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Callus distraction in the hand skeleton
Injury, Int. J. Care Injured 31 (2000) 113±120
www.elsevier.com/locate/injury
Callus distraction in the hand skeleton K.-D. Rudolf*, P. Preisser, B.-D. Partecke Department of Handsurgery, Plastic- and Microsurgery, Burns Unit, Berufsgenossenschaftliches Unfallkrankenhaus, Bergedorfer Straûe 10, D-21033 Hamburg, Germany
Abstract From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and ®ngers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and ®ngers is a feasible operative technique leading to a promising improvement of function. # 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Continuous callus distraction is a method in special cases for reconstruction of traumatic amputations and congenital malformations. The advantage is the relatively easy technique in comparison to other more complex procedures. The ®rst distraction on the lower limb was described by Codivilla in 1905 [1]. In hand surgery this method was ®rst used by Matev in 1966 for the reconstruction of a traumatically amputated thumb [2]. Subsequently the use of this method for traumatic amputations as well as for congenital malformations has been described by several authors. The fact that this technique requires an external ®xator with the option of variable length has led to further development of the devices over the past few years. 2. Materials and methods In a minimally invasive procedure an external ®xa-
* Corresponding author. Tel.: +49-40-73-060; fax: +49-40-73062750.
tor is applied to the bone which is to be lengthened. An osteotomy between the ®xator clamps is then performed and the two fragments remain in place for a period of rest, which varies from 3 to 14 days [3±8]. The distraction commences with a lengthening of 0.5± 2.4 mm per day [3±5,7±15]. After the target length is achieved some authors retain the external ®xator until union [3,7,8], while others stabilise the lengthened bone with a plate or K-wires and additional bone grafting [9,10,16]. Pollak [15] recommended overdistraction by 4 mm to put compression on the bone 2±3 weeks after the end of the lengthening to accelerate the time of bony union. Manktelow and Wainwright [11] describe a technique of Z-shape osteotomy and stabilisation of the bone with external ®xation. In the major long bones only the cortical bone is osteotomised leaving the cancellous bone intact, as described by Ilizarov. This technique is often not practicable in ®ngers because of their small diameter. Finsen and Russwurm [3] divide the whole bone, including the periosteum, and start with the distraction after a period of rest, while Pollack [15] opens the periosteum in a longitudinal direction and closes it again after the corticotomy. To protect the periosteal sleeve Preisser and Partecke [8] perform a subtotal corticotomy and break the palmar cortex, leaving the palmar periosteum intact.
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 9 ) 0 0 2 6 9 - 7
114
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
3. Indications Kessler et al., Smith and Gumley and Belusa use this method to improve function in congenital malformations with aplasia or hypoplasia of one or more rays [17±19]. Other authors report reconstructions of traumatic amputations [3±9,14±16,20,21]. Reconstruction of the thumb is the leading indication for this method, as well as for the reconstruction of bony defects, lengthening and replantation of other ®ngers [22]. A defect can be treated by continuous distraction [10], with a Z-shape osteotomy and single step lengthening and external ®xation [11] or with a single step distraction ®lling the defect with bone graft [6]. Contraindications to this technique include unstable scars, poor soft tissue envelope around the stump, or a small bony fragment without the possibility of placing a ®xator.
4. Complications The callus may rupture after too fast a distraction, resulting in non-union. A non-union has to be revised with shortening or bone graft and additional osteosynthesis. Conversely distraction performed too slowly leads to premature union. A fracture in the callus or a deviation caused by traction of the adductor pollicis in the thumb may later make a corrective osteotomy necessary. A pin-track infection, which requires premature removal of the ®xator, needs alternate methods of external or internal stabilisation. A poor soft tissue envelope may develop an unstable scar. Every distraction includes the risk of additional nerve or vessel damage caused by the operation or the soft tissue tension.
