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Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 973e977

A technique for the non-microsurgical reconstruction of thumb tip amputations
Dong Han a,b, Hongbin Sun b,*, Yunbo Jin a, Jiao Wei a, Qingfeng Li a
Department of Plastic and Reconstructive Surgery, Ninth People’s Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China b Department of Hand Surgery, The China Japan Union Hospital, Jilin University, Changchun, China Received 12 September 2012; accepted 9 March 2013

Thumb tip amputation; Nailbed; Periosteal flap; Reconstructive surgical procedures

Summary Purpose: This article aims to present a technique for thumb tip amputations using a homodigital soft-tissue/periosteum flap and a portion of the amputated digit. Methods: Eight patients (aged 21e53 years) with avulsion thumb tip amputations were reviewed. We report a new technique in which a bone and nailbed composite graft was taken from the amputated portion of the thumb and a dorsoulnar flap combined with periosteum was harvested from the first metacarpal and designed to cover the volar bone. Patients were evaluated 6 months after surgery for functional and cosmetic outcomes. Results: The radiographic evaluation showed bone healing in all of the patients 5 weeks postoperatively. With regard to pulp reconstruction, there was good recovery of static two-point discrimination. For both the reconstructed area and the donor site, the final results were good in terms of reliability and coverage as well as from a cosmetic perspective. Conclusions: This technique was found to be safe and effective. It is a good option for the non-microsurgical reconstruction of crushed and avulsed amputations of the distal thumb. Crown Copyright ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.

Avulsions and amputations of the thumb tips are common injuries to the upper extremity, and they require precise

* Corresponding author. Department of Hand Surgery, China Japan Union Hospital, Jilin University, No. 126, Xiantai Road, Changchun 130031, China. Tel.: þ86 (0) 431 84995222; fax: þ86 (0) 431 84641026. E-mail address: (H. Sun). 1748-6815/$ - see front matter Crown Copyright ª 2013 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.

wound care for optimal results. Microsurgical replantation of an amputated thumb tip is one way to achieve a painless finger with good sensitivity and mobility.1 For extensive crushing and avulsed amputations of the thumb, which preclude replantation, there are numerous reconstruction modalities: primary closure, skin grafting and close and distant flaps.2,3 The indications, advantages and disadvantages of various reconstructive procedures for

Six patients had crush injuries with amputations and two patients had avulsion-type amputations. The pedicle was elevated with a strip of skin and subdermal dissection along the dorsoulnar axis of the thumb towards the pivot point. The mean age of the patients was 35 (range. Tunnelling of the flap is not recommended because of the risk of venous congestion. Thumb is immobilised for 5 weeks. To preserve the vessel branches between the subcutaneous tissue and the periosteum. The skin between the defect and the pivot point should be incised and elevated so that the flap can be transposed and sutured covering the defect (Figure 2). We have used periostealecutaneous composite flaps to cover bone and nailbed composite grafts taken from the amputations to restore thumb function and appearance with acceptable results. the extensor pollicis brevis and extensor pollicis longus muscle tendons were located.. including the periosteum of the amputated part. and then. A case of crush amputation of the thumb tip.4 The main aim of the treatment of thumb tip amputations with no indication of replantation is to establish an acceptable functional and cosmetic outcome. The flap and pedicle must not be under any tension. and the flap was raised in a proximal-to-distal direction. The pivot point at the level of the neck of the proximal phalanx (2.10 A reverse homodigital dorsal ulnar flap with periosteum from the first metacarpal was created according to the dimensions of the defect. The proximal digital nerve stumps were isolated. Han et al. a few stitches were used to hold the periosteum and the subcutaneous tissue together to prevent them from peeling off the flap and to ensure sufficient blood supply to the periosteum. depending on the dimensions of the flap and the skin’s elasticity. Surgical technique Patients had surgery under a brachial plexus block using tourniquet control and loupe magnification.) (Figure 3). Materials and methods Between 2007 and 2011. The incision to the skin must be made superficial to preserve the pedicle. carefully pulled distally and cleanly divided with an operating scalpel so that the cut end retracted well proximal to the level of the bone resection.974 distal finger injuries have been described by Scheker et al. The donor site can be closed directly or the exposed bone can be covered by the adjacent fasci and a skin graft. While raising the flap. the skin graft was obtained from the amputated thumb tip. Figure 1 a. Patients were followed up for a mean of 8 months (range 6e12). thumb tip amputations were treated by our technique in eight patients. The axis of the flap is traced over the dorsoulnar aspect of the first metacarpal and proximal phalanx (1 cm from the median axis at the level of the neck of the proximal phalanx). was excised except for the bone and the attached germinal and sterile matrix of the nailbed. the k-wire is taken out and protected active mobilisation of the thumb encouraged. It is better to leave the wound partially open or to place a small skin graft over the exposed pedicle. the graft bone is considered ‘dead’ bone and can only heal through revascularisation.10 Proximal-to-distal dissection of the pedicle must end near the pivot point to protect the anastomosis with the palmar vessels.5e8 However. b. The level of thumb tip amputations was proximal to the germinal matrix and distal to the interphalangeal joint.5 cm proximal to the cuticle) is marked on the skin.9. this composite graft was fixed to the stump with a single k-wire (Figure 1). According to the surgical technique described by Alagoz et al. factors observed included nail cosmesis and function. In addition to the viability of the flap. 21e53) years. The pedicle was preserved at 1 cm in width to ensure the connections with the digital artery and to prevent postoperative venous insufficiency. It is more acceptable to use the bone and nail gathered from the amputated part as a graft to preserve cosmesis and function.7 the palmar segment. . The tourniquet is released with the flap in its original position to ensure both adequate refill of the vascular pedicle and vascular flow to the flap. Skin was incised at the periphery. it is important that the periosteum is flattened and covers the fracture site when periosteum sutures are placed. The critical point in the utilisation of the bone and nail tissue as a graft for reconstruction is to choose a flap that provides vascularity and periosteum to stimulate bone healing. sensation and bone healing.9. Replantation was not indicated in any of these patients. During this process. and the periosteum was dissected proximally from the first metacarpal carefully. D. according to the radiographs. The flap is rotated and sutured in place with a few stitches. The amputation level was at the proximal to the germinal matrix of the nailbed (dorsal view). The bone and nailbed composite graft from the amputated part. (In this case.

