Thumb reconstruction with a free neurovascular wrap-around flap from the big toe

Thumb reconstruction requires accurate functional and esthetic approximation to the original. Accepted methods generally have some deficiencies, particularly in appearance, and frequently the secondary morbidity is unacceptable. A method of thumb reconstruction with the use of an iliac crest bone graft and a free neurovascular "wrap-around" flap from the big toe is described that combines the attributes of previous methods without their secondary morbidity.

A new island flap transfer from the dorsum of the index to the thumb

We describe here a new island flap from the dorsum of the index finger, transferred on the first dorsal metacarpal artery with one or two veins and the terminal branches of the radial nerve. This vascular bundle is a reliable one, for we have had no necrosis in 12 consecutive cases. The quality of its venous outflow and the use of a dorsal donor site give it advantages over the Moberg-Littler island flap, unless a dorsal vein from the latter flap is preserved and sutured to a vein in the recipient site. The arterial vascularization without any skin pedicle makes this "kite" flap a more practical one than the "flag" flaps of Vilain or Holevitch or Kuhn. Finally, a one-stage transfer is usually preferable to a two-stage one (e.g. Adamson, Braillar). In a single operation, this transfer provides composite resurfacing of the thumb while bringing in new blood and nerve supply.

Musculoskeletal symptoms among mobile hand-held device users and their relationship to device use: A preliminary study in a Canadian university population

The study aims were, in a population of university students, staff, and faculty (n = 140), to: 1) determine the distribution of seven measures of mobile device use; 2) determine the distribution of musculoskeletal symptoms of the upper extremity, upper back and neck; and 3) assess the relationship between device use and symptoms. 137 of 140 participants (98%) reported using a mobile device. Most participants (84%) reported pain in at least one body part. Right hand pain was most common at the base of the thumb. Significant associations found included time spent internet browsing and pain in the base of the right thumb (odds ratio 2.21, 95% confidence interval 1.02-4.78), and total time spent using a mobile device and pain in the right shoulder (2.55, 1.25-5.21) and neck (2.72, 1.24-5.96). Although this research is preliminary, the observed associations, together with the rising use of these devices, raise concern for heavy users.

A systematic review of the outcomes of replantation of distal digital amputation

BACKGROUND

The aim of this study was to conduct a systematic review of the English literature on replantation of distal digital amputations to provide the best evidence of survival rates and functional outcomes.

METHODS

A MEDLINE search using "digit," "finger," "thumb," and "replantation" as keywords and limited to humans and English-language articles identified 1297 studies. Studies were included in the review if they (1) present primary data, (2) report five or more single or multiple distal replantations, and (3) present survival rates. Additional data extracted from the studies meeting the inclusion criteria included demographic information, nature and level of amputation, venous outflow technique, nerve repair, recovery of sensibility, range of motion, return to work, and complications.

RESULTS

Thirty studies representing 2273 distal replantations met the inclusion criteria. The mean survival rate was 86 percent. There was no difference in survival between zone I and zone II replantations (Tamai classification). There was a significant difference in survival between replantation of clean-cut versus the more crushed amputations (crush-cut and crush-avulsion). The repair of a vein improved survival in both zone I and zone II replantation. The mean two-point discrimination was 7 mm (n = 220), and 98 percent returned to work (n = 98). Complications included pulp atrophy in 14 percent of patients (n = 639) and nail deformity in 23 percent (n = 653).

CONCLUSIONS

The common perception that distal replantation is associated with little functional gain is not based on scientific evidence. This systematic review showed a high success rate and good functional outcomes following distal digital replantation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases

The foot is an invaluable bank of spare parts available for reconstructing the mutilated hand. The dorsalis pedis flap, the extensor digitorum brevis muscle, and the first and second toes can now be used as free transfers. We believe that partial toe transfers, including either sensitive cutaneous flaps or composite tissue, are also extremely useful in properly selected patients.

