Phẫu Thuật Tái Tạo Bàn Tay Và Chi Trên

Hand and Upper Extremity Reconstruction
258
A
B
C
D
FIGURE 19.1 Carpal tunnel release. A The standard carpal tunnel incision is parallel to the thenar crease along the ring fi nger axis to avoid
injury to the palmar cutaneous branches of the median and ulnar nerves. B The palmar aponeurosis is identifi ed by the longitudinally oriented
fi bers. C The fi bers of the transverse carpal ligament (TCL) are transversely oriented. Arrows are pointing to a partial incision in the ligament.
D Release of the TCL exposes the median nerve. The tip of the scissors is behind the recurrent motor branch.

Techniques for Nerve Compression Syndromes
259
Postoperative care
Finger movement begins immediately, which also aids in
median nerve excursion. A below-elbow splint is applied for
comfort for the fi rst week, followed by desensitization and
progressive strengthening.
Ancillary procedures
In advanced cases of nerve compression, internal neuroly -
sis and epineurotomy have been described. No signifi cant
differences were found between the outcomes of these
two ancillary procedures, hence they are no longer recom-
mended.22 Numbness of the small fi nger due to coexistent
Guyon’s canal compression often improves after carpal
tunnel release alone, and MRI studies have demonstrated
an increase in the volume of Guyon’s canal after a CTR.23
Routine tenosynovectomy does not provide better results
than carpal tunnel release alone, and is mostly recom-
mended with associated proliferative tenosynovitis from
some other cause, such as rheumatoid arthritis or granulo-
matous infection.24
Complications
Pillar pain is an often-cited complication after carpal tunnel
surgery. The cause of this condition is unclear and the
treatment debatable. Procedures such as z-plasty lengthen-
ing of the TCL to mini-incision and endoscopic techniques
have been proposed. Injury to the palmar cutaneous branch
of the median nerve is a cause of persistent scar tenderness
and led to the plea for a more ulnarly based incision. Blind
release of the TCL, which was commonplace in the 1960s,
occasionally resulted in laceration to the deep motor branch.
Injury to branches of the superfi cial palmar arch are repaired
or tied off as indicated. Median nerve anomalies or altered
anatomy may lead to inadvertent nerve laceration. Any
recognized fascicular lacerations should be repaired under
microscopic magnifi cation immediately or as soon as it
is recognized postoperatively to maximize the chances for
recovery. Acute infection is treated aggressively with anti-
biotics and/or drainage as necessary. Wound coverage prob-
lems with exposed tendons or nerve may be covered with
pedicled or free fl aps. Causalgia should be treated with stel-
late blocks and aggressive therapy, including edema control
and dynamic fi nger splinting.
Outcomes
Open median nerve decompression leads to symptomatic
relief in the majority of patients.26,27 When there is clinical
evidence of demyelination, patients should be informed of
the possibility of residual symptoms and delayed improve-
ment. After open carpal tunnel release, patients typically
regain their preoperative baseline grip strength within 3
months, and pinch strength within 6 weeks. Mini-incision
open techniques have similar outcomes but may carry a
higher risk of incomplete TCL release.
Endoscopic carpal tunnel release28
Indications for surgery
The indications for endoscopic carpal tunnel release (ECTR)
are the same as for an open release. The patient should
have the appropriate symptoms and signs of carpal tunnel
syndrome and have failed a trial of conservative treatment
with splinting, NSAIDs, and activity modifi cation.
Contraindications
Absolute contraindications include any distortion of the
carpal canal due to tumor, previous surgery, carpal fracture/
dislocation or malunion of the radius. A loss of wrist exten-
sion of 20–30º, either from bony fusion or from wrist con-
tracture, would hamper this procedure by impeding the
correct placement of the endoscope. Unfamiliarity with the
regional anatomy is another contraindication.
Relative contraindications abound and are not univer-
sally agreed upon. Flexor tendon thickening due to synovial
hyperplasia or adhesions from previous fl exor tendon re -
pairs will complicate the procedure. Recurrent or persistent
carpal tunnel syndrome following a previous release often
includes a component of traction neuropathy due to scar
that may thwart attempts at ECTR. If there is suspicion of
separate entrapment of the recurrent motor branch an open
procedure is required.
Surgical technique (Agee method)
The use of the Agee endoscope is integral to this procedure.
A 2.7 mm 30º angle arthroscope along with a fi beroptic
light source and camera setup are interfaced with the Agee
system. The patient is positioned supine with the arm
abducted on an arm board. The procedure is performed
under tourniquet control after limb exsanguination. The
author’s preference is to use a general anesthetic because
of the not-infrequent diffi culties with instrumentation,
E
FIGURE 19.1, cont’d E Mini-incision technique.

including fogging of the camera lens, which can be mini-
mized by warming the scope in saline. Regional and local
anesthesia are acceptable alternatives.
A number of anatomical landmarks are identifi ed and
outlined with a marking pen to guide placement of the
scope. The hamate hook, fl exor carpi ulnaris (FCU) and
pisiform are palpated and drawn on the skin. It is vital to
keep the scope radial to the hamate hook at all times in
order to prevent inadvertent penetration of Guyon’s canal.
A straight line is drawn connecting the longitudinal axis of
the ring fi nger with a transverse line across the proximal
wrist crease. The palmaris longus (PL) tendon (if present)
is traced. The dissection should stay ulnar to the PL, which
protects the median nerve. A 2-cm transverse incision is
placed in the proximal wrist crease between the PL and the
pisiform. As the surgeon’s comfort level increases, this
incision can be placed in the distal wrist crease, although
there is more subcutaneous fat to contend with. The plane
between the subcutaneous fat and the deep forearm fascia
or fl exor retinaculum (FR) is identifi ed and developed. A
distally based U-shaped fl ap of the FR is elevated by making
two parallel incisions approximately 1 cm apart and 1–2 cm
long through the deep fascia between the FCU and the PL/
median nerve. The incisions are then connected by a proxi-
mal transverse cut. Care is taken to avoid penetrating the
underlying fl exor synovium to lessen unwitting tendon lac-
eration. The distally based fl ap is elevated with a skin hook
while developing the plane between the superfi cial fl exor
tendon synovium and the undersurface of the TCL. Estab-
lishing this plane is crucial in avoiding improper scope
placement.
At this point, the wrist is hyperextended over two folded
towels. A small dilator is gently inserted superfi cial to the
fl exor tendons in line with the ring fi nger. With proper
placement, the dilator will abut against the hook of the
hamate by sweeping it in an ulnar direction. If there is no
obstruction to the ulnar passage of the dilator, the dilator
has entered ulnar to the hook of the hamate and should
be removed and reinserted, otherwise there is the dire risk
of injury to the ulnar nerve and artery. Two incrementally
sized dilators are then gently inserted to enlarge the gliding
path for the scope. The distal tip of the dilators can be
easily palpated in the midpalm by levering the tip palmar-
wards. Multiple passes of the dilators increase the risk of
a median neuropraxia, especially in small wrists. The soft
tissue elevator is then inserted and used to gently scrape
any synovium from the undersurface of the TCL. While
the assistant maintains the wrist in hyperextension, the
tip of the Agee endoscope is then gently inserted into the
canal. The surface line marking the axis of the ring fi nger
is used as a guide. The shiny transverse fi bers of the under-
surface of the TCL should now come into view. Often
fogging of the scope, fl uid from fatty tissue, or synovial
remnants will block the view. In this event, the scope
should be removed and defogged and the synovial elevator
used once more. Because the scope is often colder than the
carpal canal, keeping it in warm water until just before use
may minimize fogging. The distal edge of the TCL must
be completely visualized. This can be identifi ed by a change
of the transverse fi bers to an ill defi ned fat pad, which
contains the superfi cial palmar arch and the common
digital branch to the third web space. Ballottement of the
fat pad can help identify the demarcation zone. The hook
blade should not be engaged until the distal edge is well
seen. It is prudent to start the blade 2–3 mm from the
distal edge on the fi rst pass. The hook blade is then main-
tained upright while the scope is slowly withdrawn proxi-
mally, keeping the blade in sight at all times. The scope is
then reinserted to visualize the cut. The TCL is under
tension and will usually split apart, allowing identifi cation
of the muscle fi bers of the overlying palmaris brevis, or the
longitudinally oriented fi bers of the palmar aponeurosis. A
second pass may be made at this point to release the distal
most fi bers of the TCL. The scope is then removed (Fig.
19.2A–F).
The proximal skin fl ap is then retracted to allow visu-
alization of the deep fl exor retinaculum. Tenotomy scissors
are used to divide the retinaculum for an additional 2 cm.
The scope is then reinserted into the carpal canal and the
tourniquet is defl ated. Pulsatile bleeding is suggestive of an
injury to the superfi cial palmar arch, which is then explored
through an open incision. Digital nerve injury cannot be
recognized by any means, but a high level of suspicion and
due diligence will dictate the need for exploration. It is pos-
sible for the mesoneurial tissue surrounding the median
nerve to become interposed between the scope and the
undersurface of the TCL. It will not have the appearance
of nerve tissue, leading to a false sense of safety, but it can
be drawn in by the hook blade, which may lead to a partial
or complete median nerve laceration. If there is any doubt,
the scope should be removed and the fi eld cleared as
described above. If the view cannot be improved, then con-
version to an open procedure is necessary. The wound is
infi ltrated with marcaine and closed with an absorbable
subcuticular suture and Steristrips.
Postoperative care
The patient is placed in a large bulky hand dressing with a
volar wrist splint for comfort. Finger motion begins imme-
diately, which also results in nerve excursion. The splint
is removed at 1 week and the patient is started on a home
program of range of motion exercises. The sutures are
removed at 2 weeks and light gripping exercises begun.
Complications
Signifi cant and devastating complications have been re -
ported, often related to poor scope placement or inadequate
visualization of the TCL. These include partial and com-
plete median nerve lacerations, common digital nerve lac-
erations, and injuries to the superfi cial palmar arch.29 The
author has noted a 6-month neurapraxia of the third
common digital nerve branch in small female patients with
small carpal canals. Flexor tendon lacerations have also
been reported. If there is anything less than complete visu-
alization, the procedure should be converted to an open
CTR. Placing the scope in Guyon’s canal as a result of
inadequate identifi cation of the hook of the hamate has
resulted in ulnar nerve and artery lacerations.30 Incomplete
Hand and Upper Extremity Reconstruction
260

A
B
C
D
E
F
FIGURE 19.2 Endoscopic carpal tunnel release. A Landmarks for locating the hamate hook (*). P = pisiform, M4 = fourth metacarpal line, I-P =
Index pisiform line. B Skin incision at distal wrist crease (in red). C Outlining a distally based fascial fl ap. D Insertion of the Agee endoscope,
which is aligned with the ring fi nger axis. E View through the endoscope of the white undersurface of the transverse carpal ligament (TCL).
The appearance of the midpalmar fat pad demarcates the distal edge of the TCL(*). F After complete release of the TCL. Note the increased
separation of the ligament edges (arrows) with exposure of the palmar brevis, which denotes a complete ligament release. (From Slutsky DJ.
Endoscopic carpal tunnel release: the Agee method. In: Slutsky DJ, Nagle DJ, eds. Techniques in wrist and hand arthroscopy. Philadelphia:
Elsevier, 2007, with permission.)

Hand and Upper Extremity Reconstruction
262
release of the TCL is commonly reported and is a major
criticism of this technique.31
Outcomes
Agee et al.32 carried out a 10-center randomized prospective
study of endoscopic release using his technique. For patients
in the device group with one affected hand, the median time
for return to work was 211/2 days less than that for the
control group.32 Another large multicenter prospective study
of 192 cases demonstrated that, at least in the short term,
the patients treated with the endoscopic method had sig-
nifi cantly greater grip strength, pinch strength, and hand
dexterity. The open technique resulted in greater scar ten-
derness during the fi rst 3 months after surgery as well as a
longer time until the patients could return to work.33 Not
everyone agrees with the advantage of the endoscopic tech-
nique. In a small study of 25 patients with bilateral carpal
tunnel syndrome who underwent an endoscopic release by
the Agee technique on one hand and open release on the
other, the investigators found no signifi cant advantages
in terms of return of grip strength, manual dexterity or
sensation.34
PROXIMAL MEDIAN NEUROPATHY
Pronator syndrome
Median nerve compression neuropathies in the distal arm
and forearm are extremely uncommon compared to CTS.
The more proximal of the median nerve compression
neuropathies is the pronator syndrome. The syndrome is
classically associated with any of four potential areas of
compression, including the ligament of Struthers, the lac-
ertus fi brosis, the aponeurotic fascia of the superfi cial or
deep head of the pronator teres (PT), or the fl exor digitorum
sublimus (FDS) arch. Confounding conditions such as
carpal tunnel syndrome and anterior interosseous nerve
entrapment should be excluded.
Anatomy
The median nerve arises from the medial and lateral cords
of the brachial plexus. It contains the nerve root fi bers from
C6 to T1. It lies lateral to the axillary artery but then
crosses medial to it at the level of the coracobrachialis. At
the elbow, it travels behind the bicipital aponeurosis but in
front of the brachialis. At the distal part of the cubital fossa
the motor branches of the median nerve consistently divide
into three fascicular groups.36 There is an anterior group (to
the PT and FCR), a middle group (motor to the FDS and
hand intrinsics, sensory to the thumb, index and middle
fi ngers), and a posterior group (to the AIN branch). These
branch groups can be traced proximally without harm,
within the main trunk of the median nerve for 2.5–10 cm.
The nerve and artery pass through the antecubital fossa
underneath the lacertus fi brosis and give off branches to the
palmaris longus (PL), fl exor carpi radialis (FCR), fl exor digi-
torum superfi cialis (FDS), and rarely the fl exor digitorum
profundus (FDP). The nerve then dives between the deep
and superfi cial heads of the PT, to which it supplies up to
four branches. The fi brous arch of the PT lies 3–7.5 cm
below the humeral epicondylar line. The fi brous arch of the
superfi cialis arch lies 6.5 cm below the humeral epicondylar
line. The median nerve enters the forearm deep to the
fi brous arch of the FDS and emerges beneath the radial
side of the muscle belly of the middle fi nger superfi cialis,
where it is quite superfi cial and near the palmaris longus
tendon.
Pathophysiology
The nerve may be compressed by the ligament of Struthers,
which may or may not be associated with a supracondylar
process (1% of cases).37 This ligament spans the supracon-
dylar process and medial epicondyle and creates an arcade
that contains the median nerve and brachial artery The
ligament of Struthers has also been described in the absence
of an associated supracondylar process. In the forearm, the
median nerve can be compressed by the PT, the FDS arch
or the bicipital aponeurosis. Rare causes of compression
include a persistent median artery, Gantzer’s muscle (acces-
sory head of the FPL) and the palmaris profundus.38
History
Clinical symptoms of pronator syndrome include forearm
pain as well as paresthesia and hypoesthesia in the median
nerve distribution. Symptoms are typically precipitated by
activity, especially repetitive elbow fl exion/extension and
forearm pronation/supination. Nocturnal paresthesias are
not common, unlike with CTS. Numbness and tingling
may also involve the thenar area supplied by the palmar
cutaneous branch, which takes off proximal to the carpal
transverse ligament and is not compressed in CTS.
Physical examination
Phalen’s and Durkan’s tests are negative unless there is
coexistent CTS. There may be a positive Tinel’s sign over
the proximal nerve as well as a fi rm and tender PT, and a
tenderness along the median nerve in the proximal forearm.
Manual compression of the median nerve over the PT for
30 seconds (i.e. pronator compression test) may elicit par-
esthesia in the median nerve distribution.39 Pain or pares-
thesia produced by resisted forearm supination combined
with resisted elbow fl exion beyond 120º suggests compres-
sion at the bicipital aponeurosis. Paresthesia resulting
from resisted forearm pronation while the elbow is slowly
extended from full fl exion is indicative of compression
between the two heads of the PT. Resisted proximal inter-
phalangeal joint fl exion of the middle fi nger by producing
paresthesia in the radial three digits and/or pain over the
FDS arch is consistent with entrapment under the fi brous
origin of the FDS. These tests are, however, neither specifi c
nor sensitive.40
Electrodiagnostic studies
NCS are rarely diagnostic for pronator syndrome. There
may be prolongation of the distal median sensory latencies
as well as a reduced amplitude of the compound motor
action potential to the abductor pollicis brevis. There may
be slowing of forearm conduction, but this can be mislead-