(Dorsal view). range 6e10). a subcutaneous pulp flap combined with the cap technique of the nail complex for avulsed thumb tip is a suitable method. this technique could be inapplicable as a result of nail regeneration problems.Non-microsurgical reconstruction of thumb tip 975 Figure 2 a. No patient complained about the resulting scar.7 The bone from the amputation was essentially ‘dead’ bone and revascularisation was the only way for healing to occur. 1 cm at the level of the first phalanx. b. Vascularised periosteum is an elastic and flexible membrane with known osteogenic properties and is suitable for skeletal reconstruction because it is readily available and adaptable to the shape of the recipient area. Alagoz described one method in which a homodigital artery 1 2 3 4 5 6 7 8 Male Male Female Male Male Female Male Male Crush amputation Crush amputation Crush amputation Crush amputation Avulsion amputation Crush amputation Crush amputation Avulsion amputation . Ulnar dorsal digital artery and its anastomosis with the ulnar palmar digital artery at the neck of the first phalanx. Figure 3 The flap was covered on the bone and nailbed composite graft and the nail was replaced after drilling. 2.5 Â 1. The donor site was covered by the adjacent fasci and a skin graft. ① Distance between the median axis of the thumb and ulnar dorsal digital artery. but the nail plate was hypertrophic. The treatment of thumb tip amputations should include not only good functional but also acceptable cosmetic results with the preservation of finger length. but it took so long that the possibility of bone necrosis and nonunion was a problem. The sensitivity of the thumb was measured and was compared to the opposite thumb (the two-point discrimination values over the flap were between 8 and 11 mm. and at the 6 months follow-up. Results The clinical data are summarised in Table 1. mean 9.9 mm) at 6 months postoperatively (Table 1).3 cm. At a minimum follow-up of 6 months (mean 8. ② Distance between the palmar anastomosis and the cuticle of the nail. For thumb tip amputation distal to the germinal matrix of the nailbed. The radiographs indicated bony union at 5 weeks postoperatively in all cases (Figure 4). * Periosteum from the first metacarpus). mm 11 10 9 11 11 10 9 8 Discussion Avulsion of the thumb tip usually causes serious cosmetic and functional problems. the bone and nailbed composite grafts had survived with no obvious complications in all thumbs. (+ The first metacarpus.5 Â 2 cm.5 to 2. for thumb tip amputations proximal to the nail root. A dorsal ulnar flap with periosteum from the first metacarpus in the snuffbox was designed and dissected. Type of injury and outcome. the nails were acceptably cosmetic. ulnar dorsal digital artery). (A. especially in the distal portion (Figure 5). flap was used to cover the bone and nailbed and composite grafts taken from the amputated part were used to restore the thumb tip function and cosmesis. There were no problems with the healing of the nailbed.11 The reverse homodigital dorsal flap of the thumb is Table 1 Case No. painful neuroma or persistent cold intolerance.6 However. Sex Type of injury Two-point discrimination values. The flap sizes ranged from 1.

