Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Thumb Reconstruction Treatment & Management

  • Author: Reuben A Bueno, Jr, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Feb 23, 2016
 

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.

Next

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.

Previous
Next

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.[15] 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.[16, 1] Partial or complete thumb amputation distal to the IP joint has been described as "compensated amputation" because functional impairment may be minimal.[17, 18]

Local flap options include the following:

  • Moberg flap - The Moberg flap, as shown in the images below, 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. [19] Use of this flap may lead to stiffness or flexion contracture at the IP joint.
    Marking for the radial incision of a Moberg flap. Marking for the radial incision of a Moberg flap.
    Moberg flap raised just above the level of the fle Moberg flap raised just above the level of the flexor pollicis longus tendon sheath.
    Radial view of the markings for a volar advancemen 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.
    Volar advancement flap with modification of the in Volar advancement flap with modification of the incision at the base to allow closure in V-Y fashion after distal phalanx shortening.
    Bridging vessel to the neurovascular bundle on a v Bridging vessel to the neurovascular bundle on a volar flap.
    Flexion at the interphalangeal joint to allow clos Flexion at the interphalangeal joint to allow closure.
    Radial view of the closure of a thumb defect with Radial view of the closure of a thumb defect with a Moberg volar advancement flap.
  • Littler neurovascular island flap - This flap, as shown in the images below, which was popularized by Littler, supplies sensate, glabrous skin from the ulnar side of the long or ring finger to the volar aspect of the thumb. [20] Problems with cortical reintegration and cold intolerance have been reported and have led to the decreased use of this flap for thumb reconstruction.
    Intraoperative view of a Littler neurovascular isl Intraoperative view of a Littler neurovascular island flap.
    Postoperative view of a Littler neurovascular isla Postoperative view of a Littler neurovascular island flap.
  • 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. [21] The flap, as shown in the images below, which uses the first dorsal metacarpal artery for its blood supply, employs skin from the dorsal-radial aspect of the index finger. 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.
    Dissection for a first dorsal metacarpal artery fl Dissection for a first dorsal metacarpal artery flap.
    Isolation of the pedicle for a first dorsal metaca Isolation of the pedicle for a first dorsal metacarpal artery flap.
    Postoperative appearance of a thumb tip after cove Postoperative appearance of a thumb tip after coverage with a first dorsal metacarpal artery flap.
  • A microvascular toe transfer, or wraparound flap, is the most sophisticated reconstructive option for amputation injuries to the thumb, as shown in the images below. Since the technique allows restoration of a near-normal pulp and nail, it also provides the best functional results. [7]
  • A study by Gu et al indicated that the use of free toe flaps is a reliable means of reconstructing finger and thumb soft tissue defects. In the study, six thumbs and 15 fingers were reconstructed in adult patients, with flaps taken from the lateral aspect of the great toe (9 patients) or the medial aspect of the second toe (12 patients); the average follow-up period was 18.4 months. The investigators reported that all of the flaps survived, with none of the patients requiring urgent surgical revision for postoperative thrombosis. Patients scored an average of 4.8 mm on the static two-point discrimination test. [22]
    Free tissue transfer of great toe pulp to restore Free tissue transfer of great toe pulp to restore a volar thumb defect.
    Markings for a free tissue transfer of great toe p Markings for a free tissue transfer of great toe pulp to restore a volar thumb defect.
    Postoperative view after a free tissue transfer of Postoperative view after a free tissue transfer of great toe pulp to restore a volar defect.

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.[3, 23]

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 lengthening [17]
  • Four-flap Z-plasty to deepen the first web space [24]
  • Release of the first interosseous muscle and proximal transfer of the insertion of the adductor pollicis [25, 26]

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.[23] A neurovascular island flap may be necessary to bring sensate tissue to the reconstructed thumb at the time of flap division.[27] 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.[28]

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.[29]

The wraparound flap, introduced by Morrison, offers the advantage of generally better aesthetics than does a classic toe-to-hand transfer.[7] 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.[30]

Proximal-third amputations

Reconstruction becomes more difficult, but also more important, when a thumb amputation has occurred proximal to the MCP joint.[31]  A study by Kovachevich et al found good results with immediate great toe–to-thumb transfers in patients who had undergone amputation of the thumb through the base of the proximal phalanx, the result of locally aggressive benign or malignant tumors. Among the three patients in the study, all of the transferred toes survived, with each patient attaining full thumb opposition and protective sensation.[32]

Reconstructive options to restore thumb function also 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.[33] 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.[34] 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.[35]

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.[23] The index finger is the most commonly pollicized digit, although the long and ring fingers have been used.[36, 37, 38] 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).[39, 40]

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, as shown in the images below.

Dorsal view of the clinical appearance of a Blauth Dorsal view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Volar view of the clinical appearance of a Blauth Volar view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Radiograph of a pouce flottant thumb Radiograph of a pouce flottant thumb

For these reasons, pollicization of the index finger is recommended for reconstruction of the congenitally absent thumb, as shown in the images below.[9]

Pollicized index finger for thumb reconstruction a Pollicized index finger for thumb reconstruction at 2 weeks after surgery.
Functional use of a pollicized index finger at 8 w Functional use of a pollicized index finger at 8 weeks after surgery.

