Continually Updated Clinical Reference
 
 
  All Sources     eMedicine     Medscape     Drug Reference     MEDLINE
 
eMedicine - Thumb Reconstruction : Article by

Quick Find
Authors & Editors
Introduction
Indications
Relevant Anatomy
Workup
Treatment
Complications
Outcome and Prognosis
Multimedia
References




Patient Education
Click here for patient education.


AUTHOR AND EDITOR INFORMATION

Section 1 of 10 Click here to go to the next section in this topic  

Author: Reuben A Bueno, Jr, MD, Assistant Professor, Department of Surgery, Division of Plastic Surgery, Coordinator of Pediatric Plastic Surgery, Southern Illinois University School of Medicine; Consulting Staff, SIU Physicians and Surgeons, Inc

Reuben A Bueno, Jr, is a member of the following medical societies: American Association for Hand Surgery, American Society for Surgery of the Hand, and American Society of Plastic Surgeons

Coauthor(s): Bradon J Wilhelmi, MD, Endowed Leonard Weiner, MD, Professor and Chief of Division of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine

Editors: Joseph E Sheppard, MD, Director of Hand and Upper Extremity, Associate Professor, Department of Orthopedic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Author and Editor Disclosure

Synonyms and related keywords: thumb injury, hand injury, toe-to-thumb transfer, toe to thumb transfer, thumb replantation, thumb reconstruction, osteoplastic thumb reconstruction, Moberg flap, Littler neurovascular island flap, kite flap, dorsal metacarpal artery flap, microvascular toe transfer flap, wraparound flap, toe-to-hand transfer, toe to hand transfer, phalangization, pollicization, pouce flottant thumb, Blauth type IV, Blauth type 4, congenitally absent thumb, Blauth type V, Blauth type 5, thumb amputation, toe amputation

INTRODUCTION

Section 2 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

The thumb plays an important role in hand function. Daily tasks involving pinch, grip, grasp, and precision handling are more easily accomplished with an opposable thumb. Traumatic loss, congenital absence, or hypoplasia diminishes or eliminates the thumb's prehensile abilities and may affect overall hand function.

History of the Procedure

Attempts to restore thumb function were recorded as early as 1874, when Huguier reported on the "phalangization" of the thumb metacarpal, which was carried out by deepening the first web space.1 In 1900, Nicoladoni described a reconstruction procedure following traumatic amputation of the thumb in which a staged, pedicled transfer of the great toe was performed.2 Development of microsurgical techniques allowed successful transfer of a toe to a thumb in monkeys in 1965 and in a human in 1966.3, 4

Reports of technical refinements in the toe-to-thumb transfer subsequently appeared in the literature.5, 6 Congenital absence of the thumb from thalidomide exposure provided experience with index finger pollicization for thumb reconstruction.7 (See also the eMedicine articles Digital Amputations, Principles of Microsurgery, and Hand, Finger Nail and Tip Injuries.)

Problem

Congenital absence or traumatic injury to the thumb, resulting in a loss of its prehensile ability, significantly affects hand function.

Etiology

Traumatic loss, congenital absence, or hypoplasia of the thumb may result in a need for thumb replantation.


INDICATIONS

Section 3 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Restoration of the 5 components of thumb function described by Littler—stability, strength, mobility, sensibility, and posture—should serve as the basis for any reconstructive plan.8 Consideration of these components and how they relate to each other allows a functional approach to the thumb deficit that guides the reconstructive hand surgeon. The goals of thumb reconstruction, as outlined by Heitmann and Levin, consist of the following9:

  • Sensate and nontender thumb tip
  • Stability at the interphalangeal (IP) and metacarpophalangeal (MCP) joints
  • Adequate strength to resist the forces of the fingers
  • Correct posture and positioning of the thumb with a wide webspace
  • Mobility of the carpometacarpal (CMC) joint with intrinsic muscles to aid prehension

