finger on its flexor tendons and neu- ous tendon, and the thenar intrinsics are reat-
rovascular bundles. It is important to preserve tached to the first dorsal interosseous and lum-
the dorsal veins draining the transferred digit, brical tendons. As noted above, the pollicized
as well as the superficial radial nerve branches digit should be positioned in radial and palmar
serving the index finger. The common digital abduction, opposition, and pronation. The
nerve must be separated intraneurally to allow technical details of pollicization of damaged
untethered transposition. The length of the digits has been elegantly described recently by
index metacarpal should be adjusted to place Foucher and colleagues.31
the index metacarpophalangeal joint at the Secondary procedures may be required to
level of the thumb metacarpophalangeal joint. shorten the flexor tendons, to perform an ex-
The extensor tendon may be either transferred tensor tenolysis, or to perform an opponens-
intact, divided, and resutured, or simply pli- plasty. Extensor tenolysis may be avoided by
cated to adjust its tension to the new length of transferring the extensor tendons intact. There
the digital ray in the thumb position. Another is a tendency toward hyperextension at the
alternative for dealing with the extensor ten- metacarpophalangeal joint after transfer. This
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 117e

FIG. 19. Movement out of palmar plane.

FIG. 20. Six-month postoperative result.

FIG. 21. Six months postoperatively. Note the excellent pinch strength that has been
achieved.
118e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005
tendency can be minimized by longitudinally ics 2003 for a detailed description of the prac-
severing the extensor hood and keeping the tice of toe to hand transplantation.35
joint flexed with a K-wire postoperatively. Candidates for microvascular toe transfer
Other complications associated with polliciza- should be older than 12 months of age. The
tion include kinking, twisting, or compression procedure should be delayed until the acute
of the pedicle, especially with transfer of any injury has healed, unless a toe transfer is neces-
digit besides the index finger. Delayed union sary to prevent further tissue loss, as in a de-
or nonunion also may occur.15,30 gloving or avulsion injury. As noted above, it is
Postoperatively, the first metacarpal should paramount that the patient’s function at the
be immobilized in plaster until bony union is amputated level is carefully assessed before
demonstrated radiographically. However, if a counseling any treatment plan.
compression plate is used for osteosynthesis, Microvascular toe transfer can provide a re-
motion may be allowed at 3 to 4 weeks or constructed thumb with good mobility, sensa-
possibly sooner. Vigilance must be maintained tion, and strength (depending on the level of
for signs of kinking, compression, or twisting of amputation) in a single operation. The trans-
the pedicle, especially when the ring finger is ferred toe is similar in appearance to a thumb
transferred. and provides glabrous skin and a nail. With trans-
Microvascular toe transfer. With the develop- fer of a whole toe, the growth potential is pre-
ment of microsurgical techniques, it has be- served. However, this technique does sacrifice a
come possible to reliably perform microvascu- toe and requires microvascular expertise. The
lar toe-to-thumb transfers and spare the operation is lengthy, and the potential loss of the
remaining digits on the injured hand. The con- transferred toe is a serious consideration.36
cept of transferring a toe to the thumb origi- In terms of specific surgical indications, the
nated in 1897, when Nicoladoni performed a ideal level of amputation for microvascular toe
pedicled transfer.5 In 1966, Bunke performed a transfer is distal to the midfirst metacarpal.
successful free toe transfer in a monkey.32 Later There should be a normal carpometacarpal
that year, Yang and Cobbett both achieved suc- joint and good thenar muscles.
cess in microvascular toe transfers in human Microvascular reconstruction affords a num-
patients.9,10 ber of versatile and adaptable options. These
Since that time, the technique of microvas- include transfer of the great toe, the second
cular toe transfer has undergone a number of toe, and partial toe transfers (i.e., wraparound
developments. Until 1975, the plantar arterial and trimmed toe). The appropriate option is
system was used. O’Brien’s successful use of the determined by a number of factors: the length
dorsal vascular system and Gilbert’s landmark requirement and level of injury; the motion
anatomic study of the vascular anatomy of the requirement; the need for growth potential;
first dorsal metatarsal artery popularized the aesthetic considerations; and donor-site
use of the dorsal system. Ultimately, greater morbidity.33,36
success has been achieved using the dorsal sys- Microvascular toe transfer requires a thor-
tem than the plantar system.33 In 1980, Morri- ough familiarity with the neurovascular anat-
son described the technique of the wrap- omy of the foot. The variations of the first
around toe transfer, which allows a customized dorsal metatarsal artery have been elegantly
thumb reconstruction and preserves elements described by Gilbert and Upton.37,38 In most
of the great toe.11 cases, the first dorsal metatarsal artery is ade-
The outcomes with toe transfers are gener- quate for successful toe transfer; however, ei-
ally very good. In a very thorough retrospective ther the dorsal or plantar metatarsal systems
review, Chung and Wei showed that patients can be used successfully with intact distal com-
who had undergone toe transfer had higher munications at the transmetatarsal ligament.38
functionality and aesthetics scores when com- The surgeon must always be prepared to use
pared with patients who had not undergone the plantar system, which may be dominant in
any reconstruction for their proximal thumb 23 percent of cases.38 It may be preferable to
amputations.34 Additionally, they found that begin the dissection of the toe in a retrograde
donor-site morbidity of the foot was negligible, manner, from the webspace first, to identify
and that there was no diminishment in lower the arterial anatomy.38 On the hand, the arte-
extremity function. Readers are also referred rial anastomosis is to the radial artery in the
to Wei’s comprehensive summary in Hand Clin- anatomic snuffbox. Venous drainage of the
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 119e
transferred toe is usually provided by the dorsal second toe is smaller than the normal thumb,
venous system. Ideally, a large superficial vein its appearance on the hand is worse than that
is anastomosed to the cephalic vein on the of the great toe. However, the second toe do-
hand. The deep branch of the peroneal nerve nor site is better than that of the great toe.
