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Reconstruction after traumatic mutilations of the hand
Volume 2 Number 2
TUBIANA : TRAUMATIC MUTILATIONS OF THE HAND
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R E C O N S T R U C T I O N AFTER TRAUMATIC MUTILATIONS OF THE HAND* R. T U B I A N A
H@ital Cochin, Paris
TRAUMATIC mutilations of the hand pose a number of problems, and one of the most important is the organization of emergency treatment by a team, of which the members cannot all be specialized hand surgeons. As long as the mutilation is limited to the fingers, the rules to follow are fairly simple: avoid complex emergency plastic procedures; use simple grafts or make do with direct sutures of the stumps without excessive shortening. But, in cases of severe mutilations affecting the thumb or the metacarpal part of the hand (which are often associated with complex crushing wounds), the decisions taken when the patient is first seen will have an undoubted influence on the prognosis. One must make an accurate assessment of the lesion so as to determine : - 1. Which tissues are viable and which are unlikely to survive. 2. What can be sacrificed and what must be preserved. Such an assessment can be difficult, and as Pulvertaft (1966) quite rightly says: ' It is wise in case of doubt to be conservative and preserve viable structures, even though these structures may not in themselves contribute to function. These parts may be of great value during later reconstruction, as a source of skin with sensib i l i t y . . . ' In particular, one must always try to conserve the length and mobility of the peripheral skeletal structures, namely the first and fifth metacarpals which, as we shall see later, are frequently utilized when prehension is to be restored. I will not enlarge on those emergency problems of which the members of the Birmingham Accident Hospital have no doubt a greater experience than anybody else. I shall restrict
* The Ruscoe Clarke Memorial Lecture, delivered at Birmingham on 24 April, 1970.
myself to the late reconstruction of severely mutilated hands. Mutilations may occur at the time of the accident or may develop secondarily after necrosis; we have seen a number of such cases following thermal or electric burns. Traumatic mutilations differ from congenital ones in that scar tissue is present and that the patient is not adapted to his mutilation and will find adaptation the more difficult the older he is. Indeed, the problem of adaptation of the mutilated hand to new forms of prehension is absolutely basic to the present topic. Our duty is to help the patient mechanically by enabling him to perform the usual gripping movements. We all know that prehension is a complex mechanism, involving conscious efforts and automated circuits. Prehension must not be confused with simple gripping, as the hand is constantly adapting itself in terms of the sensory information it receives and of the purpose to be achieved. This capacity for adaptation is affected in the mutilated hand. Depending on the severity of the mutilation, one may be able, at most, to restore precision handling and power-gripping, or perhaps only the more rudimentary actions of the vice, of the pincers, of the hook, of the push-rod, or of the paper-weight. To make precision handling possible, the minimum required is a thumb or a thumb element with as near as possible to normal length and mobility, and a finger against which it can be actively opposed. The presence of a third finger will greatly increase control and precision. It must be remembered that the terminal pinch with marked flexion of the distal interphalangeal joints is used much less frequently than the subterminal hold between the pulps. It is this latter movement which one should try to restore. In power-gripping, however, the hand wraps itself around the object, and this requires mobile
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digital joints. The force of the grip will depend on the width of the palm and the conservation, at least partial, of the peripheral fingers--those on the radial side being more useful for precision, while those on the ulnar side contribute power. If the fingers have been lost, the surviving thumb will make relatively wide and precise gripping possible, provided it is mobile. In the absence of the thumb (Fig. 1), prehension will
Fig. 1.----~ the absence of the thumb, grasp is possible, but without precision.
be restricted to a digital hook, to broad finger-topalm clasping, and to narrow interdigital pinch, all of which are short of precision. When the hand is grossly mutilated and the surviving structures are stiff, only a pincer-action can be restored. This will require two opposing elements: one at least must be mobile and, as far as possible, one must have sensation. We know only too well that painful fingers and fingers deprived of sensation are seldom used. F o r this reason, one should always try to provide a good skin covering and as good a sensation as possible over the prehensile surfaces. One can, in fact, hope to restore some degree of protective sensitivity by resuturing nerves up to 2 or 3 years after the original injury. When this turns out to be impossible, a sensitized skinflap can, if required, be transferred from less
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useful areas by advancement or rotation of adjacent flaps, or a skin transplant with its neurovascular bundle can be borrowed from another finger. The treatment of a mutilated hand must therefore have two objectives : - 1. To restore an organ of sensory information. 2. To restore plasticity to the grip which must adapt itself to objects and to orders from the brain. I shall consider, in increasing orders of severity, mutilitation of the thumb alone, mutilation of the thumb and fingers, and, finally, bilateral mutilations of the hands. MUTILATIONS OF THE THUMB A hand without its thumb loses some 40 per cent of its function. Hence the importance of thumb reconstruction. Indeed, this is one of the topics most commonly discussed at meetings on surgery of the hand. To perform such a reconstruction is a technical and intellectual achievement which usually delights the surgeon. But not uncommonly, the patient is much less satisfied with the functional result than the surgeon. The new thumb has but little mobility or has a wrong orientation; it is painful or without sensation; sometimes there is a loss of power in the hand as a whole. The reason is that too often the technique was inadequate or the operation performed without proper indications. I shall not describe here the numerous reconstructive procedures which have been suggested. But they can be put into three main groups : - 1. Osteoplastic reconstruction where the thumb is constructed by lengthening the skeleton and covered with a skin-flap. 2. Pollicization, using another digit. 3. Transplantation of a toe. (We have no experience of this last procedure which, to us, seems rarely indicated.) Osteoplastie Reconstruction of the Thumb While it appears that Nicoladoni, in 1897, was the first to suggest this procedure, he was himself unable to perform such a reconstruction as his three patients refused to have a bone-graft after the skin-flap (Nicoladoni, 1900). According to Carcassone (1930), Noesske performed the first complete reconstruction in 1908, using an abdominal skin tube and a tibial graft (Noesske, 1909). Of all the procedures for reconstruction of the thumb, this is the least traumatic as far as the rest of the hand is concerned. It does, however, have some serious disadvantages which restrict~ its
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application. This procedure does n o t create a mobile articular structure and there is frequently
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resorption of the bone-graft a n d atrophic skin complications due to a poor vascular and nervesupply. We shall see how these disadvantages can be overcome. Let us start by saying that a newly constructed t h u m b does not have to possess three joints or be of normal length to be useful.
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Fig. 2.---The ' cocked h a t ' procedure of Gillies. Partial reconstruction of the thumb by iliac bone-graft and advancement of a skin-flap raised from the lateral base of the thenar eminence. The skin defect is covered by a skin-graft.
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Fig. 3.--The ' reversed cocked h a t ' procedure of Barron. The skin-flap is advanced from the medial side of the thenar eminence. The first web is deepened• A, Incision in first web space; B, Advancement of the skin-flap from the medial side; C, Final postoperative result.
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It must, however, be stable, painless, and capable of opposing the other digits, and its prehensile surface must have sensation. Depending on the length of the stump and the state of the scars, two types of osteoplastic procedures will be chosen: some use local flaps, others borrow ~f flap from some distant donor area. The advantage of the first procedure is that it can be completed in one operating session. The skeletal lengthening is usually achieved by means of a short graft (no more than 1½cm.) but occasionally by oblique osteotomy with continuous traction on the first metacarpal (Matev, 1970). The skin may be borrowed from one of several neighbouring areas : - a. F r o m flaps on the medial or lateral aspect of the base of the thumb, which are advanced en masse by the ' cocked h a t ' procedure of Gillies (1957), or the 'reversed cocked h a t ' technique of Barron (1969), which deepens the first web space (Figs. 2, 3). b. F r o m flaps from the skin of the dorsal aspect of the proximal phalanx of the index (which is supplied by sensory fibres of the radial nerve), using one of a number of techniques (Hilgenfeldt, 1959; Holevich, 1963; Gaul, 1969; Adamson, Horton, and Crawford, 1967; Bralliar and Homer, 1969; Michon and Vilain, 1969). However, the notoriously variable territory of distribution of the terminal branches of the radial nerve makes the result unpredictable. Moberg (1969) has suggested that the territory of supply of the radial nerve be assessed preoperatively by locally anaesthetizing the medial nerve. Tissue must never be taken from the radial aspect of the index, as this is one of the most commonly used prehensile surfaces, especially in median nerve lesions. It is sometimes better to combine these limited local procedures with phalangization of the first metacarpal which produces a relative lengthening of the thumb by deepening the first web space. When the thumb is to be lengthened by more than 2 cm., distant flaps, usually tubular, must be introduced. Since 1959, we have been using a procedure enabling us to construct new thumbs with both a good circulation and a sensory nerve supply. Its originality lies in the combination of a bone-graft within a tubular flap and the addition of a neurovascular skin island transfer (Tubiana and Duparc, 1960) (Fig. 4). The procedure requires several stages : - -
1. Implantation o f the Skin Tube The skin tube is taken from an area where skin is supple and the subcutaneous fat is scanty,
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otherwise the pedicle tends to slip over the bone, producing an unstable grip. The contralateral subclavicular area is usually chosen in a man; in a woman, for cosmetic reasons, the tube is taken from the submammary crease or from the medial aspect of the arm. The abdomen is also a potential donor site. The flap, if not too long, can be implanted directly on the thenar eminence; it is safer otherwise to perform the fixation at a second stage. The suture line of the tube on to the thenar eminence should not be circular but elliptical or zig-zag, in order to have a longer junction zone and to avoid scar contraction. One must also make sure that the longitudinal suture of the tube is on the palmar side.
2. Separation of the Tube This stage is carried out 3 weeks after the first. If the sensitive flap is introduced at this stage it will improve the circulation of the tube. We prefer, however, to do this at a later stage, at the same time as the bone-graft, to avoid disturbing the delicate pedicle and to provide further skin covering, which is sometimes useful. 3. Insertion of the Bone-graft and Introduction of the Sensitive Skin lsland Transplant We like to use a graft from the iliac crest which is inserted deep into the medullary canal of the first metacarpal. Fixation may be by a transfixion wire. The direction and length of the graft will be adapted to each case. It is better that prehension should be subterminal and between pulps rather than terminal. The bone-graft should be palette-shaped, have a fiat, relatively broad prehensile surface, and not have a sharp extremity bent in towards the palm. The sensitive skin transplant embodies the general technique of heterodigital neurovascular island transfer, as developed by Moberg (1955) and Littler (1960), but applies it further to a particular situation. The transplant should be as wide as possible in order to restore sensation to a large surface on the thumb. We usually take half the palmar surfaces of the two distal phalanges. Hueston (1965) even takes the territory of supply of the dorsal branches of the digital nerve, and thus obtains transplants 6 cm. long and more than 2 cm. wide. The donor site should be selected so that there is a minimum of inconvenience. We like to use the medial surface of the middle finger, not only because it provides a broader flap and is but little used in prehension, but also because, like the thumb, it is supplied by the median nerve, which might facilitate integration.