Scaphotrapezial trapezoidal arthrosis

Scaphotrapezial trapezoidal degenerative arthritis as an isolated entity or as a preponderant part of a pantrapezial degenerative process was seen in 49 hands of 34 patients. Pain and weakness were the primary complaints. Point tenderness was present in all but two hands. Significant loss of grasp and pinch strength was noted in 18 hands, and loss of wrist motion occurred in 16 hands. Roentgenographic findings included narrowing of the scaphotrapezial trapezoidal joint space, subarticular cortical sclerosis, and cyst formation. A dorsiflexed position of the scaphoid, with a scapholunate angle of less than 45 degrees, was noted in 38 of the 45 hands. Late collapse of the intercarpal joint with dorsiflexion instability of the lunate also was noted. Twenty-nine hands were treated conservatively by protective splints, corticosteroid injections, and avoidance of exacerbating activities. Surgical treatments consisted of fibrous arthroplasty (four), silicone interposition arthroplasty (six), trapezial replacement arthroplasty (three), arthrodesis (five), joint debridement (one), and trapezial excision (one). Late results were more encouraging than were early results and were moderately satisfactory for each method. Improvement in grasp and pinch strength was most predictable for arthrodesis, although wrist motion was diminished.

Acute dislocation of the carpometacarpal joint of the thumb: an anatomic and cadaver study

An anatomic study was undertaken to provide an understanding of the ligamentous disruption that occurs during acute dislocation of the thumb carpometacarpal joint. Thirty-eight cadaver thumbs were dissected free of soft tissue, with the ligaments preserved. The dorsoradial, posterior oblique, anterior oblique, and intermetacarpal ligaments were identified in all specimens. A dorsal dislocating force was applied to the base of the thumb metacarpal to recreate the mechanism of clinical dislocation. Serial sectioning of the ligaments was performed with the metacarpal in neutral, flexion, and extension. The primary restraint to dorsal dislocation was found to be the dorsoradial ligament, with the anterior oblique ligament allowing dislocation by subperiosteal stripping from the base of the first metacarpal. After reduction, the joint was most stable in pronation and extension, which tightened the anterior oblique ligament. We conclude that the dorsoradial ligament is the primary restraining force with respect to acute dorsal dislocation of the thumb carpometacarpal joint.

Methods and results of replantation following traumatic amputation of the thumb in sixty-four patients

Immediate survival and functional results were studied in 64 thumb replantations performed during a 3 year period. The failure rate, 27% overall, was higher in patients over 50 years of age (50%) and following avulsions with or without crushing injuries (58%). Long vein grafts from the radial artery proximally to the thumb arteries distally were employed in 15 patients to bypass the traumatized area in the first web space. A higher survival rate (90%) was associated with the use of vein grafts to restore venous return. Half of the patients followed 6 months or longer had good discriminatory sensibility (less than 10 mm). Sensory return and cold intolerance were worse in older patients and were not related to level of injury, mechanism of amputation, total ischemia time, or number of arteries or veins repaired. Loss of motion of the replanted thumb was a frequent cause for inadequate return of function. All thumbs should be considered for replantation, but the results will be poorer in older patients. If possible, motion of the interphalangeal and metacarpophalangeal joints should be preserved.

Reconstruction of the thumb with a trimmed-toe transfer technique

The trimmed-toe transfer is a new modification of the existing great-toe transfer technique for thumb reconstruction. This procedure was devised to circumvent patient concerns regarding overly large reconstructed digits following total great-toe-to-hand transfer. This technique involves reduction of both the bony and soft-tissue elements along the medial aspect of the transferred great toe in order to produce a more normal sized thumb. Follow-up of the initial 20 patients from 1983 to 1986 demonstrates good stability, grip strength, and pinch strength. Although compared with total great-toe transfer a modest reduction in joint motion of trimmed toes has been observed, the overall appearance and usefulness of the reconstructed thumbs have been excellent.

Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time

Three successful digital replantations were performed on a patient after 84, 86, and 94 hours of prolonged cold ischemia time. Both the intraoperative and postoperative courses were smooth. Functional evaluation 8 months after operation revealed a normal speed of sensory recovery and nail growth. The atrophic changes in all three replants are mild. Total active movement was 45, 100, and 70 degrees in the replanted left thumb, left index finger, and right thumb, respectively. There is no cold intolerance. The overall functional result is satisfactory. Replantation of an amputated digit that is properly cooled immediately after injury should be attempted in selected patients even after prolonged ischemia time.