Techniques for Nerve Compression Syndromes
263
ing because a reduced forearm NCV is seen up to 20–30%
of the time when there is a markedly delayed distal median
motor latency due to severe CTS. This slowing was initially
thought to be due to retrograde nerve demyelination but
is currently attributed to test artifact. Sequential needle
stimulation of the median nerve in 1-cm increments while
recording from the APB may identify an area of focal con-
duction block near the PT muscle. Nerve conduction studies
during provocative maneuvers such as elbow fl exion,
forearm pronation and middle fi nger fl exion against resis-
tance do not increase the yield.41–43 The EMG, however,
may be of some value because membrane instability may
be seen in the median-innervated muscles, including the
PT, fl exor carpi radialis and FDS.
Quantitative sensory testing
As with CTS, testing of the index pulp may initially show
an abnormal 2PS pressure threshold. With progression one
sees a widening of the 2PS distance, followed by an abnor-
mal 1PS threshold. In this syndrome, PSSD testing of the
thenar eminence is especially useful and may help to dif-
ferentiate pronator syndrome from CTS. Because the palmar
cutaneous branch of the median nerve (PCBMN) takes off
proximal to the TCL, one would expect an abnormal 2PS
and possibly 1PS in pronator syndrome, whereas this should
be normal in isolated CTS. In the author’s experience,
however, a coexisting C6 radiculopathy can complicate the
picture, and can lead to abnormal 2PS and 1PS over both
the thenar eminence and the dorsum of the fi rst web space.
This can mimic compression of both the PCBMN and
superfi cial radial nerve, hence clinical correlation is
prudent.
Non-operative management
The hallmark of treatment consists of activity modifi cation
and NSAIDs. Steroid injections are of no benefi t. Immobi-
lization in an above elbow splint with the elbow fl exed 90º
with slight forearm pronation and wrist fl exion for 4–6
weeks may relieve pressure and traction on the median
nerve. The majority of patients will respond to non-opera-
tive therapy.
Surgical indications
The diagnosis of this condition is based mainly on the
exclusion of other causes. Many patients will have already
undergone a carpal tunnel release. The main indication is
failure to improve to conservative treatment combined with
reproducible physical fi ndings compatible with this diagno-
sis. Other straightforward indications are a positive EMG
demonstrating denervation of the proximal forearm muscles
or MRI evidence of nerve compression due to an underlying
tumor.
Contraindications
A coexisting polyneuropathy, C6–7 radiculopathy or a bra-
chial plexitis (Parsonage–Turner syndrome) may mimic
the physical fi ndings and should be ruled out, because
these conditions will not benefi t from a median nerve
decompression.
Surgical technique
The procedure is performed under tourniquet control. An
anteromedial incision is made crossing the antecubital
fossa, starting 5 cm above the elbow fl exion crease. The
medial antebrachial cutaneous nerve is isolated as it runs
with the basilic vein. The median nerve is identifi ed proxi-
mal to the elbow, next to the brachial artery, and it is traced
distally, resecting the ligament of Struthers if present. The
nerve is followed through the two heads of the PT where
branches from the anterior bundle (FCR, PT fascicles) are
given off. Both the superfi cial head of the PT and the FDS
can be divided and tagged for later repair if better exposure
is needed. The posterior (AIN branch) and the middle
(intrinsic, sensory) bundles pass deep to the superfi cialis
arch, which is also incised. Epineurotomy or internal neu-
rolysis are of no benefi t. Subcutaneous transposition of the
median nerve is also not recommended.
Postoperative management
Postoperatively, the arm is placed in an above elbow splint
for comfort with the elbow fl exed 90º, the forearm in mid-
pronation and the wrist in slight fl exion. Gentle elbow
range-of-motion exercises are begun after the fi rst week
unless it is necessary to protect the reattachment of the PT
and/or FDS insertions. Resistive activities are avoided until
6–8 weeks after surgery.
Complications
One main complication is failure to improve due to a mis-
diagnosis. Vascular injury is a signifi cant risk and meticu-
lous hemostasis is necessary. Injury to the proximal
muscular branches ranging from neuropraxia to laceration
can be minimized by careful nerve handling.
Outcomes
Surgical decompression generally yields good results.
Olehnik et al.39 reported improvement in 77% of their
patients, with 33 of 36 returning to work. A clinical series
by Hartz et al. and Johnson et al. reported improvement in
92% of patients.42,43 Patients with normal NCS seem to fare
better than patients with abnormal studies, which may be
related to the severity of the compression.
Anterior interosseous nerve syndrome
Isolated anterior interosseous nerve (AIN) palsy is a rare
occurrence, accounting for <1% of all upper extremity
peripheral neuropathies.37 It is still uncertain whether
this syndrome is due to a neuritis and/or a compressive
neuropathy.
Anatomy
The AIN is the largest muscular branch to emerge from the
median nerve. It innervates the FDP to the index and middle
fi ngers, the FPL, and the pronator quadratus (PQ). The ter-
minal portion also provides sensory innervation to the
carpal joints. The AIN arises from the median nerve on the
dorsoradial surface about 5–8 cm distal to the medial epi-
condyle. The AIN travels between the FDS and FDP, and

Hand and Upper Extremity Reconstruction
264
then passes dorsally in the interval between the FPL and
FDP, giving off two to six branches to each of these muscles.
The nerve reaches the anterior surface of the interosseous
membrane and travels with the anterior interosseous artery,
where it passes deep to the PQ, which it also innervates. It
ends by sending sensory afferent branches to the intercarpal,
radiocarpal, and distal radioulnar joints.
Pathophysiology
The AIN may be compressed by fi brous bands from the
deep (most common) or superfi cial head of the PT, the
fi brous arcade of the FDS, enlarged bursae or tumors, aber-
rant or thrombosed vessels, an accessory bicipital aponeu-
rosis and fractures of the forearm and distal humerus.
History
AIN syndrome (AINS) must be differentiated from a bra-
chial plexus neuritis, i.e. Parsonage–Turner syndrome.44 In
a brachial neuritis there is usually no history of trauma.
The pain symptoms may be unrelated to the motor fi nd-
ings, and can appear spontaneously or following a viral
illness or vaccination. By contrast, the patient with AINS
will usually have a history of trauma or repetitive injury.
They typically complain of vague, aching pain in the proxi-
mal forearm, which occurs at rest and is exacerbated by
activity. The patient can have diffi culty with writing and
pinching activities, and may have sensory abnormalities in
the median nerve distribution.
Physical examination
AINS is characterized by loss of function of the FPL and
FDP to the index and sometimes the long fi nger and the
PQ. Sensibility is unaffected. The patient cannot make an
‘O’ sign (see Fig. 19.1A). During attempted tip pinch, the
index fi nger extends at the distal interphalangeal joint with
compensatory increased fl exion at the proximal interpha-
langeal joint. The thumb hyperextends at the interphalan-
geal joint with increased fl exion of the metacarpophalangeal
joint. The PQ can be tested by resisted pronation with the
elbow fl exed to relax the pronator teres.
AINS can be incomplete, with either weakness or
absence of the FPL or FDP of the index fi nger alone and
normal PQ function. All of the profundus tendons may
be AIN-innervated, with subsequent weakness of all the
fi ngers. The hand intrinsic muscles may be affected if there
is a coexisting Martin–Gruber connection. This is where
C8–T1 motor fi bers destined for the hand intrinsic muscles
travel in the median nerve. They then cross over to the
ulnar nerve, usually through connections in the AIN (91%).
If the FDS is also innervated by the AIN (30%), patients
may present with weakness in this muscle as well.45
One must differentiate between AINS and rupture of the
FDP or FPL, which may occur from rheumatoid arthritis,
Keinböck’s disease, and scaphoid non-union. The integrity
of these tendons can be assessed by observing the tenodesis
effect of the intact FPL and the index FDP, which causes
passive thumb IP and index DIP fl exion with passive wrist
extension.
Electrodiagnostic studies
Shoulder girdle and upper limb EMG should be performed
to rule out a brachial plexitis. In this case there will be
membrane instability in the proximal limb muscles. The
most appropriate technique involves recording the com-
pound motor action potential (CMAP) from the pronator
quadratus. The active surface electrode is placed in the
midline dorsally, 3 cm proximal to the ulnar styloid. The
median nerve is stimulated at the cubital fossa. The mean
onset latency for the PQ is 3.6 ± 0.4 ms, with a side-to-side
difference of 0.4 ms. Normal amplitudes range from 2.0 to
5.5 mV.46 Side-to-side comparative latencies are helpful in
establishing the diagnosis. EMG testing of the PQ and FPL
muscles should demonstrate signs of membrane instability
(Fig. 19.3B).
Quantitative sensory testing
This should be entirely normal because the condition only
affects a motor branch. Any abnormalities are due to unre-
lated causes and conditions.
Surgical indications
If there is no improvement either clinically or by EMG
studies 4–6 months after onset, surgical exploration is indi-
cated. Even though return of function has been reported up
to 18 months after onset of symptoms, expectant treatment
is less predictable than surgical intervention.
Surgical technique
The surgical approach for AIN palsy is essentially the same
as for pronator syndrome. The median nerve is followed
through the two heads of the PT where branches from the
anterior bundle (FCR, PT fascicles) are given off. Both the
superfi cial head of the PT and the FDS can be divided and
tagged for later repair if better exposure is needed. The
posterior (AIN branch) and the middle (intrinsic, sensory)
bundles pass deep to the superfi cialis arch, which is incised
(Fig. 19.3C–D). A microscopic interfascicular neurolysis of
the AIN up to the elbow should be considered in cases in
which there is no obvious compression site, because hour-
glass-like fascicular constrictions that are not discernible
through the intact epineurium have been reported.47
Postoperative management
The arm is placed in a bulky, above-elbow plaster splint
that maintains the elbow in 90º of fl exion, the forearm in
45º of pronation, and the wrist in slight fl exion for
comfort.
Complications
The anatomy and hence the complications are virtually
identical to those of pronator syndrome.
Outcomes
Clinical improvement may be seen for up to 1 year follow-
ing surgery, but recovery is often incomplete (see Fig. 19.3E).
Non-surgical management is recommended for brachial
plexus neuritis-induced AIN palsy.

Techniques for Nerve Compression Syndromes
265
FIGURE 19.3 Anterior interosseous nerve compression. A Inability to
perform the ‘O’ sign. B Needle placement during EMG of the pronator
quadratus. C Anteromedial approach to the median nerve. Note the
fi brous border of the sublimus muscle. PT = pronator teres, AIN =
anterior interosseous nerve. D Following release of the sublimus arch
(FDS). E Clinical photo at 8 months showing active fl exion of the
distal phalanx of the index but no active thumb interphalangeal joint
fl exion. (From Slutsky DJ. Electrodiagnostic studies of the upper
extremity. In: Slutsky DJ, Hentz VR, eds. Peripheral nerve surgery:
practical applications in the upper extremity. Philadelphia: Elsevier,
2006, with permission.)
A
B
C
D
E

Hand and Upper Extremity Reconstruction
266
ULNAR NEUROPATHIES
Proximal ulnar neuropathy
Ulnar nerve compression at the elbow is the second most
common neuropathy in the upper limb after carpal tunnel
syndrome.
Anatomy
The ulnar nerve arises from the medial cord of the brachial
plexus and contains the nerve root fi bers from C8 to T1. It
provides the motor supply to the hypothenar muscles, the
ulnar two lumbricals, the interosseous muscles, the adduc-
tor pollicis, the FCU and the profundus muscles to the ring
and small fi ngers. Its sensory distribution includes the
palmar surface of the small and the ulnar half of the ring
fi nger, as well as the dorsoulnar hand. It lies medial to the
axillary artery and continues distally to the mid-arm. It
then passes through a fi brous canal (erroneously labeled the
arcade of Struthers) from the anterior to the posterior com-
partments of the arm. The canal is approximately 6 cm
long, with the proximal extent located approximately 10 cm
from the medial epicondyle. The proximal opening of the
canal is a V-shaped window made up of the medial inter-
muscular septum, which divides the anterior and the pos-
terior compartments of the arm and the internal brachial
ligament.48 The internal brachial ligament supports the
origin of the most superfi cial layer of the medial head of
the triceps, from the inferior border of the teres major to
its fusion back to the septum. This layer appears as an
oblique muscular curtain covering the medial aspect of the
ulnar nerve. In one anatomical study, the internal brachial
ligament was present in 22/30 specimens.49 The septum
makes up the anterior part of the canal; the rest is made
up of deep investing fascia and epimysium of the triceps
muscle. The nerve is often accompanied by the superior
ulnar collateral artery. At the elbow, it lies between the
medial epicondyle and the olecranon, where it is covered
by Osborne’s ligament. It enters the forearm between the
two heads of the FCU and is covered by a fi brous aponeu-
rosis (the cubital tunnel). It runs deep to the FCU as far as
the distal forearm.
Pathophysiology
The ulnar nerve may be compressed anywhere from 10 cm
proximal to approximately 5 cm distal to the medial epi-
condyle. Five potential sites for compression have been
described. The most proximal site is the point at which the
ulnar nerve takes a direction change as it passes through
the V-shaped canal from the anterior to the posterior com-
partments of the arm. Hourglass indentations of the nerve
were found at this point in 11 of 11 cadaver arms.48 Although
this has been labeled the arcade of Struthers, recent inves-
tigators have shown this to be historically incorrect.50,51
They note that Struthers did not describe an arcade over
the ulnar nerve, but did describe the internal brachial liga-
ment. Other investigators, however, have noted a muscu-
lotendinous arcade in eight of 60 cadaver arms that could
form a secondary compression site after anterior transposi-
FIGURE 19.4 Anconeus epitrochlearis. Note how this anomalous
muscle attaches to the fi broaponeurotic bands (forceps), which arc
over the ulnar nerve (*) as it traverses the olecranon groove.
tion of the ulnar nerve.52 The second site is at the medial
epicondyle, where a cubitus valgus deformity is present.
The third site is the olecranon groove, which is a fi bro-
osseous tunnel bounded anteriorly by the medial epicon-
dyle, laterally by the olecranon and ulnohumeral ligament,
and covered by a fi broaponeurotic band. Compression at
this site can be caused by lesions within the groove, such
as tumors (Fig. 19.4), conditions outside the groove such
as external compression by anomalous muscles, and condi-
tions that predispose the nerve to displace from the groove.
The fourth site is where the nerve passes between the two
heads of the fl exor carpi ulnaris (FCU) muscle. The fl oor
of the passageway through FCU is the medial collateral
ligament of the elbow and the roof is a fi brous band
(Osborne’s ligament or the arcuate ligament), which is a
continuation of the fi broaponeurotic covering of the epicon-
dylar groove.53
At the elbow the ulnar nerve contains about 20 fasci-
cles, including the motor branches to the forearm muscles.
The fascicles within a nerve are not uniformly affected by
compression. Those on the periphery of a nerve sustain
greater injury than centrally placed fascicles. The motor
fascicles to the FCU and the intrinsic muscles are cen-
trally located, whereas the sensory fi bers are superfi cially
located. The usual sites of compression in cubital tunnel
syndrome are superfi cial to the nerve (Osborne’s ligament,
arcade of Struthers).54 The internal topography of the ulnar
nerve at the elbow explains the relative sparing of the
fl exor carpi ulnaris and fl exor digitorum profundus because
their motor fi bers lay deep within the nerve.55 The intrin-
sic muscles are often uninvolved until the late stages of
compression for similar reasons, whereas the superfi cially
located sensory fi bers are more susceptible to early
compression.