5. Results Between 1992 and 1996 we performed 36 distractions in 27 patients with four congenital malformations, while the rest suered from posttraumatic amputations. Our results are retrospective and based on hospital notes. Objective results or long-term results are not available. In the cases of malformations we had two patients with oligosyndactyly who had several operations before. In one of these patients we lengthened the ®rst metacarpal, in the other we lengthened the proximal phalanx of the ®fth ®nger both with bone graft from the iliac crest. To improve function we lengthened the grafted fragment with distraction. The other two mal-
formations were in the hand of a lady with symbrachydactyly. In 15 cases we lengthened one ®fth metacarpal, 12 proximal phalanges and two middle phalanges after amputation. In the thumb we distracted two proximal phalanges and 15 metacarpals. The amputations were caused by accidents with a circular saw, a drill, ®reworks, a mincing machine and fractures with bony defects. Apart from the patient who underwent corrective osteotomy and lengthening of the proximal phalanx of his ®fth ®ngers, all patients had been operated on before. These previous operations are shown in Table 1. For the distraction we used the Ilizarov ®xator. We used a ring-®xator 25 times, a frame-®xator seven times and in four cases we applied a clamp-®xator. The average length we achieved was 34 mm at the ®rst metacarpal, 13 mm at the ®fth metacarpal, 17.5 mm at the proximal phalanx of the thumb, 11 mm at the proximal phalanx of the ®ngers and 23 mm at the middle phalanx. In 20 of our cases we had no complications. In four cases we had pin-track infections of which one settled with antibiotics, another settled after resiting of the ®xator pins and two required removal of the ®xator with secondary bone grafting. One non-union had to be bone grafted. In 10 cases a correction of the pins became necessary, while in three cases a reapplication of the external ®xator was required because of pin breakage. In one patient we experienced a fracture of the callus after bone grafting. To improve function at the thumb we performed a deepening of the web space with a Z-plasty and a free ¯ap from the upper arm or a distal radial ¯ap, in
Table 1 Additional procedures and previous operations in patients with lengthenings Procedure
Number
Replantation Revision Scar correction at stump Radial forearm ¯ap Foucher ¯ap Inguinal ¯ap Wrap around ¯ap Deepening of web space Osteosynthesis Distraction Toe transfer Interposition of bone graft Reconstruction of ¯exor tendon
3 1 1 4 1 1 1 1 2 2 5 2 1
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120 Table 2 Operations following distraction
115
Table 3 Complications during distraction
Procedures
Number
Complications
Number
Bone graft Correction of ®xator position Resiting of ®xator Deepening of web space Mobilisation of carpometacarpal joint
3 10 2 7 4
Pin-track-infections Pin breakage Pin loosening Fracture of callus
3 3 2 1
Fig. 1. (a) Amputation of the thumb at the level of the proximal phalanx in a patient with a complex hand injury. A pollizisation of the second ®nger was impossible because of the severe restriction in the movement of the third ®nger. (b) Clinical picture after lengthening of the ®rst metacarpal and widening of the ®rst web space with a pedicled ¯ap. (c, d) X-ray pre- and postdistraction.
116
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 1 (continued)
seven cases. In four patients an additional operative mobilisation of the ®rst carpometacarpal joint with transposition of the insertion of adductor pollicis became necessary. Table 2 shows the additional procedures, Table 3 the complications. Fig. 1 shows the clinical and radiological pictures of a lengthening procedure of a thumb after traumatic amputation. In Fig. 2 additional steps of a reconstructive procedure of a thumb are demonstrated with distraction following a wrap-around-¯ap operation and a deepening of the web space with a Z-plasty. 6. Discussion The main indication for the use of callus distraction in the hand is in the reconstruction of the thumb, but only in those cases with a good soft tissue envelope and if the patient refuses alternative methods. The level of amputation should not be proximal. Distrac-
tion is useful as an additional method to improve function, as shown in the illustrations. The advantage of the method lies in its relative safety in comparison with pollizisation or a toe transfer. The distraction of a metacarpal needs additional procedures like widening of the web space, which can be done with a relatively simple Z-plasty or with the use of ¯aps, a more complicated procedure. During distraction there is always the risk of an adduction contracture which often requires mobilisation of the carpometacarpal joint. Distraction may also be used to lengthen a thumb after transplantation of a toe. In complex hand injuries with amputations of multiple digits a simple lengthening leads to an unsatisfactory result. In this case toe transplantations should be preferred. Defects of the metacarpals or congenital malformations should be treated by a single step procedure (interposition of bone graft) which is the quicker method and has fewer complications.