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, respectively [9]
  • Final stabilization and positioning with appropriate tension of transferred tendons
Previous
Next

Complications

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.

Previous
Next

Outcome and Prognosis

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.[2, 41, 42, 43] 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.[44]

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.[45, 46]

Previous
 
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, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Bradon J Wilhelmi, MD Leonard J Weiner Professor and Chief of Plastic Surgery, Plastic Surgery Residency Program Director, Hiram C Polk Jr Department of Surgery, 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 Society for Reconstructive Microsurgery, Association for Surgical Education, Plastic Surgery Research Council, American Association of Clinical Anatomists, Wound Healing Society, American Society for Aesthetic Plastic Surgery, American Burn Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

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, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern 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, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedics Overseas, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

References
  1. Horta R, Barbosa R, Oliveira I, Amarante JM, Marques M, Cruz Reis J, et al. Neurosensible reconstruction of the thumb in an emergency situation: review of 107 cases. Tech Hand Up Extrem Surg. 2009 Jun. 13(2):85-9. [Medline].

  2. Ray EC, Sherman R, Stevanovic M. Immediate reconstruction of a nonreplantable thumb amputation by great toe transfer. Plast Reconstr Surg. 2009 Jan. 123(1):259-67. [Medline].

  3. Huguier PC. Du remplacement du pouce par son metacarpien, par l'agrandissement du premier espace interosseux. Arch Gen Med. 1874. 1:78.

  4. Nicoladoni C. Daumenplastik und organischer Ersatz der Fingerspitze (Anticheiroplastik und Daktyloplstik). Arch Klin Chir. 1900. 61:606-14.

  5. 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. 1966 Oct. 19(4):332-7. [Medline].

  6. 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. 1969 Nov. 51(4):677-9. [Medline]. [Full Text].

  7. Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am]. 1980 Nov. 5(6):575-83. [Medline].

  8. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg. 1994 Feb. 93(2):345-51; discussion 352-7. [Medline].

  9. Buck-Gramcko D. Pollicization of the index finger. Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am. 1971 Dec. 53(8):1605-17. [Medline].

  10. Littler JW. On making a thumb: one hundred years of surgical effort. J Hand Surg [Am]. 1976 Jul. 1(1):35-51. [Medline].

  11. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast Reconstr Surg. 2002 Nov. 110(6):1492-503; quiz 1504-5. [Medline].

  12. Littler JW. On the adaptability of man's hand (with reference to the equiangular curve). Hand. 1973 Oct. 5(3):187-91. [Medline].

  13. Napier JR. The prehensile movements of the human hand. J Bone Joint Surg Br. 1956 Nov. 38-B(4):902-13. [Medline]. [Full Text].

  14. Kleinman WB, Strickland JW. Thumb reconstruction. Green DP, ed. Operative Hand Surgery. 2nd ed. New York, NY: Churchill Livingstone; 1999. 2068-170.

  15. Morrison WA. Thumb reconstruction: a review and philosophy of management. J Hand Surg [Br]. 1992 Aug. 17(4):383-90. [Medline].

  16. 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].

  17. Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg [Am]. 1980 Sep. 5(5):482-7. [Medline].

  18. 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. 2006 May. 117(6):1906-15. [Medline].

  19. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg [Am]. 1964 Jun. 46:817-25. [Medline].

  20. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint Surg. 1956. 38A:917.

  21. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast Surg. 1997 Jan. 24(1):1-32. [Medline].

  22. Gu JX, Pan JB, Liu HJ, et al. Aesthetic and sensory reconstruction of finger pulp defects using free toe flaps. Aesthetic Plast Surg. 2014 Feb. 38(1):156-63. [Medline].

  23. Lister G. The choice of procedure following thumb amputation. Clin Orthop Relat Res. 1985 May. (195):45-51. [Medline].

  24. Broadbent TR, Woolf RM. Thumb reconstruction with contiguous skin-bone pedicle graft. Plast Reconstr Surg. 1960. 26:494-49.

  25. Emerson ET, Krizek TJ, Greenwald DP. Anatomy, physiology, and functional restoration of the thumb. Ann Plast Surg. 1996 Feb. 36(2):180-91. [Medline].

  26. Goldner RD, Howson MP, Nunley JA, et al. One hundred eleven thumb amputations: replantation vs revision. Microsurgery. 1990. 11(3):243-50. [Medline].

  27. Reid DA. Reconstruction of the thumb. J Bone Joint Surg Br. 1960 Aug. 42-B:444-65. [Medline]. [Full Text].

  28. Cheema TA, Miller S. One-stage osteoplastic reconstruction of the thumb. Tech Hand Up Extrem Surg. 2009 Sep. 13(3):130-3. [Medline].

  29. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. Daniller AI, Strauch B, eds. Symposium on Microsurgery. St Louis, Mo: CV Mosby; 1976.