Techniques for Nerve Compression Syndromes
267
History
The patient presents with complaints of numbness and/or
tingling in the small and/or ring fi nger. Symptoms can range
from mild numbness in the ring and little fi ngers to severe
pain on the medial aspect of the elbow, with dysesthesias
radiating distally into the hand. In chronic cases patients
may complain of a loss of dexterity with fi ne manipulation
tasks. Symptoms are provoked by repetitive or sustained
elbow fl exion activities.
Physical examination
The ulnar nerve is palpated for enlargement or subluxation
during elbow fl exion. There may be a positive Tinel’s sign
at the epicondylar groove or over the proximal FCU. An
elbow fl exion test is performed by placing the elbow in full
fl exion with a hyperextended wrist, while manual pressure
is applied to the nerve for 1 minute.56 The test is considered
positive when paresthesia and/or numbness occur in the
ulnar nerve distribution of the hand. False positive results
occur in approximately 10% of patients.
There may be a sensory defi cit involving all or part of the
ulnar nerve distribution, including the dorsoulnar wrist.
When intrinsic muscle weakness is severe, there is often
clawing of the ring and little fi ngers. One may see a positive
Froment’s sign (fl exion of the interphalangeal joint of the
thumb with side pinch, a positive Jeanne’s sign (hyperex-
tension of the metacarpophalangeal joint of the thumb) and
paradoxical abduction of the small fi nger due to a paralyzed
third palmar interosseous (positive Wartenberg sign). Extrin-
sic weakness may involve the fl exor digitorum profundus
to the little fi nger and ring fi nger. Weakness of the fl exor
carpi ulnaris rarely occurs.
Non-operative treatment
Most acute or subacute cases are treated with activity modi-
fi cation to avoid activities that require repetitive elbow
fl exion and to reduce external pressure from leaning on
their medial elbow or forearm. Alterations can sometimes
be made in the workplace, such as positioning a computer
keyboard so that the operator’s elbows are not acutely
fl exed. When symptoms are severe and have persisted for
weeks, temporarily immobilizing the elbow in approxi-
mately 35º of fl exion and the wrist in neutral may provide
relief. Patients are instructed to wear the splint day and
night for 3–4 weeks. Non-steroidal anti-infl ammatory drugs
can be helpful, but corticosteroid injections around the
nerve are ineffective.
Indications for surgery
Sensory loss in the ulnar nerve distribution with nerve
studies and clinical evidence of intrinsic muscle denerva-
tion are major indications. In these cases, conservative
treatment is not justifi ed. Across elbow motor conduction
<45 m/s with a >20% drop in amplitude is another strong
indication. Relative drops of >10 m/s are a softer indication
that should be approached cautiously because technical
error can produce this quite easily. Focal slowing on seg-
mental stimulation is another appropriate indication.
Contraindications
Ulnar nerve symptoms due to brachial plexus compression
from a Pancoast tumor or a C8–T1 radiculopathy are infre-
quent contraindications. Some authors maintain that normal
electrodiagnostic studies are another contraindication to
surgery. Patients with normal electrodiagnostic studies but
appropriate signs and symptoms (McGowan Stage I: pares-
thesia and numbness but no weakness) can still benefi t from
surgery and are appropriate candidates if conservative mea-
sures over a 3–6 month period have failed.60
Surgical technique
Surgery can be divided into two groups of procedure: decom-
pression without transposition of the ulnar nerve, and
decompression with transposition of the nerve. The proce-
dures are performed under axillary block or general anes-
thesia using a tourniquet.
Subcutaneous anterior transposition
A 5 cm posteromedial incision is made centered on the
medial epicondyle. Branches of the medial antebrachial
cutaneous nerve are identifi ed and protected. The deep
fascia overlying the proximal ulnar nerve is divided, as well
as any associated ligament of Struthers. The fascia over the
nerve is released sequentially, fi rst in the upper arm, fol-
lowed by the fi broaponeurotic covering of the epicondylar
groove, then Osborne’s ligament at the cubital tunnel, and
fi nally the fascia where the nerve passes between the two
heads of the FCU. A 1 cm segment of the medial intermus-
cular septum is resected where it attaches to the epicondyle
to prevent a secondary site of compression, taking care to
prevent injury to fragile veins medial to the septum. Articu-
lar branches to the elbow are divided, but motor branches
to the FCU should be preserved. A vessel loop is placed
around the nerve, which is then gently transposed anterior
to the medial epicondyle along with the superior ulnar col-
lateral vessels. A 1 cm wide medially based fl ap of fascia
from the common fl exor origin can be turned down and
sutured to the proximal skin edge to prevent posterior sub-
luxation of the nerve. The patient uses a sling for comfort
postoperatively and is started on progressive elbow exten-
sion as tolerated. These same principles can be applied to
a mini-incision technique (Fig. 19.5).
Submuscular transposition
A slightly larger incision is made and the nerve is decom-
pressed in a similar fashion. A z-plasty lengthening of the
common fl exor origin is preserved and the nerve is trans-
posed deep to the muscle. Care must be taken to divide the
fi brous attachment of the FDS to the humeral epicondyle
to prevent secondary impingement while avoiding injury to
the medial collateral ligament of the elbow. The ulnar nerve
is now positioned on the bed of the brachialis muscle. The
fl exor–pronator mass is then repaired with 2/0 non-
absorbable sutures (Fig. 19.6A–C). Postoperatively the
elbow is immobilized at 90º for 4 weeks, allowing elbow
fl exion but no extension. The elbow is then gradually
extended over the ensuing 2–4 weeks.

Hand and Upper Extremity Reconstruction
268
Complications
The most dire complication is ulnar nerve laceration. More
commonly, injury to the medial antebrachial cutaneous
nerve results in a tender scar and hypoesthesia along the
medial forearm. Injury to the superior ulnar collateral artery
or its branches is a cause of postoperative hematoma. The
median nerve lies on the brachialis just behind the medial
intermuscular septum, and is at risk during resection of the
distal septum or with aggressive retraction. Large intramus-
cular veins medial to the septum can also be injured during
this step and are very diffi cult to ligate. Secondary entrap-
ment due to creation of a fascial sling can occur with
subcutaneous transpositions. Postoperative ulnar nerve
subluxation due to a failure of this sling can result in
painful paresthesia with elbow fl exion. Secondary impinge-
ment may also occur following a submuscular transposition
due to a failure to release the deep fi bers of the sublimus
origin on the medial epicondyle. The ulnar collateral liga-
ment can also be injured during this step, resulting in
postoperative elbow instability.
Outcomes
As in CTS, the patient’s clinical fi ndings and response to
conservative measures should be a major determinant in
the surgical decision making. In one study, 92% of patients
recovered grade 3 motor strength or better.61 The results are
largely determined by the preoperative degree of compres-
sion. When there are constant symptoms and demyelin-
ation, recovery may take 6–8 months. Residual sensory
complaints are common. Even though intrinsic wasting
rarely recovers in an adult, prevention of further denerva-
tion is crucial.
Distal ulnar neuropathy
Anatomy
The ulnar tunnel or Guyon’s canal is approximately 4 cm
long; it begins at the proximal edge of the carpal transverse
FIGURE 19.5 Mini-incision subcutaneous ulnar nerve transposition.
A
B
C
FIGURE 19.6 Submuscular ulnar nerve transposition. A The ulnar
nerve has been released and is being retracted by a vessel loop. The
z-plasty lengthening of the common fl exor origin has been outlined.
B Scissors are behind the fi brous origin of the sublimus, which must
be released to prevent secondary ulnar nerve impingement following
transposition. C Course of the ulnar nerve (*) following the
submuscular transposition and repair of the common fl exor origin.

Techniques for Nerve Compression Syndromes
269
ligament and ends at the fi brous arch of the hypothenar
arch. It is bounded medially by the pisiform, and radially
by the hamate hook. The fl oor consists of the carpal trans-
verse ligament and the roof consists of the continuation
of the deep forearm fascia, the volar carpal ligament. The
ulnar nerve has 15–25 fascicles at the wrist, and can be
clearly divided into a volar sensory component and a dorsal
motor component. At the wrist, the ulnar nerve passes over
the TCL, medial to the ulnar artery, through Guyon’s canal.
The deep motor branch is given off at the pisiform and
passes underneath a fi brous arch to lie on the palmar
surface of the interossei. It crosses the palm deep to the
fl exor tendons, to terminate in the adductor pollicis and the
ulnar head of the fl exor pollicis brevis.
Pathophysiology
The standard teaching divides the sites of compression in
Guyon’s canal into three zones. In zone 1, nerve compres-
sion leads to mixed motor and sensory symptoms. In zone
II symptoms are purely sensory, and in zone III symptoms
are purely motor and restricted to muscles innervated by
the deep ulnar motor branch.62 Two sites of entrapment
distal to the abductor digiti minimi (ADM) have also been
described.63 In these cases the ADM will be preserved, but
there is weakness and wasting of the intrinsic muscles.
History
The patient may also present with complaints of numbness
and tingling of the small and/or ring fi nger. The dorsoulnar
aspect of the hand is not affected. The patient may give a
history of repetitive pounding using the hypothenar emi-
nence that may occur with autobody technicians, martial
artists and Kodo drummers. Cyclists who ride for extended
periods in the crouching position may entrap the deep
motor branch against the hamate hook while grasping the
handlebars. A history of Raynaud’s symptoms should alert
one to the possibility of ulnar artery thrombosis.
Physical examination
There are no characteristic fi ndings of ulnar tunnel entrap-
ment per se. A Tinel’s sign may be present at the wrist, but
not the elbow unless there is an associated cubital tunnel
entrapment. Intrinsic muscle atrophy may also occur in
chronic compression, but the FCU and the FDP are not
affected. There should be a negative Tinel’s sign at the
elbow and a negative elbow fl exion test. If there is an associ-
ated ulnar artery aneurysm there may be a palpable thrill
and an audible bruit. With ulnar artery thrombosis, the
Allen’s test will be positive for ulnar artery occlusion. With
an associated fracture of the hook of the hamate, there will
be localized tenderness in the palm, 1 cm radial and 1 cm
distal to the pisiform. Ancillary testing such as ultrasound,
CT, angiography and MRI, may be used to aid in the diag-
nosis of these associated entities.
Electrodiagnostic studies
The usual nerve conduction studies are inadequate in
assessing ulnar nerve entrapment in the palm. Short
segment incremental studies (SSIS) are a sensitive and spe-
cifi c way to assess the deep motor branch because focal
conduction abnormalities also tend to be normalized over
the distance between the ADM and the FDI.64 The ulnar
nerve is stimulated in 1 cm increments from 3–4 cm proxi-
mal and distal to the wrist crease. Abnormal values include
a >0.5 ms jump or a >120% drop in amplitude. When this
is combined with FDI conduction and interosseous-latency
differences, the diagnostic yield increases.
Quantitative sensory testing
The 2PS to the small fi nger is the fi rst to go, followed
by an abnormal 1PS. The dorsoulnar wrist should
remain normal unless there is an associated C8–T1
radiculopathy.
Non-operative treatment
The mainstay of treatment is activity modifi cation. Cyclists
should avoid riding in the crouching position with their
hands low on the handlebars because this is a recognized
precipitant of symptoms; they should change their hand
position frequently. Autobody repair technicians, martial
artists and Kodo drummers should avoid repetitive percus-
sion on the ulnar border of their palm. Wrist splinting and
cortisone injections have no role in this condition.
Indications for surgery
Intrinsic muscle wasting and/or sensory loss are a sine qua
non for decompression. The presence of a mass occupying
lesion also mandates surgical treatment. Ulnar artery
thrombosis or aneurysm may be treated with ulnar artery
repair or ligation.
Contraindications
Ulnar motor and/or sensory disturbances due to more prox-
imal causes preclude a distal release. Ulnar sensory distur-
bances in CTS were a common indication for release in the
1980s, but have since become an infrequent indication for
the release of Guyon’s canal because the majority of patients
experience improvement following CTR.23
Surgical technique
The ulnar nerve is identifi ed proximal to the distal wrist
crease between the FCU and the fl exor tendons through a
curving incision that crosses the wrist obliquely and bisects
the interval between the pisiform and the hook of the
hamate. The ulnar nerve is followed distally as the volar
carpal ligament is released. The ulnar artery is inspected
for thrombosis or aneurysm. The fi brous arch of the hypo-
thenar muscles is incised and the fl oor of the canal is
explored for masses, fi brous bands or anomalous muscles.
With entrapment in the palm, the deep motor branch is
followed distally as it traverses the palm lying on the inter-
osseous fascia, deep to the fl exor tendons and superfi cial
palmar arch. The dissection is completed as the motor
branch ends in the muscle belly of the adductor pollicis
(Fig. 19.7A–D).
Complications
These are mostly related to injury to the branches of the
ulnar nerve or artery. Injury to the palmar cutaneous
branches of the ulnar nerve or the nerve of Henle (if present)

Hand and Upper Extremity Reconstruction
270
A
B
FIGURE 19.7 Distal ulnar neuropathy. A Dorsal preoperative photograph of attempted index fi nger abduction. Note the marked wasting of the
fi rst, second and third dorsal interossei. B Volar preoperative photograph of attempted index fi nger abduction. Note the marked wasting of the
fi rst, second and third dorsal interossei, but the normal bulk of the abductor digiti minimi (arrows).
may result in scar tenderness and hypoesthesia. Uncom-
monly injury to the pisiform ligament complex can result
in instability of the pisotriquetral joint.65
Outcomes
Clinical recovery is seen in the majority of patients when
the ulnar nerve entrapment is due to a space-occupying
lesion.66 Motor recovery is less predictable than sensory
recovery, especially when the compression is due to a
fi brotic hypothenar arch or is long-standing.67
RADIAL NEUROPATHIES
Upper arm
Anatomy
The radial nerve arises from the posterior cord of the bra-
chial plexus and receives contributions from C5–C8 spinal
roots. The nerve contains approximately 16 000 myelin-
ated fi bers.12 At the level of the coracobrachialis it courses
posteriorly to lie in the spiral groove of the humerus. In the
lower arm it pierces the lateral intermuscular septum to
run between the brachialis and the brachioradialis. Oppo-
site the head of the radius there are some fi brous bands
from the joint’s capsule, and immediately distal to this the
nerve is regularly crossed by several prominent veins, the
‘leash of Henry.’ It divides 2 cm distal to the elbow into a
superfi cial radial sensory branch (SRN) and a deep motor
branch, the posterior interosseous nerve (PIN). Before giving
off the PIN branch it gives off branches to the extensor carpi
radialis longus and brevis, brachioradialis and anconeus.
The PIN continues on between the superfi cial and deep
head of the supinator muscle, to exit on the dorsal forearm.
After it emerges from the distal border of the supinator, the
PIN sends branches, in descending order, to the extensor
digitorum communis, extensor carpi ulnaris, extensor digiti
quinti, extensor pollicis longus and brevis and the extensor
indicis proprius, although there may be considerable
variation.
History
In the arm region the radial nerve is often injured in
association with some form of unconsciousness. In a ‘Sat-
urday night palsy’ an obtunded patient sits with the arm
over a chair back or rests his/her head on the lateral surface
of the arm. Alternatively, the radial nerve can be com-
pressed in the groove between the brachialis and forearm
muscles when one person rests their head on the middle
third of the arm of another, for example in ‘Honeymooner’s
palsy.’

