The document discusses various techniques for reconstructing amputated or injured thumbs, including: - Osteoplastic reconstruction, which uses bone grafts and flaps in multiple staged procedures. - Metacarpal distraction lengthening, which uses an external fixator to gradually lengthen the thumb's metacarpal bone. - Phalangization, which transfers a finger to reconstruct the thumb, though it does not provide much functional improvement. - Various flap options are also described, such as cross-finger flaps and neurovascular island pedicle flaps, to provide skin and sensory coverage. Thumb reconstruction remains challenging due to the thumb's importance, though following indications carefully and using the appropriate technique

1. Thumb Reconstruction by
Conventional Technique
Dr. Suiyibangbe
M.Ch. 2nd year
Plastic and Reconstructive Surgery

2. Introduction
The thumb plays a crucial role in proper
functioning of the hand.
It is unimportant to humans only during the
first 3 months of life.
Thumb opposition, unique to primates, allows
the human hand to perform power grip and
precision handling.
In fact, the thumb itself is responsible for 40%
to 50% of the overall function of the hand.

3. Cont...
Reconstruction of the thumb remains a major
surgical challenge because of its unique
"position" in the hand's structure.
To provide a painless thumb with good stability,
sensibility, and mobility to oppose the adjacent
fingers.
The first priority is pain follow by stability, and
only then are sensibility and mobility considered.
Stability concerns both the skeleton and the skin
cover; the necessity of a distal vascularized bone
for avoidance of any long term resorption.

4. History
 Littler has extensively reviewed the history of thumb
reconstruction, a field in which he has been a major
contributor.
 Nicoladoni introduced two techniques, namely, osteoplastic
reconstruction and toe transfer through the pedicle
method.
 Guermonprez was among the first to pollicize a finger, a
technique subsequently refined by the island principle,
attributed to Gosset and Littler. A mobile and sensible
thumb was obtained, but at the price of sacrificing a finger.
 Matev originated the technique of progressive lengthening
through distraction, maintaining good sensibility and
improving length.

7. CAMPBELL-REID CLASSIFICATION FOR THUMB
AMPUTATION
Group 1:- Amputation distal to the
metacarpophalangeal joint, leaving an adequate
stump.
Group 2:- Amputation of the thumb distal to or
through the metacarpophalangeal joint, leaving a
stump of inadequate length.
Group 3:- Amputation through the metacarpal,
with preservation of some functioning thenar
muscles.
Group 4:- Amputation at or near the
carpometacarpal joint

8. Indication
A replanted thumb, seems to be the best possible
reconstruction
– Not always more functional than an amputation
properly revised at the same level
Strong contraindications
– significant vascular disease
– short life expectancy
– chronic pain with disuse of the limb
– unreconstructable sensory loss
– unrealistic patient expectations

9. Component loss
 Soft-tissue loss – Skin grafts or flaps.
Composite loss – urgent soft-tissue cover with
skeletal stabilization and possible bone
grafting.
As with any mangling limb injury, the best
time to proceed with completion of
amputation is at the first operation

10.  Because sensory perception is key to effective use of
the thumb, innervated flaps are much preferred for
contact area resurfacing.
 Innervated flaps – Moberg palmar adv. flap – Holevich
FDMA flap from index – Heterodigital N-V sensory
“island” flaps – Free finger or toe pulp flaps.
 Standard local digital flaps – V-Y adv. – Dorsal or volar
cross-finger flaps.
 Noninnervated regional flaps – Posterior interosseous –
Radial forearm and intrinsic muscle flaps

11. Amputated Thumb reconstruction
 Whenever possible, replantation should be considered for
thumb amputation.
 Amputation Distal to the Metacarpophalangeal Join
– Primary reconstructive goals are length, stability, and
adequate web space
– Choices
 bone graft with a local flap
 osteoplastic reconstruction
 Phalangization
 distraction lengthening
 toe-to-thumb transfer

12. Basic requirement for a good result
 The stump needs to demonstrate sufficient length to allow
contact, after transfer, with the opposite remaining fingers.
 Vascularization must be good (at least one intact artery).
 There must be good sensibility (at least on the ulnar
aspect), with satisfactory skin cover. This means nontender
stable skin (or at least without painful neuroma).
 Scars must be well placed, and padding adequate.
 The immediately adjacent finger has to retain at least one
feeding artery after transfer.
 The level of thumb amputation needs to preserve a good
carpometacarpal joint and good thenar muscles.
 The first web has to be either intact or reconstructed.