  30. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg. 1988 Sep. 82(3):506-15. [Medline].

  31. Shin AY, Bishop AT, Berger RA. Microvascular reconstruction of the traumatized thumb. Hand Clin. 1999 May. 15(2):347-71. [Medline].

  32. Kovachevich R, Giuffre JL, Shin AY, Bishop AT. Immediate Great Toe Transfer for Thumb Reconstruction After Tumor Resection: Report of 3 Cases. Ann Plast Surg. 2016 Mar. 76 (3):280-4. [Medline].

  33. Leung PC. Thumb reconstruction using second-toe transfer. Hand Clin. 1985 May. 1(2):285-95. [Medline].

  34. Valauri FA, Buncke HJ. Thumb and finger reconstruction by toe-to-hand transfer. Hand Clin. 1992 Aug. 8(3):551-74. [Medline].

  35. Weinzweig N, Chen L, Chen ZW. Pollicization of the mutilated hand by transposition of middle and ring finger remnants. Ann Plast Surg. 1995 May. 34(5):523-9. [Medline].

  36. Letac R. Pollicization of the ring finger. J Int Coll Surg. 1954 Dec. 22(6, Part 1):649-55. [Medline].

  37. Littler JW. Reconstruction of the thumb in traumatic loss. Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, Pa: WB Saunders; 1977.

  38. Reid DA. Thumb reconstruction in the mutilated hand with special reference to pollicization. Campbell Reid DA, Gosset J, eds. Mutilating Injuries of the Hand. New York, NY: Churchill Livingstone; 1979.

  39. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of the thumb in the adult by pollicization. Hand Clin. 1992 Feb. 8(1):41-55. [Medline].

  40. Stern PJ, Lister GD. Pollicization after traumatic amputation of the thumb. Clin Orthop Relat Res. 1981 Mar-Apr. (155):85-94. [Medline].

  41. Buncke HM, Valauri FA, Buncke GM. Great toe-to-hand transfer. Meyer VE, Black MJ, eds. Microsurgical Procedures: The Hand and Upper Limb. New York, NY: Churchill Livingstone; 1991.

  42. 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].

  43. Rosson GD, Buncke GM, Buncke HJ. Great toe transplant versus thumb replant for isolated thumb amputation: critical analysis of functional outcome. Microsurgery. 2008. 28(8):598-605. [Medline].

  44. Chung KC, Wei FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg [Am]. 2000 Jul. 25(4):651-8. [Medline].

  45. Manske PR, Rotman MB, Dailey LA. Long-term functional results after pollicization for the congenitally deficient thumb. J Hand Surg [Am]. 1992 Nov. 17(6):1064-72. [Medline].

  46. Aliu O, Netscher DT, Staines KG, Thornby J, Armenta A. A 5-year interval evaluation of function after pollicization for congenital thumb aplasia using multiple outcome measures. Plast Reconstr Surg. 2008 Jul. 122(1):198-205. [Medline].

  47. Gossett J. La pollicisation de l'index (technique chirurgicale). J Chir. 1949. 65:403.

  48. 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].

 
Previous
Next
 
Diagram of a Moberg volar advancement flap being used for a thumb tip defect.
Marking for the radial incision of a Moberg flap.
Moberg flap raised just above the level of the flexor pollicis longus tendon sheath.
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.
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.
Volar advancement flap with modification of the incision at the base to allow closure in V-Y fashion after distal phalanx shortening.
Thumb tip defect that is amenable to closure with a Moberg volar advancement flap.
Incision marking for a Moberg flap. The neurovascular bundle should be kept with the volar advancement flap.
Bridging vessel to the neurovascular bundle on a volar flap.
Flexion at the interphalangeal joint to allow closure.
Volar view of the closure of a thumb defect with a Moberg volar advancement flap.
Radial view of the closure of a thumb defect with a Moberg volar advancement flap.
Diagram of a Littler neurovascular island flap for the coverage of a thumb tip defect.
Intraoperative view of a Littler neurovascular island flap.
Postoperative view of a Littler neurovascular island flap.
Second postoperative view of a Littler neurovascular island flap.
Markings for the pedicle of a first dorsal metacarpal artery flap.
Dissection for a first dorsal metacarpal artery flap.
Isolation of the pedicle for a first dorsal metacarpal artery flap.
Postoperative appearance of a thumb tip after coverage with a first dorsal metacarpal artery flap.
Second view of the postoperative appearance of a thumb after coverage with a first dorsal metacarpal artery flap.
Free tissue transfer of great toe pulp to restore a volar thumb defect.
Markings for a free tissue transfer of great toe pulp to restore a volar thumb defect.
Postoperative view after a free tissue transfer of great toe pulp to restore a volar defect.
Dorsal view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Volar view of the clinical appearance of a Blauth type IV pouce flottant thumb.
Radiograph of a pouce flottant thumb
Pollicized index finger for thumb reconstruction at 2 weeks after surgery.
Functional use of a pollicized index finger at 8 weeks after surgery.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.