eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Thumb Reconstruction

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
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
Contributor Information and Disclosures

Updated: Nov 29, 2007

Introduction

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

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

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.

More on Thumb Reconstruction

Overview: Thumb Reconstruction
Workup: Thumb Reconstruction
Treatment: Thumb Reconstruction
Follow-up: Thumb Reconstruction
Multimedia: Thumb Reconstruction
References
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References

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Further Reading

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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

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Contributor Information and Disclosures

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, MD 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
Disclosure: Nothing to disclose.

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
Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Association of Clinical Anatomists, American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Society of Reconstructive Microsurgery, Association for Surgical Education, Plastic Surgery Research Council, and Wound Healing Society
Disclosure: Nothing to disclose.

Medical Editor

Joseph E Sheppard, MD, Director of Hand and Upper Extremity, Associate Professor, Department of Orthopedic Surgery, University of Arizona
Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Society for Surgery of the Hand, Southern Orthopaedic Association, and Western Orthopaedic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

N Ake Nystrom, MD, PhD, Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

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
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

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