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TUBIANA: TRAUMATICMUTILATIONSOF THE HAND
If the middle finger is not available, we use the medial surface of the ring finger or some other sensitive area, while avoiding the anterolateral surface of the index. The sensitive flap is transferred on to the palmar and medial aspect of the neo-thumb along the line of closure of the tube in the optimal prehensile zone, extending if possible over the tip. This additional skin makes it easier to close the tube after inclusion of the bone-graft. To lessen the tendency for the flap to slip on the surface of the underlying bone-graft, a few sutures are used to fix its deep aspect to the margins of the bone peg.
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although two-point discrimination (Weber's test) is invariably less than on the normal thumb.
Results As it is a non-articulated structure, the reconstructed thumb ideally should be shorter than a normal thumb, but the degree of mobility of the opposable fingers should be taken into consideration, and the length of the new thumb designed accordingly. For cosmetic and functional reasons, it should not be too fat. The sensation on the reconstructed thumb should be carefully analysed. Over the skin transplant, the sensory acuity is close to normal,
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Fig. 4.--Reconstruction of the thumb by a tubed flap, a bone-graft, and a neurovascular skin island transferred from the medial surface of the middle finger.
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At first, sensation is referred to the donor finger; then, over a variable period of time, the ' p h e n o m e n o n of double sensation' develops, whereby perception of the thumb is superimposed on sensation of the donor finger. Objective examination reveals errors of perception between the thumb and donor finger, but in the course of normal activity the more the patient uses the thumb the fewer mistakes he is likely to
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after a traumatic amputation of the thumb, but shall just point out some aspects of the technique. The transfer of a finger as an ' island ' with the neurovascular pedicles described by Littler (1953) has simplified and improved the technique. Any finger can be transferred to replace the thumb. We shall discuss the advantages of using each particular finger, but first, we shall state the principles which are valid for every pollicization : the pollicized finger must be provided with a good web and must have an adequate bloodsupply, sensation, length, and mobility.
1. The Incision The incision runs across the base of the transferred finger anteriorly, and a long V-shaped tongue of skin is preserved on the dorsum of the finger. The flap for the cleft is usually based anteriorly (Fig. 5). This is sometimes made difficult when traumatic mutilation has left extensive scars and a destroyed web. It becomes necessary in such cases to provide supplementary skin cover before the pollicization proper. This will usually come from a distant flap, the position of which will have to be carefully worked out (Fig. 6). Fig. 5.--Pollicization of the index finger. On the dorsum of the hand, this photograph shows the V-shaped flap at the base of the index and the dorsal flap for the cleft. The incision runs across the base of the index anteriorly. make. Integration comes earlier in the young, active patient; it does not occur, however, if for some local reason such as pain or instability, or for psychological reasons, the patient does not use his thumb. These neurovascular skin transplants should only be performed in painless hands and in active and preferably young patients. By this procedure, the newly constructed thumb is provided not only with sensation but also with a significant blood-supply, so that the new thumb has a normal colour, the bone-graft consolidates rapidly, and resorption phenomena are markedly reduced. Pollicization
Like osteoplastic procedures, pollicization has undergone successive improvements. Since Guermonprez, o f Lille, who described this operation in 1887, a number of names have been associated with this procedure, including Bunnell (1929), Murray (1946), Gosset (1949), Hilgenfeldt (1950), and Littler (1953). I cannot discuss here all the problems in relation to pollicization
2. Vascular Supply It is obviously preferable that the transferred finger should have a normal vascular bundle, but we have succeeded in pollicizing fingers in which one collateral artery had been destroyed. An arteriogram is sometimes helpful when assessing preoperatively the possibility of transferring a previously injured finger. When the circulation is poor, one can transfer a skin island with its neurovascular bundle over to a finger which will be pollicized later (Snell, 1969). The venous return occurs along the small deep veins which accompany the palmar arteries. Ideally, one should preserve one or two dorsal veins, although this is only feasible when the index finger is pollicized. 3. Sensibility The pollicized finger must have sensation and be painless. A tender neuroma, whether on the transferable finger or on the thumb remnant, must be dealt with before pollicization. We must stress that the transplanted finger is not perceived by the patient as a thumb; it retains its original identity. As in the case with heterodigital sensory island transfers, a certain difficulty in perception results which requires reorientation by the patient. Proprioception is improved if the flexor pollicis longus is inserted into the flexor profundus of the transferred finger (Hilgenfeldt, 1950).
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Fig. 6.--In case of extensive scars, an abdominal tube flap is brought before pollicization to provide supplementary skin covering. A, Preoperative total loss of thumb with severe scarring of the aspect of the hand; B, Abdominal tube flap, attached both dorsally and volarly about the base index finger; C, The tube flap is divided at its middle portion; the index finger is pollicized; D, The half of the tube flap is used for dorsal skin coverage, while the anterior half forms the volar aspect newly created web space; E, Final postoperative result.
lateral of the dorsal of the
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4. Length The tip of a normal thumb reaches to just short of the proximal interphalangeal joint of the index finger. A reconstructed thumb should be as near to this length as possible; but it must not be any longer nor have any more phalanges than the normal thumb. The length of the transfer will depend on the site of the mutilation, the adjustment of length during reconstruction being made at the proximal end. If an intact finger is transferred, the proximal phalanx will become the first metacarpal; this allows retention of the distal phalanx with the flexor profundus insertion and the nail, which improves the appearance and makes finger-nail pinch possible. The proximal interphalangeal joint of the finger will become the metacarpophalangeal joint of the new thumb, the distal interphalangeal joint the interphalangeal, and, if necessary, the metacarpophalangeal can be transferred as a carpometacarpal joint.
5. Positioning The reconstructed thumb must be fixed in position after rotation through about 120 ° so that the pulp does not face anteriorly but inwards, towards the palm. Bony fixation and control of rotation are effected by the use of Kirschner wires.
6. Stability and Mobility The transferred finger must have stable joints, and at least some of them must be mobile. G o o d movement in the distal joints is all the more important if the first carpometacarpal joint has a limited range and vice versa. It is well known that stability in a proximal joint is necessary for motion in a more distal joint, and for this reason the principal stabilizing muscles must be carefully retained or reattached: abductor pollicis longus for the first carpometacarpal joint, and the aponeurotic insertion of the intrinsic muscles for the metacarpophalangeal joint. It is essential to reconstitute the musculature of the thumb, not only the long muscles, but also the intrinsic muscles. A different scheme for reactivation of the thumb may be required for each case. Extension, flexion, abduction, adduction, and opposition of the reconstructed thumb must all be considered. It is inadequate simply to attach a thumb extensor to the finger extensor: an extension deficit will occur and persist. One must also supply motor power to the intrinsic muscle insertions of the transferred finger by attaching those thenar muscles that are present. The
Injury Oct. 1970
adductor pollicis is attached to the palmar interosseus and abductor pollicis brevis to the dorsal interosseus. If all the thenar muscles have been destroyed, each of the two lateral bands of the extensor communis tendons are attached to an interosseus, the first palmar interosseous becoming an adductor of the new thumb and the first dorsal interosseous an abductor pollicis brevis. The distal part of the extensor communis of the transferred finger is attached to the extensor pollicis longus; the proximal part is, if necessary, fixed to the lateral part of the base of the first phalanx, which is now the first metacarpal to replace the abductor pollicis longus. It is often necessary to counteract the natural tendency to adduction of the pollicized finger. This may be difficult in those cases, seen relatively often, in which the lateral units of the thenar eminence have been destroyed. One must therefore restore abduction and rotation. One of the long extensor tendons of the index finger can be employed, as Harrison (1964) proposed, to restore opposition; for this, the tendon is divided proximally, re-routed, and sutured to the existing flexor pollicis longus muscle. Other tendon transfers are possible, such as that of abductor digiti minimi, which has the advantage of providing a good thenar contour as well as motor power. Flexion is provided by the long flexor tendons transferred with the finger. It is usually sufficient after pollicization of partially amputated fingers. The muscles adjust and will compensate for moderate shortening. In cases where utilization of the proximal phalanx as the metacarpal results in marked shortening of the transferred finger (this may be up to 5 cm. in the adult), it may later be necessary, in a few cases, to adjust the length of the flexor tendons. In the forearm, the flexor profundus tendon is divided and resutured, preferably to the flexor pollicis at its musculotendinous junction; but first it must be pulled into the palm, and passed through the carpal tunnel in the space of the flexor pollicis tendon (Littler, 1966). Flexor sublimis which is independent, adjusts more readily, but it may also have to be shortened in the forearm at a later stage.
Choice of Transfer It is important that the use of a finger to replace the thumb should not create a significant deficit in the hand, nor seriously alter its architecture. If the index finger is used, the dorsal veins can be preserved and the ncurovas~ular
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TUBIANA~ TRAUMATIC MUTILATIONS OF THE H A N D
pedicles shifted without the problem of angulation or crossing. Besides, the architecture of the hand is minimally upset by the displacement of this peripheral finger. The web is created with the help of a dorsal flap, but it is deeper than normal because the finger has been moved proximally. A pollicized index provides two long extensors, and both of them are extremely useful for reconstructing the musculature. The middle finger was preferred by Hilgenfeldt (1950) because it is larger and less important than the index. However, the displacement of this central digit affects the strength and stability of the hand. In resecting the head of the third metacarpal, there is a risk of producing rotation and overriding of the adjacent fingers, and an unattractive hand posture. When the middle finger is used in pollicization, the index ray should ideally be transferred to the third metacarpal. The ring finger was recommended by Letac, (1954) and is the present choice of Gosset (1964) and many others, because it is of little importance for hand function. It certainly constitutes, with the index, the best finger to be transferred. It is distant enough for satisfactory tension to be re-established in the flexors after transfer. The architecture of the hand is upset less by using the ring finger than by using the middle finger because the mobile fourth and fifth basal metacarpal joints allow the little finger to approximate to the rest of the hand. The little finger can be used, but it is really too slender to make a good thumb, and contrary to general opinion, this finger is far from being unimportant. Its removal reduces the stability of palmar grip. In spite of the good results obtained by pollicization, now that the technique is well established, we are reluctant to move an intact finger after a traumatic thumb amputation, when another method of reconstruction is available. When possible, we use a finger which has been damaged. These shortened or slightly stiffened fingers that are of little intrinsic value, especially when the thumb is absent, may gain considerably in importance when transferred. A thumb of adequate length is obtained if a remaining metacarpal is used, and even though there may be a cosmetic loss from lack of a nail, the functional value is great.