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
117
Fig. 2. (a) Amputation of the thumb at the level of the proximal phalanx. (b, c) Clinical and radiological result after correction with a wrap around ¯ap. (d, e) Situation after healing of the ¯ap and distraction of the ®rst metacarpal. (f) Finally a widening of the ®rst web space with a Z-plasty was performed to improve function.
118
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 2 (continued)
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 2 (continued)
119
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K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
References [1] Codivilla A. On the means of lengthening in the lower limb the muscle and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353±69. [2] Matev I. Reconstructive surgery of the thumb. Ortop Traum 1966;3:126±32. [3] Finsen V, Russwurm H. Metacarpal lengthening after traumatic amputation of the thumb. J Bone Joint Surg (Br) 1996;78:133± 6. [4] Hette K, Lemke T, Knaepler H, Gotzen L. Die sekundaÈre DaumenverlaÈngerung als Alternative zur Replantation im Endgelenkbereich. Heft Unfallheilkd 1990;212:348. [5] Hette K, Lemke T, Sangmeister M, Gotzen L. Die Daumenersatzoperation mittels metacarpaler Distraktionsosteotomie als SekundaÈreingri nach Daumenamputation. Langenbecks Arch Chir 1990;(suppl. II):761±2. [6] Kessler I, Hecht O, Baruch A. Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg (Am) 1979;61:83±7. [7] Preisser P, Partecke BD. Erste Erfahrungen mit der IlisarowMethode am Handskelett. Unfallchirurg 1992;95:547±50. [8] Preisser P, Partecke BD. VerlaÈngerungsosteotomie mit dem Ilisarow-Fixateur. Handchir Mikrochir Plast Chir 1995;27:28± 37. [9] Hette K, Lemke T, Knaepler H. Die Distraktion des ersten Mittelhandknochens zur Daumenersatzbildung. Unfallchirurg 1992;95:294±7. [10] Kanaujia RR, Fukuhara C, Yoshioka K, Miyamoto Y, In Hoo K. Experience with Ikuta's phalangeal compression±distraction± ®xation device. J Hand Surg (Am) 1988;13:515±21.
[11] Manktelow RT, Wainwright DJ. A technique of distraction osteosynthesis in the hand. J Hand Surg (Am) 1984;9:858±62. [12] Matev I. Thumb reconstruction after amputation at the matecarpophalangeal joint by bone-lengthening. J Bone Joint Surg (Am) 1970;52:957±65. [13] Matev I. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 1980;5:482±7. [14] Paneva-Holevich E, Yanko E. A distraction for lengthening of the ®nger metacarpals: a preliminary report. J Hand Surg 1980;5:160±7. [15] Pollack HJ. Rekonstruktion des traumatisch amputierten Daumens durch kontinuierliche Distraktion nach Matev. Handchir Mikrochir Plast Chir 1994;26:291±7. [16] Tanaka J. VerlaÈngerung von Mittelhandund FingergliedstuÈmpfen nach traumatischen Amputationen und bei angeborenen Fehlbildungen durch externe Distraktionsapparate. Handchir Mikrochir Plast Chir 1988;20:198±203. [17] Belusa M. Die DistraktionsverlaÈngerung bei Brachymetakarpie. Handchir Mikrochir Plast Chir 1994;26:298±301. [18] Kessler I, Baruch A, Hecht O. Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg 1977;2:394±401. [19] Smith RJ, Gumley GJ. Metacarpal distraction lengthening. Hand Clin 1985;3:417±29. [20] Kessler I. Transposition of a digital ray after multiple amputations of ®ngers. Hand 1976;8:176±8. [21] Mulliken JB, Curtis RM. Thumb lengthening by metacarpal distraction. J Trauma 1980;20:250±5. [22] Lee JW, Chiu HY, Hsu HY. Distraction lengthening of a replanted digit. Plast Reconstr Surg 1995;96:1438±41.