Techniques for Nerve Compression Syndromes
271
Physical examination
The patient will typically present with a wrist drop and an
inability to extend the fi ngers, thumb or wrist. In addition,
the brachioradialis will be affected along with variable
involvement of the triceps. There will also be diminished
sensation over the dorsum of the fi rst web space. The NCS
typically demonstrates the absence of the superfi cial radial
SNAP. Motor recordings are more diffi cult because no
muscle is suffi ciently isolated from other radially inner-
vated muscles.
Indications for surgery
For the majority of patients, non-operative treatment is the
mainstay. Failure to improve within 6 months, combined
with a non-advancing Tinel’s sign, is an indication for
exploration.
Contraindications
The time for reinnervation must take the distance from the
injury to the motor endplate into account. As a general rule,
motor endplates degrade at about 1% per week, and the
nerve regenerates about 1 inch per month. By 12 months,
the nerve will have grown approximately 12 inches and
there will be a 50% loss of endplates, hence the maximum
length that a nerve can grow to restore motor function is
approximately 13–18 inches. For practical purposes, nerve
decompression will be of no value with injuries that are
more than 18 months old (>75% loss of endplates) and
alternative methods should be explored.
Surgical technique
A 6–8 cm incision is made over the posterolateral aspect of
the midhumerus. The radial nerve is identifi ed in the spiral
groove and followed distally through the intermuscular
septum. Any obvious areas of nerve constriction or loss of
the normal striations (bands of Fontana) should undergo
epineurolysis. The use of intraoperative nerve stimulation
will help differentiate a neuroma-in-continuity from non-
viable nerve tissue. In the former case an internal neuroly-
sis is justifi ed rather than excision and grafting.
C
D
FIGURE 19.7, cont’d C Intraoperative view following an ulnar nerve decompression in Guyon’s canal as it splits into a superfi cial sensory
branch (white asterisk) and deep motor branch (*) which passes under the hypothenar arch. D Six months after operation. Note the normal
bulk of the dorsal interossei and the active index fi nger abduction. (From Slutsky DJ. Electrodiagnostic studies of the upper extremity. In:
Slutsky DJ, Hentz VR, eds. Peripheral nerve surgery: practical applications in the upper extremity. Philadelphia: Elsevier, 2006, with permission.)

Hand and Upper Extremity Reconstruction
272
Postoperative management
Immediate elbow mobilization is instituted following nerve
decompression or neurolysis. Nerve grafting may require
temporary elbow splinting for 4 weeks, but it is preferable
to insert a graft of suffi cient length to allow early elbow
extension.
Complications
The radial nerve is accompanied by the radial collateral
artery in the spiral groove, which is at risk during decom-
pression. Injury to the muscular branches may result in
permanent denervation of one or more heads of the triceps.
Injury to the posterior cutaneous nerve of the forearm may
result in a tender scar and hypoesthesia.
Radial tunnel syndrome
History
The presenting complaint in radial tunnel syndrome is
proximal forearm pain, often coexisting with lateral epicon-
dylitis, without sensory or motor loss. The patient often
gives a history of performing repetitive pronation/supina-
tion activities, such as using a screwdriver. The symptoms
of radial tunnel syndrome often coexist with and overlap
those of lateral epicondylitis.
Physical examination
A number of provocative tests have been described, includ-
ing resisted extension of the middle fi nger, which tenses the
ECRB and entraps the nerve, tenderness over the supinator
muscle, and pain with resisted supination. None is pathog-
nomonic for this condition.69 A diagnostic local anesthetic
block of the PIN, which produces a temporary wrist drop,
is useful in confi rming the diagnosis if the pain is com-
pletely relieved. Classically the NCS is normal in radial
tunnel syndrome.
Non-operative management
The majority of cases will resolve with modifi cation of
activity. In the early stages above-elbow splinting with the
elbow fl exed to 90º and the forearm in supination will
relieve the dynamic compression and allow the infl amma-
tory response around the PIN to subside. PIN gliding exer-
cises will help maintain nerve excursion: these consist of
simultaneous elbow extension, forearm pronation, wrist
fl exion and ulnar deviation. In many instances the treat-
ment that is instituted for a coexisting lateral epicondylitis
will also resolve the symptoms of radial tunnel
compression.
Indications for surgery
Persistent
proximal
forearm
pain
that
does
not
resolve despite appropriate activity modifi cation is an
indication for decompression, especially if a lateral epi-
condylectomy has already been performed. Complete
pain relief following a diagnostic PIN block is a good
predictor of at least partial improvement following
surgery.
Contraindications
The existence of this disorder is still questioned by some
authors. All efforts should be made to rule out other causes
of pain, such as radiocapitellar joint disorders, lateral elbow
instability, and untreated lateral epicondylitis.
Surgical technique
The volar approach to the radial nerve is through an 8-cm
anterolateral incision under tourniquet control. The mus-
cular fascia is divided and the intermuscular interval
between the brachialis and brachioradialis is developed with
blunt dissection. Recurrent branches from the radial artery
must be ligated to gain access to both nerve branches. The
radial nerve is identifi ed proximal to the elbow and followed
distally. At the level of the radial head, the radial nerve gives
off branches to the ECRB and brachioradialis. It then divides
into the superfi cial radial nerve branch, which travels dis-
tally under the brachioradialis. The PIN continues distally
and is crossed by the radial recurrent vessels, which are
ligated. The proximal border of the supinator muscle (the
arcade of Frohse) is divided along with the superfi cial head
of the supinator (Fig. 19.8A,B). At this point the PIN disap-
pears from view as it penetrates the dorsal extensor com-
partment. If there is a suspicion of distal entrapment, a
separate dorsal approach to the PIN is necessary. This can
be accomplished by extending the incision distally and dor-
sally, or by making a separate incision. The PIN is then
approached through a dorsolateral approach, developing the
plane between the extensor carpi radialis brevis and the
extensor digitorum communis (Fig. 19.9A–D). At this level,
the PIN contains motor fi bers only, hence separate fascicle
identifi cation is unnecessary. The distal border of the supi-
nator is delineated and divided
Outcomes
Early reports of radial tunnel decompression were generally
optimistic. Beasley et al.71 reported 80% good or excellent
results in his series of 109 decompressions. A recent review
by Sotereanos et al.,72 however, found good results in only
11 of 28 patients, with many experiencing residual symp-
toms. The results were worse in patients receiving worker’s
compensation.
Complications
The potential complications are similar for radial tunnel
syndrome and PIN decompression. The main indication to
ligate the radial leash of vessels is to prevent postoperative
bleeding, because they are a rare cause of compression by
themselves. The superfi cial radial nerve is at risk of injury
through laceration or retraction. Persistent radial tunnel
syndrome due to unrelieved PIN compression at the distal
border of the supinator may require repeat surgery.
Posterior interosseous nerve entrapment
History
In posterior interosseous nerve syndrome the presenting
symptoms are weakness and/or paralysis of the extensor

Techniques for Nerve Compression Syndromes
273
A
B
FIGURE 19.8 Anterolateral approach to PIN decompression. A Anterior approach with a view of the proximal volar forearm demonstrating
the arcade of Struthers(*). SRN = superfi cial radial nerve. PIN = posterior interosseous nerve. B After release of the arcade. Note the normal
appearance of the PIN. RN = radial nerve. (From Slutsky DJ. Electrodiagnostic studies of the upper extremity. In: Slutsky DJ, Hentz VR, eds.
Peripheral nerve surgery: practical applications in the upper extremity. Philadelphia: Elsevier, 2006, with permission.)
muscles, which results in a wrist or fi nger drop. There may
be a history of a fall onto an extended and pronated arm,
although many cases are spontaneous, especially if due to
an underlying lipoma, ganglion or rheumatoid nodule
arising from the radiocapitellar joint.
Physical examination
The patient will present with variable weakness or paralysis
of the EPL, EIP, EDC and ECU. Motor function of the
ECRB/L should be preserved because they are innervated
before the PIN dives between the two heads of the supinator
muscle. The patient will therefore extend their wrist in
radial deviation. PIN lesions do not affect the superfi cial
radial SNAP, which should be normal. The compound
motor action potential of PIN-innervated muscles may
show a drop in conduction velocity or amplitude, but this
is diffi cult to assess with surface electrodes. Needle EMG
is the best technique for localization, especially with partial
lesions.19 The management of this syndrome is identical to
that for radial tunnel syndrome.
Superfi cial radial nerve entrapment
Anatomy
The radial sensory nerve exits from under the brachioradia-
lis approximately 5 cm proximal to the radial styloid, and
bifurcates into a major volar and a major dorsal branch at
a mean distance of 4.2 cm proximal to the radial styloid.
It then moves distally, where it supplies sensation to the
dorsum of the thumb, the fi rst web space and the dorsora-
dial aspect of the carpus, extending up to the index and
middle fi ngers.
Pathophysiology
The superfi cial radial nerve (SRN) can be injured in the distal
forearm or at the wrist by tight bracelets or watch bands,
handcuffs, radius fractures, lacerations, venous cutdown and
blunt trauma. The SRN may also be entrapped as it exits the
fascia between the tendons of the BR and ECRB.
History
Pertinent history may include compressive or crushing
forearm injuries, work activities requiring frequent prona-
tion and wrist hyperextension, and associated illnesses,
such as diabetes. Symptoms included altered sensibility
over the dorsoradial aspect of the hand, and dorsoradial
cutaneous pain with ulnar fl exion of the wrist or with grip-
ping and pinching.
Physical examination
Physical examination includes altered touch perception,
moving 2PD >15 mm, static 2PD that is 5 mm greater than

Hand and Upper Extremity Reconstruction
274
at the contralateral fi rst web space, a positive Tinel’s sign
over the SRN, and aggravation of the patient’s symptoms
with forced forearm pronation and wrist ulnar fl exion.74
Quantitative sensory testing
The patients will have an abnormal 2PS and possibly 1PS
over the dorsum of the fi rst web.
Electrodiagnostic studies
The distal radial sensory latency may be normal even
in the presence of abnormal forearm conduction. This
commonly occurs with nerve entrapment due to segmental
conduction velocity slowing. In more advanced cases
slowing or a complete block of the distal SRN occurs. If the
response is absent, it is diffi cult to localize the lesion.
Indications for surgery
Failure to improve following conservative treatment, with
avoidance of repetitive wrist deviation and tight bands or
jewelry, is an appropriate reason.
Contraindications
De Quervain’s tenosynovitis often includes a component
of superfi cial radial nerve irritation and should be treated
before considering SRN decompression.
Surgical technique
A 2 cm incision is made approximately proximal to the
radial styloid. The superfi cial radial nerve is identifi ed as it
exits from underneath the tendon of the brachioradialis.
The overlying fascia is split, care being taken not to disturb
the nerve.
Outcomes
Dellon and MacKinnon74 reported on a group of 51 patients
with complaints related to entrapment of the superfi cial
sensory branch of the radial nerve. Seven (37%) of 19
patients treated with non-operative modalities were
improved after a mean of 28 months from the onset of
symptoms or their injury. Of the 32 patients treated with
surgery, there was excellent subjective improvement in
A
B
C
D
FIGURE 19.9 Combined anterior and posterolateral approach to P.I.N. decompression. A Skin incision for combined approach. B Exposure of
the PIN (*) between the extensor carpi radialis brevis and the extensor digitorum communis. C Dissection of the superfi cial radial nerve (SRN)
showing its relation to the PIN. Note the radial leash of vessels (*). D After skin closure.

Techniques for Nerve Compression Syndromes
275
37%, good subjective improvement in 49%, and fair subjec-
tive improvement in 6%; 8% were not improved.74
Complications
The complications for each procedure are similar. They
include wound problems related to infection, skin healing,
tender scars due to injured cutaneous nerves, hematoma
and iatrogenic injury due to rough nerve handling and/or
retraction. These can be minimized by meticulous hemo-
stasis, gentle nerve handling, and precise surgical tech-
nique. Stiffness can occur and is minimized by early joint
mobilization. The incidence of residual symptoms is predi-
cated by the preoperative degree of nerve injury.
CONCLUSIONS
It is apparent that compressive neuropathies share similar
features. Although each focal neuropathy has been dis-
cussed in isolation, multiple compressive neuropathies
often coexist. The element common to all focal neuropa-
thies is nerve ischemia, which leads to the sensory and/or
motor abnormalities in the distribution of the specifi c nerve
that is affected. Provocative tests exploit this feature by
seeking to dynamically increase the ischemia through exter-
nal pressure and/or traction in order to magnify the symp-
toms. Although ancillary testing can yield useful information,
most hand surgeons intuitively understand that the indica-
tion for surgery still hinges on reproducible physical fi nd-
ings combined with the appropriate clinical symptoms
rather than on a test abnormality.
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277
C H A P T E R
20
Thumb Reconstruction
Sang-Hyun Woo
The importance of thumb reconstruction cannot be over-
emphasized, as 40–50% of total hand function is performed
by the thumb. Replantation of the thumb is mandatory,
irrespective of the level of amputation, because successful
replantation both maximizes patient satisfaction and mini-
mizes donor-site morbidity from subsequent reconstructive
efforts. When replantation is not a viable option, this
chapter will provide the surgeon with a number of options
for thumb reconstruction, based on the type and extent of
the tissue defect.
The objective of thumb reconstruction is to restore
mobility, stability, pain-free sensibility, suffi cient length
to provide opposition, and good appearance. In children,
growth potential must also be considered.
Although there are a number of very successful recon-
structive procedures, and new procedures are continually
being developed, the surgeon must always take into consid-
eration the informed decision of the patient over and above
their own preference.
PULP DEFECT
The pulp area of the thumb is characterized by its high
concentration of sensory nerve endings. The pulp has there-
fore been referred to as a ‘third eye.’ Also, because of the
numerous septa between the distal phalangeal bone and the
skin, the pulp works to prevent slippage when pinching
objects. In reconstruction, the original pulp thickness and
color should be well matched and the result of the recon-
struction should be stable and durable. Adequate thickness
with excellent two-point discrimination in the pulp is
essential, and there ought to be no shearing between the
bone and the skin.
There are various options for reconstruction based on
the size and shape of the defect, as well as the surgeon’s
preference. First, the size of the defect can be classifi ed as
small, medium, large or very large (Fig. 20.1). A small defect
is half the length of the nail. In cases where there is no
exposure of the distal phalangeal bone, such defects can
heal spontaneously with conservative management, such as
occlusive or semiocclusive dressings, especially in children.
Another option is a simple volar V-Y advancement fl ap,
although this procedure sometimes results in cold intoler-
ance and a hook-nail deformity.
A medium defect is one confi ned to the area extending
proximally to the halfway point of the nail, but limited to
the level of the nail fold. This defect can be covered by a
cross-fi nger or cross-side fi nger fl ap. In addition, a palmar
advancement fl ap1 or extended palmar advancement fl ap2
can be used, as well as the modifi cation of this procedure
that encompasses the complete mobilization of all proximal
palmar soft tissue, as demonstrated by Hueston3 and
Argamaso4 (Fig. 20.2).
In cases where there is a large defect that extends proxi-
mally to the nail fold at the interphalangeal crease, a palmar
advancement fl ap is not ideal because it often causes an
interphalangeal joint contracture.5 For a large defect, the
surgeon may opt to employ a dorsolateral island fl ap,6 a
dorsoulnar reversed island fl ap,7 a neurovascular island fl ap,
or Littler’s fl ap8 from the non-critical side of the middle or
ring fi nger. However, the neurovascular island fl ap presents
some disadvantages with regard to cortical reorientation
problems and scarring of the donor fi nger.9 Another sensate
fl ap is the dorsal island or kite fl ap,10 in spite of the differ-
ences in skin texture between dorsal and volar skin. This
fl ap is harvested from the dorsum of the proximal phalanx
of the index fi nger based on the fi rst dorsal metacarpal
artery, with one or two superfi cial draining veins and
branches of the superfi cial radial nerve (Fig. 20.3). Very large
defects proximal to the interphalangeal crease require some
kind of free fl ap or reversed radial forearm island fl ap.
However, the fi bular aspect of the great toe is an excel-
lent donor site for providing sensate and glabrous tissue in
a pulp fl ap to cover the volar aspect of the thumb.11–13 This
fl ap includes the fi rst dorsal metatarsal artery, the superfi -
cial vein, the deep peroneal nerve, and the digital nerves.