Indications for Operation The decision to operate and the choice of operative procedure are almost as important as the technique, when one is faced with an amputation of the thumb. A patient may be quite
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adjusted to a partial amputation of the thumb, especially if it is on the non-dominant side and if the lesion is long-standing. Many reconstructed thumbs are not used by the patient. A major reconstructive procedure, such as pollicization or a tube flap with bone-graft and sensory island demands some technical experience. 'Unfortunately ', as Littler (1966) said about pollicization, 'fascination with this procedure on the part of the inexperienced surgeon has left a wake of meager results that have somewhat stigmatized the operation's potential contribution '. It may be as well to recall Hueston's (1965) aphorism that ' the most difficult thing about pollicization is to resist the temptation to do it '. Each case of thumb restoration poses particular problems. Factors that must be considered are : - 1. The level of amputation and the usefulness of the stump. 2. The condition of the remaining fingers, of the hand as a whole, and of the other hand. 3. The age of the patient, his occupation and his psychological condition. One must know that a good result after any procedure can only be expected if the hand is painless and the patient intelligent and active. The operative indications are governed also by the advantages and disadvantages of the various procedures at our disposal. Pollicization has the advantage of being usually completed in one stage. A mobile thumb with sensibility is provided, but there is the disadvantage that one of the remaining fingers is removed. Admittedly, pollicization of a finger does not in itself produce a deficit, as it redistributes the existing fingers in such a way as to improve their usefulness. This is true when the thumb is amputated together with its metacarpal, but, as Verdan (1968) pointed out, it does not apply when the first metacarpal remains; in these cases, phalangization of an intact finger will at most provide only two more phalanges to an existing unit while it suppresses a whole digit. A tube flap with bone-graft and sensory island flap allows one to retain all the fingers, but several operative stages are usually required, and a mobile joint is not provided. Osteoplasty, using a local skin-flap, provides an expedient solution but achieves only limited lengthening. It can be performed only if the remaining bone stump is of sufficient length, and if healthy covering tissue is locally available. As a guide the following levels are considered (Fig. 7):
1. When a sufficiently longfragment of proximal phalanx remains, it is unnecessary to have recourse to a major procedure.
It suffices simply to
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phalangize the first metacarpal, or, if the neighbouring soft tissues are of good quality, a short osteoplasty can be carried out, covered by a local skin-flap. 7
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POLLICl ,,~.AT I.Q.N..~ Fig. 7.--Diagram showing the procedure of choice for thumb reconstruction, according to the amputation level. (Reproduced by courtesy of J. Bone Jt Surg., from Tubiana, Stack, and Hakstian, 1966). 2. When the amputation is at the level of the metacarpophalangeal joint, if the first carpometacarpal joint is mobile, we employ a bonegraft and tube flap with a sensory pedicle. Pollicization is reserved for the following situations : - a. When another partially damaged digit is available. b. For occupations where precision is essential. c. F o r aesthetic reasons, especially in women. 3. When the amputation is close to the first carpometacarpal joint, either major procedure can be used, but pollicization is especially indicated when the joint is stiff and if the thenar muscles have been destroyed. M U T I L A T I O N S O F T H E T H U M B AND FINGERS One must, in these complex cases, be judicious and selectively conservative. The aim is not necessarily the same as in the care of the freshly injured hand when one strives to conserve all
Injury Oct. 1970
remaining fragments. The object is how to improve the nutrition, sensibility, mobility, and orientation of the available elements to restore a useful pinch grip. Reconstructive measures can be discussed under the following headings according to the level of a m p u t a t i o n : - 1. Cases in which some phalanges are present. 2. Cases with no phalanges but with mobile metacarpals which can be used. 3. Amputations through the metacarpals or the carpus. 1. When Some Phalangeal Stumps remain a. It may be possible to create opposition between these by some rotation or angulation osteotomies at the metacarpal bases or by a more or less atypical pollicization, if the state of the stump to be transferred permits this. At least one palmar neurovascular pedicle must be intact. In doubtful cases, a preoperative arteriogram may be helpful. When the opposable elements are of unequal length, one may consider lengthening the shorter segment to allow the digits to meet. Sometimes the first ray can be lengthened by using the metacarpal of an amputated index finger, which also permits the deepening of the cleft. These operations for lengthening are only indicated if the nutrition of the skin is satisfactory, and if the sensation can be preserved or restored on the areas of prehension. N o benefit will accrue from having a fixed element longer than its mobile opposable partner. b. When it is not possible to transfer the remaining elements into an opposable relationship because of poor local conditions, a post can be constructed. The functional result will depend on whether the amputation is predominantly radial or ulnar, the former being the more severe. Sensation can be provided by using a sensory flap, based on one of the neurovascular pedicles of a remaining stump. 2. When the Fingers and the Thumb are grossly amputated but Mobile Metacarpals remain Phalangization of the most mobile metacarpals, the first and the fifth, increases their independence and creates useful new clefts. It is well known that the second and third metacarpals are fixed. They constitute the stable element of the metacarpal arch. The peripheral metacarpals, however, possesses a variable degree of mobility. This is quite considerable for the first metacarpal, which can oppose all other metacarpals, but is much less marked, though
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TUBIANA" TRAUMATIC MUTILATIONS OF THE H A N D
extremely useful, in the fifth metacarpal, which can come forward some 25 ° anterior to the plane of the fixed metacarpals and move across to meet the first metacarpal in opposition. a. Phalangization of the first metacarpal was performed by Huguier as early as 1873. We start with a Z-shaped incision which straddles the web; the anterior arm follows the opposition crease, while the posterior arm must be such that it can be extended up to the first carpometacarpal joint or even further, if required, to free the posterior extrinsic tendons of the thumb as they run in the radial grooves. The adductors of the thumb and the first dorsal interosseus are covered, on their superficial surface, by dorsal and palmar fascia. Each of these sends in a sheet which lines the deep surface of the muscle. These fibrous structures are all liable to retract rapidly following an injury. They must therefore be incised layer by layer. Any significant deepening of the first cleft requires division of the sesamoid tendon of the adductor. This tendon is then reimplanted halfway down the shaft of the first metacarpal. If the muscle is grossly fibrotic, it is preferable to detach most of its attachment and to reinforce its action by means of a powerful tendon transfer. We have used the tendon of flexor pollicis longus or the flexor of an amputated finger for this purpose. The transferred tendon is implanted into the first metacarpal through a small bony tunnel. When the whole muscle is fibrosed, one may have to excise it and establish a useful range of passive mobility of the metacarpal before performing the transfer. One must make sure that the first carpometacarpal joint has preserved sufficient mobility. If the movements are still restricted after a dorsal capsulectomy, an arthroplasty using a silastic implant can be considered. The skin covering will have to take into account the quality of the graft bed and of the adjacent skin. The Z-plasty is often completed by skin-grafts if there is an adequate graft-bed. If not, a flap must be introduced. This can be taken from an adjacent area on the dorsal aspect of the hand if the skin is healthy, or, even better, from the opposite limb, especially if there is a broad area to be covered. The flap must be thin and stripped of its fatty tissue to avoid filling up the newly constructed cleft. Ideally, pressure areas should be covered with sensitive skin. b. We described the technique for phalangization of the fifth metacarpal in 1958 and have applied it many times since. A n incision is made opposite the fourth metacarpal, on both the dorsal and palmar aspects
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of the hand, so as to preserve a sensitive covering on the lateral aspect of the fifth metacarpal, or at least on the extremely of the stump. The incision should be sinuous or angulated to prevent retraction. The dorsal longitudinal veins should be preserved, if possible. On the palmar side, the digital artery and the nerve of the fourth interspace are traced down to the proximal part of the palm. The interglenoid ligament or deep transverse intermetacarpal ligament of the palm is then divided. All hypothenar muscles of carpal origin are preserved. The interspace is split open down to the deep palmar arch and to the deep branch of the ulnar nerve, which is handled with care and preserved. An osteotomy is carried out at the base of the fifth metacarpal through the dorsal incision. The bone is sectioned some 1½ cm. from the carpometacarpal joint. The distal part of the metacarpal is angled forward and laterally. The osteotomy is maintained in position by two Kirschner wires which obviously must not interfere with the movements of the adjacent joint. Finally, a skin-graft, taken from the forearm, is used to cover the lateral side of the cleft. c. Simultaneous phalangization of the first and fifth metacarpals (Fig. 8) is indicated when the thumb and all the fingers are amputated; it may provide a fair degree of useful prehension. The essential element of the pinch is obviously the mobile first metacarpal. If this is stiff or absent, phalangization of the fifth metacarpal alone will be useless. In cases of distal hemi-amputation, resection of the second and fourth metacarpals will deepen the cleft. The third metacarpal is preserved to conserve the insertions of adductor pollicis. Besides, the presence of this third opposition post will lend precision when larger objects are pinched. Very small objects, such as pins and sheets of paper, can be pinched between the phalangized first and fifth metacarpals.
3. Transmetacarpal and Transcarpal Amputations If all mobilization operations at the level of the metacarpals prove impracticable, use of the movements of the wrist can be quite useful. Flexion of the wrist provides a powerful natural hook. The movements of flexion and extension of the wrist can also be used to establish sensory prehension against a prosthetic opposition post. Disarticulation through the carpometacarpal joint can be approached in the same way if active movements of the radiocarpal joint are present. It is useful to fix the flexor and extensor tendons of the wrist distally at the level of the carpus (Swanson, 1964).
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A
C
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B
D
Fig. 8.---Phalangization of the first and fifth metacarpals. A, Amputation of all the fingers and the thumb. B, Simultaneous phalangization of the first and fifth metacarpals, with resection of the second and fourth metacarpals and osteotomy of the fifth metacarpal. C, The distal part of the fifth metacarpal is angled forward and laterally. D, The presence of a third point of contact (the third metacarpal) improves the precision of prehension.