is harvested and connected to the superficial Because the second toe is not critical for gait,
branch of the radial nerve, while the proper the entire metatarsophalangeal joint can be
digital nerves of the toe are connected to the taken, as well as part of the metatarsal. Second
stumps of the digital nerves in the thumb. toe transfer is ideal for amputation levels at or
Preoperatively, the type of toe transfer re- distal to the proximal metacarpal. As with the
quired should be determined and an angio- great toe, second toe transfer preserves the
gram may be performed to elucidate the opti- growth potential of the toe and provides good
mal donor vessel. The design of the skin flaps motion. However, the transferred second toe
and coverage of wounds on the hand must be tends to be weaker than the great toe.33,36
planned carefully; in some cases, a staged ap- Skin coverage must be planned carefully
proach may be necessary to first provide ade- when the second toe is transferred with its
quate soft tissue (usually in the form of a groin metatarsal. Occasionally a preliminary flap may
flap) on the hand before toe transfer. Any of be required to ensure stable coverage of the
the commonly used methods of osteosynthesis transferred metatarsal. In such cases, the in-
may be used; the surgeon should choose one terosseous muscle should be transferred with
with which he/she is comfortable. the toe to allow skin grafting over the trans-
Great toe ferred ray, if necessary.
The great toe is 20 percent larger than the The distal interphalangeal joint of the trans-
thumb in all dimensions; however, it generally ferred second toe should be pinned in exten-
appears more “thumb-like” than does the sec- sion for 2 to 3 weeks to prevent a mallet defor-
ond toe. When harvesting the great toe, the toe mity. When the thumb amputation is at the
is removed at the metatarsophalangeal joint, proximal metacarpal level, an opposition trans-
preserving the volar aspect of the head of the fer will be required as a secondary procedure
first metatarsal and the sesamoid bones to after second toe transfer33,36
avoid gait disturbance. The ipsilateral toe Partial toe
should be used, if possible. With the ipsilateral As an alternative to transfer of a complete
toe, the pedicle is located in a favorable posi- great or second toe, a partial toe transfer can
tion for anastomosis in the recipient site. More- be performed using microvascular techniques.
over, there is a 10- to 15-degree angulation at Partial toe transfers include the wraparound
the metatarsophalangeal and interphalangeal technique, the trimmed toe technique, and the
joints of the toe that facilitates opposition of transfer of individual toe components.11,33,36 In-
the transferred ipsilateral toe to the fingers. troduced by Morrison in 1980, the wraparound
Also, use of the ipsilateral toe permits the use technique transfers a soft-tissue flap and nail
of skin from the first web space of the foot to from the great toe to cover an iliac crest bone
reconstruct the first web space of the hand.33,36 graft.11 This method allows the surgeon to cre-
Frequently, however, some patients have such a ate a customized appearance. However, the
significant lack of thumb tissue that the deficit reconstructed thumb has no motion, nor does
cannot be compensated by the transferred it have growth potential. Thus, the wraparound
great toe alone. In these cases, it may be neces- technique is ideally used in adult patients with
sary to precede the toe transfer with a soft-tissue an amputation level distal to the metacarpo-
transfer procedure, such as the groin flap. phalangeal joint. A normal carpometacarpal
The great toe can be used to reconstruct joint and good thenar muscles are required for
amputations at the distal half of the metacarpal success. To decrease resorption of the bone
to the proximal part of the proximal phalanx. graft, it is recommended that the distal pha-
Microvascular great toe transfer is ideal in chil- lanx of the toe be included in the transfer,
dren, since the growth potential of the toe is thereby sandwiching the bone graft between
preserved. In addition, transfer of the great toe two vascularized bones (i.e., the metacarpal
provides good mobility and strength.33,36 and the transferred distal phalanx). The soft
Second toe tissue flap is designed on the great toe by
The second toe also may be used for micro- matching the thumb circumference, leaving a
vascular transfer to the thumb. Because the medial strip on the toe. The residual toe is
120e PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005
then shortened to allow closure with a medial PROSTHETICS
flap and split thickness skin graft.11,33 The surgeon must be familiar with the role
The trimmed toe technique combines the of prosthetics in posttraumatic thumb recon-
mobility obtained with a great toe transfer and struction. In general, prostheses provide a
the custom size obtained with the wraparound greater benefit with more distal amputations.