and a good recovery of static two-point discrimination was obtained. can be done to improve the cosmetic appearance of the nail. In our experience.9. This flap design with a strip of skin takes advantage of the subdermal plexus and avoids compression and vascular compromise from pressure. Nevertheless. in which we used a dorsoulnar flap and vascularised periosteum to re-establish the function and cosmesis of the thumb ray. was hypertrophic due to malnutrition as a result of poor vascular supply in the early healing phase. especially females.976 D. A split nailbed graft from another digit or toe. a problem that remains unresolved is the sensory resurfacing in the palmar reconstruction of the thumb. any hypertrophic scarring or contracture resulting from the additional skin resection did not occur in our patients. The nail plate. This flap with periosteum not only covered and nourished the bone and nailbed composite grafts but also provided excellent osteogenic properties and promoted bone healing. termed reverse dorsoulnar flap with periosteum. and patients were satisfied with the thumb’s function and appearance. Figure 5 The cosmetic appearance of the nail and donor-site were acceptable at 6 months after surgery (dorsal view). the use of periosteal flaps is not recommended in skeletally immature patients to avoid potential consequences on skeletal growth. the follow-up at 6 months demonstrated that the flap had retracted and the bone/terminal tuft had undergone a little resorption on radiographs. and if the radiographs demonstrated union. With respect to the cosmesis. Because the dorsal skin of the hand is stretchable and the excision of a narrow cutaneous bridge does not obviously increase the tension of the skin. Brunelli9 and Tera ´n12 et al. especially the distal part. the thumb was typically immobilised for 5 weeks. electrolysis and laser therapy might be a complementary procedure for this technique. However. the dissection of the vascularised periosteum from the metacarpus did not damage the bone tissue. we find poor results with the hair-bearing skin of the dorsal hand on the thumb tip rather than the use of the homodigital flap using non-hair bearing more palmar-like skin. We advocate the preservation of a sufficient amount of soft tissue around the vascular pedicle to overcome the venous insufficiency while preserving the narrow cutaneous bridge in the flap. However. Faster healing allowed for early motion and less potential for stiffness. Figure 4 A radiographic evaluation clearly indicated that the bone trabeculae had crossed the junction of the bone extremities in the postoperative 5 weeks. For patients with thick hair. According to the radiographic evaluation at 5 weeks postoperatively. The outcome was satisfactory in all patients. Sensory recovery seems to depend on the age of the patient and the quality of the . low morbidity and preservation of the primary artery. we developed a new procedure. the k-wire was removed and protective active mobilisation was encouraged. Han et al.10 Based on these operative techniques. especially in women and adolescents. Full flexion and extension of the thumb were maintained. such as the big toe. reported that no important difference was observed between the patients in whom the nerve of the flap had been reconnected to one of the volar collateral nerves of the thumb and those who had not undergone nerve reconnection. The length of the thumb was acceptable. a good option for the reconstruction of the thumb because of its rich vascular supply.

Ann Plast Surg 2006. Miranda R. Very distal finger amputations: replantation or “reposition-flap” repair? J Hand Surg 1997. Casoli V.33A:254e6. Jaeger M. Dickson MG. 9. Brunelli GR. Chan YS. Kankaya Y. Carnero S. J Hand Surg Br 2001 Jun. 6. 8. Kerem M. An alternative technique for microsurgically unreplantable fingertip amputations. Fingertip reconstruction with a dorsal island homodigital flap. Uysal CA. 4.35(8):1356e9. The drawbacks of the reverse homodigital dorsal flap with periosteum were the extended operation time when compared with local flaps.9 mm with no nerve repair.26(3):207e11. Tera ´n P.44:204e8. Han D. Dorsoulnar osteocutaneous reverse flow flap of the thumb.47:60e3. Trillo E. Lin SS. Li QF. Dinh A. 5.24A:803e11. Ulusoy MG. Pelissier P. total or partial flap failure is a possibility. Lim A. Reverse homodigital artery flap coverage for bone and nailbed grafts in fingertip amputations.67:165e7. Houimli S. J Hand Surg Am 2010 Aug. Mahaffey PJ. Martin D. Ann Plast Surg 2001. J Hand Surg 2008. Refinements in dorsoulnar flap of the thumb: 15 cases. In addition. Hu HT.57:545e51. Baudet J.36A:521e8. 7. Conclusion The homodigital soft-tissue/periosteum flap and bone and nailbed composite grafts are safe. Graham K. Ethics The study was performed according to the local ethical guidelines. avulsing amputations of the distal thumb. Ueng SW.12 In our cases. Jiang H. Further cases are needed to evaluate the possibility of restoring sensation by nerve reconnection techniques. Valenti P. et al. Brunelli F. J Plast Surg Hand Surg 2010. .Non-microsurgical reconstruction of thumb tip substratum of the donor site. Vigasio A. Shibu MM. Tarabe MA. the necessity of microsurgical instrumentation and the meticulous dissection of the pedicle and periosteum. and we found a mean value of 9. It is a good option for the non-microsurgical reconstruction of crushing. Estefanı ´a M. Becker GW.56:279e83. New technique for non-microsurgical reattachment of avulsed fingertips in adults. 11. Distal finger replantation. J Trauma 2009. Scheker LR. Han D. Ann Plast Surg 2006. Braga-Silva J. effective and relatively easy. Chen AC.22 B:353e8. J Hand Surg 1999. Funding source The conduct of this study was not funded. Lee MS. Valenti P. Alagoz MS. static two-point discrimination was evaluated only for palmar reconstruction. Osteogenesis of prefabricated vascularized periosteal graft in rabbits. Arterial anatomy and clinical application of the dorsoulnar flap of the thumb. 2. 3. The subcutaneous pulp flap for fingertip defects. Dubert T. Br J Plast Surg 1997. Uysal A. J Hand Surg 2011. Pistre V.50:121e4. Conflict of interest statement None. Repositioning and flap placement in fingertip injuries. 12. Sensoz O. 10. 977 References 1.