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T U B I A N A : TRAUMATIC MUTILATIONS OF THE H A N D
BILATERAL HAND MUTILATIONS We have had to treat a number of cases of bilateral hand mutations, most of whom came from the Burns Unit at H6pital Cochin. We have also treated bilateral mutilations caused by frost-bite, by explosives, or sustained in industrial and road accidents. Severe bilateral mutilations pose a number of problems which differ from those of unilateral mutilation in their severity and psychological effect on the patient. Bilateral mutilation is obviously a major disaster. It would be an error to think that it is simply twice the disability of a unilateral case. Admittedly, the
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important to restore the patient's independence as soon as possible by operating first on the better side while preparing the other at the same time. 3. Very Severe Bilateral Mutilations One should make use of all remnants to restore bilateral prehension. It is preferable to wait for the functional improvement on the better side before undertaking repair on the other. If only weak pinching with minimal opening of the pincer has been obtained, one will concentrate on restoring powerful grasping on the other side, by converting the hand mutilation into a more
Fig. 9.--Bilateral amputation after an explosion. A Krukenberg operation has been performed on both sides with an excellent functional result.
problems may at first appear to be the same, but they are, in fact, more complex, more varied, and some are altogether new. While in unilateral injuries surgery will aim at restoring a useful instrument intended to be complementary to the other intact limb, in severe bilateral mutilations every effort must be made to restore to the patient the independence he has lost. The therapeutic programme of such severe bilateral mutilations must take into account the age of the patient, his mental state, his occupation, and especially the extent of his lesions. On this last criterion, we can distinguish three groups of mutilations (Tubiana, 1969):-1. Mutilations where One can hope to restore Good Bilateral Manual Prehension In such cases, one of the procedures commonly utilized in the treatment of unilateral mutilation will be employed. 2. Mutilations very Severe on One Side, and more Limited on the Other In such cases one can hope to restore good manual prehension on at least one side. It is
Fig. 10.---The three muscles required for activating the two branches after a Krukenberg operation--the biceps, the supinator, and the pronator teres--have a proximal situation.
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proximal pincer. This can be done by performing a Krukenberg operation which creates a pinch at forearm level by opposing the radius to the ulna. It offers the inestimable advantage of retaining sensation for grasp and appears to be specially indicated in blind patients or in cases of bilateral
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mutilation. This procedure can be performed on both sides (Fig. 9) in cases of bilateral amputation of the hands, but is usually indicated on one side only in cases of severe bilateral mutilations, as it is important to preserve one limb long enough to reach the lumbar, scapular, and buttock regions. Krukenberg's operation can be performed even after amputation halfway up the forearm, as the three muscles required for activating the pincer: the biceps, the supinator, and the pronator teres lie very proximally (Fig. 10). In some cases, we have been forced to perform a very short Krukenberg with arms only 7 cm. long (Fig. 11). F o r social reasons, the rather grotesque appearance of the pincer may be masked by a prosthesis which is itself activated by the pincers of the Krukenberg. PROSTHETIC APPLIANCES FOR MUTILATED HANDS I shall not dwell for long on the question of prosthetic appliances for these hands. Unilateral Mutilation
The patient will use his good hand for work and will hardly utilize his prosthesis, unless it is a partial prosthesis designed to carry out a specific function, leaving the sensory prehensile areas uncovered. Apart from their work, patients tend
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Fig. 11.--Severe burns on both hands and forearms. A useful Krukenberg operation was done on one side, in spite of very short stumps.
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to be more eager now to wear more aesthetic prostheses, such as supple, plastic gloves which are reasonable models of the normal hand (Fig. 12). Severe Bilateral Mutilations Total hand prostheses could in theory spare the patient a long series of operations. But whatever the progress achieved in the field of prosthetics,
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to his view. Two individual factors that will have particular influence on the patient are his intelligence and his determination to overcome his disability. It is vital therefore that the collaboration of the patient be obtained right from the start, that he should be told about the possible lines of treatment and that his own wishes be taken into account. Each result obtained should
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Fig. 12.--Mutilation of right hand on a young woman. A flexible glove prosthesis, now made in silicone, modelled on the normal hand, masks the mutilation (prosthesis made by Dr. Pillet). these prostheses are without sensation. They should not replace surgery when there is a chance of restoring sensory prehension by reconstructive procedures. Judicious splintage, however, may be of great cosmetic, as well as functional value. But one must make sure that prostheses are not prescribed hurriedly, before all surgical possibilities have been explored. This would prevent optimal usage of the remaining stumps and delay the patient's adjustment to his disability. Splintage should not precede surgery; it should complement surgery and improve on its results. We believe that every decision concerning prostheses should be made by the surgeon after discussion with the splintmaker and the patient. From a psychological point of view, it is essential that the patient be allowed to take an active part in his own treatment. The psychological effect of hand mutilations is always an important factor, not only because man is constantly making use of his hands, but also because hands are the only parts of his body which are always exposed
be discussed with him and used as a guide in planning further therapeutic steps. Patients with bilateral mutilations will obviously be the most anxious. But urged as they are by the necessity of having to use their mutilated hands, their functional results can be remarkable, and often proportionally much better than those achieved by others with unilateral injuries. We cannot overstress the fact that restoring a natural grasp, if it is efficient and with sensation, will help the patient enormously to face and to accept his new condition. Quite often we find that the patients themselves request further surgery. It is just such collaboration based on the confidence of these severely disabled people which will, to a large extent, make possible their occupational, psychological, and social readjustment. REFERENCES ADAMSON, J. E., HORTON, C. E., and CRAWFORD, H. H. (1967), 'Sensory Rehabilitation of the Injured Thumb ', Plastic reconstr. Surg., 40, 53.
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~BARRON,J. (1969), personal communication. BRALLIAR,F., and HORNER,R. L. (1969), 'Sensory Cross-finger Graft ', J. Bone Jt Surg., 51A, 1264. BUNNELL, S. (1929), in J. H. BoYES BUNNELL'S Surgery of the Hand, 4th ed. (1964), p. 545. Philadelphia and Montreal: Lippincott. CARCASSONE, F. (1930), ' Contribution a I'l~tude des Restaurations Anatomiques et FonctionneIles du Pouce dans les Traumatismes de la Main ', Ann. Chir., Lyon, Thesis. GAUL, J. S., jun. (1969), ' Radial Innervated Crossfinger flap ', J. Bone Jt Surg., 51A, 1257. GILLIES, Sir H., and MILLARD,D. R. (1957), The Principles and Art of Plastic Surgery. Boston: Little, Brown. GOSSET, J. (1949), ' L a Pollicisation de l'Index (Technique Chirurgicale) ', J. Chit., Paris, 65, 403. - - (1964), ' Technique, Indications et Resultats de la Pollicisation de l'Annulaire ', Mere. Acad. Chir., 150. GUERMONPREZ, F. (1887), Notes sur Quelques Resections et Restaurations du Pouce. Paris: Asselin. HARRISON, S. H. (1964), 'Restoration of Muscle Balance in Pollicization ', Plastic reconstr. Surg., 34, 236. H1LGENFELDT, O. (1950), Operativer Daumenersatz. Stuttgart: Enke. HOLEVlCI-I, J. (1963), ' A New Method for restoring Sensibility to the Thumb ', J. Bone Jt Surg., 45B, 496. HUESTON, J. (1965), ' T h e Extended Neurovascular Island Flap ', Br. J. plast. Surg., 18, 304. HUGmER, P. C. (1873/4), ' Consid&ations Anatomiques et Physiologiques sur le R61e du Pouce et sur la Chirurgie de Cet Organe ', Archs gen. M~d., 22, 404, 567, 692; 23, 54. KALUO, K. E. (1948), ' Recent Advance in Krukenberg's Operation ', Acta chir. scand., 97, 165. LETAC, R. (1954), ' Pollicization of the Ring Finger ', J. int. Coll. Surg., 22, 649. LITTLER, J. W. (1953), ' T h e Neurovascular Pedicle Method of Digital Transposition for Reconstruction of the Thumb ', Plastic reconstr. Surg., 12, 303. - - (1960), ' Neurovascular Skin Island Transfer in Reconstructive Hand Surgery ', Trans. int. Soc. plast. Surg., Second Congress (London, 1959), p. 175. - -
9 0 ,
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LITTLER,J. W. (1966), ' Digital Transposition ', Congr. Soc. int. Chir. orthop. Traumat., p. 828. MATEV, I. (1970), 'Reconstruction of the T h u m b through Gradual Elongation of the Thumb Metacarpal '. Paper given at the annual meeting of the American Society for Surgery of the Hand, Chicago. MICHON, J., and VtLA1N, R. (1968), ' Le Lambeau en Drapeau H6t6ro-digital ', in Chirurgie Plastique Cutande de la Main. Paris: Masson. MOBERG, E. (1955), Discussion of ' T h e Place of Nerve-grafting in Orthopaedic Surgery ', J. Bone Jt Surg., 37A, 305. - - (1969), Discussion o f ' Radial Innervated Crossfinger Flap ', 1bid., 51A, 1268, 1342. MURRAY, A. R. (1946), 'Reconstructive Surgery of the Hand with Special Reference to Digital Transplantation ', Br. J. Surg., 34, 131. NICOLADONI, C. (1900), ' Daumenplastik und Organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplastick) ', Arch. klin. Chir., 61,606. NOESSKE, K. (1909), ' Ueber den Plastichen Ersatz von ganz oder teilweise verlorenen Fingern, insbesondere des Daumens, und tiber Handtellerplastik ', Miinch. med. Wschr., 56, 1403. PULVERTAFT, G. (1966), ' T r a u m a t i c Mutilation of the Hand--Severe Combined Mutilations of the Thumb and Fingers ', Congr. Soc. int. Chir. orthop. Traumat., p. 819. SNELL, J. A. (1969), ' A Further Use for the Neurovascular Island Flap Principles in Hand Surgery-The Piggy-back Flap ', Br. J. plast. Surg., 22, 149. SWANSON, A. B. (1964), ' Levels of Amputations of Fingers and Hand--Considerations for Treatment ', Surg. Clins N. Am., 44, 1115. TUalANA, R. (1958), ' Phalangisation du Cinqui/~me M6tacarpien ', Acta orthop, belg., Suppl. 3, 120. - - (1969), ' Repair of Bilateral Hand Mutilations ', Plastic reconstr. Surg., 44, 323. - - - - and DUPARC, J. (1960), ' Un Proc6d6 Nouveau de Reconstruction d'un Pouce Sensible ', M b n . Acad. Chit., 86, 264. - - - - S T A C K , G., and HAKSTIAN, R. W. (1966), 'Restoration of Prehension after Severe Mutilations of the Hand ', J. Bone Jt Surg., 48B, 455. VERDAN, C. (1968), ' T h e Reconstruction of the Thumb ', Surg. Clins N. Am., 48, 1033. - -
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Reauestsfor reprints shouMbe addressed to:--Dr. R. Tubiana, 47 Quai des Grands Augustins, Paris 6¢me.
