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Total thumb reconstruction by an index finger transposition
Total Thumb Reconstruction by an Index Finger Transposition H.>TAKAMI, S. TAKAHASHI, and M. AND0 From Kanto Rosai Hospital, Kawasaki, Japan A case of total thumb reconstruction after traumatic amputation is described. The reconstruction was carried out as a staged procedure with preliminary application of a pedicle flap, and a normal index finger transposition, followed by opposition transfer using the abductor digiti quinti muscle. Twenty-seven months after the index finger pollicization, the reconstructed thumb had satisfactory function. Total thumb loss after traumatic amputation presents a difficult reconstruction problem to the surgeon. Amputation through the trapezio-metacarpal joint results in lack of all the thenar muscles as well as the valuable trapezio-metacarpal saddle joint. Osteoplastic reconstruction using pedicle skin flap with bone graft and neurovascular island transfer is devoid of mol;ement and sensibility may not be satisfactory. An infinitely better thumb may be provided by the transposition of an available digit preserving its metacarpophalangeal joint. A case report is presented here describing a method of total thumb reconstruction which gave a gratifying result. Case Report A thirty six-year-old male sustained a traumatic crush avulsion of the.right thumb as a result of an automobile accident. At the initial examination four months after injury, the thumb had been amputated through the carpometacarpal joint (Figures 1 to 3). The amputation stump was covered with a split thickness skin graft. The index finger had some limitation of motion, and the radial side of the finger had decreased sensibility. Other fingers were intact. Preoperative angiograms revealed a patent ulnar digital vessel and an obstructed radial vessel to the index finger. Prior to pollicization, a groin flap was applied to resurface the amputation stump. Polhcization of the index finger was performed seven months after injury. Utilizing the pre-existing scar, a zig-zag skin incision was made in the palm. With some difficulty, the neurovascular pedicles to the index finger were dissected out from the surrounding scar tissue. Patency of the ulnar digital artery to the index finger was confirmed intraoperatively, but that of the radial one could not be ascertained. The first dorsal interosseous muscle was severely damaged. On the dorsum of the hand, a dorsal vein was preserved. The second metacarpal was divided transversely at its neck and the index finger was isolated on its neurovascular with the pedicles and a dorsal vein, together metacarpophalangeal joint, and flexor and extensor tendons. An oblique osteotomy was made at the base of Received for publication Hirost,i Takami, M.D., ku, Kawasaki, Japan.
June, 1985. Section of Orthopaedic
VOL. II-B No. 1 FEBRUARY
1986
Surgery,
Kanto
Rosai
Hospmi,
Nakahara
Fig. 1,
Fig. 2: Preoperative loss of the thumb.
views of the right
hand
showing
total
31
H. TAKAMI,
S. TAKAHASHI,
AND
Fig. 4
Fig. 3
A preoperative radiograph showing amputation through the carpometacarpal joint.
M. AND0
Extension
of the reconstructed
thumb.
of the thumb
the second metacarpal and the ray was shortened by removing the diaphysis of the metacarpal. The isolated digit was transposed and fixed to the base of the second metacarpal by Kirschner wires, ensuring that the reconstructed thumb was in the optimal position of opposition and abduction. The thumb extensors were unavailable for tendon transfer because of damage from the original trauma. The extensor digitorum communis tendon was shortened at the wrist and the extensor indicis proprius tendon was sutured to the ulnar lateral band of the index extensor aponeurosis. The flexor tendons were left undisturbed. In order to provide opposition for the transposed index finger, an abductor digiti quinti transfer was performed three weeks after the digital transposition. At operation, the radial lateral band of the index extensor aponeurosis was separated from the middle band along the entire length of the proximal phalanx. The tendinous insertion of the abductor digiti quinti muscle was attached to the radial lateral band of the index extensor aponeurosis. The hand was splinted for three weeks with the wrist in neutral position and the thumb in palmar abduction. 32
Fig. 5
Flexion of the reconstructed
thumb.
THE JOURNAL
OF HAND
SURGERY
TOTAL THUMB RECONSTRUCTION
months pollicization, the Twenty-seven after reconstructed thumb had satisfactory function (Figures 4 to 7). The patient was able to grasp large objects powerfully and to manipulate small objects with ease. He could fully extend the thumb, and flex the metacarpophalangeal joint (proximal interphalangeal joint of the index) to 65 degrees, and the interphalangeal joint to 50 degrees. The thumb was able to oppose to all three residual fingers. The patient had excellent sensibility on the ulnar side of the thumb and minimal sensory deficit on the radial side. Grip strength measured 28 kilograms (left hand 43 kilograms). There were no daily activities the patient could not perform with his new thumb. Radiographs demonstrated solid union between the index metacarpal neck and basal portion of the second metacarpal (Figure 8). Discussion
Fig. 15 Pinch finger.