MR imaging of ligament and tendon injuries of the fingers

Magnetic resonance (MR) imaging can provide important information for diagnosis and evaluation of soft-tissue trauma in the fingers. An optimal imaging technique should include proper positioning, dedicated surface coils, and specific protocols for the suspected abnormalities. Familiarity with the fine anatomy of the normal finger is crucial for identifying pathologic entities. MR imaging is a powerful method for evaluating acute and chronic lesions of the stabilizing articular elements (volar plate and collateral ligaments) of the fingers and thumbs, particularly in the frequently affected proximal interphalangeal and metacarpophalangeal joints. As in other body regions, MR imaging is also useful for depicting traumatic conditions of the extensor and flexor tendons, including injuries to the pulley system. In general, normal ligaments and tendons have low signal intensity on MR images, whereas disruption manifests as increased signal intensity. Radiologists need to understand the full spectrum of finger abnormalities and associated MR imaging findings.

Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius

We report three complete ruptures and one partial rupture of the flexor pollicis longus tendon in association with the insertion of a volar plate for the treatment of fracture of the distal radius. Rupture was associated with the chronic use of steroids.

Skier's thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb's metacarpophalangeal joint

Acute rupture of the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb is often sustained in downhill skiing accidents an is hence called "skier's thumb." All complete ruptures seen at our hospital between 1975 and 1979 were operated using the "fishhook" pullout wire technique. Follow-up results 29 months after early operation are presented for 47 cases. The overall results are excellent in 29, good in 14, and fair in 3 patients. Our result had to be considered a failure. No patient had serious functional impairment or major constant pain. No patient took any pain medication. No reintervention was necessary. The distal bony avulsions showed the most favorable prognosis, and the ligamentous midsubstance tears, the least favorable. The fishhook pullout wire technique can be used in both ligamentous and bony avulsions of the ulnar collateral ligament and provides good or excellent results in 90% of the cases.

An outcome study of thumb reconstruction using microvascular toe transfer

The purpose of this study was to evaluate outcomes following microvascular toe to thumb transfer in a cohort study using the Michigan Hand Outcomes Questionnaire, the 36-item Short-Form Health Survey, the Lower Limb Function Questionnaire, and standardized hand function tests. Twenty-one patients who had unilateral, isolated thumb amputations at the metacarpophalangeal joints were studied: 16 patients had toe transfer and 5 patients did not have reconstruction. The mean follow-up period was 7.2 years (range, 3-13 years). Toe transfer patients showed statistically significantly better overall hand function (effect size = 1.4), ADL (effect size = 3.4), work performance (effect size = 2.1), aesthetics (effect size = 1.9), and satisfaction (effect size = 1.1). Functional testing showed that strength and dexterity of the toe transfer hands were comparable to the opposite normal hands. Foot donor site morbidity was minimal. No significant difference was found in the mean Lower Limb Function Questionnaire scores between the toe transfer patients (1.4) and the amputation patients who did not undergo reconstruction (1.6). The results of our study showed that patients with toe transfer have better hand function than patients with thumb amputations at the level of the metacarpophalangeal joints.

Biomechanics and hand trauma: what you need

Mutilating hand trauma presents the surgeon with many reconstructive challenges. This article establishes some biomechanical guidelines to help the surgeon evaluate the hand trauma patient. Through a basic understanding of hand biomechanics, the surgeon may access more accurately what motion and function can best be salvaged. By understanding how amputation, fusion, and tendon loss impact on postoperative hand motion, the surgeon can better focus his or her reconstructive efforts to achieve the highest functional outcome for the patient.

Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US and MR imaging

PURPOSE

To compare the usefulness of ultrasound (US) and magnetic resonance (MR) imaging in the differentiation of displaced and nondisplaced tears of the ulnar collateral ligament (UCL).

MATERIALS AND METHODS

Seventeen patients (eight female and nine male, aged 14-70 years) with clinically diagnosed tears underwent examination with US and MR imaging. T1-weighted, spin-echo (SE) and T2-weighted, turbo SE sequences were used. MR and US findings were compared with those of surgery. Normal UCLs in 21 volunteers were also examined with MR imaging.

RESULTS

The results of US were correct in 15 patients, but displaced and nondisplaced ruptures were misinterpreted in two patients (sensitivity, 88%; specificity, 83% for displaced, 91% for nondisplaced). Sensitivity and specificity were both 100% for MR imaging. The T2-weighted sequence was more useful because the normal UCL is rarely homogeneously hypointense.

CONCLUSION

MR imaging is better than US, but both methods are useful in the evaluation of the torn UCL.