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R E C O N S T R U C T I O N AFTER TRAUMATIC MUTILATIONS OF THE HAND* R. T U B I A N A
H@ital Cochin, Paris
TRAUMATIC mutilations of the hand pose a number of problems, and one of the most important is the organization of emergency treatment by a team, of which the members cannot all be specialized hand surgeons. As long as the mutilation is limited to the fingers, the rules to follow are fairly simple: avoid complex emergency plastic procedures; use simple grafts or make do with direct sutures of the stumps without excessive shortening. But, in cases of severe mutilations affecting the thumb or the metacarpal part of the hand (which are often associated with complex crushing wounds), the decisions taken when the patient is first seen will have an undoubted influence on the prognosis. One must make an accurate assessment of the lesion so as to determine : - 1. Which tissues are viable and which are unlikely to survive. 2. What can be sacrificed and what must be preserved. Such an assessment can be difficult, and as Pulvertaft (1966) quite rightly says: ' It is wise in case of doubt to be conservative and preserve viable structures, even though these structures may not in themselves contribute to function. These parts may be of great value during later reconstruction, as a source of skin with sensib i l i t y . . . ' In particular, one must always try to conserve the length and mobility of the peripheral skeletal structures, namely the first and fifth metacarpals which, as we shall see later, are frequently utilized when prehension is to be restored. I will not enlarge on those emergency problems of which the members of the Birmingham Accident Hospital have no doubt a greater experience than anybody else. I shall restrict
* The Ruscoe Clarke Memorial Lecture, delivered at Birmingham on 24 April, 1970.
myself to the late reconstruction of severely mutilated hands. Mutilations may occur at the time of the accident or may develop secondarily after necrosis; we have seen a number of such cases following thermal or electric burns. Traumatic mutilations differ from congenital ones in that scar tissue is present and that the patient is not adapted to his mutilation and will find adaptation the more difficult the older he is. Indeed, the problem of adaptation of the mutilated hand to new forms of prehension is absolutely basic to the present topic. Our duty is to help the patient mechanically by enabling him to perform the usual gripping movements. We all know that prehension is a complex mechanism, involving conscious efforts and automated circuits. Prehension must not be confused with simple gripping, as the hand is constantly adapting itself in terms of the sensory information it receives and of the purpose to be achieved. This capacity for adaptation is affected in the mutilated hand. Depending on the severity of the mutilation, one may be able, at most, to restore precision handling and power-gripping, or perhaps only the more rudimentary actions of the vice, of the pincers, of the hook, of the push-rod, or of the paper-weight. To make precision handling possible, the minimum required is a thumb or a thumb element with as near as possible to normal length and mobility, and a finger against which it can be actively opposed. The presence of a third finger will greatly increase control and precision. It must be remembered that the terminal pinch with marked flexion of the distal interphalangeal joints is used much less frequently than the subterminal hold between the pulps. It is this latter movement which one should try to restore. In power-gripping, however, the hand wraps itself around the object, and this requires mobile
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digital joints. The force of the grip will depend on the width of the palm and the conservation, at least partial, of the peripheral fingers--those on the radial side being more useful for precision, while those on the ulnar side contribute power. If the fingers have been lost, the surviving thumb will make relatively wide and precise gripping possible, provided it is mobile. In the absence of the thumb (Fig. 1), prehension will
Fig. 1.----~ the absence of the thumb, grasp is possible, but without precision.
be restricted to a digital hook, to broad finger-topalm clasping, and to narrow interdigital pinch, all of which are short of precision. When the hand is grossly mutilated and the surviving structures are stiff, only a pincer-action can be restored. This will require two opposing elements: one at least must be mobile and, as far as possible, one must have sensation. We know only too well that painful fingers and fingers deprived of sensation are seldom used. F o r this reason, one should always try to provide a good skin covering and as good a sensation as possible over the prehensile surfaces. One can, in fact, hope to restore some degree of protective sensitivity by resuturing nerves up to 2 or 3 years after the original injury. When this turns out to be impossible, a sensitized skinflap can, if required, be transferred from less
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useful areas by advancement or rotation of adjacent flaps, or a skin transplant with its neurovascular bundle can be borrowed from another finger. The treatment of a mutilated hand must therefore have two objectives : - 1. To restore an organ of sensory information. 2. To restore plasticity to the grip which must adapt itself to objects and to orders from the brain. I shall consider, in increasing orders of severity, mutilitation of the thumb alone, mutilation of the thumb and fingers, and, finally, bilateral mutilations of the hands. MUTILATIONS OF THE THUMB A hand without its thumb loses some 40 per cent of its function. Hence the importance of thumb reconstruction. Indeed, this is one of the topics most commonly discussed at meetings on surgery of the hand. To perform such a reconstruction is a technical and intellectual achievement which usually delights the surgeon. But not uncommonly, the patient is much less satisfied with the functional result than the surgeon. The new thumb has but little mobility or has a wrong orientation; it is painful or without sensation; sometimes there is a loss of power in the hand as a whole. The reason is that too often the technique was inadequate or the operation performed without proper indications. I shall not describe here the numerous reconstructive procedures which have been suggested. But they can be put into three main groups : - 1. Osteoplastic reconstruction where the thumb is constructed by lengthening the skeleton and covered with a skin-flap. 2. Pollicization, using another digit. 3. Transplantation of a toe. (We have no experience of this last procedure which, to us, seems rarely indicated.) Osteoplastie Reconstruction of the Thumb While it appears that Nicoladoni, in 1897, was the first to suggest this procedure, he was himself unable to perform such a reconstruction as his three patients refused to have a bone-graft after the skin-flap (Nicoladoni, 1900). According to Carcassone (1930), Noesske performed the first complete reconstruction in 1908, using an abdominal skin tube and a tibial graft (Noesske, 1909). Of all the procedures for reconstruction of the thumb, this is the least traumatic as far as the rest of the hand is concerned. It does, however, have some serious disadvantages which restrict~ its
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application. This procedure does n o t create a mobile articular structure and there is frequently
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resorption of the bone-graft a n d atrophic skin complications due to a poor vascular and nervesupply. We shall see how these disadvantages can be overcome. Let us start by saying that a newly constructed t h u m b does not have to possess three joints or be of normal length to be useful.
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Fig. 2.---The ' cocked h a t ' procedure of Gillies. Partial reconstruction of the thumb by iliac bone-graft and advancement of a skin-flap raised from the lateral base of the thenar eminence. The skin defect is covered by a skin-graft.
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Fig. 3.--The ' reversed cocked h a t ' procedure of Barron. The skin-flap is advanced from the medial side of the thenar eminence. The first web is deepened• A, Incision in first web space; B, Advancement of the skin-flap from the medial side; C, Final postoperative result.
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It must, however, be stable, painless, and capable of opposing the other digits, and its prehensile surface must have sensation. Depending on the length of the stump and the state of the scars, two types of osteoplastic procedures will be chosen: some use local flaps, others borrow ~f flap from some distant donor area. The advantage of the first procedure is that it can be completed in one operating session. The skeletal lengthening is usually achieved by means of a short graft (no more than 1½cm.) but occasionally by oblique osteotomy with continuous traction on the first metacarpal (Matev, 1970). The skin may be borrowed from one of several neighbouring areas : - a. F r o m flaps on the medial or lateral aspect of the base of the thumb, which are advanced en masse by the ' cocked h a t ' procedure of Gillies (1957), or the 'reversed cocked h a t ' technique of Barron (1969), which deepens the first web space (Figs. 2, 3). b. F r o m flaps from the skin of the dorsal aspect of the proximal phalanx of the index (which is supplied by sensory fibres of the radial nerve), using one of a number of techniques (Hilgenfeldt, 1959; Holevich, 1963; Gaul, 1969; Adamson, Horton, and Crawford, 1967; Bralliar and Homer, 1969; Michon and Vilain, 1969). However, the notoriously variable territory of distribution of the terminal branches of the radial nerve makes the result unpredictable. Moberg (1969) has suggested that the territory of supply of the radial nerve be assessed preoperatively by locally anaesthetizing the medial nerve. Tissue must never be taken from the radial aspect of the index, as this is one of the most commonly used prehensile surfaces, especially in median nerve lesions. It is sometimes better to combine these limited local procedures with phalangization of the first metacarpal which produces a relative lengthening of the thumb by deepening the first web space. When the thumb is to be lengthened by more than 2 cm., distant flaps, usually tubular, must be introduced. Since 1959, we have been using a procedure enabling us to construct new thumbs with both a good circulation and a sensory nerve supply. Its originality lies in the combination of a bone-graft within a tubular flap and the addition of a neurovascular skin island transfer (Tubiana and Duparc, 1960) (Fig. 4). The procedure requires several stages : - -
1. Implantation o f the Skin Tube The skin tube is taken from an area where skin is supple and the subcutaneous fat is scanty,
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otherwise the pedicle tends to slip over the bone, producing an unstable grip. The contralateral subclavicular area is usually chosen in a man; in a woman, for cosmetic reasons, the tube is taken from the submammary crease or from the medial aspect of the arm. The abdomen is also a potential donor site. The flap, if not too long, can be implanted directly on the thenar eminence; it is safer otherwise to perform the fixation at a second stage. The suture line of the tube on to the thenar eminence should not be circular but elliptical or zig-zag, in order to have a longer junction zone and to avoid scar contraction. One must also make sure that the longitudinal suture of the tube is on the palmar side.
2. Separation of the Tube This stage is carried out 3 weeks after the first. If the sensitive flap is introduced at this stage it will improve the circulation of the tube. We prefer, however, to do this at a later stage, at the same time as the bone-graft, to avoid disturbing the delicate pedicle and to provide further skin covering, which is sometimes useful. 3. Insertion of the Bone-graft and Introduction of the Sensitive Skin lsland Transplant We like to use a graft from the iliac crest which is inserted deep into the medullary canal of the first metacarpal. Fixation may be by a transfixion wire. The direction and length of the graft will be adapted to each case. It is better that prehension should be subterminal and between pulps rather than terminal. The bone-graft should be palette-shaped, have a fiat, relatively broad prehensile surface, and not have a sharp extremity bent in towards the palm. The sensitive skin transplant embodies the general technique of heterodigital neurovascular island transfer, as developed by Moberg (1955) and Littler (1960), but applies it further to a particular situation. The transplant should be as wide as possible in order to restore sensation to a large surface on the thumb. We usually take half the palmar surfaces of the two distal phalanges. Hueston (1965) even takes the territory of supply of the dorsal branches of the digital nerve, and thus obtains transplants 6 cm. long and more than 2 cm. wide. The donor site should be selected so that there is a minimum of inconvenience. We like to use the medial surface of the middle finger, not only because it provides a broader flap and is but little used in prehension, but also because, like the thumb, it is supplied by the median nerve, which might facilitate integration.
