Thumb Reconstruction Flashcards by M A

The minimum length for acceptable thumb function

is at
the interphalangeal joint

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selection ofsensate flaps is essential.

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position ofthe thumb axis
at the trapeziometacarpal (TM) joint, which is pronated and flexed
with respect to the other metacarpals.

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Opposition is the result of wich muscle

abductor pollicis brevis, opponens pollicis, and superficial head of the flexor pollicis brevis flexing
and rotating the TM and metacarpophalangeal (MP) joints simultaneously.

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The abductor pollicis brevis inserts on the radial sesamoid and radial base of the proximal phalanx

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In proximal transmetacarpal thumb injuries, patients may still able to do apposition how ?

the opponens pollicis, which inserts on the volar-radial aspect of the thumb metacarpal, may still provide some opposition function
at the TM joint

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secondary opposition transfer may be
required after reconstruction to maximize thumb function in proximal injuries

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Speacial view for evaluation of the
TM joint

Roberts view for evaluation ofthe
TM joint)

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Advanced imaging (computerized axial tomography, magnetic resonance imaging) is t indicated in the evaluation of acute injuries

F Advanced imaging is not indicated in the evaluation of acute injuries but
maybe helpful in patients presenting with complicated injuries for secondary reconstruction.

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overall goal of thumb reconstruction is to maximize hand
function

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The
goals of reconstruction creating a thumb with adequate length, with optimal mobility
and/or position for opposition, and with a sensate, painless tip

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The minimum required length for a functional thumb is at the level of
the IP joint. An amputation at this level decreases the function of the
thumb by 50%

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Thumb amputations at or distal
to the IP joint do not necessarily require additional length or bony
reconstruction

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In injuries distal to the MP joint, the majority of thumb mobility will be maintained, and the goals of length and sensibility will take precedence

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In injuries proximal to the MP joint Secondary opposition transfers may
be required to maximize the function

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Thumb injuries without a
functional TM joint require a reconstructive procedure to create a
neo-TM joint (e.g., pollicization) or the creation of immobile post

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Lister’s scheme depend on the two main issues to be addressed in reconstructing a thumb

a thumb-length and soft tissue coverage

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no need for normal sensibility in Dorsal soft tissue

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First webspace deepening may
improve functional length
in distal proximal phalanx
injuries

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Amputation distal to the MP joint
but inadequate length

Bone and soft tissue
reconstruction must restore
minimal functional length

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Amputation proximal to the MP
joint but preserved TM join we can use great toe transfer

F
■ Second toe transfer
■ Osteoplastic reconstruction
■ Distraction lengthening
■ Pollicization/on-topplasty

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Pollicization standard option
for the TM joint and thumb
reconstruction

T with Second-toe transfer with
TM fusion

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Significant volar soft tissue loss with exposed bone or tendons require
sensate and durable reconstruction. Local, regional, and microvascular
flaps

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A proximal transverse incision at the MCP flex.ion crease, leaving the neurovascular bundles
intact, provides greater advancement up to 2 cm in mOberg flap

T but requires a skin
graft in the donor site

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IP joint flex.ion is frequently required to get complete distal coverage and patients may be left with a residual IP joint contracture

Foucher or kite flap include all of the dorsal skin and soft tissue between the MCP and PIP joints ofthe index finger

This flap is reliable and provides a significant amount oftissue for large defect

The static two-point discrimination {s2PD) of the dorsal index finger is 10 decrease 2 by transfer the flap

The static two-point discrimination {s2PD) of the dorsal index finger is 12 to 15 mm and this sensibility is maintained in the standard flap design

Patients may have double-sensitivity, experiencing sensation in the dorsal index finger when using the thumb

however, all patients are able to cortically reorient over time

F however, some patients are able to cortically reorient over time

divide the radial nerve branches proximally and perform a neurorrhaphy to the proper digital nerves of the thumb to restore normal cortical function and this may improve s2PD to 8 mm

limitation of this flap

double-sensitivity The flap cannot reach the tip of the volar aspect of the thump unless thump adducted and flexed conspicuous donor site

A cross-finger flap from the dorsal aspect of the index finger is another option for distal thumb coverage

The flap is designed over the proximal phalanx of the index finger and raised in the standard fashion with the donor site covered by a full thickness skin graft.

