This document discusses reconstruction options following thumb trauma or amputation. Replantation is the ideal treatment if possible, otherwise reconstruction is necessary. Factors such as level of injury, soft tissue integrity, and patient needs guide the choice of procedures like flaps, lengthening, joint fusion, or toe transfers to restore function. Close monitoring after microsurgery and long-term rehabilitation are important for successful outcomes. Complications can include joint stiffness, non-union and sensory abnormalities requiring further procedures.

1. By Dr Akasha Amber
PGR P&R.S

3.  Loss of thumb: trauma
 Best ideal way: replantation
 Next option: reconstruction
 Level of loss
 rehabilitation

4.  Trauma; most common
 Working age males
 Mechanism:
 Sharp cuts
 Avulsion
 Crush
 Mixed (saw or lawn motor injuries)
 Infections
 Neoplasm
 Congenital absence

5.  History
 Complete examination of thumb
 Every component
 Integrity of skin, tendons and skeleton, neurovascular
evaluation, feasibility of arterial & venous anastomosis
 Examination of entire hand
 Examination in infections/tumors of thumb
 Particular note to peri-operative & intra-operative
procedures
 Radiographic evaluation

6.  Patient’s expectation (personal & professional needs)
 Patient’s own decision
 Informed consent
 End goals : stability, motion & sensibility with
adequate length
 Adherence with the choice of reconstructive method
type, adherence with the rehabilitation
 Medically optimized (DM & CVD control, tobacco
cessation
 Infection control prior to reconstruction

7.  Proximal
 From CMCJ to metacarpal neck
 Middle
 From metacarpal neck till IPJ
 Distal
 IPJ to thumb-tip

8.  Distal 3rd
 Middle 3rd
 Proximal 3rd

9.  Functional
 Rarely requires lengthening
 Chief goals: soft tissue coverage, maintenance of length, sensory
perception
 OPTIONS:
 When no bony exposure:
 Secondary healing:
 upto 1.5cm,
 daily dressings( petroleum/bismuth impregnated gauze)
 Stable scar, two point discrimination,sensate,easy,preferred
 Skin grafts:
 Large defects, less sensate
 Split or full thickness
 Hypothenar eminence, volar wrist crease, groin crease

10.  When bone exposed:
 Size & location
 Vascularised flap coverage
 ASTOY’s V-Y advancement flap
 Neurovascular volar advancement flap(Moberg Flap)
 Cross finger flap from index
 Littler neurovascular island flap
 1st dorsal metacarpal artery flap

11.  Thumb tip closure via volar V-Y
advancement flap, perfused by small
vessels traversing the subcutaneous
tissues
 Small areas
 Limited advancement
 Moberg thumb (neurovascular) volar
advancement flap
 sensate flap
 Midlateral line incision to prox phalanx
 IPJ flexed and fixed
 Defects of 1–2 cm sq.
 Island flap,variation
 Flap elevated,only attachment is NVB

12.  CROSS-FINGER FLAP TO THE THUMB
 Defects of 2-3 cm sq.
 Disadvantage:
thumb cooptation with index for 2-3 weeks
need of skin graft on index defect
 Cleland’s ligament of the index radial neurovascular bundle can kink the flap, needs release

13. Neurovascular island flap (Littler's flap)
Rarely as primary coverage
Commonly for sensation restoration to
thumb pulp
Ulnar NVB of middle or ring finger
minimum impact on pinching & grip
function
Thick cough of fatty tissue around NVB,
vasa vasorum of artery, only venous outflow
At webspace, radial br of corresponding
common digital artery divided, nerve fascicles
split
Flap transposition to thumb via tunnel or
direct incision
Donor site; grafting

14. First Dorsal Metacarpal Artery Flap
(“kite flap”)
Dorsal thumb defects
Anatomical snuffbox: princeps pollices
artery(radially) & FDMA(ulnarly)
 from index-finger dorsum,
Must include subcutaneous fat and
interosseous muscle fascia with the
pedicle
thick fatty tissue with venae
comitantes of artery (venous outflow)
Flap transpositioned via tunneling or
direct incision
Donor site; grafting