www.elsevier.com/locate/injury
Callus distraction in the hand skeleton K.-D. Rudolf*, P. Preisser, B.-D. Partecke Department of Handsurgery, Plastic- and Microsurgery, Burns Unit, Berufsgenossenschaftliches Unfallkrankenhaus, Bergedorfer Straûe 10, D-21033 Hamburg, Germany
Abstract From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and ®ngers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and ®ngers is a feasible operative technique leading to a promising improvement of function. # 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction Continuous callus distraction is a method in special cases for reconstruction of traumatic amputations and congenital malformations. The advantage is the relatively easy technique in comparison to other more complex procedures. The ®rst distraction on the lower limb was described by Codivilla in 1905 [1]. In hand surgery this method was ®rst used by Matev in 1966 for the reconstruction of a traumatically amputated thumb [2]. Subsequently the use of this method for traumatic amputations as well as for congenital malformations has been described by several authors. The fact that this technique requires an external ®xator with the option of variable length has led to further development of the devices over the past few years. 2. Materials and methods In a minimally invasive procedure an external ®xa-
* Corresponding author. Tel.: +49-40-73-060; fax: +49-40-73062750.
tor is applied to the bone which is to be lengthened. An osteotomy between the ®xator clamps is then performed and the two fragments remain in place for a period of rest, which varies from 3 to 14 days [3±8]. The distraction commences with a lengthening of 0.5± 2.4 mm per day [3±5,7±15]. After the target length is achieved some authors retain the external ®xator until union [3,7,8], while others stabilise the lengthened bone with a plate or K-wires and additional bone grafting [9,10,16]. Pollak [15] recommended overdistraction by 4 mm to put compression on the bone 2±3 weeks after the end of the lengthening to accelerate the time of bony union. Manktelow and Wainwright [11] describe a technique of Z-shape osteotomy and stabilisation of the bone with external ®xation. In the major long bones only the cortical bone is osteotomised leaving the cancellous bone intact, as described by Ilizarov. This technique is often not practicable in ®ngers because of their small diameter. Finsen and Russwurm [3] divide the whole bone, including the periosteum, and start with the distraction after a period of rest, while Pollack [15] opens the periosteum in a longitudinal direction and closes it again after the corticotomy. To protect the periosteal sleeve Preisser and Partecke [8] perform a subtotal corticotomy and break the palmar cortex, leaving the palmar periosteum intact.
0020-1383/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 9 ) 0 0 2 6 9 - 7
114
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
3. Indications Kessler et al., Smith and Gumley and Belusa use this method to improve function in congenital malformations with aplasia or hypoplasia of one or more rays [17±19]. Other authors report reconstructions of traumatic amputations [3±9,14±16,20,21]. Reconstruction of the thumb is the leading indication for this method, as well as for the reconstruction of bony defects, lengthening and replantation of other ®ngers [22]. A defect can be treated by continuous distraction [10], with a Z-shape osteotomy and single step lengthening and external ®xation [11] or with a single step distraction ®lling the defect with bone graft [6]. Contraindications to this technique include unstable scars, poor soft tissue envelope around the stump, or a small bony fragment without the possibility of placing a ®xator.
4. Complications The callus may rupture after too fast a distraction, resulting in non-union. A non-union has to be revised with shortening or bone graft and additional osteosynthesis. Conversely distraction performed too slowly leads to premature union. A fracture in the callus or a deviation caused by traction of the adductor pollicis in the thumb may later make a corrective osteotomy necessary. A pin-track infection, which requires premature removal of the ®xator, needs alternate methods of external or internal stabilisation. A poor soft tissue envelope may develop an unstable scar. Every distraction includes the risk of additional nerve or vessel damage caused by the operation or the soft tissue tension.