flap from the dorsal middle phalanx of the index or long finger has also been reported

sensory recovery of the cross finger flap is excelnt

F is variable and ranges between poor {>12 mm s2PD) and normal ( <6 mm s2PD) sensation, and can take more than a year for the final outcome.

sensory recovery can be improved by branches of the superficial radial nerve can be isolated during proximal flap dissection and pedicled during flap inset or these nerves can be divided and neurorrhaphy performed to the digital nerves of the thumb

this flap has the advantage of being easily executed

limit the routine use of this technique

the donor site morbidity, need for two operations, and potential index finger and thumb stiffness due to prolonged immobilization"

The Littler flap22 is a flap transferred from the ulnar aspect of the middle finger or radial aspect of the ring finger to the thumb tip

The flap is harvested from the hemipulp of the respective finger and transferred on the neurovascular pedicle after dissection through the palm

The donor site is leave to secondary intension

The donor site is covered with a skin graft

Due to the inclusion of the donor digital nerve, most patients have s2PD <8 mm but suffer from double-sensitivity

Hoe you can improve the cortical orientation ?

Division of the nerve and coaptation to the thumb digital nerves result in minimal loss in s2PD (<10 mm) but better cortical integration.

This flap is commonly used?

Due to the issues with donor site morbidity, significant dissection in the palm, and poor cortical reorientation, routine use of this flap should be limited to use in combination with other methods for subtotal thumb reconstruction as discussed later

Microsurgical reconstruction of distal thumb soft tissue defects has the advantage of transferring sensate soft tissue to the thumb while limiting morbidity to the already injured hand

The most common method i

free toe-pulp flap taken from the lateral great toe, though the second toe is an alternative donor site

static 2PD <15mm can be achieved

F static 2PD <5 mm can be achieved

Osteoplastic Reconstruction options

The classic description is an iliac crest bone graft and a pedicled groin flap either in separate (flap followed by graft) or in the same operation posterior interosseous osteocutaneous and radial forearm osteocutaneous flaps are alternative single stage options

this approach does not provide sensibility to the reconstructed thumb so hoe you can provide sensibility?

often augmented with a heterodigital neurovascular island flap at a later operation.

Limitation of osteoplastic reconstruction

the bulky appearance, bone graft resorption, need for multiple stages, and issues with double sensitivity limit the use of this procedure

One stage sensate osteoplastic reconstruction has been reported

Though these operations do not require microvascular anastomosis, the complexity of the dissection is significant and provides inferior results compared to microsurgical techniques

microsurgical options exist for proximal phalanx amputations

Sensate osteocutaneous free flaps such as the radial forearm, lateral arm, or superficial circumflex iliac artery flaps toe-to-thumb transfers

Limitation of osteocutaneous free flaps

require secondary debulking

the advantage of toe-to-thumb transfers

single-stage reconstruction and can be tailored to optimally restore a functional and aesthetic thumb

Amputation Through the Metacarpal but With a Preserved TM Joint secondary opposition transfers may be required to optimize its function

Amputation Through the Metacarpal but With a Preserved TM Joint secondary regional flaps or free tissue transfer may be required in injuries that compromise the first webspace

Osteoplastic reconstruction and distraction lengthening may be options for distal metacarpal amputations

Distraction lengthening requires that the majority of the metacarpal remains for placement of the external fixator.

maximum amount of length gained IS 5 CM

F 3 CM

In proximal metacarpal amputations, osteoplastic reconstruction and distraction lengthening can also be applied

In proximal metacarpal amputations, osteoplastic reconstruction and distraction lengthening are most successful in combination with other methods such as transfer of an injured index finger ray or microsurgical toe-transfer.

The transfer of an adjacent finger to the thumb position on its intact neurovascular pedicle is called a pollicization

When transferring a partial digit to add length to the reconstructed thumb, the term on-top-plasty

with a fully functioning index finger, loss of grip strength and the resulting three-finger hand provide inferior results when compared to toe-transfer.

On-top-plasty indication

toe-transfer is contraindicated due to comorbidities or the patient's wishes. It may also be a useful adjunct to add length to the proximal thumb in combination with toe-transfer techniques

Toe-to-thumb transfer represents the standard of reconstruction for complete thumb amputations proximal to the MP joint.