15.  Functionally limiting
 Soft tissue coverage, function & lengthening
 Acute phase:
 Revise Amputation Primary Closure Later
Reconstruction
 Length restoration
 Absolute or relative
 Relative lengthening: (phalangization)
 Allows thumb excursion( opposition;palmar & radial abduction)
 Small webspace deepening:
 Z-plasties & skin grafting
 Large webspace deepening:
 Dorsal hand flap, radial forearm flap, posterior interosseous flap

16. four-flap Z-plasty used for deepening of the
first webspace and/or releasing a first
webspace contracture
First webspace ,
full-thickness skin graft

17. double-opposing Z-plasty (known as the “jumping man”
flap). This Z-plasty

18. Thumb
amputation
stump
Scar band Dorsal hand flap Skin graft
•Based on metacarpal arterial system, more than one metacarpal artery
•Can release adductor pollices

19. Radial artery forearm flap
•Major drawback:
•compromises future thumb
reconstruction
•However ,radial artery
perforator flap
•Fascia alone,suprafascial skin
flap ,fsaciocutaneous flap
•Allen’s test
•Pivot point;midway
•BR & FCR

20. •Posterior interosseous artery flap
•Reverse flow via anatomic connection
btw AIA & PIA just proximal to DRUJ
•Marking btw ulnar head and
lat.epicondyle of elbow
•Pedicle btw FCU & FDM
•Drawback: appearance/color

21. Groin flap

22.  Absolute lengthening:
 Metacarpal lengthening
 MATEV
 Osteoplastic reconstruction: bone graft wrapped with a
flap
 On-top plasty
 pollicization

23.  MATEV
 More proximal loss in middle third of thumb injuries
 Contraindicated in thumb metacarpal remnant <3cm
 Long period of ext.fixation,multiple visits
 Osteotomy, proximal and distal pins for distraction
device
 Distraction: 1 mm /day
 Ossification of gap, or bone grafting(iliac crest/radius)
 Drawback: 1st webspace contracture

25.  3 stages:
 Skeletal reconstruction with iliac crest bone graft
wrapped with a flap(groin flap)
 Groin flap division & serial thinning
 Pulp reconstruction with NV island flap
 Drawback:
 Multiple stages
 Bone resorption
 bulky appearance

26. Iliac crest bone graft used for
osteoplastic reconstruction of a
thumb.
The fixation of the bone graft is in
progress, and will be covered by a
groin flap

28.  Good for more proximal middle 3rd thumb injuries
 Pollicization &/or on-top plasty
 Pollicization vs on-top plsty
 Racket type incision for ontop plasty at base of thumb
stump and donor finger
 Dorsal vein taken, nerves, arteries taken
 Thumb prepared
 Bony fixation; internal fixation,screw & plates

29. Pollicization of the 2nd ray.
Preoperative appearance; Postoperative appearance; Opposition between new thumb and
the little finger

30.  Challenging
 Loss of thenar musculature
 Microsurgical reconstruction
 Pollicization with later opponensplasty
 On-top plasty
 Osseointegrated prosthetic digits & thumb

31.  Immobilisation (plaster spnit)…..1 week
 Removable splint…..2 weeks
 Suture removal
 Active range of motion exercises….6 week
 Late scar modification techniques

32.  1st webspace contracture
 Tendon adhesions
 Non-union, malunion
 Joint stiffness
 neuromas

34.  Replantation
 Toe to hand transfer
 Prosthesis
 Nonmicrosugrical techniques for minimum optimal
function

35.  Hand with amputation of all fingers proximal to
functional level, with or without thumb amputation

36.  Immediate management
 Resuscitation, dealing life threatening injuries,
preserving amputated digits
 Assessment
 Initial operation
 Debridement with preserving all viable structures
 Avoid shortening of structures
 Cauterization and pull & cut method for nerves avoided
 Tag all structures

37.  Function decreases by 50% if amputation is proximal
to PIP, 100% loss if proximal to MCPJ
 Great toe, trimmed great toe, great toe wrap around
flap, pulp flap or second toe flap
 Additional bone graft interpositioning between
transferred toe and metacarpal or distraction
lengthening

38.  Proximal or distal amputations( related to insertion of
FDS)
 Partial toe flap(including either DIP or PIP & DIP) for
distal amputations
 More proximal injury; whole second toe transfer
 Adjacent or separate 2 toe transfer
 Ulnar 2 fingers: strong hook grip
 Radial: tripod pinch