5. Results Between 1992 and 1996 we performed 36 distractions in 27 patients with four congenital malformations, while the rest suered from posttraumatic amputations. Our results are retrospective and based on hospital notes. Objective results or long-term results are not available. In the cases of malformations we had two patients with oligosyndactyly who had several operations before. In one of these patients we lengthened the ®rst metacarpal, in the other we lengthened the proximal phalanx of the ®fth ®nger both with bone graft from the iliac crest. To improve function we lengthened the grafted fragment with distraction. The other two mal-
formations were in the hand of a lady with symbrachydactyly. In 15 cases we lengthened one ®fth metacarpal, 12 proximal phalanges and two middle phalanges after amputation. In the thumb we distracted two proximal phalanges and 15 metacarpals. The amputations were caused by accidents with a circular saw, a drill, ®reworks, a mincing machine and fractures with bony defects. Apart from the patient who underwent corrective osteotomy and lengthening of the proximal phalanx of his ®fth ®ngers, all patients had been operated on before. These previous operations are shown in Table 1. For the distraction we used the Ilizarov ®xator. We used a ring-®xator 25 times, a frame-®xator seven times and in four cases we applied a clamp-®xator. The average length we achieved was 34 mm at the ®rst metacarpal, 13 mm at the ®fth metacarpal, 17.5 mm at the proximal phalanx of the thumb, 11 mm at the proximal phalanx of the ®ngers and 23 mm at the middle phalanx. In 20 of our cases we had no complications. In four cases we had pin-track infections of which one settled with antibiotics, another settled after resiting of the ®xator pins and two required removal of the ®xator with secondary bone grafting. One non-union had to be bone grafted. In 10 cases a correction of the pins became necessary, while in three cases a reapplication of the external ®xator was required because of pin breakage. In one patient we experienced a fracture of the callus after bone grafting. To improve function at the thumb we performed a deepening of the web space with a Z-plasty and a free ¯ap from the upper arm or a distal radial ¯ap, in
Table 1 Additional procedures and previous operations in patients with lengthenings Procedure
Number
Replantation Revision Scar correction at stump Radial forearm ¯ap Foucher ¯ap Inguinal ¯ap Wrap around ¯ap Deepening of web space Osteosynthesis Distraction Toe transfer Interposition of bone graft Reconstruction of ¯exor tendon
3 1 1 4 1 1 1 1 2 2 5 2 1
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120 Table 2 Operations following distraction
115
Table 3 Complications during distraction
Procedures
Number
Complications
Number
Bone graft Correction of ®xator position Resiting of ®xator Deepening of web space Mobilisation of carpometacarpal joint
3 10 2 7 4
Pin-track-infections Pin breakage Pin loosening Fracture of callus
3 3 2 1
Fig. 1. (a) Amputation of the thumb at the level of the proximal phalanx in a patient with a complex hand injury. A pollizisation of the second ®nger was impossible because of the severe restriction in the movement of the third ®nger. (b) Clinical picture after lengthening of the ®rst metacarpal and widening of the ®rst web space with a pedicled ¯ap. (c, d) X-ray pre- and postdistraction.
116
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 1 (continued)
seven cases. In four patients an additional operative mobilisation of the ®rst carpometacarpal joint with transposition of the insertion of adductor pollicis became necessary. Table 2 shows the additional procedures, Table 3 the complications. Fig. 1 shows the clinical and radiological pictures of a lengthening procedure of a thumb after traumatic amputation. In Fig. 2 additional steps of a reconstructive procedure of a thumb are demonstrated with distraction following a wrap-around-¯ap operation and a deepening of the web space with a Z-plasty. 6. Discussion The main indication for the use of callus distraction in the hand is in the reconstruction of the thumb, but only in those cases with a good soft tissue envelope and if the patient refuses alternative methods. The level of amputation should not be proximal. Distrac-
tion is useful as an additional method to improve function, as shown in the illustrations. The advantage of the method lies in its relative safety in comparison with pollizisation or a toe transfer. The distraction of a metacarpal needs additional procedures like widening of the web space, which can be done with a relatively simple Z-plasty or with the use of ¯aps, a more complicated procedure. During distraction there is always the risk of an adduction contracture which often requires mobilisation of the carpometacarpal joint. Distraction may also be used to lengthen a thumb after transplantation of a toe. In complex hand injuries with amputations of multiple digits a simple lengthening leads to an unsatisfactory result. In this case toe transplantations should be preferred. Defects of the metacarpals or congenital malformations should be treated by a single step procedure (interposition of bone graft) which is the quicker method and has fewer complications.
