- Email: [email protected]
Immediate pollicization of an amputated index finger
Immediate pollicization of an amputated index finger A case of immediate pol/icization of an amputated index finger is reported. The patient sustained accidental amputation of the entire thumb and index finger and subtotal amputation of the middle finger of her left hand. Two years following replantation of the index finger to the thumb position, the finger has limited motion but the patient has a functional replanted digit.
John E. Keiter, M.D., Ogden, Utah
Although digital replantation by microvascular anastomosis is a well-established procedure, immediate pollicization of an amputated index, middle, ring, or little finger is rare. Although such procedures were known in China, I have been unable to find one described in the U.S. literature.
Case report Ori October 25, 1977, L.R., a 62-year-old secretary in a lumber mill, accidently amputated the entire thumb and index finger and subtotally amputated the middle finger of her left hand in a band saw. She was immediately referred to me, along with the amputated parts which had been placed on ice . The thumb was badly mutilated and was not suitable for replantation . The index finger, however, was amputated cleanly, just proximal to the metacarpophalangeal (MP) joint. Because the thumb had been totally severed proximal to the MP joint, pollicization of the index finger was undertaken. Following bone shortening and fixation of the thumb metacarpal to the index proximal phalanx, microscopic arterial and venous anastomoses were performed using a single digital artery and the confluence of two dorsal veins. Blood flow was established early, and the finger remained pink and vigorous throughout the postoperative period . Subsequently, sural nerve grafts , tendon grafts , and capsulotomy and tenolysis procedures have been done and the patient has received dynamic splinting and active and passive exercises in the occupational therapy hand clinic.
Discussion Immediate pollicization of an amputated digit is indicated when an amputated thumb is not suitable for replantation. In the reported case, pollicization placed
Received for publication Dec. 26, 1979; revised April 12 , 1980. Reprint requests: John E. Keiter, M.D., 3905 Harrison Blvd., Suite 511, Ogden, UT 84403.
584
THE JOURNAL OF HAND SURGERY
Fig. 1. Abduction of replanted digit at 2 years.
the replanted index finger in a fuctionally superior position for the obvious reason of allowing prehensile grip. In restoring sensation to the thumb, nerve grafts were interposed between the replanted index and thumb digital nerves. As a result, the digit feels like a thumb rather than an index finger. Thenar muscle function was retained and allows opposition. Now, 2 years following replantation, the patient has limited but functionally adequate interphalangeal (IP) joint motion, both actively and passively. The index proximal interphalangeal joint, located at the thumb MP joint level, lacks 15° of full extension but retains 25° of active flexion. The index distal interphalangeal joint, which serves as the thumb IP joint, has only 5° active motion, but it is in a favorable position for pinch and grip actions . Pinch and grip strengths are 2 and 5 pounds, respectively. This is about 15% of the patient's opposite, dominant, hand. There is retained hypersensitivity of the digit. Two-
0363-5023/80/060584+02$00.20/0 © 1980 American Society for Surgery of the Hand
Vol. 5, No. 6 November 1980
Fig. 2. Key pinch of replanted digit at 2 years .
point discrimination in the distal volar pad is 11 mm . The patient has learned to use the hand effectively in household chores, but because of her relatively advanced age she has not attempted to return to work at her previous job.
Pollicization of index finger
585
Fig. 3. Opposition and prehensile grip at 2 years.
REFERENCES I. Kaplan, EB : Functional and surgical anatomy of the hand , ed . 2 , Philadelphia, 1965, JB Lippincott Co 2. Tsai , TM: A complex reimplantation of digits: A case report , J HAND SuRG 4:145-9, 1979
John E. Keiter, M.D., Ogden, Utah
Although digital replantation by microvascular anastomosis is a well-established procedure, immediate pollicization of an amputated index, middle, ring, or little finger is rare. Although such procedures were known in China, I have been unable to find one described in the U.S. literature.
Case report Ori October 25, 1977, L.R., a 62-year-old secretary in a lumber mill, accidently amputated the entire thumb and index finger and subtotally amputated the middle finger of her left hand in a band saw. She was immediately referred to me, along with the amputated parts which had been placed on ice . The thumb was badly mutilated and was not suitable for replantation . The index finger, however, was amputated cleanly, just proximal to the metacarpophalangeal (MP) joint. Because the thumb had been totally severed proximal to the MP joint, pollicization of the index finger was undertaken. Following bone shortening and fixation of the thumb metacarpal to the index proximal phalanx, microscopic arterial and venous anastomoses were performed using a single digital artery and the confluence of two dorsal veins. Blood flow was established early, and the finger remained pink and vigorous throughout the postoperative period . Subsequently, sural nerve grafts , tendon grafts , and capsulotomy and tenolysis procedures have been done and the patient has received dynamic splinting and active and passive exercises in the occupational therapy hand clinic.
Discussion Immediate pollicization of an amputated digit is indicated when an amputated thumb is not suitable for replantation. In the reported case, pollicization placed
Received for publication Dec. 26, 1979; revised April 12 , 1980. Reprint requests: John E. Keiter, M.D., 3905 Harrison Blvd., Suite 511, Ogden, UT 84403.
584
THE JOURNAL OF HAND SURGERY
Fig. 1. Abduction of replanted digit at 2 years.
the replanted index finger in a fuctionally superior position for the obvious reason of allowing prehensile grip. In restoring sensation to the thumb, nerve grafts were interposed between the replanted index and thumb digital nerves. As a result, the digit feels like a thumb rather than an index finger. Thenar muscle function was retained and allows opposition. Now, 2 years following replantation, the patient has limited but functionally adequate interphalangeal (IP) joint motion, both actively and passively. The index proximal interphalangeal joint, located at the thumb MP joint level, lacks 15° of full extension but retains 25° of active flexion. The index distal interphalangeal joint, which serves as the thumb IP joint, has only 5° active motion, but it is in a favorable position for pinch and grip actions . Pinch and grip strengths are 2 and 5 pounds, respectively. This is about 15% of the patient's opposite, dominant, hand. There is retained hypersensitivity of the digit. Two-
0363-5023/80/060584+02$00.20/0 © 1980 American Society for Surgery of the Hand
Vol. 5, No. 6 November 1980
Fig. 2. Key pinch of replanted digit at 2 years .
point discrimination in the distal volar pad is 11 mm . The patient has learned to use the hand effectively in household chores, but because of her relatively advanced age she has not attempted to return to work at her previous job.
Pollicization of index finger
585
Fig. 3. Opposition and prehensile grip at 2 years.
REFERENCES I. Kaplan, EB : Functional and surgical anatomy of the hand , ed . 2 , Philadelphia, 1965, JB Lippincott Co 2. Tsai , TM: A complex reimplantation of digits: A case report , J HAND SuRG 4:145-9, 1979