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TUBIANA: TRAUMATICMUTILATIONSOF THE HAND
If the middle finger is not available, we use the medial surface of the ring finger or some other sensitive area, while avoiding the anterolateral surface of the index. The sensitive flap is transferred on to the palmar and medial aspect of the neo-thumb along the line of closure of the tube in the optimal prehensile zone, extending if possible over the tip. This additional skin makes it easier to close the tube after inclusion of the bone-graft. To lessen the tendency for the flap to slip on the surface of the underlying bone-graft, a few sutures are used to fix its deep aspect to the margins of the bone peg.
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although two-point discrimination (Weber's test) is invariably less than on the normal thumb.
Results As it is a non-articulated structure, the reconstructed thumb ideally should be shorter than a normal thumb, but the degree of mobility of the opposable fingers should be taken into consideration, and the length of the new thumb designed accordingly. For cosmetic and functional reasons, it should not be too fat. The sensation on the reconstructed thumb should be carefully analysed. Over the skin transplant, the sensory acuity is close to normal,
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Fig. 4.--Reconstruction of the thumb by a tubed flap, a bone-graft, and a neurovascular skin island transferred from the medial surface of the middle finger.
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At first, sensation is referred to the donor finger; then, over a variable period of time, the ' p h e n o m e n o n of double sensation' develops, whereby perception of the thumb is superimposed on sensation of the donor finger. Objective examination reveals errors of perception between the thumb and donor finger, but in the course of normal activity the more the patient uses the thumb the fewer mistakes he is likely to
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after a traumatic amputation of the thumb, but shall just point out some aspects of the technique. The transfer of a finger as an ' island ' with the neurovascular pedicles described by Littler (1953) has simplified and improved the technique. Any finger can be transferred to replace the thumb. We shall discuss the advantages of using each particular finger, but first, we shall state the principles which are valid for every pollicization : the pollicized finger must be provided with a good web and must have an adequate bloodsupply, sensation, length, and mobility.
1. The Incision The incision runs across the base of the transferred finger anteriorly, and a long V-shaped tongue of skin is preserved on the dorsum of the finger. The flap for the cleft is usually based anteriorly (Fig. 5). This is sometimes made difficult when traumatic mutilation has left extensive scars and a destroyed web. It becomes necessary in such cases to provide supplementary skin cover before the pollicization proper. This will usually come from a distant flap, the position of which will have to be carefully worked out (Fig. 6). Fig. 5.--Pollicization of the index finger. On the dorsum of the hand, this photograph shows the V-shaped flap at the base of the index and the dorsal flap for the cleft. The incision runs across the base of the index anteriorly. make. Integration comes earlier in the young, active patient; it does not occur, however, if for some local reason such as pain or instability, or for psychological reasons, the patient does not use his thumb. These neurovascular skin transplants should only be performed in painless hands and in active and preferably young patients. By this procedure, the newly constructed thumb is provided not only with sensation but also with a significant blood-supply, so that the new thumb has a normal colour, the bone-graft consolidates rapidly, and resorption phenomena are markedly reduced. Pollicization
Like osteoplastic procedures, pollicization has undergone successive improvements. Since Guermonprez, o f Lille, who described this operation in 1887, a number of names have been associated with this procedure, including Bunnell (1929), Murray (1946), Gosset (1949), Hilgenfeldt (1950), and Littler (1953). I cannot discuss here all the problems in relation to pollicization
2. Vascular Supply It is obviously preferable that the transferred finger should have a normal vascular bundle, but we have succeeded in pollicizing fingers in which one collateral artery had been destroyed. An arteriogram is sometimes helpful when assessing preoperatively the possibility of transferring a previously injured finger. When the circulation is poor, one can transfer a skin island with its neurovascular bundle over to a finger which will be pollicized later (Snell, 1969). The venous return occurs along the small deep veins which accompany the palmar arteries. Ideally, one should preserve one or two dorsal veins, although this is only feasible when the index finger is pollicized. 3. Sensibility The pollicized finger must have sensation and be painless. A tender neuroma, whether on the transferable finger or on the thumb remnant, must be dealt with before pollicization. We must stress that the transplanted finger is not perceived by the patient as a thumb; it retains its original identity. As in the case with heterodigital sensory island transfers, a certain difficulty in perception results which requires reorientation by the patient. Proprioception is improved if the flexor pollicis longus is inserted into the flexor profundus of the transferred finger (Hilgenfeldt, 1950).
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TUBIANA: TRAUMATIC MUTILATIONS OF THE HAND
t :.
\
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/
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A
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Fig. 6.--In case of extensive scars, an abdominal tube flap is brought before pollicization to provide supplementary skin covering. A, Preoperative total loss of thumb with severe scarring of the aspect of the hand; B, Abdominal tube flap, attached both dorsally and volarly about the base index finger; C, The tube flap is divided at its middle portion; the index finger is pollicized; D, The half of the tube flap is used for dorsal skin coverage, while the anterior half forms the volar aspect newly created web space; E, Final postoperative result.
lateral of the dorsal of the
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4. Length The tip of a normal thumb reaches to just short of the proximal interphalangeal joint of the index finger. A reconstructed thumb should be as near to this length as possible; but it must not be any longer nor have any more phalanges than the normal thumb. The length of the transfer will depend on the site of the mutilation, the adjustment of length during reconstruction being made at the proximal end. If an intact finger is transferred, the proximal phalanx will become the first metacarpal; this allows retention of the distal phalanx with the flexor profundus insertion and the nail, which improves the appearance and makes finger-nail pinch possible. The proximal interphalangeal joint of the finger will become the metacarpophalangeal joint of the new thumb, the distal interphalangeal joint the interphalangeal, and, if necessary, the metacarpophalangeal can be transferred as a carpometacarpal joint.
5. Positioning The reconstructed thumb must be fixed in position after rotation through about 120 ° so that the pulp does not face anteriorly but inwards, towards the palm. Bony fixation and control of rotation are effected by the use of Kirschner wires.
6. Stability and Mobility The transferred finger must have stable joints, and at least some of them must be mobile. G o o d movement in the distal joints is all the more important if the first carpometacarpal joint has a limited range and vice versa. It is well known that stability in a proximal joint is necessary for motion in a more distal joint, and for this reason the principal stabilizing muscles must be carefully retained or reattached: abductor pollicis longus for the first carpometacarpal joint, and the aponeurotic insertion of the intrinsic muscles for the metacarpophalangeal joint. It is essential to reconstitute the musculature of the thumb, not only the long muscles, but also the intrinsic muscles. A different scheme for reactivation of the thumb may be required for each case. Extension, flexion, abduction, adduction, and opposition of the reconstructed thumb must all be considered. It is inadequate simply to attach a thumb extensor to the finger extensor: an extension deficit will occur and persist. One must also supply motor power to the intrinsic muscle insertions of the transferred finger by attaching those thenar muscles that are present. The
Injury Oct. 1970
adductor pollicis is attached to the palmar interosseus and abductor pollicis brevis to the dorsal interosseus. If all the thenar muscles have been destroyed, each of the two lateral bands of the extensor communis tendons are attached to an interosseus, the first palmar interosseous becoming an adductor of the new thumb and the first dorsal interosseous an abductor pollicis brevis. The distal part of the extensor communis of the transferred finger is attached to the extensor pollicis longus; the proximal part is, if necessary, fixed to the lateral part of the base of the first phalanx, which is now the first metacarpal to replace the abductor pollicis longus. It is often necessary to counteract the natural tendency to adduction of the pollicized finger. This may be difficult in those cases, seen relatively often, in which the lateral units of the thenar eminence have been destroyed. One must therefore restore abduction and rotation. One of the long extensor tendons of the index finger can be employed, as Harrison (1964) proposed, to restore opposition; for this, the tendon is divided proximally, re-routed, and sutured to the existing flexor pollicis longus muscle. Other tendon transfers are possible, such as that of abductor digiti minimi, which has the advantage of providing a good thenar contour as well as motor power. Flexion is provided by the long flexor tendons transferred with the finger. It is usually sufficient after pollicization of partially amputated fingers. The muscles adjust and will compensate for moderate shortening. In cases where utilization of the proximal phalanx as the metacarpal results in marked shortening of the transferred finger (this may be up to 5 cm. in the adult), it may later be necessary, in a few cases, to adjust the length of the flexor tendons. In the forearm, the flexor profundus tendon is divided and resutured, preferably to the flexor pollicis at its musculotendinous junction; but first it must be pulled into the palm, and passed through the carpal tunnel in the space of the flexor pollicis tendon (Littler, 1966). Flexor sublimis which is independent, adjusts more readily, but it may also have to be shortened in the forearm at a later stage.
Choice of Transfer It is important that the use of a finger to replace the thumb should not create a significant deficit in the hand, nor seriously alter its architecture. If the index finger is used, the dorsal veins can be preserved and the ncurovas~ular
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TUBIANA~ TRAUMATIC MUTILATIONS OF THE H A N D
pedicles shifted without the problem of angulation or crossing. Besides, the architecture of the hand is minimally upset by the displacement of this peripheral finger. The web is created with the help of a dorsal flap, but it is deeper than normal because the finger has been moved proximally. A pollicized index provides two long extensors, and both of them are extremely useful for reconstructing the musculature. The middle finger was preferred by Hilgenfeldt (1950) because it is larger and less important than the index. However, the displacement of this central digit affects the strength and stability of the hand. In resecting the head of the third metacarpal, there is a risk of producing rotation and overriding of the adjacent fingers, and an unattractive hand posture. When the middle finger is used in pollicization, the index ray should ideally be transferred to the third metacarpal. The ring finger was recommended by Letac, (1954) and is the present choice of Gosset (1964) and many others, because it is of little importance for hand function. It certainly constitutes, with the index, the best finger to be transferred. It is distant enough for satisfactory tension to be re-established in the flexors after transfer. The architecture of the hand is upset less by using the ring finger than by using the middle finger because the mobile fourth and fifth basal metacarpal joints allow the little finger to approximate to the rest of the hand. The little finger can be used, but it is really too slender to make a good thumb, and contrary to general opinion, this finger is far from being unimportant. Its removal reduces the stability of palmar grip. In spite of the good results obtained by pollicization, now that the technique is well established, we are reluctant to move an intact finger after a traumatic thumb amputation, when another method of reconstruction is available. When possible, we use a finger which has been damaged. These shortened or slightly stiffened fingers that are of little intrinsic value, especially when the thumb is absent, may gain considerably in importance when transferred. A thumb of adequate length is obtained if a remaining metacarpal is used, and even though there may be a cosmetic loss from lack of a nail, the functional value is great.