Hand and Upper Extremity Reconstruction
278
thumb, the medial plantar area is an ideal choice in replac-
ing that lost tissue.18 With regard to the morbidity of the
donor site, the medial plantar skin seems more reasonable
than harvesting a fl ap from the pulp of the great toe for
thumb reconstruction.
Soft tissue defect of the dorsum
Small defects of the dorsum can be covered using a local
transposition fl ap. This is a random pattern fl ap based on
the subdermal plexus and superfi cial veins.
A medium defect can be resurfaced using a de-epithelial-
ized cross-fi nger fl ap from the dorsum of the index fi nger,
but the donor site and outer surface of the fl ap will require
a full-thickness skin graft. The kite fl ap13 is an extremely
mobile fl ap that can reach any surface of the dorsum, as
well as being useful in volar reconstruction. Another advan-
tage of the kite fl ap is its generous size.
Large dorsal defects can be repaired with a reversed
island fl ap. The available donor fl aps are the radial forearm
fl ap19 or the posterior interosseous fl ap.20 The radial forearm
fl ap is easy to harvest and reliable, but has severe donor site
morbidity. It is also quite bulky and requires the sacrifi ce
of a major artery. The posterior interosseous artery fl ap is
not reliable and is also bulky. Another suitable method is
to use a distally based forearm island fl ap that is vascular-
ized by the perforators of the distal radial artery.21 This fl ap
lies along the axis of the radial artery; the pivot point of
its subcutaneous pedicle is 2–4 cm proximal to the radial
styloid process. This fl ap can also be innervated, and is
useful for resurfacing the hand. The donor site morbidity
is minimal, but fl ap dissection must be meticulously per-
formed. This fl ap can also be used to reconstruct compound
extensor tendon and skin defects.22,23
Regarding the free fl ap option, the dorsalis pedis fl ap
used to be very popular because of its close resemblance to
the anatomy of the hand and foot.24,25 It is quite versatile
in replacing skin, tendons, and nerves in the hand.15,26 The
extensor digitorum longus tendon of the second toe can be
included in a tendocutaneous fl ap transfer. This fl ap must
Spontaneous healing
Skin graft
volar V-Y advancement flap
A Small defect
Cross-finger flap
Cross-side finger flap
Palmar advancement flap
and its modified procedures
B Medium-sized defect
Dorsolateral island flap
Neurovascular island flap
Kite flap
Pulp free flap
Medial plantar flap
C Large defect
Pulp free flap
Medial plantar flap
Perforator flap
Reversed radial forearm
island flap
D Very large defect
FIGURE 20.1 Classifi cation of pulp defects and options for treatment.
FIGURE 20.2 Rotation–transposition method for soft tissue replacement on the distal segment of the thumb.
The shape and texture of the pulp are so similar to those
of the normal thumb that there is no need for a secondary
operation. Moreover, a new fl exor crease will form at the
interphalangeal joint by 6 months after surgery (Fig. 20.4).
The static two-point discrimination in the lateral side of
the great toe is on average 11.3 mm.12,14 In a group of
patients after toe fl ap transfer and nerve repair a mean
static two-point discrimination of 6 mm was obtained,
which implies that the sensation of the transferred toe fl ap
is more precise than at the donor site.15 Although there are
several possible explanations for this, this phenomenon is
probably best explained by cortical re-education and adapta-
tion with continuous, repetitive use postoperatively.12,16,17
An aggressive rehabilitative program is essential for sensory
restoration.
Additionally, in view of the unique characteristics of
the skin and subcutaneous tissue covering the pulp of the

Thumb Reconstruction
279
A
B
C
D
FIGURE 20.3 A Pulp necrosis of the thumb. B Design of the kite fl ap.
C Nerve coaptation between branch of the superfi cial radial nerve
and radial digital nerve of the thumb. D Postoperative view 14
months later.

Hand and Upper Extremity Reconstruction
280
be carefully dissected to minimize scarring in the dorsum
of the foot, and an unmeshed, thick split-thickness skin
grafting to the foot is recommended.27 Because of the
unsightly donor site, this fl ap is used only in specifi c situ-
ations where compound tissue is needed, but its advantages
must outweigh the morbidity at the donor site.
Soft tissue and bone defects
For small defects of bone and soft tissue, the thumb can be
reconstructed with an iliac bone graft and a reversed fascio-
cutaneous island fl ap. Combined soft tissue defects with
bone loss of more than 2–3 cm can be reconstructed with
a distally based island osteocutaneous fl ap. The transfer of
a vascularized combined osteocutaneous fl ap is advanta-
geous, because of the ability of the fl ap to survive in a
hypovascular and potentially infected environment. The
vascularized bone heals better and can hypertrophy to with-
stand continuous physical stresses.
The available donor fl aps are radial,28 ulnar,29 and pos-
terior interosseous.30 The bone contained within these fl aps
remains viable because of an intact blood supply via the
vascular pedicle. The transferred bone unites directly with
the recipient bone without the need for revascularization
by creeping substitution. Therefore, the vascularized bone
segment provides better union rates and undergoes less
resorption than a free bone graft.31 The osteocutaneous
radial forearm fl ap (Fig. 20.5) is the most popular as well
as being very reliable.32 A newly designed transverse radial
artery forearm fl ap33 reduces donor site morbidity. The
donor defect can be closed by a V-Y advancement of a fas-
ciocutaneous fl ap based on the ulnar artery, which signi-
fi cantly improves the aesthetic result. Potential radius
fracture can be prevented by removing a smaller segment
of the bone, using a boat-shaped osteotomy, and ensuring
adequate immobilization with a long-arm plaster cast for
6 weeks.34
The osteocutaneous posterior interosseous fl ap is also
recommendable for a single-stage reconstruction of the
thumb. The source of the blood supply to the segment of
the ulna is mainly musculoperiosteal in its proximal two-
thirds and fascioperiosteal in its distal third. Therefore, the
fl ap must be harvested from the proximal two-thirds of the
ulna with a portion of the extensor pollicis longus muscle.
A
B
FIGURE 20.4 A Large pulp defect of the right thumb. Preoperative view. B Postoperative view, 18 months later.

Thumb Reconstruction
281
Compared to the radial osteocutaneous fl ap, this fl ap pre-
serves the major arterial supply and can be used even where
there is damage to the radial or ulnar arteries or the palmar
arch. The ulna is broad and triangular, and its shape at this
level allows the segment to be excised while leaving a sub-
stantial skeletal framework.30 Immobilization is necessary
for only a short period of time, i.e., 1 week.35 This enables
both the wrist and the other fi ngers to start early mobiliza-
tion and the patient to begin physiotherapy as early as
possible.
NAIL AND SOFT TISSUE DEFECT
Nonvascularized composite nail grafts for nail defects in
both congenital anomalies and traumatic defects have not
shown excellent results. To get a predictable fi nal result in
nail reconstruction, vascularized nail transfer has been per-
formed. Because thumb nail defects occur concomitantly
with injury to adjacent skin, onychocutaneous fl aps can be
harvested based on the vascular pedicle of the fi rst dorsal
metatarsal artery and dorsal vein of the foot (Fig. 20.6). The
distal part of the distal phalangeal bone under the nail bed
should always be included in the osteo-onychocutaneous
fl ap, because dissection of the nail bed from the periosteum
of the distal phalangeal bone causes iatrogenic injury to the
germinal matrix, which can lead to a deformity of the nail
plate. Also, it can cause delayed growth of the nail plate
because of damage to the subungual vascular arcade during
surgical dissection.36
MICROSURGICAL THUMB RECONSTRUCTION
When replantation is impossible, emergency or immediate
toe-to-hand transfer36,37 is one treatment option based on
the concept of early microsurgical reconstruction in acute
trauma to the extremities.38 Compared with the later elec-
tive operation, immediate toe transfer for thumb recon-
struction has several advantages. It allows easy dissection
of the intact neurovascular pedicles through the open
wound that has not developed fi brosis or scar adhesion. The
lack of scar tissue enhances tendon and joint movement
after reconstruction. It also reduces the convalescent period
by using a single-stage reconstruction, and disability time
may be shortened. However, a signifi cant disadvantage of
early reconstruction relates to the patient’s lack of under-
standing of the reconstructive procedure and inability to
C
D
FIGURE 20.4, cont’d C Design of the pulp fl ap on the lateral aspect of the great toe. D Dissected pulp fl ap with fi rst dorsal metatarsal artery
(red arrow), superfi cial vein (blue arrow), and digital nerve (white arrow).

A
B
C
D
FIGURE 20.5 A Preoperative photograph of the thumb shows severe
crush injury of the soft tissue. B Preoperative X-ray of the left thumb
shows comminuted fracture of the proximal phalangeal bone and
metacarpal bone. C The osteocutaneous island fl ap, which is based
on the pedicle of reversed radial artery and vena comitantes, includes
8×8 cm of skin fl ap as well as 6 cm of radius. D Postoperative X-ray
taken 20 months later shows healing of the fractures.

recognize the signifi cance of thumb loss. Preoperative angi-
ography is only recommended if the patient has peripheral
vascular disease. Depending on the amount of thumb loss,
there are many options for its reconstruction.39,40 In chil-
dren, reconstructive options are limited to the second-toe
option because growth is an important consideration.
Second-toe transfer is a useful procedure for a thumb defect
distal to or at the metacarpophalangeal joint. Thumb loss
proximal to the metacarpal shaft requires pollicization.
Figure 20.7 gives recommendations for microsurgical and
non-microsurgical reconstructive options in adults.
Defects distal to or at the interphalangeal joint:
partial great toe transfer
The distal part of the thumb is composed of the nail bed
and plate with adjacent dorsal skin, pulp, and distal pha-
langeal bone. Reconstruction of composite defects of the
distal thumb to its original function and appearance is very
challenging. This level of amputation does not cause much
disability or functional impairment, and some patients
may not feel the need for reconstruction, depending on
their lifestyle, customs, or cultural background. However,
in patients with a high demand for a better esthetic appear-
ance and more refi ned thumb function, a procedure to
make the thumb as natural as possible is needed.
The amputation level of the distal thumb can be subdi-
vided into three levels (Fig. 20.8). Level 1 has pulp, partial
nail bed, and dorsal skin defects involving less than 60% of
the nail width, irrespective of the defect at the distal pha-
langeal bone. It is reconstructed with an osteo-onychocuta-
neous fl ap with a partial nail from the great toe. The distal
phalangeal bone under the nail bed is always included in
the fl ap (Fig. 20.9). In level 2, an osteo-onychocutaneous
fl ap with a whole nail from the great toe is used to recon-
struct nail bed defects involving more than 60% of the
width. In level 3 a partial great toe transfer with arthrodesis
of the interphalangeal joint can be performed to reconstruct
defects caused by amputation at the level of the interpha-
langeal joint. In cases where the difference of nail width
between the thumb and the great toe is more than 3 mm,
the great toe partial-nail-preserving transfer technique is
useful41 (Fig. 20.10).
There are various methods of great toe-to-hand transfer
to restore the interphalangeal joint that play a critical role
in key pinch and vice grip for larger objects.42 The mini
wraparound fl ap can be harvested from the great toe, and
an arthrodesis of the interphalangeal joint at the recon-
E
F
FIGURE 20.5, cont’d E Photograph showing the healed hand, 20 months postoperatively. F Photograph taken 20 months after surgery
showing function of the injured hand.
Thumb Reconstruction
283

Hand and Upper Extremity Reconstruction
284
A
B
FIGURE 20.6 A Preoperative view of nail deformity of the right thumb. B Harvested onychocutaneous fl ap from the left great toe. The red
arrow is pointing to the fi rst dorsal metatarsal artery and the blue arrow is pointing to the superfi cial vein.
structed thumb is performed.43 Approximately 60–66% key
pinch and 57% power grip can be achieved compared to the
contralateral side.41 With activities of daily life, patients’
complaints are not serious. Arthrodesis of the thumb inter-
phalangeal joint is quite suitable when there are intact
metacarpophalangeal and carpometacarpal joints. Primary
closure of the donor great toe with a medial skin fl ap from
the remnant great toe is more acceptable after disarticula-
tion at the interphalangeal joint to minimize the morbidity
of the donor site.
Operative procedure
Dissection of the distal part of the great toe is tedious
because the pulp tissue must be freed from the distal pha-
langeal bone for trimming of its tip. It is diffi cult to dissect
the small digital artery distal to the interphalangeal joint of
the great toe. Thus, in most cases, a larger skin fl ap with
a V-shaped lateral pulp area is harvested. Using a retrograde
approach44 on the fi rst web space of the foot, the author
harvests a composite fl ap that is pedicled on the fi rst dorsal
metatarsal or dorsal digital artery. The artery is skeleton-
ized by a radical resection of the adventitia and the vein
dissected with a cuff of perivenous tissue. Digital nerves of
the great toe are also harvested to coapt with the corre-
sponding structures of the thumb. The composite fl ap
always includes a partial distal phalangeal bone, whether
the distal phalangeal bone of the recipient site had a bone
defect or not. The venous network on the medial aspect of
the great toe is more reliable than the fi rst web space. There
is usually a prominent branch of the great saphenous vein
proximal to the medial nail fold on the tibial aspect of the
great toe (Fig. 20.11A). This vein should be included in the
fl ap to prevent necrosis of the remnant skin fl ap. On
the dorsum of the great toe, the subdermal venous plexus
should be preserved to close the donor site.
After fi xation of the harvested toe fl ap to the distal
phalangeal bone of the thumb using K-wires, key skin
sutures are placed. In addition, a temporary K-wire is used
to fi x the bone and prevent kinking of the anastomosed
vessels.
In cases of partial nail-bed transfer, meticulous repair of
the nail beds between the great toe and the thumb is per-
formed using 6/0 chromic catgut, and an artifi cial nail plate
or extracted nail is placed over the repaired nail bed for
compression and protection. Secure repair of the nail bed
between the great toe and thumb is essential to prevent

Thumb Reconstruction
285
C
D
FIGURE 20.6, cont’d C Photo of the revised thumb deformity 4 months after surgery. D Postoperative photo of the donor site.
Local/regional flap
Primary closure
I Partial great toe flap
Microsurgical
Non-microsurgical
Web space deepening
Metacarpal lengthening
Osteoplastic reconstruction
II Warp-around flap
Trimmed great toe transfer
Whole great toe transfer
Osteoplastic reconstruction
Dorsal rotation flap
III Whole great toe transfer
Second toe transfer
IV Pollicization
Trans-metatarsal second
toe transfer after skin flap
FIGURE 20.7 Reconstructive options of the thumb according to the
amputation level.
1 Osteo-onychocutaneous
flap with partial toe nail
2 Osteo-onychocutaneous flap
with whole toe-nail preserving
interphalangeal joint
3 Partial great toe transfer with
interphalangeal joint arthrodesis
FIGURE 20.8 Microsurgical reconstructive options of partial toe fl ap
transfer according to the amputation level at or distal to the
interphalangeal joint.