39.  Type 1A: 2 separate toes or combined 2nd & 3rd or 3rd & 4th
toe transfer
 type1B: combined 2nd & 3rd toe transfer
 Type 1C: same as other two types
 Type 2 injuries:
 reconstruction of fingers similar as in type 1
 If thenar muscles intact(IIA & IIB); one stage
reconstrcution of thumb and fingers
 If thenar muscles damaged, thumb recon delayed until
finger function is achieved, prosthesis for later thumb
position

41.  Retrograde dissection in 1st webspace, identification of
dominant pedicle (70% FDMA, 20% FPMA, 10% both)
 Identifying venous system, lazy S incision, at least one
sizeable vein from venous plexus of intermediate layer
 preservation of length of all structures

42.  Cruciate incision of recipient site
 Webspace incision stay in midline, proximal V incision
 Avoid scars in weight-bearing areas
 Skin grafts discouraged, primary closure is better

43.  Parallel intraosseous wires; require 0.5cm of bone, good
union, correct post-op malalignment or malrotation
 Extensor tendons reconstructed 1st, then flexors
 K wire is place in DIP and PIP for fixation in extension
position
 Nerve repair in next step(dorsal digital with peroneal;
superficial with deep branches)
 Arterial anastomosis
 Keep arteries in back-up when in difficulty
 Venous anastomosis
 Skeletonization of NVB
 Skin closed

44.  Trimmed great toe

46. A dorsal S incision on
dorsum of foot
expose donor veins,
extensor mechanism & arterial
pedicle
retrograde dissection in 1st
webspace
Plantar dissection begins
with midline incision, avoiding
the weight-bearing areas of
foot
expose digital nerves and
flexor tendon

47.  Specially for soft tissue loss but with intact skeleton
 Same technique as in trimmed great toe
 Disarticulation at IPJ
 Flap degloved over the toe skeleton including only
distal phalanx

48. •Markings on lateral
aspect of great toe
•Rich nerve supply
•Includes both
branches of DPN
and digital nerve
proper
•Proper digital artery

49. Surface markings on the donor
foot, showing FDMA & suitable
vein
Harvested toes with artery, veins,
nerves, and tendons

50. Combined second- and third-toe
flap
harvested as transmetatarsal
transfer for reconstruction of a
metacarpal hand
Reconstructed hand
primary closure of all wounds
without tension

51. For adjacent finger defects and larger thumb or palm defects
sensate flap

52.  Microvascular ICU,close monitoring for 5 days
 Keep patient warm, pain free and well hydrated
 Nursing
 Flap monitoring:
 Internal implantable Doppler, pulse oximetry, infrared
temperature assessment
 Clinical observation
 Any doubt: rapid action
 Slight hand elevation
 Non-bulk,non-constricting dressing
 Intraoperative dextran, continuous post-op fluid infusion
 Oral aspirin: for 2 week post-op

53.  Collaboration
 5 staged rehabilitation program
Protective stage(days 1-3)
 Pt & hand therapist
Early mobilization stage(day 4 to 4week)
 Bone-union via immobilization of osteosynthesis site
 Prevent joint stiffness by:
 Passive movement distal to union site(day4 to 2 weeks)
 Passive movement proximal to union site(at 4 weeks)
 Any malalignment/malrotation corrected; splinting
between exercises

54. Active motion stage(5-6 weeks)
 Active mobilization, scar management
 Splint(block or dynamic
 Non-weight bearing
Activities of daily living training stage (7-8 weeks)
 Educate about daily activities, sensory education
Prevocational training(8 weeks onwards)
 Return to work, Occupational capabilities
 Night splint for a year(in extension, prevents clawing)

55.  Both objective & subjective
 Early:
 learning light touch,pressure,localization,pin prick,
static & moving 2 point discrimination tests
 Late:
 Delayed retraining of central cortical function
 Memory,cncentration,relearning
 Touching objects blindly & non-blinded

56.  Vascular compromise
 Arterial spasm,thrombosis
 Release sutures, local application of lidocaine,fluid
optimization
 Re-exploration, additional anastomosis
 Repeat transfer of toe to hand
 Venous congestion
 Wound healing problems
 Skin flap necrosis
 Neuroma in donor area

57.  For functional improvement:
 Flexor tenolysis
 Arthrodesis
 Web-space deepening
 For aesthetic improvement:
 Pulp plasty
 Scar revision
 Flap thinning