technique. A medial flap is left on the toe, as in With more distal tissue loss, more parts with
a wraparound harvest. However, 4 to 6 mm of intact sensory feedback and automatic control
the medial border of the phalanges, joint remain to allow near-normal function.
prominence, and nail are also trimmed; the toe In weighing the value of a prosthetic recon-
is essentially made to match the size of the struction in any individual case, the outcome of
thumb by shaving off its medial elements and
prosthetic reconstruction must be compared
leaving them in situ in the foot. The trimmed
against surgical reconstruction. Surgical recon-
toe is best suited to amputation levels distal to
struction is preferred if it will provide a supe-
the metacarpophalangeal joint. The joints of
rior improvement in function (i.e., sensation),
the transferred toe are preserved, and no bone
if it will be socially acceptable, and if the sec-
graft is required. However, this method is still
ondary donor defects are justified by the qual-
contraindicated in children because damage to
the growth plates would be incurred during ity of the end result.39
harvest of the toe.36 As a minimal requirement, at least 1 cm of
Finally, microvascular techniques can be the thumb proximal phalanx must remain to
used to transfer specific components from toes allow prosthesis fitting; a 1.5 cm residual stump
to the thumb. For instance, a metatarsophalan- is ideal. Prosthetic reconstruction for total
geal or interphalangeal joint, with or without a thumb loss is suboptimal, requiring a glove to
skin flap, can be transferred to restore mobil- be worn over the palm. The indications for
ity. In some cases, part of the great toe and the such a reconstruction are much stronger when
skin of the first web space may be required to the patient is also missing the index or index
reconstruct a combined deficit of thumb and and middle fingers.39 In general, conventional
first web space in the hand. For more distal prosthetic reconstruction is aesthetically ac-
injuries, the pulp of a toe may be transferred to ceptable, but has poor functionality. However,
restore padding and contour to the thumb tip. osseointegrated prosthetics have been shown
Occasionally, a nail with dorsal skin may be to provide better functional outcomes in initial
transferred to enhance the aesthetic appear- studies.40
ance of a traumatized or reconstructed
thumb.36 ALGORITHM FOR POSTTRAUMATIC THUMB
Postoperatively, a microvascular toe transfer is RECONSTRUCTION
managed much like a replantation. The patient
should be well hydrated, and the patient’s room A great many options are available for post-
must be kept warm. Careful monitoring by clin- traumatic thumb reconstruction. Optimal re-
ical examination is essential. Gentle occupational sults are obtained by pursuing an organized
therapy should be instituted at 5 to 7 days. At 3 and logical approach to reconstruction based
weeks, a tendon repair protocol should begin. upon the level of tissue loss. The need to indi-
The foot should be elevated and be nonweight- vidualize the treatment for each patient based
bearing for 2 weeks postoperatively. upon an assessment of his/her postamputation
The rate of postoperative thrombosis in mi- function cannot be overemphasized.
crovascular toe transfers is reportedly 10 to 15 Amputations in the distal third of the thumb
percent.36 With prompt reexploration and re- are generally well-tolerated. The primary re-
vision, most of these cases can be salvaged. constructive issues are the restoration of a pad-
Overall, more than 95 percent of these trans- ded and sensate soft tissue cover, as well as
fers are successful.36 Sensory return can be an- aesthetic considerations. Our reconstructive al-
ticipated by 4 to 6 months, reaching its maxi- gorithm begins with homodigital flaps. If these
mum at 2 years postoperatively. Secondary flaps are not available, we proceed to het-
procedures may be necessary. These include erodigital flaps. Occasionally, a partial toe
flexor tenolysis, bone grafting, osteotomies, transfer or a great-toe wrap-around flap may be
nerve grafting, first web space deepening, and necessary. Prosthetic options should always be
tendon transfer (e.g., opponensplasty).36 considered in this zone.
Vol. 116, No. 5 / POSTTRAUMATIC THUMB RECONSTRUCTION 121e
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