Whether an indication for surgery is related to injury or congenital malformation of the thumb, the ultimate goal is optimal function of the hand. Pinch, fine manipulation, and power grip depend to some extent on stable, sensate skin in the pulp and a functional IP joint. The power grip is enhanced by the strength and mobility of the thumb, which in turn are largely defined by the integrity of the intrinsic and extrinsic musculature, as well as by the functionality of the CMC joint.10, 11

Selecting the most appropriate technique for thumb reconstruction depends on multiple factors, including the following:

  • Level of injury
  • Status of the remaining hand
  • Presence or absence of the thenar musculature
  • Age, occupation, overall health, and functional demands of the patient

In addition, the indication for surgery varies not only with the patient's needs and desires, but also with age, gender, and general health. The level of injury is among the most important factors to consider in deciding on the most appropriate reconstructive strategy. Kleinman and Strickland described a useful classification system, dividing the thumb into thirds: the distal phalanx, the proximal phalanx, and the metacarpal segment.12

The successful replantation of an amputated thumb restores the appearance of and some function to the injured hand. The procedure yields high satisfaction rates, whereas the functional outcome of other reconstructive methods tends to be less rewarding.


RELEVANT ANATOMY

Section 4 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

The thumb's arterial supply is provided mainly through the terminal branch of the radial artery, the princeps pollicis. This artery crosses the first intermetacarpal space to run on the volar aspect of the MCP joint, where it divides into the ulnar and radial collateral arteries. The ulnar collateral artery is usually larger than the radial collateral artery, and it is often easier to repair during replantation. The median nerve and the superficial radial nerve supply sensation to the palmar skin and to the dorsal side of the thumb, respectively.


WORKUP

Section 5 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Imaging Studies

  • In cases of traumatic injury to the thumb, radiographs should be obtained to determine the presence of fracture and to assess the quality of the IP, MCP, and CMC joints.
  • In evaluating a child with a congenital malformation of the thumb, radiographs should be obtained to determine the presence or absence of the bones of the thumb, the position of the bones, the quality of the joints, and the presence of any other bony abnormalities.


TREATMENT

Section 6 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Surgical Therapy

The goal of thumb reconstruction is to restore function, as well as to provide the hand with an acceptable appearance and to keep donor-site morbidity to an acceptable level. The level of amputation determines the reconstruction plan. The predicted outcome of surgery generally favors reconstruction when an amputation has occurred distal to the MCP joint and has therefore left the first web space, as well as the thenar muscles (including their insertions), preserved.

Preoperative Details

Thorough discussion with the patient and the patient's family is necessary prior to surgery to set realistic expectations for the restoration of thumb function. Despite a successful reconstruction, the thumb may never return to a pre-injury level of function. The patient and surgeon should be aware of this possibility. Similarly, in the child born with a hypoplastic or absent thumb, the reconstructed thumb will never be the same as the contralateral, nonaffected thumb. Parents must recognize this fact when thumb reconstruction is performed.

Intraoperative Details

Distal-third amputations

Although technically challenging because of the size of vessels that are distal to the IP joint, successful replantation of the thumb tip restores length, glabrous skin, and the nail. These components, combined with the return of sensibility, maximize thumb dexterity and function.13 In cases in which replantation is unsuccessful or is not desirable, healing by secondary intention, skin grafting, revision amputation, or local flaps are options for wound coverage. Partial or complete thumb amputation distal to the IP joint has been described as "compensated amputation" because functional impairment may be minimal.14, 15

Local flap options include the following:

  • Moberg flap - The Moberg flap allows advancement of volar skin of up to 1.5 cm in order to provide stable, sensate skin. The flap is raised at the level of the flexor tendon sheath in a distal-to-proximal relation to the MCP flexion crease and includes the 2 volar neurovascular pedicles.16 Use of this flap may lead to stiffness or flexion contracture at the IP joint (see Images 1-12).
  • Littler neurovascular island flap - This flap, popularized by Littler, supplies sensate, glabrous skin from the ulnar side of the long or ring finger to the volar aspect of the thumb (see Images 13-16).17 Problems with cortical reintegration and cold intolerance have been reported and have led to the decreased use of this flap for thumb reconstruction.
  • First dorsal metacarpal artery flap - Also known as the kite flap, this is another reconstructive option that can bring sensate skin to the injured thumb.18 The flap, which uses the first dorsal metacarpal artery for its blood supply, employs skin from the dorsal-radial aspect of the index finger (see Images 17-21). Pedicle length may limit this flap's use for distal thumb defects. As with the Littler neurovascular island flap, cortical reintegration may be an issue with the first dorsal metacarpal artery flap.