In distal transmetacarpal injuries, great toe and second toe transfers can provide adequate length and function.

in more proximal injuries, transfer of the great toe is t an option

F in more proximal injuries, transfer of the great toe is not an option due to the need to preserve the entire first metatarsal

Transfer of the great toe in these cases will require adjunctive procedures to add metacarpal length in combination with toe-transfer

Amputation With Destruction of the TM Joint options

creation of a stable post first webspace and may requireregional or free tissue transfer procedures

Vascularized soft tissue augmentation at the base of the thumb or in the first webspace may be required

Children accommodate extremely well to pollicization in congenital and traumatic cases

adults may require a prolonged period of retraining and secondary procedures to optimize the function

Second-toe transfer has been used as an alternative to reconstruct these proximal thumb amputations when pollicization is not an option due to injury to the index finger.

As much as 5 cm of the second metatarsal may be required to provide adequate length

The blood supply from the great toe soft tissue?

All ofthese flaps are based on the blood supply to the first webspace of the foot, usually from the first dorsal metatarsal artery (FDMtA)

One or both of the proper digital nerves and the dorsal nerves are included for neurorrhaphy depending on the flap design

The venous drainage of these flaps is most often the terminal branches of the saphenous vein harvested from the dorsal foot

In Great-Toe Transfer

Flap harvest is limited to the proximal phalanx of the hallux, preserving at least the entire head of the first metatarsal to avoid uneven plantar weight distribution and unsteady gait

With sacrifice of the great toe, there will be some decrease in push-off strength during ambulation

The great toe will appear as a short and broad thumb but has excellent functional outcomes.

The wrap-around toe-transfer is a modification of the great toe flap what is it advantage ?

preserve all or most of the hallux to avoid donor site morbidity and create a more normal size and contour to the reconstructed thumb. The flap is harvested as an onychocutaneous flap and can include a portion of the distal phalanx

wrapped around a degloved thumb or a bone graft as in traditional osteoplastic techniques.

Trimmed Great-Toe Transfer

the medial skin and dissected off the trimmed-toe flap and a longitudinal osteotomy were performed to remove 2 to 4 mm of the medial phalanges and 4 to 6 mm of the medial prominence at the IP joint.

due to the longitudinal osteotomy through the IP joint there is some loss of range of motion.

Second-Toe Transfer advantage ?

The second toe donor site decreases morbidity to the foot relative to sacrifice of the hallux. The second-toe transfer can also include the majority of the second metatarsal allowing for reconstruction of transmetacarpal thumb amputations

Second-Toe Transfer disadvantage ?

the second toe will least resemble a normal thumb in terms of its size and shape. the second toe is prone to clawing with hyperextension of the MP joint and flexion of the IP joint and may require capsular procedures to maximize function

Twisted-Toe Transfer

An osteoonychocutaneous flap similar to a trimmed toe is harvested from the lateral great toe and a cutaneous flap is harvested from the medial second toe. The second toe flap is then twisted on its pedicle to cover the exposed medial aspect of the great toe flap.

The advantages of this flap are the creation of a more normal sized thumb and the donor site closure can recreate a neo-hallux to minimize donor site morbidity

Toe Pulp and Distal Trimmed Toe-Transfer used for

Sensate cutaneous flaps can be harvested from the great and second toes to reconstruct isolated thumb pulp defects & partial tip amputations,

Donor site complications from toe transfers are uncommon

F common. As much as 35% of patients will have some degree of incisional dehiscence or delayed wound healing

When the MP joint of the hallux is preserved, both great and second toe transfers have some degree of gait changes

patients with great-toe wrap around transfers have demonstrable changes in gait.

the major disadvantage of the greattoe transfer relative to the second-toe transfer

is the change in appearance of the foot and the effect on future footwear (e.g., inability to wear sandals). The twisted-toe technique may minimize these donor site issues

Functional outcomes of toe-transfer techniques are excellent with good ROM

70% to 85% grip strength relative to the contralateral side

static 2PD averaging 10 mm

great-toe transfer will result in a stronger and more stable thumb relative to second toe

when amputations distal to the MP joint are compared, there are no statistically significant differences between techniques Between second and great toe

The decrease in strength seen in some series of second toe transfers may be due to the loss of thenar musculature in proximal amputations where the second toe is required.

For injuries in the proximal metacarpal, the second toe is the best option due to the need for additional bony length

The second toe is also preferred in the middle and distal metacarpal amputations

toe-to-thumb transfer is now the gold-standard as it provides optimal aesthetic and functional outcomes.