13. Palmar advancement flap
(Moberg)
Indication:- palmar thumb
pad defect >1cm but less than
<2cm
Exposed distal phalanx devoid
of periosteum.
A- defect reoresenting 50% of
the tactilethumb pad
B- proximal reflectionof the
advancement containing
neurovascular bundle to
exposed the sheath of FPL
C- advancement and closure
of the flap with flesion of the
MCP and IP joint

14. Palmar
advancement
flap with a
proximal
releasing
incision

15. Heterodigital flap
recostruction
Cross-finger flap from index
finger to the thumb.
Indication:- loss of entire
palmar surface of the thumb
distal to the IP joint.
A- large defect involving most
of the distal pulp of the
thumb. Outline of the cross
finger flap on the proximal
phalanx of the index finger
B- placement of the flap on
the thumb defect
C & D position of the thumb
and cross-finger flp with graft
covering the donor defect

16. Radial sensory nerve
innervated cross-finger
flap
A- outline of cross-finger
flap with dorsal web
incision connecting to the
thumb defec. The incision
is made dorsal and
proximal to the thumb
web to prevent a
subsequent scar
contracture.
B- reflection of the flap
after dissection of the
nerve brach.
C & D – position of thumb
and transferred flap with
closure of incision and
free graft coverage of the
donor defect.

17. Dual innervated cross-
finger flap
A- the dorsal sensory
branch of the index radial
digital nerve (RDN)
predictably innervate the
distal aspect of the index
proximal phalanx
B- elevation of an index to
thumb cross-finger flap with
joining incisionfor
transposition of the dorsal
sensory branch of the radial
nerve.
C- microneurorrhaphy of
the thumb ulnar digital
nerve to the dorsal branch
of the index RDN.
D- appearance of the flap at
closure

19. Neurovascular island pedicle flap

20. Phalangization
 Best Indication/Unique Advantages – Thumb
lengthening by finger transfer is a possible
consideration (rare) if the thumb is nearly long enough,
such as base of proximal phalanx.
 Usually this is a single-stage operation
 Disadvantages and Special Requirements
– Not provide much functional improvement
– Very unnatural appearance
 Particularly if the web is converted to a cleft by an
aggressive Z-plasty.

21. This is a web-deepening procedure, results of
which are so often disappointing that it is rarely a
good recommendation in view of today’s
alternatives.
To allow creation of the cleft
– Adductor muscle insertion is detached and
repositioned proximally
– First web space is deepened with a Z-plasty
– Correction of an associated first web space
contracture

22. Simple Z-plasty of the
thumb web
Indication:-
amputation near the
midportion of the
proximal phalanx
Minimal scarring of the
first web skin.
Absence of first web
muscle contracture.
Mobile first
metacarpal

24. Phalangization of the first metacarpal
with dorsal rotational flap coverage

26. Creating a web space

27. Pollicization of a traumatized finger through a purely
palmar approach. A short dorsal incision allows
microsurgical vein repair.

28. Osteoplastic Thumb Reconstruction
Best Indication/Unique Advantages – Partial or
distal subtotal amputation – No digit is
sacrificed.
Disadvantages and Special Requirements –
Multiple staged procedures – Results may be
unaesthetic, bulky, floppy, No nail – Additional
neurovascular flap for sensibility

29. Technique – Combination of a bone graft and
flap to lengthen the thumb remnant
– Three procedures
I. Lengthening the skeleton with an iliac crest
bone graft covered in a tubed distant flap
II. Division
III. Transfer of a neurovascular sensory island
flap from the ulnar side of the middle finger

30. Many donor sites are available that could provide
skin and bone either as a pedicled flap or as an
island pedicle flap.
With a pedicled flap, a piece of iliac crest or of
clavicle has been used.
Among island flaps, the forearm is currently a
popular donor site, the bone fragment being
taken from radius or ulna, based on the radial
artery, the posterior interosseous artery, the
ulnar artery, and the posterior branches of the
anterior interosseous artery.

31. Osteoplastic thumb reconstruction by a compound
radial forearm flap, including a vascularized piece of
bone taken from the radius.

32. Cont..

33. Cont...

35. Metacarpal Distraction lengthening
Indication/ Advantages – Distal subtotal
amputation (region of [MCP] joint) is an
indication for this procedure and there is little
or no donor defect except scar.
Disadvantages and Special Requirements
– Only limited lengthening is possible
– Absolute cooperation is required

36. Cont....
 Thumb’s metacarpal is lengthened using progressive adjustments of
an external fixator in the manner introduced by Ilizarov for the
lower limbs
– Metacarpal exposed
– Fixator placed
 Corticotomy made circumferentially and subperiosteally through
the metacarpal shaft
 Minimize medullary bone disruption
– After 1 week, distraction is begun at a rate of 1 mm per day
– MCP joint will be progressively flexed unless stabilized with a strong K-
pin
 In small children – new bone growth from the periosteum –
medullary bone may adequately fill in the distraction gap
 In adult – Interposition bone grafting is usually required

37. CONCLUSION
Thumb reconstruction after mutilation is often
performed in the emergency setting, and the
amputated segment can be used for replantation.
In secondary reconstruction, "classic" techniques
have not been totally replaced by microsurgical
ones.
Thumb reconstruction remains a challenging but
rewarding surgery for both patient and surgeon if
the indications are understood and the surgery is
carefully planned and performed.

38. Thank you