A microvascular toe transfer, or wraparound flap, is the most sophisticated reconstructive option for amputation injuries to the thumb (see Images 22-24). Since the technique allows restoration of a near-normal pulp and nail, it also provides the best functional results.5

Middle-third amputations

When the level of injury is distal to the MCP joint and proximal to the IP joint, length preservation becomes more of an issue because of the effect that a shorter thumb has on pinch and grip strength. Prior to the era of microsurgery, treatment options included phalangization (ie, deepening of the first web space) and osteoplastic reconstruction.1, 19

Additional length for the thumb stump can be obtained using the following methods:

  • Placement of a distraction device on the thumb metacarpal after osteotomy, with gradual lengthening14
  • Four-flap Z-plasty to deepen the first web space20
  • Release of the first interosseous muscle and proximal transfer of the insertion of the adductor pollicis21, 22

Osteoplastic thumb reconstruction offers a staged approach involving the placement of an iliac crest bone graft within a tubed pedicle flap from the groin or epigastric area and subsequent flap division to provide a stable, reconstructed thumb with some gain in length.19 A neurovascular island flap may be necessary to bring sensate tissue to the reconstructed thumb at the time of flap division.23 However, nonmicrovascular techniques have not been widely used because they can result in an unsatisfactory appearance, a lack of sensation, difficulty with cortical reintegration, and bone graft resorption.

Microsurgical techniques for toe-to-hand transfer have revolutionized the treatment of thumb amputations at the middle or third level by restoring stability, mobility, strength, and sensation, as well as by providing good appearance. By allowing the transfer of functioning units that are analogous to the lost structures, microvascular reconstruction generally provides results that are functionally and aesthetically superior to those of other techniques. The first dorsal metatarsal artery in the foot allows transfer of the great toe or second toe on a longer vascular pedicle than does a transfer based on a digital artery. The reconstructive surgeon should be aware of variations in the arterial supply to these toes.24

The wraparound flap, introduced by Morrison, offers the advantage of generally better aesthetics than does a classic toe-to-hand transfer.5 In the wraparound flap, a filleted flap of skin, digital nerves and vessels, and a nail is wrapped around a degloved distal phalanx or an iliac crest bone graft. This technique allows better size match to a normal thumb, although motion at the IP joint is not restored. The trimmed toe flap is a modification of the wraparound flap; described by Wei and colleagues, the trimmed toe flap preserves some IP joint motion by combining a longitudinal osteotomy of the phalanges with a reconstruction of the lateral collateral ligament.25

Proximal-third amputations

Reconstruction becomes more difficult, but also more important, when a thumb amputation has occurred proximal to the MCP joint.26 Reconstructive options to restore thumb function include the transfer of the second toe to the thumb or pollicization of the index finger. A second-toe transfer can restore more length than a great toe transfer can by including the MCP joint and a segment of the second metatarsal.27 A second-toe transfer is also indicated when a significant size discrepancy exists between the great toe and the thumb or when a patient does not want to lose the great toe for aesthetic, cultural, or functional reasons.28 In patients with traumatic amputation of the thumb, other digits in the hand, such as the index or long finger, also may be injured or amputated. These "spare parts" may then be transferred to the thumb stump for reconstruction.29

