One-stage thumb lengthening with use of an osteocutaneous 2nd metacarpal flap.

Abstract

Traumatic thumb amputation represents an extremely disabling entity, thus rendering its reconstruction a procedure of paramount importance. A case of a patient, who sustained a traumatic amputation of his left index finger at the metacarpophalangeal joint and of his left thumb in the middle of the proximal phalanx 4 months ago and was initially treated elsewhere, is described. For the thumb reconstruction, an osteocutaneous flap of the radial side of the 2nd metacarpal, which consisted of a 3, 5-cm bony segment with the overlying skin and its blood and nerve supply was used. The flap was transferred and fixed with a plate and screws to the palmar-medial side of the stump of the thumb, while the 1st web space was deepened by removing the rest of the second metacarpal, while a partial skin graft was used to cover a remaining gap. Thumb functionality was restored immediately postoperatively, and the overall result was satisfactory.

Full text

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CASE REPORT
One-stage thumb lengthening with use of an osteocutaneous
2nd metacarpal flap
Panagiotis Givissis•Stavros I. Stavridis•
Konstantinos Ditsios•Anastasios Christodoulou
Received: 3 August 2009/Accepted: 11 November 2009/Published online: 26 November 2009
? Springer-Verlag 2009
Abstract
extremely disabling entity, thus rendering its reconstruction
a procedure of paramount importance. A case of a patient,
who sustained a traumatic amputation of his left index
finger at the metacarpophalangeal joint and of his left
thumb in the middle of the proximal phalanx 4 months ago
and was initially treated elsewhere, is described. For the
thumb reconstruction, an osteocutaneous flap of the radial
side of the 2nd metacarpal, which consisted of a 3, 5-cm
bony segment with the overlying skin and its blood and
nerve supply was used. The flap was transferred and fixed
with a plate and screws to the palmar-medial side of the
stump of the thumb, while the 1st web space was deepened
by removing the rest of the second metacarpal, while a
partial skin graft was used to cover a remaining gap.
Thumb functionality was restored immediately postopera-
tively, and the overall result was satisfactory.
Traumatic thumb amputation represents an
Keywords
Osteocutaneous flap ? Metacarpal ? Web space deepening
Thumb amputation ? Thumb reconstruction ?
On the length, strength, free lateral motion and perfect mobility of the
thumb depends the power of the human hand.
Sir Charles Bell, 1833 [1].
Introduction
The human thumb represents undoubtedly the most
important digit, since its opposition ability greatly sepa-
rates humans from lower primates, while it accounts for
almost half or even more of hand functionality [2, 3].
Hence, traumatic amputation of the thumb constitutes an
extremely severe disability, thus rendering its adequate
management an act of paramount importance.
Position, stability, strength, length, motion, sensibility
and appearance are the attributes that make the thumb
unique. Of these qualities, the first four must be present to
an acceptable extent for function to approach normality,
while the latter three are very desirable but not essential [4].
In the majority of the cases, thumb reconstruction is
performed as a secondary procedure [5]. The indication and
the selection of the method depend upon the level of
amputation, the dominance of the injured hand, and the
presence of other injuries to the same hand as well as age,
sex, occupation, and intelligence of the patient [5].
According to different indications, a great variety of pro-
cedures have been described, such as autologous trans-
plantation of the great or second toe (toe to thumb) [6–8],
use of several types of flaps, simple or vascular, originating
from the digits up to the forearm, widening of the first web
space with Z-plasties and elongation of the 1st metacarpal
by distraction osteogenesis [9].
We report a case of an osteocutaneous flap from the
second metacarpal that was used for amputated thumb
reconstruction, a modification of Loda’s Vascular Rein
Technique [10].
P. Givissis ? S. I. Stavridis ? K. Ditsios ? A. Christodoulou
1st Orthopaedic Department of Aristotle University
of Thessaloniki, ‘‘G. Papanikolaou’’ General Hospital,
57010 Exohi, Thessaloniki, Greece
P. Givissis (&)
9 Papanikolaou Str., Panorama, Mail Box 215,
55210 Thessaloniki, Greece
e-mail: givissis@otenet.gr
123
Strat Traum Limb Recon (2009) 4:135–139
DOI 10.1007/s11751-009-0074-z