Indications for Operation The decision to operate and the choice of operative procedure are almost as important as the technique, when one is faced with an amputation of the thumb. A patient may be quite
13;5
adjusted to a partial amputation of the thumb, especially if it is on the non-dominant side and if the lesion is long-standing. Many reconstructed thumbs are not used by the patient. A major reconstructive procedure, such as pollicization or a tube flap with bone-graft and sensory island demands some technical experience. 'Unfortunately ', as Littler (1966) said about pollicization, 'fascination with this procedure on the part of the inexperienced surgeon has left a wake of meager results that have somewhat stigmatized the operation's potential contribution '. It may be as well to recall Hueston's (1965) aphorism that ' the most difficult thing about pollicization is to resist the temptation to do it '. Each case of thumb restoration poses particular problems. Factors that must be considered are : - 1. The level of amputation and the usefulness of the stump. 2. The condition of the remaining fingers, of the hand as a whole, and of the other hand. 3. The age of the patient, his occupation and his psychological condition. One must know that a good result after any procedure can only be expected if the hand is painless and the patient intelligent and active. The operative indications are governed also by the advantages and disadvantages of the various procedures at our disposal. Pollicization has the advantage of being usually completed in one stage. A mobile thumb with sensibility is provided, but there is the disadvantage that one of the remaining fingers is removed. Admittedly, pollicization of a finger does not in itself produce a deficit, as it redistributes the existing fingers in such a way as to improve their usefulness. This is true when the thumb is amputated together with its metacarpal, but, as Verdan (1968) pointed out, it does not apply when the first metacarpal remains; in these cases, phalangization of an intact finger will at most provide only two more phalanges to an existing unit while it suppresses a whole digit. A tube flap with bone-graft and sensory island flap allows one to retain all the fingers, but several operative stages are usually required, and a mobile joint is not provided. Osteoplasty, using a local skin-flap, provides an expedient solution but achieves only limited lengthening. It can be performed only if the remaining bone stump is of sufficient length, and if healthy covering tissue is locally available. As a guide the following levels are considered (Fig. 7):
1. When a sufficiently longfragment of proximal phalanx remains, it is unnecessary to have recourse to a major procedure.
It suffices simply to
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phalangize the first metacarpal, or, if the neighbouring soft tissues are of good quality, a short osteoplasty can be carried out, covered by a local skin-flap. 7
PHALANGISATION //~ L
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POLLICl ,,~.AT I.Q.N..~ Fig. 7.--Diagram showing the procedure of choice for thumb reconstruction, according to the amputation level. (Reproduced by courtesy of J. Bone Jt Surg., from Tubiana, Stack, and Hakstian, 1966). 2. When the amputation is at the level of the metacarpophalangeal joint, if the first carpometacarpal joint is mobile, we employ a bonegraft and tube flap with a sensory pedicle. Pollicization is reserved for the following situations : - a. When another partially damaged digit is available. b. For occupations where precision is essential. c. F o r aesthetic reasons, especially in women. 3. When the amputation is close to the first carpometacarpal joint, either major procedure can be used, but pollicization is especially indicated when the joint is stiff and if the thenar muscles have been destroyed. M U T I L A T I O N S O F T H E T H U M B AND FINGERS One must, in these complex cases, be judicious and selectively conservative. The aim is not necessarily the same as in the care of the freshly injured hand when one strives to conserve all
Injury Oct. 1970
remaining fragments. The object is how to improve the nutrition, sensibility, mobility, and orientation of the available elements to restore a useful pinch grip. Reconstructive measures can be discussed under the following headings according to the level of a m p u t a t i o n : - 1. Cases in which some phalanges are present. 2. Cases with no phalanges but with mobile metacarpals which can be used. 3. Amputations through the metacarpals or the carpus. 1. When Some Phalangeal Stumps remain a. It may be possible to create opposition between these by some rotation or angulation osteotomies at the metacarpal bases or by a more or less atypical pollicization, if the state of the stump to be transferred permits this. At least one palmar neurovascular pedicle must be intact. In doubtful cases, a preoperative arteriogram may be helpful. When the opposable elements are of unequal length, one may consider lengthening the shorter segment to allow the digits to meet. Sometimes the first ray can be lengthened by using the metacarpal of an amputated index finger, which also permits the deepening of the cleft. These operations for lengthening are only indicated if the nutrition of the skin is satisfactory, and if the sensation can be preserved or restored on the areas of prehension. N o benefit will accrue from having a fixed element longer than its mobile opposable partner. b. When it is not possible to transfer the remaining elements into an opposable relationship because of poor local conditions, a post can be constructed. The functional result will depend on whether the amputation is predominantly radial or ulnar, the former being the more severe. Sensation can be provided by using a sensory flap, based on one of the neurovascular pedicles of a remaining stump. 2. When the Fingers and the Thumb are grossly amputated but Mobile Metacarpals remain Phalangization of the most mobile metacarpals, the first and the fifth, increases their independence and creates useful new clefts. It is well known that the second and third metacarpals are fixed. They constitute the stable element of the metacarpal arch. The peripheral metacarpals, however, possesses a variable degree of mobility. This is quite considerable for the first metacarpal, which can oppose all other metacarpals, but is much less marked, though
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TUBIANA" TRAUMATIC MUTILATIONS OF THE H A N D
extremely useful, in the fifth metacarpal, which can come forward some 25 ° anterior to the plane of the fixed metacarpals and move across to meet the first metacarpal in opposition. a. Phalangization of the first metacarpal was performed by Huguier as early as 1873. We start with a Z-shaped incision which straddles the web; the anterior arm follows the opposition crease, while the posterior arm must be such that it can be extended up to the first carpometacarpal joint or even further, if required, to free the posterior extrinsic tendons of the thumb as they run in the radial grooves. The adductors of the thumb and the first dorsal interosseus are covered, on their superficial surface, by dorsal and palmar fascia. Each of these sends in a sheet which lines the deep surface of the muscle. These fibrous structures are all liable to retract rapidly following an injury. They must therefore be incised layer by layer. Any significant deepening of the first cleft requires division of the sesamoid tendon of the adductor. This tendon is then reimplanted halfway down the shaft of the first metacarpal. If the muscle is grossly fibrotic, it is preferable to detach most of its attachment and to reinforce its action by means of a powerful tendon transfer. We have used the tendon of flexor pollicis longus or the flexor of an amputated finger for this purpose. The transferred tendon is implanted into the first metacarpal through a small bony tunnel. When the whole muscle is fibrosed, one may have to excise it and establish a useful range of passive mobility of the metacarpal before performing the transfer. One must make sure that the first carpometacarpal joint has preserved sufficient mobility. If the movements are still restricted after a dorsal capsulectomy, an arthroplasty using a silastic implant can be considered. The skin covering will have to take into account the quality of the graft bed and of the adjacent skin. The Z-plasty is often completed by skin-grafts if there is an adequate graft-bed. If not, a flap must be introduced. This can be taken from an adjacent area on the dorsal aspect of the hand if the skin is healthy, or, even better, from the opposite limb, especially if there is a broad area to be covered. The flap must be thin and stripped of its fatty tissue to avoid filling up the newly constructed cleft. Ideally, pressure areas should be covered with sensitive skin. b. We described the technique for phalangization of the fifth metacarpal in 1958 and have applied it many times since. A n incision is made opposite the fourth metacarpal, on both the dorsal and palmar aspects
137
of the hand, so as to preserve a sensitive covering on the lateral aspect of the fifth metacarpal, or at least on the extremely of the stump. The incision should be sinuous or angulated to prevent retraction. The dorsal longitudinal veins should be preserved, if possible. On the palmar side, the digital artery and the nerve of the fourth interspace are traced down to the proximal part of the palm. The interglenoid ligament or deep transverse intermetacarpal ligament of the palm is then divided. All hypothenar muscles of carpal origin are preserved. The interspace is split open down to the deep palmar arch and to the deep branch of the ulnar nerve, which is handled with care and preserved. An osteotomy is carried out at the base of the fifth metacarpal through the dorsal incision. The bone is sectioned some 1½ cm. from the carpometacarpal joint. The distal part of the metacarpal is angled forward and laterally. The osteotomy is maintained in position by two Kirschner wires which obviously must not interfere with the movements of the adjacent joint. Finally, a skin-graft, taken from the forearm, is used to cover the lateral side of the cleft. c. Simultaneous phalangization of the first and fifth metacarpals (Fig. 8) is indicated when the thumb and all the fingers are amputated; it may provide a fair degree of useful prehension. The essential element of the pinch is obviously the mobile first metacarpal. If this is stiff or absent, phalangization of the fifth metacarpal alone will be useless. In cases of distal hemi-amputation, resection of the second and fourth metacarpals will deepen the cleft. The third metacarpal is preserved to conserve the insertions of adductor pollicis. Besides, the presence of this third opposition post will lend precision when larger objects are pinched. Very small objects, such as pins and sheets of paper, can be pinched between the phalangized first and fifth metacarpals.
3. Transmetacarpal and Transcarpal Amputations If all mobilization operations at the level of the metacarpals prove impracticable, use of the movements of the wrist can be quite useful. Flexion of the wrist provides a powerful natural hook. The movements of flexion and extension of the wrist can also be used to establish sensory prehension against a prosthetic opposition post. Disarticulation through the carpometacarpal joint can be approached in the same way if active movements of the radiocarpal joint are present. It is useful to fix the flexor and extensor tendons of the wrist distally at the level of the carpus (Swanson, 1964).
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A
C
Injury Oct. 1970
B
D
Fig. 8.---Phalangization of the first and fifth metacarpals. A, Amputation of all the fingers and the thumb. B, Simultaneous phalangization of the first and fifth metacarpals, with resection of the second and fourth metacarpals and osteotomy of the fifth metacarpal. C, The distal part of the fifth metacarpal is angled forward and laterally. D, The presence of a third point of contact (the third metacarpal) improves the precision of prehension.