With a more proximal amputation, one resulting in the loss of intrinsic muscles and the destruction of the CMC joint, pollicization of another finger to restore thumb function and opposition may be the only option to offer.19 The index finger is the most commonly pollicized digit, although the long and ring fingers have been used.30, 31, 32 The transposed finger provides length, sensation, proper positioning, and motion for grasp and pinch functions, with acceptable donor-site deficits (although retraining may be difficult in an adult patient).33, 34

Congenital absence

The deficit from a proximal-third amputation most closely resembles that of a congenitally absent thumb (a Blauth type V thumb). However, the distinction between a normal thumb that has been amputated and congenital aplasia or hypoplasia of the thumb must be recognized. Normal structures were present in the amputated thumb prior to injury, whereas in thumb aplasia or hypoplasia, bone, tendons, nerves, and vessels may be poorly developed or completely absent (see Images 25-27). For these reasons, pollicization of the index finger is recommended for reconstruction of the congenitally absent thumb (see Images 28-29).7 (See also the eMedicine article Hand, Congenital Hand Deformities.)

The principles of pollicization are as follows:

  • Well-designed skin incisions to reduce scar contracture in the first web space
  • Careful dissection of the neurovascular bundles to the index finger
  • Shortening of the index metacarpal to achieve the desired thumb length
  • Proper positioning of the thumb with hyperextension of the proximal phalanx on the metacarpal head
  • Anchoring of the pollicized digit to the distal carpus
  • Tendon reconstruction, including transfer of the first palmar and dorsal interosseous muscles to the lateral bands of the index finger to provide abduction and adduction, respectively7
  • Final stabilization and positioning with appropriate tension of transferred tendons


COMPLICATIONS

Section 7 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Sequelae to finger trauma may include edema, hypertrophic scarring, nail deformity, cold intolerance, abnormal sensitivity, joint stiffness, and generally decreased function. Complications that are directly related to reconstructive surgery include postoperative bleeding, infection, anesthesia-related problems, complex regional pain syndrome, and the loss of a skin flap, a replanted or transferred part, or a pollicized digit.


OUTCOME AND PROGNOSIS

Section 8 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

As reported by Buncke and others, toe-to-hand transfer for thumb reconstruction can provide excellent end results and a high degree of patient satisfaction.35 The survival rate of these transfers has been reported to be as high as 98%, with 2-point discrimination of 8 mm or less in 80% of cases and, following reconstruction of the dominant thumb, a grip strength that is equal to 80% of the noninjured hand's grip strength.

In addition, most patients who have undergone toe-to-thumb transfer return to work and resume previous leisure activities, leading to a high degree of patient satisfaction. These findings are supported by Chung and Wei, who found better hand function in patients with toe-to-thumb transfer than they did in patients with a thumb amputation.36

In his review of index finger pollicizations employed to treat the congenital absence of a thumb, Manske found that patients had an average active range of motion of 98º in the pollicized digit (half the range of a normal thumb). He also determined that the average grip strength among these patients was 21% of normal grip strength and that their pinch strength ranged between 22% and 26% of normal pinch strength. Although these values are significantly lower than normal, they still indicate that index finger pollicization provides functional and aesthetic improvements over an absent thumb.37


