Thumb Reconstruction Flashcards
What is the ideal timing of acquired thumb defect reconstruction
- Delayed - to allow pt to determine level of functional disability
- ACute - if exposed PP/avulsed pulp
How do you classify acquired thumb defects?
BY LOCATION
- proximal 1/3 => MC
- middle 1/3
- A- proximal => IP
- B- distal =>PP to DIP
- Distal 1/3 => DP
What are treatment goals and options for acquired thumb defect in distal 1/3 (distal to IP jt)
- ISSUE; soft tissue coverage. Length adeqaute if amputated thorugh IP jt.
- Goal: well padded, sensation, painless. Length can be maintaine, does not need to be increased
TREATMENT OPTIONS
- <50% of DP pulp
- 2’ intention (best 2PD <1.5cm2defect)
- skin graft (FT)
- local flap V-Y
- >50% of DP pulp
- Local flap
- neurovascular island, crossfinger, moberg
- Distant free flap
- toe pulp
- Local flap
- VOLAR defects
- best flap includes cross finger, moberg, neurovasc island littler flap
- DORSAL defects
- best flap is FDMA
What are treatment goals and options for acquired thumb defect in middle 1/3
Split into 2 regions - distal half of PP shaft and DIP)
Goals: maintain/restore length for pinch and grasp
TREATMENT
Phalangization = restoring funcitonal length, no change in absolute length:
- Deepen webspace - require at least half PP, gain 2cm
- If linear scar contracture:
- zplasty, 4 flap zplasty, jumping man (4flap opposing z plasty
-
If broad constracture:
- FTSG, local flap (DMCA, dorsal rotation)
- regional (reverse radial forearm, PIA)
- If linear scar contracture:
What are treatment goals an options for acquired thumb defect in middle 1/3
split into regions - proximal half of PP shaft and MCPjt
GOALS: lengthen bone that is present or add bone and coverage
TREATMENT OPTIONS
- MC lengthening
- On-top plasty (pollicization of injured digit)
- Osteoplastic recon
- Wrap-around toe transfer - all ST, no bone harvest
What are prerequisites for MC lengthening
- at least 2/3rd of MC
- good CMC ROM with no arthritis
- good ST coverage of distal stump
- motivated patient
=> done w web deepenign procedure
=>gain 3-3.5cm
What are principles for MC lengthening
- stable ex-fix
- maintained extraosseous and meduallry blood supply
- 1mm/day distraction rate
- consolidation phase prior to removal
ADVANTAGE
- good sensation to tip, no donor site morbidity, satisfactory cosmesis
DISADVANTAGE
- prolonged course, may get hardware issues/nonunion
What are the steps for osteoplastic reconstruction
Requires functional thenar musculature and CMC jt
OPTIONS (4)
- Reverse radial forearm osteocutaneous flapw LABC n
- Neurocutaneous free flap w ICBG
- Staged ICBG and groin flap and little NV island
- ICBG and ST vascularized coverage with groin flap
- BG secured w plate/screws to remaning PP
- Division of groin flap pedicle @ 2-3wks (also may need debulking procedures)
- Inset of sensory tissue at pulp with neurovascular littler island flap (ulnar D3/4) @ 3-6mths
- ICBG and ST vascularized coverage with groin flap
ADVANTAGES
- sensate pulp, good length restoration
DISADVANTAGE
- multiple procedures, bone resorption, bulkiness
What are treatment goals an options for acquired thumb defect of proximal 1/3 (from metacarpal neck to CMC jt)
ISSUES - loss of length, function and thenar musculature is compromised
GOAL - length restored and function
TREATMENT
- Nonmicrosurgical - Pollicization
- Microsurgical - toe transfer
Describe the principles of whole great toe trasnfer
- Harvest ipsilateral at level of MTPjt. Leave intact MT head.
- A: common digital atery arises from branch of dorsalis pedis (either FDMA or deep plantar a)
- V: VC and superficial dorsal vein
- N: common digital nerve and deep peroneal branch
- Tendons: FHL> FPL, EHL>EPL, EHB>EPB
What are goals of thumb reconstruction?
- Adeqaute length- at least hald of PP
- Sensation
- Strength - based on thenar musculature
- ROM - based on CMC
- Stability
- painless
- Durable cover
What are etiologies of thumb deformities?
CONGENITAL
- Failure of formation
- radial longitudinal deficiency (RLD)->hypoplasia
- transverse arrest
- Failure of differentiation
- symbrachydactyly
- Duplication
- Constriction band syndome
ACQUIRED
- Trauma
- Tumor extirpation
What is the epidemiology of congenital thumb defomrities
- 11% of birth defects
- 50% are duplications
- most sporadic except TRIPHALANGEAL THUMB (AD)
What syndromes are associated with thumb hypoplasia?
- Fanconi (renal tubules)
- Aperts (crnaiofacial)
- Ruberstein Taybi (pseudo hyper paraT)
- Holt-Oram (CVS anomalies)
- TAR (Thrombocytopenia absent radius)
- VACTERL (vertebral, anal, cardiac, TE fistula, Renal, Limb)
When is ideal timing for thumb reconstruction?
- 1-2yr
Because
- 7mths grasp
- 12mths pinch
- 18mths release