between
the
reconstructed
thumb
and
the middle
Total thumb loss after traumatic amputation is relatively uncommon. Reports on the total thumb reconstruction by pollicization have been scant, and the clinical results presented in the literature have generally been unsatisfactory (Peacock, 1966; Harkins, 1972; Kelleher, 1975; Langlais, 1979; Stern, 1981). Kelleher (1975) reported a successful little finger pollicization for reconstruction of a mutilating injury in which the thumb and the index finger had been amputated. Stern (1981) reported a pollicized index finger with limited motion. There is some controversy among the authors as to the technical details of the procedure. Various methods have been presented for restoring opposition at the time of pollicization. In cases of traumatic thumb loss, the first dorsal interosseous muscle is often difficult to mobilize because of damage from the original trauma, and unlike in congenital cases, it does not always adapt well as a thenar muscle. Therefore, an opposition transfer utilizing residual motor units should be considered. The abductor digiti quinti transfer offers certain advantages because an intrinsic muscle replaces intrinsic muscle of similar excursion with adequate power transmitted directly without intervening pulley or gliding tendon. Furthermore the appearance of the hand is improved by the transfer (Littler, 1963).
Fig. 7
Opposition
of the reconstructed
VOL. 11-B No. I FEBRUARY
1986
thumb.
With our case under discussion, although the normal three extensor tendons of the thumb were reduced to only one, satisfactory stability and mobility were restored to the new thumb. Tilting of the former metacarpal head into flexion to prevent thumb hyperextension as suggested by some authors (BuckGramcko, 1977; Stern, 1981) was not necessary. We consider that it is the abductor digiti quinti transfer that made a great contribution towards stability and mobility of the thumb. The abductor digiti quinti 33
H. TAKAMI, S. TAKAHASHI,
AND M. AND0
muscle proved to be powerful, exerting a strong force through a short excursion and simulating the action of the abductor pollicis brevis muscle. As to the choice of digit for pollicization, we prefer to transpose the index finger rather than the little finger because the little finger is too slender to make a good thumb. A preliminary pedicle flap should be applied if there is excessive scarring on the amputation stump. The additional skin facilitates placement of the pollicized digits in its new position and minimizes the chance of a web space contracture. Although the method described here requires several operative stages, it is presented as a practical one for reconstruction following total loss of the thumb. References
Fig. 8
A postoperative
34
showing solid union between the neck and basal portion of the second
radiograph
index metacarpal metacarpal.
D. (1977). Thumb Reconstruction by Digital BUCK-GRAMCKO, Transposition, Orthopedic Clinics of North America, 8: 329-342. HARKINS, P. D. and RAFFETY, J. E. (1972), Digital Transposition in the Injured Hand. The Journal of Bone and Joint Surgery, 54A:5: 1064-1069. KELLEHER, J. C., SULLIVAN, J. Ci., BAIBAK, G. J. and DEAN, R. K. Reconstruction of the Thumb, in Hand Surgery. Ed. Flynn, .I. E. Baltimore, Williams and Wilkins Company, 1975: 367-382. LANGLAIS, F. and GOSSET, J. Results of Thumb Reconstruction. in Mutilating Injuries ofthe Hand. G. E. M. Monograph. Ed. Reid D.A.C. and Gosset J., Edinburgh, Churchill Livingstone, 1979: 78-80. LITTLER, J. W. and COOLEY, S. G. E. (1963). Opposition of the Thumb and Its Restoration by Abductor Digiti Quinti Transfer. The Journal of Bone and Joint Suraerv. 45A: 7: 1389-1396. PEACOCK, E. E. Jr. Reconstruction of the Thumb, in Hand Surgery. Ed. Flynn, J. E. Baltimore, Williams and Wilkins Company, 1966: 561-582. STERN, P. J. and LISTER, G. D. (1981). Pollicization after Traumatic Amputation of the Thumb, Clinical Orthopaedics and Related Research, 155: 85-94.
THE JOURNAL OF HAND SURGERY
June, 1985. Section of Orthopaedic
VOL. II-B No. 1 FEBRUARY
1986
Surgery,
Kanto
Rosai
Hospmi,
Nakahara
Fig. 1,
Fig. 2: Preoperative loss of the thumb.
views of the right
hand
showing
total
31
H. TAKAMI,
S. TAKAHASHI,
AND
Fig. 4
Fig. 3
A preoperative radiograph showing amputation through the carpometacarpal joint.
M. AND0
Extension
of the reconstructed
thumb.
of the thumb
the second metacarpal and the ray was shortened by removing the diaphysis of the metacarpal. The isolated digit was transposed and fixed to the base of the second metacarpal by Kirschner wires, ensuring that the reconstructed thumb was in the optimal position of opposition and abduction. The thumb extensors were unavailable for tendon transfer because of damage from the original trauma. The extensor digitorum communis tendon was shortened at the wrist and the extensor indicis proprius tendon was sutured to the ulnar lateral band of the index extensor aponeurosis. The flexor tendons were left undisturbed. In order to provide opposition for the transposed index finger, an abductor digiti quinti transfer was performed three weeks after the digital transposition. At operation, the radial lateral band of the index extensor aponeurosis was separated from the middle band along the entire length of the proximal phalanx. The tendinous insertion of the abductor digiti quinti muscle was attached to the radial lateral band of the index extensor aponeurosis. The hand was splinted for three weeks with the wrist in neutral position and the thumb in palmar abduction. 32
Fig. 5
Flexion of the reconstructed
thumb.