Hand and Upper Extremity Reconstruction
286
A
B
FIGURE 20.9 A Preoperative photograph showing the traumatic defect on the radial half of the distal thumb. The defect includes partial nail
bed and the distal tip of distal phalangeal bone. B Preoperative design of the osteo-onychocutaneous fl ap, including the fi bular half of the
great toe nail.
nail-fold deformities such as splitting or ridge formation. If
the nail defect is vertical or straight, it should be converted
into an oblique one. The nail-bed repair is performed from
the eponychium proximally using an extended incision.
Smooth, normal-appearing nail growth may be helped by
tight compression of the artifi cial nail on the repaired
nail bed.
Arterial anastomosis is performed with the ulnar digital
artery at the proximal phalanx, the princeps pollicis artery,
or the superfi cial radial artery at the anatomical snuffbox,
depending on the quality of pulsation in the recipient artery
of the hand. When the arterial anastomosis is performed at
the anatomical snuffbox, a subcutaneous tunnel is made by
intraoperative expansion using a Nelaton catheter or silas-
tic drain between two incisions for passage of the vascular
pedicle (Fig. 20.11B). This helps avoid the scarring caused
by a long incision and the need to perform a skin graft on
the reconstructed thumb. Venous anastomosis is performed
with a superfi cial vein at the dorsal aspect of the thumb.
In most cases the donor site is repaired primarily with-
out tension. A cross-toe fl ap or skin graft from the plantar
aspect is performed to resurface the donor defect.
The purpose of distal thumb reconstruction with toe
transfer is focused more on cosmetic appearance than on
functional restoration. Because of this consideration, several
articles introduce a short neurovascular pedicle technique
for toe transfer to reduce postoperative scarring on the
newly reconstructed fi ngers.45,46 Another advantage is that
it avoids the long surgical time required for dissection of a
lengthy vascular pedicle. However, these short pedicle pro-
cedures are risky in anastomosis of vessels less than 0.8 mm
in diameter at the middle phalanx. A moderately long vas-
cular pedicle is good for anastomosis of the vessels at the
fi rst web space of the thumb (Fig. 20.11C).
Postoperative management and
secondary procedures
Intensive postoperative monitoring of the perfusion of the
transferred toe and anticoagulation therapy with heparin,
aspirin, and prostaglandin E1 is given for 5–7 days. After
removal of the temporary K-wire used to block joint motion
on day 14, passive movement of the fi nger is begun. From
the third week after the operation, rehabilitation therapy is
started to restore sensation, and Coban (3M, St Paul, MN)
taping is applied to reduce edema in the transferred toe. At
7–8 weeks after the operation, the remaining K-wires are
removed. Secondary procedures such as pulp plasty, nail-

Thumb Reconstruction
287
C
D
FIGURE 20.9, cont’d C Placement of the dissected toe fl ap on the thumb defect. The yellow arrow is pointing to the digital nerve, the blue
arrow is pointing to the superfi cial vein, and the red arrow is pointing to the fi rst dorsal metatarsal artery. D Immediate postoperative view of
the fl ap transfer.
fold plasty or scar revision can be carried out 3–6 months
after surgery.
Defects distal to the proximal phalanx: wrap-
around procedure and trimmed great
toe transfer
The modifi ed wrap-around fl ap47 includes skin, nail and
nail bed, pulp, and part of the distal phalangeal bone from
the great toe as well as a tricortical bone graft from the iliac
crest. The neurovascular pedicle is based on the fi rst dorsal
metatarsal artery or the dorsalis pedis artery, dorsal venous
system, plantar digital nerves, and deep or superfi cial
peroneal nerves. This technique is most suitable for
reconstructing thumbs amputated distal to the metacarpo-
phalangeal joint and with complete skin avulsion injuries
but intact bone and tendons (Fig. 20.12). The main advan-
tage of this fl ap is that it is well matched in size in relation
to the contralateral normal thumb and morbidity at the
donor site is reduced.
The disadvantage of this technique is that it is not
applicable for thumb reconstruction in children because of
the lack of growth potential. The reconstructed thumb may
have limited motion and resorption of the bone graft may
occur. The donor site needs a cross-toe fl ap to cover the
defect.
The trimmed great-toe transfer is another modifi cation
of the great-toe transfer technique for thumb reconstruc-
tion.48,49 It includes a reduction of both the bony and the
soft tissues on the medial aspect of the great toe to create
a more natural-looking thumb. The bone is reduced using
a longitudinal osteotomy over the medial aspect of the
distal and proximal phalangeal bone. The periosteum and
medial collateral ligament of the interphalangeal joint of
the great toe are harvested as a proximally based fl ap. The
stability of the new interphalangeal joint can be achieved
by simple repair of the periosteum, medial collateral liga-
ment, and joint capsule. Although the cosmetic appearance
is better, there is some loss of interphalangeal joint motion.
The trimmed toe technique provides the esthetic advan-
tages of the wraparound fl ap and avoids the problems of
bone graft resorption, reduced joint mobility, and tedious
dissection.
In addition to these procedures, modifi ed twisted-toe
fl ap techniques have been proposed.13,50,51 These are a com-
bination of the wrap-around fl ap and vascularized joint

Hand and Upper Extremity Reconstruction
288
E
F
FIGURE 20.9, cont’d E 28-month follow-up photograph showing the appearance of the newly reconstructed thumb. F Postoperative
radiographic view of the reconstructed thumb.
transfer or neurovascular cutaneous fl ap and osteotendi-
nous fl ap based on a single vascular pedicle. They provide
a normal-looking thumb, preserve the epiphyses for future
growth, and reduce donor site morbidity, but because they
are very complicated these techniques are not popular.
Defects at or near the metacarpophalangeal
joint: whole great toe transfer
Buncke42 asserted that ‘great toes make great thumbs.’ In
cases of amputation at the proximal region of the proximal
phalanx or distal metacarpal area with an intact thenar
muscle and trapeziometacarpal joint, whole great toe trans-
fer is one of the most acceptable indications. Compared
with second toe transfer, it can provide a broad contact pulp
area for strong grip and pinch power as well as optimal
mobility. Donor site morbidity and a relatively poor appear-
ance are the main pitfalls.
The operative procedures have been described in detail
elsewhere.52–54 Some procedural tips and guidance are
given here.
Hand dissection
A criss-cross incision is made on the metacarpal stump to
expose both the digital nerves and the arteries. The proxi-
mal ends of the skin fl ap of the great toe can be inserted
into the incisions in the thumb. When the hand has fi rst
web space contracture, more skin from the lateral aspect of
the great toe is harvested to resurface the defect after con-
tracture release. Through the skin incision, the subcutane-
ous veins are dissected and the intact digital nerves and
superfi cial radial nerve is tagged. The extensor pollicis
longus, abductor pollicis brevis, and adductor pollicis
muscles are defi ned. A healthy bony stump should be
created by powered saw for osteosynthesis. Usually, a sepa-
rate zigzag incision is made on the anatomical snuffbox to
dissect the superfi cial radial artery, one more subcutaneous
vein, and the superfi cial radial nerve. More distally, the fi rst
dorsal metacarpal artery is another candidate for the recipi-
ent artery. Another separate incision is made on the
radial aspect of the wrist to fi nd the fl exor pollicis longus
tendon.
Foot dissection
To make vein dissection easier, a pneumatic tourniquet is
applied on the upper thigh; the leg is elevated without exsan-
guination prior to infl ation of the tourniquet. The incision
starts at the dorsal aspect of the fi rst web space to determine
which artery is dominant to the great toe. According to
Wei,52 the fi rst dorsal metatarsal artery is dominant in 70%

Thumb Reconstruction
289
A
B
C
D
E
F
FIGURE 20.10 A Dorsal view of incision and design of the great toe partial-nail-preserving transfer technique. Shaded region indicated
osteotomy site, black line shows the incision. B Volar view of the incision for the design of great toe partial-nail-preserving transfer technique.
C Donor site closure of the great toe with partial remnant nail as a fi llet fl ap. D Preoperative photograph of the thumb. E Postoperative view of
the reconstructed thumb with great toe nail. F Postoperative view of the donor site.

Hand and Upper Extremity Reconstruction
290
A
B
FIGURE 20.11 A Photograph showing a prominent branch of the great saphenous vein proximal to the medial nail fold on the tibial aspect of
the great toe. This vein should be used for anastomosis. On the dorsum of the great toe, the subdermal venous plexus should be preserved in
the dissected skin fl ap. B To avoid a long incision scar, a subcutaneous tunnel is made by intraoperative expansion with a silastic drain or
Nelaton catheter for passage of the vascular pedicle.
of patients, the fi rst plantar metatarsal artery in 20%,
and the remaining 10% have a similar caliber in both
arteries. Based on the dominant artery, dissection con-
tinues in a dorsal or plantar direction. After identifi cation
of the subcutaneous venous system, the extensor hallucis
longus tendon is dissected to the appropriate length. Next,
the deep peroneal nerve and dorsalis pedis artery are dis-
sected distally. On the plantar side, both digital nerves are
dissected. The fl exor hallucis longus tendon is usually har-
vested through a separate incision on the proximal plantar
area for tendon repair at the wrist. If a longer tendon is
needed, an incision can be made around the ankle. After
dissecting all the structures needed, the bone or joint capsule
is divided. All tissues are divided except arteries and veins,
and the tourniquet is released. The surgeon should wait
15–30 minutes for complete reperfusion of the great toe.
Irrigation with warm saline or 2% lidocaine is helpful to
achieve a more rapid ‘pink-up’ of the toe. If the toe remains
pale after this time, careful examination of the main pedicle
under the operating microscope is necessary. It may need
meticulous ligation of the tiny branches of the main artery.
In addition, the patient’s blood pressure as well as the tem-
perature of the operating room needs to be checked.
Toe-to-thumb reattachment
A combination of multiple K-wires fi xed interosseously is
the most effective way to achieve strong osteosynthesis.
Fixation should be checked with a C-arm. The K-wires will
be removed serially. Composite joint reconstruction is
another good method when the level of the amputation is
just at the joint. Joint stability requires strong repair of the
capsule and soft tissues between the two joints.55 In the
case of amputation at the metacarpal neck, the shape of
the metatarsophalangeal joint of the great toe should be
made with an angled osteotomy (about 45º) on the dorsal
aspect of the metatarsal head to preserve the plantar aspect
of the fi rst metatarsal head and the sesamoid bone (Fig.
20.13). The metatarsal head is fi xed to the metacarpal bone
to convert a hyperextension joint into a fl exion joint.

Thumb Reconstruction
291
C
FIGURE 20.11, cont’d C Dissected partial toe fl ap with moderately
long vascular pedicles. Yellow arrows show both digital nerves, the
blue arrow is pointing to the superfi cial vein, the red arrow is
pointing to the fi rst dorsal metatarsal artery.
To achieve a strong repair of the tendons, the author
uses a modifi ed Becker’s technique56 or Pulvertaft interlace
suture for both fl exor and extensor tendons. After tendon
repair, the range of motion of the interphalangeal joint
should be checked by passive fl exion and extension of the
wrist.
Arterial repair can now be performed. Once perfusion is
obtained, all the nerves are sutured. One or two veins are
repaired. The skin is sutured without tension. Small skin
grafts may be used for open areas.
The management of the donor site is not easy. The
bulging part of the metatarsal bone should be trimmed and
the skin can be closed primarily, without tension.
Donor site problems
Even though a successful great toe transfer can provide
satisfactory results in both function and appearance, donor
site complications should be minimized. Some patients
complain of occasional mild discomfort of the foot and
intolerance to cold.57 After a whole great toe transfer, the
weightbearing area shifts to the second and third metatarsal
heads. There is no signifi cant complaint of metatarsalgia
after the wound has healed. Additionally, in sports activi-
ties it may be diffi cult to ‘push off’ from the involved foot.
This is caused by the descent of the fi rst metatarsal head
secondary to proximal migration of the sesamoid bones and
increased plantar fl exion of the fi rst metatarsal shaft.58 To
prevent these complications, at least 1 cm of the proximal
phalanx should be preserved. Wound healing at the donor
site is also very important to maintain a normal gait.
Primary closure of the donor site provides early and stable
wound healing compared to a skin graft or any type of fl ap
procedure.
The failure rate of toe transfer is reported to be 2.5–
7.2%.59–61 The primary factors in failure are the anatomical
variation of the fi rst dorsal metatarsal artery and the diam-
eter and pattern of the branches of the main artery. Other
factors leading to failure include smoking, age, and the
condition of the patient’s coagulation system.
The most important consideration during the dissection
of the artery is the meticulous ligation of any small branches
of the main artery. Rarely after toe dissection there is a
lack of reperfusion in the toe after release of the tourniquet,
even 20 or 30 minutes later. In this case, the status of the
main artery should be rechecked under a microscope. If any
small branch of the main artery remains open, it should be
ligated to prevent segmental spasm.62 If there is no problem
involving the vessels, irrigation with warm saline is the best
way to obtain reperfusion.
In the diffi cult case of lack of perfusion, even after
perfect arterial anastomosis, fi rst recheck the condition of
the recipient artery proximally under a microscope. If a
problem cannot be identifi ed, a sympathetic block on the
brachial plexus is needed to achieve vasodilatation. Awak-
ening the patient from general anesthesia is another way to
stimulate perfusion.
Intensive monitoring of perfusion status is mandatory
for 5–7 days postoperatively. To further guarantee complete
survival of the transferred toe, the threshold for re-
exploration should be very low. Any circulatory problem
should be checked under a microscope in an operating room
immediately.
Unfortunately, even after all possible efforts to achieve
normal circulation, persistent circulatory problems can
occur. In this case, a tubed groin fl ap can be the last resort
to salvage the transplanted bone.63
SECOND TOE TRANSFER
Compared to great toe transfer, second-toe transfer is indi-
cated in a proximal metacarpal amputation because there
is less donor site morbidity associated with harvesting the
second toe. Because of the need to maintain the great toe
metatarsophalangeal joint for push-off, the use of the great
toe for proximal metacarpal amputation is not suitable. In
this case, second-toe transfer is used for thumb reconstruc-
tion instead of great toe transfer, although the postoperative
appearance is not great. This procedure usually needs a

Hand and Upper Extremity Reconstruction
292
FIGURE 20.12 A Schematic view of the wrap-around procedure as described by Morrison and O’Brien (1980).
preliminary fl ap to provide redundant soft tissue around the
metacarpal area to wrap around the second toe (Fig. 20.14).
For a single-stage reconstruction a combined dorsalis pedis
fl ap with transmetatarsal second-toe transfer is also possi-
ble, although the problems at the donor site can be
substantial.
A V-shaped incision is made on both the dorsal and the
plantar aspects of the foot. This provides adequate skin
coverage for both donor and recipient sites. The procedure
for foot dissection is not much different from that of a great
toe transfer. If there is not enough soft tissue for coverage,
the metatarsal bone should be harvested with the interos-
seus muscle, but it is better to add redundant soft tissue to
the thumb in the fi rst stage using a groin fl ap. It is not
advisable to take precious soft tissue from the foot to add
coverage in the hand. The arc of motion in the metatarso-
phalangeal joint is mainly dorsifl exion, and this may cause
a hyperextension deformity of the thumb. This can be pre-
vented by shortening the volar plate and using an angled
osteotomy of the metatarsal head.
Regarding donor site closure, the intermetatarsal liga-
ments should be repaired between the great and third toes.
Temporary K-wire fi xation between metatarsals may be
used to ensure a narrow interdigital web space and preserve
the appearance of the donor site.
POLLICIZATION
Since the introduction of the microvascular toe-to-thumb
transfer procedure, pollicization using a normal index or
ring fi nger for thumb reconstruction has become less
favored. However, in reconstructing a thumb amputated at
or proximal to the metacarpophalangeal joint, this proce-
dure is still useful, considering the amputation level.
Pollicization of the index fi nger is much easier and
safer than that of other fi ngers, because there is no need for
the cross-over of vessels, nerves, or tendons. The middle
fi nger spontaneously replaces the function of the trans-
ferred index fi nger. Moreover, the excision of the second
metacarpal bone results in a deepening of the fi rst web
space.
The presence of thenar muscle function is critical for
obtaining satisfactory results in pollicization.64 However,
even if the thenar muscles are not present, the recon-
A1
A2
A3
A5
A6
A4

Thumb Reconstruction
293
B
C
D
FIGURE 20.12, cont’d B Preoperative view of an avulsion amputation of the left thumb. C Wrap-around fl ap is harvested. Blue arrows show the
superfi cial veins, yellow arrow shows the digital nerve, red arrow shows the fi rst dorsal metatarsal artery. D The appearance of reconstructed
thumb 43 months postoperatively.