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T U B I A N A : TRAUMATIC MUTILATIONS OF THE H A N D
BILATERAL HAND MUTILATIONS We have had to treat a number of cases of bilateral hand mutations, most of whom came from the Burns Unit at H6pital Cochin. We have also treated bilateral mutilations caused by frost-bite, by explosives, or sustained in industrial and road accidents. Severe bilateral mutilations pose a number of problems which differ from those of unilateral mutilation in their severity and psychological effect on the patient. Bilateral mutilation is obviously a major disaster. It would be an error to think that it is simply twice the disability of a unilateral case. Admittedly, the
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important to restore the patient's independence as soon as possible by operating first on the better side while preparing the other at the same time. 3. Very Severe Bilateral Mutilations One should make use of all remnants to restore bilateral prehension. It is preferable to wait for the functional improvement on the better side before undertaking repair on the other. If only weak pinching with minimal opening of the pincer has been obtained, one will concentrate on restoring powerful grasping on the other side, by converting the hand mutilation into a more
Fig. 9.--Bilateral amputation after an explosion. A Krukenberg operation has been performed on both sides with an excellent functional result.
problems may at first appear to be the same, but they are, in fact, more complex, more varied, and some are altogether new. While in unilateral injuries surgery will aim at restoring a useful instrument intended to be complementary to the other intact limb, in severe bilateral mutilations every effort must be made to restore to the patient the independence he has lost. The therapeutic programme of such severe bilateral mutilations must take into account the age of the patient, his mental state, his occupation, and especially the extent of his lesions. On this last criterion, we can distinguish three groups of mutilations (Tubiana, 1969):-1. Mutilations where One can hope to restore Good Bilateral Manual Prehension In such cases, one of the procedures commonly utilized in the treatment of unilateral mutilation will be employed. 2. Mutilations very Severe on One Side, and more Limited on the Other In such cases one can hope to restore good manual prehension on at least one side. It is
Fig. 10.---The three muscles required for activating the two branches after a Krukenberg operation--the biceps, the supinator, and the pronator teres--have a proximal situation.
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proximal pincer. This can be done by performing a Krukenberg operation which creates a pinch at forearm level by opposing the radius to the ulna. It offers the inestimable advantage of retaining sensation for grasp and appears to be specially indicated in blind patients or in cases of bilateral
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mutilation. This procedure can be performed on both sides (Fig. 9) in cases of bilateral amputation of the hands, but is usually indicated on one side only in cases of severe bilateral mutilations, as it is important to preserve one limb long enough to reach the lumbar, scapular, and buttock regions. Krukenberg's operation can be performed even after amputation halfway up the forearm, as the three muscles required for activating the pincer: the biceps, the supinator, and the pronator teres lie very proximally (Fig. 10). In some cases, we have been forced to perform a very short Krukenberg with arms only 7 cm. long (Fig. 11). F o r social reasons, the rather grotesque appearance of the pincer may be masked by a prosthesis which is itself activated by the pincers of the Krukenberg. PROSTHETIC APPLIANCES FOR MUTILATED HANDS I shall not dwell for long on the question of prosthetic appliances for these hands. Unilateral Mutilation
The patient will use his good hand for work and will hardly utilize his prosthesis, unless it is a partial prosthesis designed to carry out a specific function, leaving the sensory prehensile areas uncovered. Apart from their work, patients tend
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Fig. 11.--Severe burns on both hands and forearms. A useful Krukenberg operation was done on one side, in spite of very short stumps.
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TUBIANA:
TRAUMATIC
MUTILATIONS
to be more eager now to wear more aesthetic prostheses, such as supple, plastic gloves which are reasonable models of the normal hand (Fig. 12). Severe Bilateral Mutilations Total hand prostheses could in theory spare the patient a long series of operations. But whatever the progress achieved in the field of prosthetics,
• -.,
.
OF THE HAND
141
to his view. Two individual factors that will have particular influence on the patient are his intelligence and his determination to overcome his disability. It is vital therefore that the collaboration of the patient be obtained right from the start, that he should be told about the possible lines of treatment and that his own wishes be taken into account. Each result obtained should
v
Fig. 12.--Mutilation of right hand on a young woman. A flexible glove prosthesis, now made in silicone, modelled on the normal hand, masks the mutilation (prosthesis made by Dr. Pillet). these prostheses are without sensation. They should not replace surgery when there is a chance of restoring sensory prehension by reconstructive procedures. Judicious splintage, however, may be of great cosmetic, as well as functional value. But one must make sure that prostheses are not prescribed hurriedly, before all surgical possibilities have been explored. This would prevent optimal usage of the remaining stumps and delay the patient's adjustment to his disability. Splintage should not precede surgery; it should complement surgery and improve on its results. We believe that every decision concerning prostheses should be made by the surgeon after discussion with the splintmaker and the patient. From a psychological point of view, it is essential that the patient be allowed to take an active part in his own treatment. The psychological effect of hand mutilations is always an important factor, not only because man is constantly making use of his hands, but also because hands are the only parts of his body which are always exposed
be discussed with him and used as a guide in planning further therapeutic steps. Patients with bilateral mutilations will obviously be the most anxious. But urged as they are by the necessity of having to use their mutilated hands, their functional results can be remarkable, and often proportionally much better than those achieved by others with unilateral injuries. We cannot overstress the fact that restoring a natural grasp, if it is efficient and with sensation, will help the patient enormously to face and to accept his new condition. Quite often we find that the patients themselves request further surgery. It is just such collaboration based on the confidence of these severely disabled people which will, to a large extent, make possible their occupational, psychological, and social readjustment. REFERENCES ADAMSON, J. E., HORTON, C. E., and CRAWFORD, H. H. (1967), 'Sensory Rehabilitation of the Injured Thumb ', Plastic reconstr. Surg., 40, 53.
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~BARRON,J. (1969), personal communication. BRALLIAR,F., and HORNER,R. L. (1969), 'Sensory Cross-finger Graft ', J. Bone Jt Surg., 51A, 1264. BUNNELL, S. (1929), in J. H. BoYES BUNNELL'S Surgery of the Hand, 4th ed. (1964), p. 545. Philadelphia and Montreal: Lippincott. CARCASSONE, F. (1930), ' Contribution a I'l~tude des Restaurations Anatomiques et FonctionneIles du Pouce dans les Traumatismes de la Main ', Ann. Chir., Lyon, Thesis. GAUL, J. S., jun. (1969), ' Radial Innervated Crossfinger flap ', J. Bone Jt Surg., 51A, 1257. GILLIES, Sir H., and MILLARD,D. R. (1957), The Principles and Art of Plastic Surgery. Boston: Little, Brown. GOSSET, J. (1949), ' L a Pollicisation de l'Index (Technique Chirurgicale) ', J. Chit., Paris, 65, 403. - - (1964), ' Technique, Indications et Resultats de la Pollicisation de l'Annulaire ', Mere. Acad. Chir., 150. GUERMONPREZ, F. (1887), Notes sur Quelques Resections et Restaurations du Pouce. Paris: Asselin. HARRISON, S. H. (1964), 'Restoration of Muscle Balance in Pollicization ', Plastic reconstr. Surg., 34, 236. H1LGENFELDT, O. (1950), Operativer Daumenersatz. Stuttgart: Enke. HOLEVlCI-I, J. (1963), ' A New Method for restoring Sensibility to the Thumb ', J. Bone Jt Surg., 45B, 496. HUESTON, J. (1965), ' T h e Extended Neurovascular Island Flap ', Br. J. plast. Surg., 18, 304. HUGmER, P. C. (1873/4), ' Consid&ations Anatomiques et Physiologiques sur le R61e du Pouce et sur la Chirurgie de Cet Organe ', Archs gen. M~d., 22, 404, 567, 692; 23, 54. KALUO, K. E. (1948), ' Recent Advance in Krukenberg's Operation ', Acta chir. scand., 97, 165. LETAC, R. (1954), ' Pollicization of the Ring Finger ', J. int. Coll. Surg., 22, 649. LITTLER, J. W. (1953), ' T h e Neurovascular Pedicle Method of Digital Transposition for Reconstruction of the Thumb ', Plastic reconstr. Surg., 12, 303. - - (1960), ' Neurovascular Skin Island Transfer in Reconstructive Hand Surgery ', Trans. int. Soc. plast. Surg., Second Congress (London, 1959), p. 175. - -
9 0 ,
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Injury Oct. 1970
LITTLER,J. W. (1966), ' Digital Transposition ', Congr. Soc. int. Chir. orthop. Traumat., p. 828. MATEV, I. (1970), 'Reconstruction of the T h u m b through Gradual Elongation of the Thumb Metacarpal '. Paper given at the annual meeting of the American Society for Surgery of the Hand, Chicago. MICHON, J., and VtLA1N, R. (1968), ' Le Lambeau en Drapeau H6t6ro-digital ', in Chirurgie Plastique Cutande de la Main. Paris: Masson. MOBERG, E. (1955), Discussion of ' T h e Place of Nerve-grafting in Orthopaedic Surgery ', J. Bone Jt Surg., 37A, 305. - - (1969), Discussion o f ' Radial Innervated Crossfinger Flap ', 1bid., 51A, 1268, 1342. MURRAY, A. R. (1946), 'Reconstructive Surgery of the Hand with Special Reference to Digital Transplantation ', Br. J. Surg., 34, 131. NICOLADONI, C. (1900), ' Daumenplastik und Organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplastick) ', Arch. klin. Chir., 61,606. NOESSKE, K. (1909), ' Ueber den Plastichen Ersatz von ganz oder teilweise verlorenen Fingern, insbesondere des Daumens, und tiber Handtellerplastik ', Miinch. med. Wschr., 56, 1403. PULVERTAFT, G. (1966), ' T r a u m a t i c Mutilation of the Hand--Severe Combined Mutilations of the Thumb and Fingers ', Congr. Soc. int. Chir. orthop. Traumat., p. 819. SNELL, J. A. (1969), ' A Further Use for the Neurovascular Island Flap Principles in Hand Surgery-The Piggy-back Flap ', Br. J. plast. Surg., 22, 149. SWANSON, A. B. (1964), ' Levels of Amputations of Fingers and Hand--Considerations for Treatment ', Surg. Clins N. Am., 44, 1115. TUalANA, R. (1958), ' Phalangisation du Cinqui/~me M6tacarpien ', Acta orthop, belg., Suppl. 3, 120. - - (1969), ' Repair of Bilateral Hand Mutilations ', Plastic reconstr. Surg., 44, 323. - - - - and DUPARC, J. (1960), ' Un Proc6d6 Nouveau de Reconstruction d'un Pouce Sensible ', M b n . Acad. Chit., 86, 264. - - - - S T A C K , G., and HAKSTIAN, R. W. (1966), 'Restoration of Prehension after Severe Mutilations of the Hand ', J. Bone Jt Surg., 48B, 455. VERDAN, C. (1968), ' T h e Reconstruction of the Thumb ', Surg. Clins N. Am., 48, 1033. - -
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