MULTIMEDIA

Section 9 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic  

Media file 1:  Diagram of a Moberg volar advancement flap being used for a thumb tip defect.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 2:  Marking for the radial incision of a Moberg flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 3:  Moberg flap raised just above the level of the flexor pollicis longus tendon sheath.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 4:  Markings for a volar advancement flap with modification of the incision at the base to allow closure in V-Y fashion after distal phalanx shortening.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 5:  Radial view of the markings for a volar advancement flap with modification of the incision at the base to allow closure in V-Y fashion after distal phalanx shortening.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 6:  Volar advancement flap with modification of the incision at the base to allow closure in V-Y fashion after distal phalanx shortening.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 7:  Thumb tip defect that is amenable to closure with a Moberg volar advancement flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 8:  Incision marking for a Moberg flap. The neurovascular bundle should be kept with the volar advancement flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 9:  Bridging vessel to the neurovascular bundle on a volar flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 10:  Flexion at the interphalangeal joint to allow closure.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 11:  Volar view of the closure of a thumb defect with a Moberg volar advancement flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 12:  Radial view of the closure of a thumb defect with a Moberg volar advancement flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 13:  Diagram of a Littler neurovascular island flap for the coverage of a thumb tip defect.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 14:  Intraoperative view of a Littler neurovascular island flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 15:  Postoperative view of a Littler neurovascular island flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 16:  Second postoperative view of a Littler neurovascular island flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 17:  Markings for the pedicle of a first dorsal metacarpal artery flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 18:  Dissection for a first dorsal metacarpal artery flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 19:  Isolation of the pedicle for a first dorsal metacarpal artery flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 20:  Postoperative appearance of a thumb tip after coverage with a first dorsal metacarpal artery flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 21:  Second view of the postoperative appearance of a thumb after coverage with a first dorsal metacarpal artery flap.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 22:  Free tissue transfer of great toe pulp to restore a volar thumb defect.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 23:  Markings for a free tissue transfer of great toe pulp to restore a volar thumb defect.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 24:  Postoperative view after a free tissue transfer of great toe pulp to restore a volar defect.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 25:  Dorsal view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 26:  Volar view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 27:  Radiograph of a pouce flottant thumb
Click to see larger pictureClick to see detailView Full Size Image
Media type:  X-RAY

Media file 28:  Pollicized index finger for thumb reconstruction at 2 weeks after surgery.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 29:  Functional use of a pollicized index finger at 8 weeks after surgery.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo


REFERENCES

Section 10 of 10 Click here to go to the previous section in this topic Click here to go to the top of this page

