Reconstruction of multiple finger amputations

When presented with the even more devastating amputations that involve several fingers, sometimes bilaterally, the reconstructive plan becomes more complicated. Replantations must be attempted whenever indicated and possible [28,29]. For nonreplantable amputations, toe transplantation remains the most useful reconstructive option [28,29]. Initial evaluation must entail a detailed and thoughtful discussion about the patient's special skills, occupation, handedness, and hobbies. It should be remembered that the nondominant hand has an indispensable role during orchestrated bilateral highly skilled activities, such as playing the piano or flute. Some activities are mandatorily left or right handed, and therefore demand that the nondominant hand be used in a dominant fashion in some patients; this may sometimes be the case for cere-brally left-handed individuals who have been trained to use their right hand dominantly instead for activities important to their livelihood. These are special circumstances that need to be explored with the patient before replantation and reconstruction are attempted.

Apart from the thumb, the radial two digits play the dominant role in global hand function for most patients, especially during fine manipulation, and should be preferentially reconstructed (Fig. 2) [16,17,29]. A few patients, nevertheless, have specific demands for maximal hand span; for them, an ulnar digit may be more important.

The reconstructive principles applied to a single finger amputation essentially apply also to multiple distal finger amputations. Prehensile ability is

Fig. 1. Single pulp reconstruction with a hemipulp flap from the medial great toe. (A) Degloved thumb pulp with intact flexor pollicis longus insertion. (B) Design of the hemipulp flap to be raised from the fibular side of the left great toe. (C) Hemipulp flap raised on a single artery and vein with a sensory nerve. (D) Good cosmetic result and sensory reinnervation.

Fig. 1. Single pulp reconstruction with a hemipulp flap from the medial great toe. (A) Degloved thumb pulp with intact flexor pollicis longus insertion. (B) Design of the hemipulp flap to be raised from the fibular side of the left great toe. (C) Hemipulp flap raised on a single artery and vein with a sensory nerve. (D) Good cosmetic result and sensory reinnervation.

Toe Thumb Transplant Photos

Fig. 2. Reconstruction of the radial two digits in a type IB metacarpal hand injury using a combined second and third toe transplant. (A) Appearance before reconstruction. (B) Combined second and third toe transplant based on a single pedicle artery and vein. (C) Appearance after inset of the transplant. (D) A broad first web space and good functional outcome have been achieved.

always the most important function to restore, particularly for multiple amputations involving proximal fingers [30,31]. Many different types of grip, grasp, and pinch exist in the human hand, and some are more important to some individuals than others. Universally important are the pulp-to-pulp pinch for fine manipulation and the tripod pinch for a more powerful yet precise pinch grip [30,31]. A broad hand span and palmar grasp and an ulnar digit wraparound grasp may be more important for the manual laborer who performs more powerful tasks, such as striking a hammer or handling large heavy objects, however. It is recommended that at least two fingers be reconstructed instead of only one to provide tripod pinch and a stronger hook grip and to improve lateral stability and handling precision (see Fig. 2D) [27].

When reconstructing adjacent fingers distal to the web space, two separate toe harvests are preferable to preserve a deep web space and avoid a syndactylous appearance [32,33]. More proximal amputations are preferably reconstructed with combined toe harvests, such as combined second and third or third and fourth toes based on a single vascular pedicle, to restore the web space appearance (see Fig. 2C, D) [32,33]. A further consideration is that the remaining fingers should be shorter than the tip of the normal little finger, because, otherwise, a transplanted two-toe unit does not restore an acceptable pinch point and grasp arch in the reconstructed hand [32,33]. The metacarpophalangeal joint can be reconstructed by adjoining the articular surface of the proximal phalanx and joint capsule in a transplanted toe with the intact articular surface of the metacarpal head. Transmetatarsal toe transplantation is preferable if the metacarpal head is damaged or lost [27].

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