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Case report
A 56-year-old manual worker had sustained a traumatic
amputation of the left index finger at the level of the
metacarpophalangeal joint, and of the left thumb in the
middle of the proximal phalanx, with additional injury of
the distal phalanx of the left ring finger, during a work
accident with a ribbon saw 4 months ago. Immediately post
injury, the patient was admitted to a regional hospital,
where the hand was cleaned up and stump closure was
performed. Upon his reference to us, surgical wound
healing was satisfactory, and there were no signs of further
lesions such as infection or neuroma formation in his hand
(Fig. 1a, b).
Based on the concept of restoring thumb sensibility [11]
and the fact that the useless second metacarpal stump
should be removed in order to deepen the 1st web space,
we modified Loda’s Vascular Rein Technique [10], uti-
lizing an osteocutaneous 2nd metacarpal flap for thumb
reconstruction.
Detailed preoperative planning and drawing of the flap
(Fig. 2a), were followed by a dorsal approach and thorough
tissue preparation. A longitudinal osteotomy of the 2nd
metacarpal starting at its distal end was performed with a
saw blade. An osseous fragment of the radial side of the
2nd metacarpal with a length of ca 3.5 cm was prepared in
that way.
Apart from the metacarpal bony fragment, the osteocu-
taneous flap also contained the overlying skin which is
perfused by a branch of the radial artery and innervated by
a branch of the superficial radial nerve (Fig. 2b, c).
The remaining second metacarpal was removed at a
level just distal to the 2nd carpometacarpal joint. The flap
was transferred to the palmar-medial side of the thumb
stump that had been adequately prepared before, through
an extension of the skin incision (Fig. 2d). An osteosyn-
thesis by using a special plate and screws (Profyle Small
Bone Plating System, Stryker?, MI, USA) was performed
(Fig. 2e).
Having already removed the remaining 2nd metacarpal,
first web space deepening was completed by extending the
palmar skin incision and developing a flap that was trans-
ferred on the dorsal skin defect of the first web space
(Fig. 3a). In order to cover a small remaining gap in the
palmar side of the first web space, a free partial skin graft
that had been harvested from the palmar surface of the
forearm was applied (Fig. 3b).
Antibiotics were administered for 3 days following
surgery, and the sutures were removed after 2 weeks. The
patient’s postoperative course was generally uneventful
both in terms of wound healing and survival of the flap and
the graft.
Immediately postoperatively, a restoration of the hand’s
grip function was achieved. The thumb demonstrated a
satisfactory mobility due to retention of the muscle’s
insertions at the base of the 1st phalanx, while sensation
was also preserved (Fig. 3c). At the last follow-up exam-
ination 14 months postoperatively, the patient scored 16
points in the DASH score and 8 points in the Kapandji
score (Fig. 4a, b). He reported complaints due to the screws
throughout gripping of objects.
Discussion
Traumatic thumb amputation constitutes a devastating
injury with dramatic consequences in patient’s everyday
life, since it is generally accepted that the thumb represents
more than 40% of hand function [3].
A variety of surgical techniques for thumb reconstruc-
tion have been described in the literature, according to
various indications, among which the level of amputation is
the most important. In cases similar to our case, where the
Fig. 1 Preoperative clinical (a) and radiological picture of the
amputated hand
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amputation level is at the proximal half of the middle third,
an elongation of the ray of the thumb is necessary. Alter-
native options are the application of distraction osteogen-
esis, autologous toe transplantation by use of microsurgical
techniques and the use of parts originating from other
injured digits for pollicisation (spare part technique) [12].
While metacarpal lengthening via distraction osteo-
genesis can achieve a mean elongation of 3.5 cm, it bears
the significant drawback that the full treatment lasts
several months with continuous application of the external
fixator [9].
Another valuable option for amputated thumb recon-
struction is the autologous transplantation of the great or
the second toe, which is a demanding and time consuming
procedure. Moreover, this method bears the disadvantage
of significant donor site morbidity, especially when the
great toe has been used, while several weeks are required
until neothumb sensation and mobility are restored [2, 4].
Fig. 2 After detailed flap-drawing (a) the 2nd metacarpal osteocutaneous flap (b, c) and thumb stump (d) were prepared followed by transfer and
osteosynthesis (e)
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Since the first description in 1950 by Otto Hilgenfeldt of
thumb reconstruction by great toe transplantation [13],
many refinements and modifications of the autologous
transplantation method have been evolved, in an effort to
successfully address the issues related to this procedure
[14].
In a case that even a small part of the first phalanx is
preserved, a modified wrap-around flap [8, 14, 15] or a
twisted two toe flap as described by Fouchet [6, 14] would
have been the treatment of choice. Both methods reduce
donor site morbidity by preserving toe osseous structures,
while both cosmetic and functional results were reported to
be superior for toe transfer compared to pollicisation, when
used for thumb reconstruction [16].
Although we agree that the modified wrap-around flap
or the twisted two toe flap would have been the treatment
of choice, we felt that in our case the use of an osteocu-
taneous vascularised flap harvested from the remaining 2nd
metacarpal was justified, as the presence of the 2nd
metacarpal stump posed a significant obstacle to hand
function and simultaneously was an ideal donor site.
Moreover, the removal of the remaining 2nd metacarpal
allowed the more effective deepening of the first web
space. The stable osteosynthesis performed, combined with
the preserved perfusion and innervation of the neothumb,
allowed the immediate postoperative restoration of its
mobility and sensation. In this aspect, significant was the
contribution of the retention of the proximal part of the first
phalanx, as the insertion point of abductor pollicis brevis,
adductor pollicis and flexor pollicis brevis muscles. The
function of opponens pollicis muscle was unaffected, since
this muscle inserts into the distal part of the first
metacarpal.
Further advantages of this technique are the relative
short surgical time and the absence of donor site morbidity,
while in case of failure alternative options remain open.
As a conclusion, it seems that under proper indications,
the creation of a neothumb by use of an osteocutaneous,
vascularised, 2nd metacarpal flap poses a valuable alter-
native option with significant advantages in the treatment
Fig. 3 After deepening of the first web space, a palmar flap (a) and a free partial skin graft (b) were used to cover the remaining gap. The hand’s
grip function was immediately restored postoperatively (c)
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of traumatic thumb amputation, since it combines the
avoidance of both complex microsurgical techniques and
donor side morbidity with very good functional and aes-
thetic result.
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andradiological appearance14 months
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