Hand and Upper Extremity Reconstruction
294
Stance
Toe-off
Sesamoid bone
Hyperextension joint
Flexion joint
Angled osteotomy
+
Shortening of
plantar plate
FIGURE 20.13 Schematic view of an angled osteotomy and
shortening of the plantar plate. This procedure facilitates a
hyperextension joint in its conversion into a fl exion joint.
A
B
C
FIGURE 20.14 A Traumatic amputation of the left thumb at the level of the metacarpal head. B A distant groin fl ap is utilized to provide soft
tissue around the thumb. C Photograph showing the plantar plate shortening by elliptical resection after the second toe is harvested.

Thumb Reconstruction
295
D
E
F
FIGURE 20.14, cont’d D Postoperative photograph showing
transferred toe. E Postoperative functional photograph showing
range of motion of implanted toe. F Radiograph of the transferred
second toe. G Postoperative view of healed donor site.
structed thumb may function as a stationary post to oppose
the other fi ngers for grasping and pinching. If necessary, a
secondary opponensplasty using the ring fl exor digitorum
superfi cialis or abductor digiti quinti minimi muscle can
provide more opposition.
There are some differences when comparing polliciza-
tion with congenital cases. In adult traumatic situations,
both fl exor and extensor tendons should be divided and
resutured to balance the tension in the new thumb, with
its different length and position. Also, because of previous
scarring in the region, secondary procedures including
tenolysis or opponensplasty may be required. Functional
results have shown a 61º total arc of motion of the inter-
phalangeal and metacarpophalangeal joints, and 69% and
41% grip and pinch strength, respectively, compared to the
contralateral uninjured thumb.64
‘ON-TOP PLASTY’
Where thumb amputation is combined with multiple digital
amputations, a short thumb ceases to be functional.
To achieve a more useful length, a short amputated digit
can be transferred on top of the amputated thumb as an
island fl ap by including the phalangeal bone (Fig. 20.15).
This procedure is called ‘on-top plasty.’65 This type of
pollicization was introduced by Littler66 in 1952 as the
G

A
B
C
FIGURE 20.15 A Preoperative photograph showing partial
amputation of the right thumb and complete amputation of the
index fi nger. B X-ray showing amputation of the right thumb and
index fi nger with destruction of the PIP joint of the long fi nger.
C On-top plasty with neurovascular island fl ap from the long fi nger.
Hand and Upper Extremity Reconstruction
296

D
E
F
FIGURE 20.15, cont’d D Postoperative view. E Postoperative
functional view. F Postoperative radiograph.

Hand and Upper Extremity Reconstruction
298
neurovascular pedicle method of digital transposition for
subtotal reconstruction of the thumb. In multidigital ampu-
tations this technique can be applied at any level of thumb
amputation. In correct terminology, reconstruction of the
amputated thumb with heterodigital transfer as an island
fl ap is true pollicization, but this procedure is based on the
pattern of a free fl ap and should be called ‘free on-top
plasty.’ In multiple digital amputations in both hands, an
injured digit can be transferred for reconstruction of the
contralateral thumb. This technique has its advantages in
composite tissue reconstruction as a single procedure and
provides acceptable results in sensation and appearance.
CONCLUSION
Toe transfer is the most complex option for thumb recon-
struction and can cause signifi cant psychological stress to
both surgeon and patient. For patients, it requires pro-
longed anesthesia and a long rehabilitation time. For sur-
geons, the operation demands a high level of microsurgical
skill to yield an esthetically and functionally acceptable
thumb. Regardless of whether the operation is performed
electively or in emergency treatment of acute hand injuries,
the indications should be highly restricted and the use of
toe transfer decided on only after thorough analysis of the
advantages and disadvantages of each method, as well as
consideration of the overall condition of the patient (Table
20.1).
REFERENCES
1. Moberg E. Aspects of sensation in reconstructive surgery
of the upper extremity. J Bone Joint Surg [Am] 1964; 46:
817–825.
2. Dellon AL. The extended palmar advancement fl ap. J Hand Surg
[Am] 1983; 8: 190–194.
3. Hueston J. Local fl ap repair of fi ngertip injuries. Plast Reconstruct
Surg 1966; 37: 349–350.
4. Argamaso RV. Rotation–transposition method for soft tissue
replacement on the distal segment of the thumb. Plast Reconstruct
Surg 1974; 54: 366–368.
5. Posner MA, Smith RJ. The advancement pedicle fl ap for thumb
injuries. J Bone Joint Surg 1971; 53A: 1618–1621.
6. Pho RW. Restoration of sensation using a local neurovascular
island fl ap as a primary procedure in extensive pulp loss of the
fi ngertip. Injury 1976; 8: 20–24.
7. Brunelli F. Dorso-ulnar thumb fl ap. Ann Chir Main Memb Sup
1993; 12: 105–114.
8. Littler JW. Neurovascular pedicle transfer of tissue in
reconstructive surgery of the hand. J Bone Joint Surg [Am] 1956;
38: 917.
9. Littler JW, Markley JM. Digital neurovascular island skin fl ap.
In: Strauch B, Vasconez LO, Hall-Findlay EZ, eds. Grabb’s
encyclopedia of fl aps. Vol. II. Boston: Little, Brown, 1990;
887–891.
10. Foucher G, Braun JB. A new island fl ap transfer from the dorsum
of the index to the thumb. Plast Reconstruct Surg 1979; 63:
344–349.
11. Daniel RK, Terzis J, Midgley RD. Restoration of sensation to an
anesthetic hand by a free neurovascular fl ap from the foot. Plast
Reconstruct Surg 1976; 57: 275–280.
12. Strauch B, Tsur H. Restoration of sensation to the hand by a free
neurovascular fl ap from the fi rst web space of the foot. Plast
Reconstruct Surg 1978; 62: 361.
13. Foucher G, Merle M, Maneaud M, Michon J. Microsurgical free
partial toe transfer in hand reconstruction: a report of 12 cases.
Plast Reconstruct Surg 1980; 65: 616–627.
14. Morrison WA, O’Brien BM, MacLeod AM, Gilbert A.
Neurovascular free fl aps from the fi rst web of the foot. J Hand
Surg 1978; 3: 235.
15. Woo SH, Kim JS, Kim HH, Seul JH. Microsurgical
reconstruction of partial thumb defects. J Hand Surg [Br] 1999;
24: 161–169.
16. May JW, Chait LA, Cohen BE, O’Brien BM. Free neurovascular
fl ap from the fi rst web space of the foot in hand reconstruction.
J Hand Surg 1977; 2: 387–393.
17. Woo SH, Choi BC, Oh SJ, Seul JH. Classifi cation of the fi rst web
space free fl ap of the foot and its applications in reconstruction of
the hand. Plast Reconstruct Surg 1999; 103: 508–517.
18. Lee HB, Tark KC, Rah DK, Shin KS. Pulp reconstruction of fi ngers
with very small sensate medial plantar free fl ap. Plast Reconstruct
Surg 1998; 101: 999–1005.
19. Song R, Gao Y, Song Y, et al. The forearm fl ap. Clin Plast Surg
1982; 9: 21–26.
20.Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the
fascio-cutaneous fl ap of the posterior interosseous artery. Surg
Radiol Anat 1986; 8: 209–215.
21. Jeng SF, Wei FC. The distally based forearm island fl ap in hand
reconstruction. Plast Reconstruct Surg 1998; 102: 400.
22. Reid CD, Moss LH. One-stage fl ap repair with vascularised tendon
grafts in a dorsal hand injury using the ‘Chinese’ forearm fl ap. Br J
Plast Surg 1983; 36: 473–479.
23. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior
interosseous fl ap and its composite fl ap: Experience with 201 fl aps.
J Plast Reconstruct Aesthet Surg 2007; 60: 876–882.
TABLE 20.1 Comparison of available toe-to-hand transfer techniques
Whole great toe
Trimmed great toe
Wrap-around
Second toe
Partial great toe
Function
mobility
++++
+++
+
++
+
sensation
++++
++++
++++
++
++++
Appearance
+++
++++
++++
+
++++
Strength
++++
+++
+++
++
+++
Donor Site
function
+
++
+++
++++
++++
appearance
+
++
+++
++++
+++
Technical diffi culty
easy
diffi cult
more diffi cult
easy
most diffi cult
Complication
none
none
bone resorption no growth
claw-fi nger
none

Thumb Reconstruction
299
24. Daniel RK, Terzis J, Midgely RD. Restoration of sensation to an
anesthetic hand by a free neurovascular fl ap from the foot. Plast
Reconstruct Surg 1976; 57: 275–281.
25. McCraw JB, Furlow LT. The dorsalis pedis arterialized fl ap. A
clinical study. Plast Reconstruct Surg 1975; 55: 117–185.
26. Woo SH, Seul JH. Optimizing the correction of severe postburn
hand deformities by using aggressive contracture releases and
fasciocutaneous free-tissue transfers. Plast Reconstruct Surg 2001;
107: 1–8.
27. Samson MC, Morris SF, Tweed AEJ. Dorsalis pedis fl ap donor site:
Acceptable or not? Plast Reconstruct Surg 1998; 102: 1549–1554.
28. Biemer E, Stock W. Total thumb reconstruction: a one-stage
reconstruction using an osteo-cutaneous forearm fl ap. Br J Plast
Surg 1983; 36: 52–55.
29. Guimberteau JC, Goin JL, Panconi B, Schuhmacher B. The reverse
ulnar artery forearm island fl ap in hand surgery: 54 cases. Plast
Reconstruct Surg 1988; 81: 925.
30. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the
posterior interosseous osteocutaneous fl ap. Br J Plast Surg 1988;
41: 228–233.
31. Cutting CB, McCarthy JG, Knize DM. Repair and grafting of bone.
In: McCarthy JG, ed. Plastic surgery. Vol. 1. Philadelphia: WB
Saunders, 1990; 583–629.
32. Yajima H, Tamai S, Yamauchi T, Mizumoto S. Osteocutaneous
radial forearm fl ap for hand reconstruction. J Hand Surg [Am]
1999; 24: 594–603.
33. Ahn HC, Choi MS, Hwang WJ, Sung KY. The transverse radial
artery forearm fl ap. Plast Reconstruct Surg 2007; 119:
2153–2160.
34. Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing
morbidity in the radial forearm fl ap donor site. Plast Reconstruct
Surg 1990; 86: 287–292.
35. Akin S, Ozgenel Y, Ozcan M. Osteocutaneous posterior
interosseous fl ap for reconstruction of the metacarpal bone and
soft-tissue defects in the hand. Plast Reconstruct Surg 2002; 109:
982–987.
36. Woo SH, Lee GJ, Kim KC, et al. Immediate partial great toe
transfer for the reconstruction of composite defects of the distal
thumb. Plast Reconstruct Surg 2006; 117: 1906–1915.
37. Wei FC, Epstein MD, Chen HC, et al. Microsurgical
reconstruction of distal digits following mutilating hand injuries:
results in 121 patients. Br J Plast Surg 1993; 46: 181–186.
38. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstruct Surg 1986; 78: 285–292.
39. Morrison WA, O’Brien BM, MacLeod AM. Experience with thumb
reconstruction. J Hand Surg [Br] 1984; 9: 223–233.
40. Kleinman WB, Struickland JW. Thumb reconstruction. In:
Green DP, Hotchkiss RN, Pederson WC, eds. Green’s Operative
hand surgery, 4th edn. New York: Churchill Livingstone, 1999;
2096.
41. Woo SH, Seul JH. Distal thumb reconstruction with a great toe
partial-nail preserving transfer technique. Plast Reconstruct Surg
1998; 101: 114–119.
42. Buncke HJ, Valauri FA. Reconstruction of the thumb with a
trimmed-toe transfer technique [Discussion]. Plast Reconstruct
Surg 1988; 82: 514–515.
43. Adani R, Cardon LJ, Castagnetti C, Pinelli M. Distal thumb
reconstruction using a mini wrap-around fl ap from the great toe.
J Hand Surg [Br] 1999; 24: 437–442.
44. Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the
vascular pedicle in toe harvest. Plast Reconstruct Surg 1995; 96:
1211–1214.
45. Endo T, Nakayama Y. Short-pedicle vascularized nail fl ap. Plast
Reconstruct Surg 1996; 97: 656.
46. Spokevicius S, Vitkus K. Reconstruction of the distal phalanx of
the fi ngers by free toe-to-hand transfer. J Hand Surg [Br] 1991; 16:
169–174.
47. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction
with a free neurovascular wrap-around fl ap from the big toe.
J Hand Surg [Am] 1980; 5: 575–583.
48. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction
of the thumb with a trimmed-toe transfer technique. Plast
Reconstruct Surg 1988; 82: 506–515.
49. Upton J, Mutimer K. A modifi cation of the great-toe transfer for
thumb reconstruction. Plast Reconstruct Surg 1988; 82: 535–538.
50. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast
Reconstruct Surg 1991; 88: 149–153.
51. Iglesias M, Butron P, Serrano A. Thumb reconstruction with
extended twisted toe fl ap. J Hand Surg [Am] 1995; 20:
731–736.
52. Wei FC. Toe-to-hand transplantation. In: Green DP, Hotchkiss
RN, Pederson WC, Wolfe SW, eds. Green’s Operative hand
surgery, 5th edn. New York: Churchill Livingstone, 2005; 1835.
53. Vedder NB, Maser BM: Thumb reconstruction: Microvascular
methods. In: Mathes SJ, Hentz VR. Plastic surgery. Vol. 7 The
hand and upper limb: Part I. Philadelphia: WB Saunders, 2006;
253–280.
54. Morrison W. Microsurgical thumb reconstruction. In: Strickland
JW, ed. The hand and upper limb. Vol 11. Edinburgh: Churchill
Livingstone, 1994; 133–150.
55. Wilson CS, Buncke HJ, Alpert BS, Gordon L. Composite
metacarpophalangeal joint reconstruction in great toe-to-hand free
tissue transfers. J Hand Surg [Am] 1984; 9: 645–649.
56. Wassermann RJ, Howard R, Markee B, et al. Optimization of the
MGH repair using an algorithm for tenorrhaphy evaluation. Plast
Reconstruct Surg 1997; 99: 1688–1694,.
57. Lipton HA, May JW Jr, Simon SR. Preoperative and postoperative
gait analyses of patients undergoing great toe-to-thumb transfer.
J Hand Surg [Am] 1987; 12: 66–69.
58. Poppen NK, Mann RA, O’Konski M, Buncke HJ. Amputation of
the great toe. Foot Ankle 1981; 1: 333–337.
59. Buncke HJ, Buncke GM, Lineaweaver WC, et al. Bad results after
large toe to thumb transplantation. Ann Chir Main Memb Sup
1991; 10: 513–516.
60. Foucher G, Moss ALH. Microvascular second toe to fi nger transfer:
a statistical analysis of 55 transfers. Br J Plast Surg 1991; 44:
87–90.
61. Gu YD, Zhang GM, Chen DS, et al. Toe-to-hand transfer: an
analysis of 14 failed cases. J Hand Surg [Am] 1993; 18:
823–827.
62. Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand
with free microneurovascular toe-to-hand transfer: experience with
54 toe transfers. Plast Reconstruct Surg 1983; 71: 371–386.
63. Ozkan O, Chen HC, Mardini S, et al. Principles for the
management of toe-to-hand transfer in reexploration: toe salvage
with a tubed groin fl ap in the last step. Microsurgery 2006; 26:
100–105.
64. Ishida O, Taniguchi Y, Sunagawa T, et al. Pollicization of the
index fi nger for traumatic thumb amputation. Plast Reconstruct
Surg 2006; 117: 909–914.
65. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. ‘On-top plasty’ for
amputated fi ngers. Plast Reconstruct Surg 1968; 42: 242–248.
66. Littler JW. Subtotal reconstruction of the thumb. Plast Reconstruct
Surg 1952; 10: 215–226.