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
117
Fig. 2. (a) Amputation of the thumb at the level of the proximal phalanx. (b, c) Clinical and radiological result after correction with a wrap around ¯ap. (d, e) Situation after healing of the ¯ap and distraction of the ®rst metacarpal. (f) Finally a widening of the ®rst web space with a Z-plasty was performed to improve function.
118
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 2 (continued)
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
Fig. 2 (continued)
119
120
K.-D. Rudolf et al. / Injury, Int. J. Care Injured 31 (2000) 113±120
References [1] Codivilla A. On the means of lengthening in the lower limb the muscle and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353±69. [2] Matev I. Reconstructive surgery of the thumb. Ortop Traum 1966;3:126±32. [3] Finsen V, Russwurm H. Metacarpal lengthening after traumatic amputation of the thumb. J Bone Joint Surg (Br) 1996;78:133± 6. [4] Hette K, Lemke T, Knaepler H, Gotzen L. Die sekundaÈre DaumenverlaÈngerung als Alternative zur Replantation im Endgelenkbereich. Heft Unfallheilkd 1990;212:348. [5] Hette K, Lemke T, Sangmeister M, Gotzen L. Die Daumenersatzoperation mittels metacarpaler Distraktionsosteotomie als SekundaÈreingri nach Daumenamputation. Langenbecks Arch Chir 1990;(suppl. II):761±2. [6] Kessler I, Hecht O, Baruch A. Distraction-lengthening of digital rays in the management of the injured hand. J Bone Joint Surg (Am) 1979;61:83±7. [7] Preisser P, Partecke BD. Erste Erfahrungen mit der IlisarowMethode am Handskelett. Unfallchirurg 1992;95:547±50. [8] Preisser P, Partecke BD. VerlaÈngerungsosteotomie mit dem Ilisarow-Fixateur. Handchir Mikrochir Plast Chir 1995;27:28± 37. [9] Hette K, Lemke T, Knaepler H. Die Distraktion des ersten Mittelhandknochens zur Daumenersatzbildung. Unfallchirurg 1992;95:294±7. [10] Kanaujia RR, Fukuhara C, Yoshioka K, Miyamoto Y, In Hoo K. Experience with Ikuta's phalangeal compression±distraction± ®xation device. J Hand Surg (Am) 1988;13:515±21.
[11] Manktelow RT, Wainwright DJ. A technique of distraction osteosynthesis in the hand. J Hand Surg (Am) 1984;9:858±62. [12] Matev I. Thumb reconstruction after amputation at the matecarpophalangeal joint by bone-lengthening. J Bone Joint Surg (Am) 1970;52:957±65. [13] Matev I. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 1980;5:482±7. [14] Paneva-Holevich E, Yanko E. A distraction for lengthening of the ®nger metacarpals: a preliminary report. J Hand Surg 1980;5:160±7. [15] Pollack HJ. Rekonstruktion des traumatisch amputierten Daumens durch kontinuierliche Distraktion nach Matev. Handchir Mikrochir Plast Chir 1994;26:291±7. [16] Tanaka J. VerlaÈngerung von Mittelhandund FingergliedstuÈmpfen nach traumatischen Amputationen und bei angeborenen Fehlbildungen durch externe Distraktionsapparate. Handchir Mikrochir Plast Chir 1988;20:198±203. [17] Belusa M. Die DistraktionsverlaÈngerung bei Brachymetakarpie. Handchir Mikrochir Plast Chir 1994;26:298±301. [18] Kessler I, Baruch A, Hecht O. Experience with distraction lengthening of digital rays in congenital anomalies. J Hand Surg 1977;2:394±401. [19] Smith RJ, Gumley GJ. Metacarpal distraction lengthening. Hand Clin 1985;3:417±29. [20] Kessler I. Transposition of a digital ray after multiple amputations of ®ngers. Hand 1976;8:176±8. [21] Mulliken JB, Curtis RM. Thumb lengthening by metacarpal distraction. J Trauma 1980;20:250±5. [22] Lee JW, Chiu HY, Hsu HY. Distraction lengthening of a replanted digit. Plast Reconstr Surg 1995;96:1438±41.