  1. Huguier PC. Du remplacement du pouce par son metacarpien, par l'agrandissement du premier espace interosseux. Arch Gen Med. 1874;1:78.
  2. Nicoladoni C. Daumenplastik und organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplstik). Arch Klin Chir. 1900;61:606-14.
  3. Buncke HJ Jr, Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascular anastomoses. Br J Plast Surg. Oct 1966;19(4):332-7. [Medline].
  4. Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. Nov 1969;51(4):677-9. [Medline]. [Full Text].
  5. Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am]. Nov 1980;5(6):575-83. [Medline].
  6. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg. Feb 1994;93(2):345-51; discussion 352-7. [Medline].
  7. Buck-Gramcko D. Pollicization of the index finger. Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am. Dec 1971;53(8):1605-17. [Medline].
  8. Littler JW. On making a thumb: one hundred years of surgical effort. J Hand Surg [Am]. Jul 1976;1(1):35-51. [Medline].
  9. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg. Nov 2002;110(6):1492-503; quiz 1504-5. [Medline].
  10. Littler JW. On the adaptability of man's hand (with reference to the equiangular curve). Hand. Oct 1973;5(3):187-91. [Medline].
  11. Napier JR. The prehensile movements of the human hand. J Bone Joint Surg Br. Nov 1956;38-B(4):902-13. [Medline]. [Full Text].
  12. Kleinman WB, Strickland JW. Thumb reconstruction. In: Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1999:2068-170.
  13. Morrison WA. Thumb reconstruction: a review and philosophy of management. J Hand Surg [Br]. Aug 1992;17(4):383-90. [Medline].
  14. Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg [Am]. Sep 1980;5(5):482-7. [Medline].
  15. Woo SH, Lee GJ, Kim KC, et al. Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb. Plast Reconstr Surg. May 2006;117(6):1906-15. [Medline].
  16. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am]. Jun 1964;46:817-25. [Medline].
  17. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg. 1956;38A:917.
  18. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast Surg. Jan 1997;24(1):1-32. [Medline].
  19. Lister G. The choice of procedure following thumb amputation. Clin Orthop Relat Res. May 1985;(195):45-51. [Medline].
  20. Broadbent TR, Woolf RM. Thumb reconstruction with contiguous skin-bone pedicle graft. Plast Reconstr Surg. 1960;26:494-49.
  21. Emerson ET, Krizek TJ, Greenwald DP. Anatomy, physiology, and functional restoration of the thumb. Ann Plast Surg. Feb 1996;36(2):180-91. [Medline].
  22. Goldner RD, Howson MP, Nunley JA, et al. One hundred eleven thumb amputations: replantation vs revision. Microsurgery. 1990;11(3):243-50. [Medline].
  23. Reid DA. Reconstruction of the thumb. J Bone Joint Surg Br. Aug 1960;42-B:444-65. [Medline]. [Full Text].
  24. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller AI, Strauch B, eds. Symposium on Microsurgery. St Louis, Mo: CV Mosby; 1976.
  25. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg. Sep 1988;82(3):506-15. [Medline].
  26. Shin AY, Bishop AT, Berger RA. Microvascular reconstruction of the traumatized thumb. Hand Clin. May 1999;15(2):347-71. [Medline].
  27. Leung PC. Thumb reconstruction using second-toe transfer. Hand Clin. May 1985;1(2):285-95. [Medline].
  28. Valauri FA, Buncke HJ. Thumb and finger reconstruction by toe-to-hand transfer. Hand Clin. Aug 1992;8(3):551-74. [Medline].
  29. Weinzweig N, Chen L, Chen ZW. Pollicization of the mutilated hand by transposition of middle and ring finger remnants. Ann Plast Surg. May 1995;34(5):523-9. [Medline].
  30. Letac R. Pollicization of the ring finger. J Int Coll Surg. Dec 1954;22(6, Part 1):649-55. [Medline].
  31. Littler JW. Reconstruction of the thumb in traumatic loss. In: Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1977.
  32. Reid DA. Thumb reconstruction in the mutilated hand with special reference to pollicization. In: Campbell Reid DA, Gosset J, eds. Mutilating Injuries of the Hand. New York, NY: Churchill Livingstone; 1979.
  33. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin. Feb 1992;8(1):41-55. [Medline].
  34. Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop Relat Res. Mar-Apr 1981;(155):85-94. [Medline].
  35. Buncke HM, Valauri FA, Buncke GM. Great toe-to-hand transfer. In: Meyer VE, Black MJ, eds. Microsurgical Procedures: The Hand and Upper Limb. New York, NY: Churchill Livingstone; 1991.
  36. Chung KC, Wei FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg [Am]. Jul 2000;25(4):651-8. [Medline].
  37. Manske PR, Rotman MB, Dailey LA. Long-term functional results after pollicization for the congenitally deficient thumb. J Hand Surg [Am]. Nov 1992;17(6):1064-72. [Medline].
  38. American Medical Association. Guides to the Evaluation of Permanent Impairment. 4th ed. Chicago, Ill: American Medical Association; 1993.
  39. Cheng G, Fang G, Hou S, et al. Aesthetic reconstruction of thumb or finger partial defect with trimmed toe-flap transfer. Microsurgery. 2007;27(2):74-83. [Medline].
  40. Cong HB, Chang SM, Qiao YP, et al. One-stage reconstruction of complicated thumb injury with combination of microsurgical transplantations. Microsurgery. 2007;27(3):181-6. [Medline].
  41. Flatt AE. The Care of Congenital Hand Anomalies. 2nd ed. St Louis, Mo: Quality Medical Pub; 1994.
  42. Gossett J. La pollicisation de l'index (technique chirurgicale). J Chir. 1949;65:403.
  43. Matev IB. Reconstructive Surgery of the Thumb. Brentwood, Essex, England: Pilgrims Press; 1983.
  44. Ozkan O, Chen HC, Mardini S, et al. Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step. Microsurgery. 2006;26(2):100-5. [Medline].
  45. Winspur I. Single-stage reconstruction of the subtotally amputated thumb: a synchronous neurovascular flap and Z-plasty. J Hand Surg [Am]. Jan 1981;6(1):70-2. [Medline].

Thumb Reconstruction excerpt

Article Last Updated: Nov 29, 2007