301
C H A P T E R
21
Congenital Hand Procedures
Scott N. Oishi, Peter Carter and Marybeth Ezaki
Many children are born with congenital anomalies that
affect the upper extremity. In the embryo, upper limb
bud formation begins 4 weeks after fertilization. With
rapid growth and differentiation, all limb structures are
present by 8 weeks after fertilization. Congenital upper
extremity anomalies are present in 0.1–0.2% of newborns.1
Most of these anomalies occur spontaneously without any
family history, and the cause of many is not known;
however, some medications have been implicated, includ-
ing thalidomide, warfarin, phenytoin, and valproic acid.
Illicit drugs such as cocaine, along with alcohol and ciga-
rette smoking, have also been associated with the develop-
ment of congenital hand anomalies.2 Hand anomalies can
be very disturbing psychologically to both the patient and
parents.
Polydactyly is the most common hand anomaly, with
an incidence of 1 per 600 live births, and is 10 times more
common in African-Americans. Isolated syndactyly is also
a common hand anomaly, with an incidence of 1 per 2000–
2500 live births. Bifi d thumb, or radial polydactyly, has an
incidence of about 1 per 3000 live births.1,3,4
The timing of early surgical reconstruction must be
weighed against the anesthetic risks and patient safety
issues. Some anomalies are associated with systemic disor-
ders that must be addressed before any surgical inter vention.
An example of this is radial dysplasia, which is frequently
associated with other systemic conditions/syndromes that
need to be evaluated prior to any reconstructive
procedure.
In this chapter we will discuss reconstructive procedures
for some of the most common congenital anomalies of the
upper extremity.
SYNDACTYLY
Isolated syndactyly occurs in 1 in 2000–2500 live births. It
is twice as common in boys as in girls, and more common
in Caucasians than in African-Americans.2–4 It results from
lack of segmentation of the digits. Syndactylies can be clas-
sifi ed into simple (Fig. 21.1) or complex (Fig. 21.2), incom-
plete (Fig. 21.3) or complete (see Fig. 21.1) depending on
their composition. A simple syndactyly has no bony attach-
ment between the two digits, whereas a complex syndactyly
has bony connections between the two digits. Incomplete
or complete describes whether the skin connection involves
a portion of the fi ngers or extends all the way to the tips.
Indications and contraindications for surgery
Timing of syndactyly release is not the same for every
patient. Ideally, syndactyly reconstruction should take place
after about 1.5 years of age, at which time the child is larger
and important anatomic structures can be more easily
identifi ed. However, complex syndactylies and syndactylies
involving the fi rst and/or fourth web spaces may benefi t
from earlier release because of the tethering effect of differ-
ent lengths of digits that can cause deformity with differ-
ential growth (Fig. 21.4).
Preoperative history and considerations
Although rare, some syndactylies can be associated with
syndromes. For this reason careful examination of the
entire patient is essential. Also, it is our feeling that a
patient with syndactyly affecting both sides of a digit should
undergo staged reconstruction instead of releasing both
sides at once, to avoid potentially devascularizing the central
digit (Fig. 21.5).
Simple syndactyly
Whether the syndactyly is complete or incomplete does not
matter in the surgical approach. A standard dorsal fl ap
is outlined with double-opposing Z-plasties on the dorsal

FIGURE 21.1 Simple syndactyly with no bony attachments between
the fi ngers.
FIGURE 21.2 Complex syndactyly involving bony fusion of the
terminal phalanges of the fi ngers.
FIGURE 21.3 Incomplete syndactyly with soft tissue attachment that
does not extend to the tips of the fi ngers.
FIGURE 21.4 For border digits, the diff erential length of the ring and
little fi nger, if left untreated, will cause deviation of the ring fi nger
towards the little fi nger. This will cause growth disturbance for both
digits, and this type of syndactyly may need to be released before
1 year of age.
and volar portions of the syndactyly (Fig. 21.6). In the palm
the appropriate position of the web is determined and
marked.
Surgery begins by incising the dorsal fl ap. Next, the
volar web-space incision is made and the neurovascular
pedicles are identifi ed and isolated. Careful dissection of the
neurovascular pedicle is crucial, and often limits the proxi-
mal extent of the syndactyly release. The double-opposing
Z-plasty incisions are then carefully made, preserving the
neurovascular bundles. If the syndactyly is complete, pulp
fl aps may be necessary to provide adequate tip coverage.13
After separation of the digits, the fl aps are inset and a tem-
plate of the soft tissue defects is made. Often, there is

fi brous tissue between the fi ngers that needs to be removed
before the fl aps are inset. In our opinion, skin grafts are
essential in trying to prevent web-creep postoperatively. It
is important to have appropriate tension on the skin grafts
and fl aps (Fig. 21.7). Healing by secondary intention often
leads to signifi cant postoperative scarring and deformity.
A long-arm cast is placed for 3–4 weeks to allow wound
healing.
Complex syndactyly
The design of skin incisions is very similar to that for
simple syndactyly, but the tips of the syndactylies need
special consideration, especially when the nail is involved.
They often need pulp fl aps and full-thickness skin graft
(FTSG) to give the best postoperative appearance. At times
several adjacent fi ngers may be involved. If this is the case
we usually perform syn dactyly reconstruction in a staged
fashion. We try not to completely separate adjacent web
spaces in one operation because of the risk of vascular
compromise. However, we have found it useful to release
the tips of the adjacent involved fi ngers. We have found
that this releases the tethering effect (see Fig. 21.4), which
facilitates later formal syndactyly reconstruction.
Congenital Hand Procedures
303
A
B
FIGURE 21.5 A For complex syndactyly involving four fi ngers, one should plan the staging operation effi ciently to minimize the number of
surgical procedures. This child will have syndactyly releases between the index and middle fi ngers and the ring and little fi ngers in order to
avoid operating on both sides of the digits and prevent injuring the vascular structures on both sides of the fi nger. B Postoperative view
showing release of the border digits using a combination of skin grafts and skin fl aps.
Optimizing outcomes
●
Ensure adequate length of dorsal fl ap
●
Careful design of Z-plasties
●
Liberal use of skin grafts
Complications and side-eff ects
● Web creep Attempt to prevent this by using appropriate
skin fl aps and skin grafts. If this occurs, deepening of
the web is usually required.
● Neurovascular injury This can occur during separation
of the digits. The best way to avoid it is with careful

Hand and Upper Extremity Reconstruction
304
A
B
A
B
FIGURE 21.6 A typical fl ap incision design with the proximal fl ap
fi tting into the web space and zigzag incisions to fi t either side of the
released fi ngers.
FIGURE 21.7 The fl aps fi t into place and the open wounds will be
covered with skin grafts from the groin, or in this case from the
hypothenar area.

Congenital Hand Procedures
305
dissection, frequently assessing the location of the neu-
rovascular bundles.
● Hypertrophic/keloid scarring This can occur despite
appropriate surgery. May also occur if there is skin fl ap
and/or skin graft loss. This may require repeat grafting.
If more severe or recurrent, may require more aggressive
adjunctive treatment (i.e. methotrexate).14
● Inadequate tip coverage May require pulp grafts from
ulnar hand or foot. These are taken as pinch grafts from
either the ulnar side of the hand or side of the
big toe. This provides a better match for the glabrous
skin than the usual FTSG taken from the groin or
wrist.
Postoperative care
● Long-arm cast for 3–4 weeks. No reason to examine
wounds earlier. If still unsure of wound healing, we
place the patient back in a long-arm cast for an addi-
tional 2–3 weeks.
● Scar contracture. Try to avoid with carefully designed
fl aps. If it occurs, release and skin grafting may be
needed.
Conclusion
Syndactyly reconstruction is a very common congenital
hand surgery procedure. Careful patient evaluation and
design of surgical fl aps will optimize the fi nal outcome.
However, it should be noted that these patients often
require secondary revisions as they go through growth
spurts. This is especially true if the initial syndactyly recon-
struction is performed at an early age.
POSTAXIAL POLYDACTYLY
Postaxial (ulnar) polydactyly is divided into two types,
depending on the development of the supernumerary digit.
Type A is a well-developed digit (Fig. 21.8), whereas type B
is pedunculated and rudimentary. Postaxial polydactyly is
10 times more common in African-Americans than in Cau-
casians. In blacks, it usually is an isolated fi nding and
inherited in an autosomal dominant fashion. In whites it
is frequently syndromic and autosomal recessive.5
Indications and contraindications
● Type A – must be corrected in the operating room.
● Type B – can be treated in a nursery or clinic. We fi nd
that this is very easily done in our clinic and saves the
child a general anesthetic.
Preoperative history and considerations
The most important factor is determining which type of
postaxial polydactyly is present. If type B, it can be easily
treated in the nursery or outpatient clinic. Type A should
be treated in the operating room. Because of the increased
anesthetic risks in newborns, the operative procedure
should be delayed until at least 6 months of age.
Operative approach
Type A
Under general anesthesia an elliptical incision is made
around the base of the supernumerary digit. The digit is
explored to check for any functional parts that can be saved
and transferred to the hand. At times a bony connection
can be present and must be addressed carefully. The neu-
rovascular bundles to the digit are identifi ed and transected.
The skin is closed with 6/0 plain absorbable suture and the
extremity placed in a long-arm cast for 2–3 weeks to allow
wound healing.
Type B
The base of the rudimentary digit is prepared and injected
with 1% lidocaine plus epinephrine. A ligaclip is then
applied around the base (Fig. 21.9). The hand is then
wrapped for 2 weeks, leading to autoamputation of the
supernumerary digit.
FIGURE 21.8 Type A postaxial polydactyly.

Hand and Upper Extremity Reconstruction
306
the type of polydactyly present. Type B may be treated
easily in the nursery or clinic, whereas type A requires sur-
gical excision in the operating room.
PREAXIAL (RADIAL) POLYDACTYLY
In the past this has been termed duplicated thumb, but it
should more appropriately be termed bifi d or split thumb.
Each bifi d (split) thumb is usually small and the two
together would equal one normal-sized thumb. The inci-
dence is about 1 in 3000 live births, with most being spo-
radic in inheritance and unilateral in presentation. The
exception is the triphalangeal thumb, which is usually auto-
somal dominant. As opposed to postaxial (ulnar) polydacy-
tyly, preaxial polydactyly is more common in Caucasians
and other systemic problems are usually not present.6–8 The
most common classifi cation system is that described by
Wassel in 1969, which categorizes bifi d thumbs based on
skeletal replication. Type IV (replication of the distal and
proximal phalanges) is the most common.9
Indications and contraindications
Usually the authors perform thumb reconstruction between
the ages of 1 and 2 years, when there is a lower anesthetic
risk and the structures are larger, for ease of identifi cation.
Preoperative history and considerations
Before surgery, the thumbs must be assessed to determine
which one is the most dominant. Although this is usually
the ulnar thumb, careful observation for joint mobility and
stability is mandatory before determining which thumb to
remove.
Although we will describe reconstruction based on type
of split thumb, the general goals are the same for every type.
The more hypoplastic thumb is ablated, and the soft-tissue
elements from the ablated thumb are added to the retained
thumb to improve the aesthetic appearance and function.
Operative approach
Types I and II split thumbs
Although some authors have advocated the Bilhout–Cloquet
procedure, in general we have not found this to be reliable.
We prefer to ablate the radial thumb and reconstruct the
ulnar thumb for types I (Fig. 21.10) and II. The fi rst step
is to outline the proposed surgical incision line. This will
frequently require the incorporation of a fl ap taken from
the ablated thumb to provide soft-tissue coverage for the
radial side of the reconstructed thumb. After the incisions
are made, the skin fl aps are carefully raised (Fig. 21.11).
We use a proximal zigzag incision to examine the extensor
tendons to both thumbs. The extensor tendon is central-
ized, with augmentation from the ablated thumb if neces-
sary. This is done by transferring the extensor tendon from
the ablated digit to the body of the remaining extensor
tendon. If this is a type II confi guration, it is important to
dissect the collateral ligament from the ablated thumb
FIGURE 21.9 Ligaclip ligation of the pedunculated extra digit is an
eff ective mode of treatment in the nursery. The distal digit will
necrose and fall off spontaneously.
Optimizing outcomes
●
Correct identifi cation of the type of postaxial polydactyly.
●
Ensuring that the base of a type B postaxial polydactyly is
small enough to be treated with the appropriate size of
ligaclip.
Complications
The most common complication of autoamputation is a
residual nubbin. On occasion this can be quite large and
require a secondary revision procedure. The patient under-
going treatment of a type A postaxial polydactyly may have
a well-developed nerve that must be transected carefully to
prevent a painful neuroma.
Postoperative care
Local wound care is all that is needed for the majority of
these conditions.
Conclusion
Postaxial polydactyly is a common congenital anomaly.
Appropriate treatment mandates correct identifi cation of

Congenital Hand Procedures
307
using a periosteal sleeve. The periosteal sleeve is then
sutured to the appropriate area on the retained thumb for
collateral ligament reconstruction. The articular surface of
the proximal phalanx may need to be narrowed to better
reconstitute the interphalangeal (IP) joint. The incision is
closed with chromic sutures (Fig. 21.12). A Kirschner wire
is used to stabilize the IP joint. A long-arm cast is placed
for 5–6 weeks, followed by pin removal.
Types III and IV thumbs
Draw the incisions carefully to permit excision of the least-
developed thumb and preserve the excess skin as a fl ap for
later use. For types III and IV (Fig. 21.13A) a proximal zigzag
incision is used to explore the extensor and fl exor systems
as well as the thenar intrinsic muscles. If the extensor and
fl exor systems on the ablated thumb are well developed they
may be used to augment the existing system. Also, it is
important that the extensor and fl exor systems are central-
ized on the reconstructed thumb. If this is not done the
action of the tendons will cause eccentric pull on the fi nger
instead of true fl exion/extension. This can tend to angula-
tion of the thumb. The radial collateral ligament is dissected
off with a periosteal sleeve. In the majority of cases, the
articular surface of the metacarpal needs to be narrowed to
improve joint congruity and bony alignment. At this point
the reconstructed thumb is assessed for angulation, which
may benefi t from a closing wedge osteotomy for more severe
deformity. It is important to perform this carefully to stay
out of the epiphysis. A Kirschner wire is placed (Fig. 21.13B)
for bone and joint stabilization, the radial collateral liga-
ment is repaired and the thenar intrinsic muscle is reat-
tached, if necessary. A long-arm cast is placed for 5–6 weeks,
after which time the pin is removed.
Types V and VI thumbs
Reconstruction for types V and VI is similar to that for
types III and IV, but requires more intrinsic muscle recon-
struction and may require fi rst web-space Z-plasty.
A
B
FIGURE 21.10 This is a type 1 bifi d thumb with a shared base of the
distal phalanx. This classifi cation system is quite simplistic, but useful
in which the odd numbers have a shared base of the phalange while
even numbers have separation of the base of the phalanges.