Ski injury statistics, 1982 to 1993, Jackson Hole Ski Resort

A retrospective analysis was conducted on injury statistics compiled over 12 seasons, from 1982 to 1993 (2.55 million skier-days), at a Wyoming ski resort. The population at risk was determined by ticket sales per year. A total of 9749 skiing injuries was indexed by anatomic region and severity according to diagnosis on initial evaluation. Injury rates were then analyzed as a function of time. The injury rate remained constant at 3.7 injuries per 1000 skier-days during the 12 seasons. The rate of lower extremity to upper extremity injury decreased from 4:1 to 2:1 during the study period (P < 0.03). The ankle injury rate also decreased with time (P < 0.04). Ulnar collateral ligament sprains make up 7% of all injuries. Knee sprains in general account for 30% of all injuries. The incidence of anterior cruciate ligament tears increased as a function of time (P < 0.04) and accounted for 16% of all skiing injuries during the study period. The medial collateral ligament sprain was the most common injury, making up 18% of skiing injuries. Forty-seven snowboard injuries from the 1992 to 1993 season are also presented. Our injury statistics mirror those currently reported in North America, except our data reflect a higher incidence of knee sprains.

Upper extremity injuries in skiing

In a six-year study, 1,711 ski injuries and 998 controls at Sugarbush North Ski Area were studied. Upper extremity injuries, which constituted 25% of all ski injuries, did not increase in frequency. Men and women were at equal risk of injury. When edging conditions were poor, upper extremity injuries were more common than lower extremity injuries. Forty percent of all upper extremity injuries involved the thumb (85% included injuries to the ulnar collateral ligament of the metacarpophalangeal joint). Twenty-five percent of 405 skiers interviewed had, at one time, injured their thumbs while skiing but only one-quarter of these reported their injury. Our study suggests that injury to the ulnar collateral ligament of the metacarpophalangeal joint may be the most frequent in skiing and that gripping the ski pole outside the strap may prevent these injuries.

Survival factors in replantation and revascularization of the amputated thumb--10 years experience

An unabridged series of 73 thumb amputations subjected to replantation or revascularization surgery in the years 1971 to 1980 has been examined in detail as a combined prospective and retrospective study to determine the factors playing a role in survival and failure. The causes of failure and complications are demonstrated. The overall failure rate was 27%. The factors influencing the outcome were: the injury--mechanical type and degree of amputation; the patient--age and amputation level; and the surgeon--frequency of utilization of vein grafts. The highest failure was seen in the complete amputation with avulsion/diffuse crush injury group (63%). Incomplete amputations had the lowest failure rate, particularly if the injury type was guillotine/local crush and at a level proximal to the metacarpophalangeal joint. Patients aged 11 to 20 years had a low failure rate (18%) whereas children under 5 years had a high failure rate (40%). Arterial thrombosis was the most frequent complication and cause of failure. The surgeon could modify the result by frequent use of vein grafts for arterial reconstruction and by reoperation for thrombotic complication. Five thumbs failed to revascularize at the primary operation and were removed at this primary operation.

Clinical results of tension band fixation of avulsion fractures of the hand

We report 100 cases in which a tension-band technique was used to secure fixation of avulsion fractures within the digits. Included are 51 bony mallet fractures that were subluxed or irreducible, 38 displaced bony gamekeeper's fractures of the thumb, 8 fractures of the lateral phalangeal base, and 3 avulsion fractures that involved the base of the dorsal aspect of the middle phalanx. We evaluated results on the basis of clinical and x-ray film criteria. Excellent or satisfactory results were found in all 38 bony gamekeeper's injuries. All but one gamekeeper's fracture healed; the one nonunion was asymptomatic. All eight patients with lateral avulsion fractures had an excellent or satisfactory result on clinical examination. Seven of the eight had an excellent result on x-ray film evaluation; the one malnuion was asymptomatic. Two of the three fractures with dorsal avulsions of the base of the middle phalanx had a satisfactory result on clinical and x-ray film examination; the one poor result was due to the severity of the comminution of the fracture. However, 21 of the 51 bony mallet injuries had a poor result both clinically and radiographically. We noted numerous postoperative complications including dorsal skin breakdown, superficial and deep infection, and secondary displacement of the fragment. Tension-band fixation is an excellent method for treating various avulsion fractures of the hand such as bony gamekeeper's thumb, lateral avlusion injuries, and dorsal avulsions of the middle phalanx. However, the treatment of bony mallet fingers with tension band fixation is less predictable and should be used with caution.