THE JOURNAL
OF HAND
SURGERY
TOTAL THUMB RECONSTRUCTION
months pollicization, the Twenty-seven after reconstructed thumb had satisfactory function (Figures 4 to 7). The patient was able to grasp large objects powerfully and to manipulate small objects with ease. He could fully extend the thumb, and flex the metacarpophalangeal joint (proximal interphalangeal joint of the index) to 65 degrees, and the interphalangeal joint to 50 degrees. The thumb was able to oppose to all three residual fingers. The patient had excellent sensibility on the ulnar side of the thumb and minimal sensory deficit on the radial side. Grip strength measured 28 kilograms (left hand 43 kilograms). There were no daily activities the patient could not perform with his new thumb. Radiographs demonstrated solid union between the index metacarpal neck and basal portion of the second metacarpal (Figure 8). Discussion
Fig. 15 Pinch finger.
between
the
reconstructed
thumb
and
the middle
Total thumb loss after traumatic amputation is relatively uncommon. Reports on the total thumb reconstruction by pollicization have been scant, and the clinical results presented in the literature have generally been unsatisfactory (Peacock, 1966; Harkins, 1972; Kelleher, 1975; Langlais, 1979; Stern, 1981). Kelleher (1975) reported a successful little finger pollicization for reconstruction of a mutilating injury in which the thumb and the index finger had been amputated. Stern (1981) reported a pollicized index finger with limited motion. There is some controversy among the authors as to the technical details of the procedure. Various methods have been presented for restoring opposition at the time of pollicization. In cases of traumatic thumb loss, the first dorsal interosseous muscle is often difficult to mobilize because of damage from the original trauma, and unlike in congenital cases, it does not always adapt well as a thenar muscle. Therefore, an opposition transfer utilizing residual motor units should be considered. The abductor digiti quinti transfer offers certain advantages because an intrinsic muscle replaces intrinsic muscle of similar excursion with adequate power transmitted directly without intervening pulley or gliding tendon. Furthermore the appearance of the hand is improved by the transfer (Littler, 1963).
Fig. 7
Opposition
of the reconstructed
VOL. 11-B No. I FEBRUARY
1986
thumb.
With our case under discussion, although the normal three extensor tendons of the thumb were reduced to only one, satisfactory stability and mobility were restored to the new thumb. Tilting of the former metacarpal head into flexion to prevent thumb hyperextension as suggested by some authors (BuckGramcko, 1977; Stern, 1981) was not necessary. We consider that it is the abductor digiti quinti transfer that made a great contribution towards stability and mobility of the thumb. The abductor digiti quinti 33
H. TAKAMI, S. TAKAHASHI,
AND M. AND0
muscle proved to be powerful, exerting a strong force through a short excursion and simulating the action of the abductor pollicis brevis muscle. As to the choice of digit for pollicization, we prefer to transpose the index finger rather than the little finger because the little finger is too slender to make a good thumb. A preliminary pedicle flap should be applied if there is excessive scarring on the amputation stump. The additional skin facilitates placement of the pollicized digits in its new position and minimizes the chance of a web space contracture. Although the method described here requires several operative stages, it is presented as a practical one for reconstruction following total loss of the thumb. References
Fig. 8
A postoperative
34
showing solid union between the neck and basal portion of the second
radiograph
index metacarpal metacarpal.
D. (1977). Thumb Reconstruction by Digital BUCK-GRAMCKO, Transposition, Orthopedic Clinics of North America, 8: 329-342. HARKINS, P. D. and RAFFETY, J. E. (1972), Digital Transposition in the Injured Hand. The Journal of Bone and Joint Surgery, 54A:5: 1064-1069. KELLEHER, J. C., SULLIVAN, J. Ci., BAIBAK, G. J. and DEAN, R. K. Reconstruction of the Thumb, in Hand Surgery. Ed. Flynn, .I. E. Baltimore, Williams and Wilkins Company, 1975: 367-382. LANGLAIS, F. and GOSSET, J. Results of Thumb Reconstruction. in Mutilating Injuries ofthe Hand. G. E. M. Monograph. Ed. Reid D.A.C. and Gosset J., Edinburgh, Churchill Livingstone, 1979: 78-80. LITTLER, J. W. and COOLEY, S. G. E. (1963). Opposition of the Thumb and Its Restoration by Abductor Digiti Quinti Transfer. The Journal of Bone and Joint Suraerv. 45A: 7: 1389-1396. PEACOCK, E. E. Jr. Reconstruction of the Thumb, in Hand Surgery. Ed. Flynn, J. E. Baltimore, Williams and Wilkins Company, 1966: 561-582. STERN, P. J. and LISTER, G. D. (1981). Pollicization after Traumatic Amputation of the Thumb, Clinical Orthopaedics and Related Research, 155: 85-94.
THE JOURNAL OF HAND SURGERY