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30 Rehabilitation in Pediatric Hand Trauma
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Fig. 30.7 The silicone elastomer used in the night time to
treat the scar
When all the wounds will be completely
Fig. 30.8 A kind of exercise to stimulate hand using in
manual play and daily living activity
371
healed, the hand therapist will make a removable
splint in order to protect the stump, the parents
will learn how to massage the scars, and the use
of silicon sheets will be suggested for the night.
Also in this case, sensibility has to be stimulated
through different tissues. It is very important that
the little patient at the end of the therapy is able to
use the ngers involved in the trauma for all the
activities of daily living (Fig.30.8).
30.2 Tendon Lesions inPediatrics
Tendon lesions in children have a high incidence
because they explore the world outside with their
little hands often without paying attention. If
these lesions are not treated properly, they can
cause important functional decits and decits of
growth; the child in fact can learn daily activities
with the complete exclusion of the segment or of
the whole hand.
However, it is very difcult to treat children
with this kind of lesions because sometimes they
have a very low compliance and little hands and
little ngers which are very difcult to treat and
to splint.
The major difference between the treatment of
an adult and a child in this eld is that treating a
child means a bigger immobilization and bigger
splints that can include also digit and joint that
are not directly involved in the trauma, with the
aim of giving more stability and to be safer
(Fig.30.9a–c).
The time of immobilization is on average longer
than in adults, for example, in the lesion of exor
tendons, we begin to physiotherapy at the end of the
fourth week keeping the splint that will be made
removable, with the wrist extended 0–20°, metacarpal-phalangeal joint at about 30°, and interphalangeal joint extended (Fig. 30.10a). Disposition is
chosen in order to avoid intrinsic muscle retraction.
Sometimes the surgeon chooses the pullout
technique (Fig.30.11); this can allow the immediate mobilization. The little patient will have of
course a limit in the maximum open extension.
The splint is going to be removable from the very
beginning and will be made in the same position
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R. Pagliaro et al.
a
b
c
Fig. 30.9 Immobilization splint in pediatric hand tendon lesion
ab
30 Rehabilitation in Pediatric Hand Trauma
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373
Fig. 30.10 Flexor tendons removable splint to start physiotherapy
that we explain before in order to protect the
suture of the tendon.
The wearing of the splint will take a little bit
longer for your patients, especially during the
night and in risky situation.
The recovery will be placed basically on playing; the therapist will choose with the little
patient games and toys that can be appropriate for
the situation and the age (Fig.30.12a).
Fortunately in children, the elasticity of the
tissues helps to reduce the post-immobilization
stiffness (Fig.30.13).
The massage of the scar will be extremely
important and has to be done more than four
times a day, not very long but very often during
the day. The technique of the massage is to do it
slowly with pressure in order to avoid a thickening of the scar and to limit the establishment of
adherence in the deep tissues.
Another tool that needs to be associated with
the massage is the use of silicon sheets, to wear
during the night, which means for at least 8 hours
Fig. 30.11 Start rehabilitation with exor tendon pull
out technique repair
per night. It is very important to spend some time
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R. Pagliaro et al.
Fig. 30.12 Example of exercise in rehabilitation in exor tendon lesion
during the rehabilitation, putting attention on the
recovery of sensibility on the scar and nearby; this
can be done with the stimulation of the part with
different tissues from the softer to the rougher.
In case of stiffness after eight weeks, it will be
possible to make dynamic splint to increase the
mobility of the single nger or of more of them.
During the tenth week. The therapist can try to
use electrostimulation in order to promote the
sliding of the tendons and reduce the possibility
of adherence and bio-feedback.
At about 12 weeks, if there are no decits, the
patient can go back to the normal activities and
use the whole limb like the other.
Also in extensor tendon lesion, the therapeutic
approach is cautious. Normally, the time of
immobilization is of six weeks with a splint in
extension of the ngers and wrist in a neutral
position (Fig.30.14).
At the end of the sixth week, we start to move
the little hand of the child, making a removable
Fig. 30.13 Result of exor tendon lesion
splint. The therapist will teach the little patient
30 Rehabilitation in Pediatric Hand Trauma
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Fig. 30.14 Example of cast immobilization for extensor
tendon lesion
and parents some exercises for the ngers like the
“hook” and the “roof,” so gradually as the exion
improves, the patient will be able to do a com-
375
plete st. To help the patient to understand how to
close the hand, the therapist will provide some
targets, like cylinders from bigger ones to smaller
ones. During the rehabilitative session, different
kinds of grips will be offered to the child in order
to recorticalize the correct gesture of the single
hand and of both in bimanual grips.
For sure also in this case, the treatment of this
scar when healed will be very important and will
follow the rules that we have explained before
such as multiple massages during the day and the
use of silicon sheets during the night. The
extensor tendons slide immediately under the
skin; this means that normally a scar has more
possibility to do adherence with the next tissues
and this can limit the range of motion. For this
reason the parents need to learn from the therapist how to do dynamic sliding in schools; this
means that they x the skin in one way and they
asked the child to extend or ex which has a double effect on the scar, and this can be very useful.
Also in this case during the week, if there is stiffness, the therapist can make dynamic splint in
exion to increase the range of motion.
At about 12 weeks like for exor tendons, the
rehabilitative protocol ends if the patients do not
present any decit, and normal activity is
permitted.
Toe-to-Hand Transfers for
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Posttraumatic and Congenital
Reconstruction in Children:
Indications and Surgical Technique
NeilJones andChiaraParolo
31
Abstract
Miraculous improvement in hand function can
be achieved by microsurgical toe-to-hand transfers, either for children who have sustained
severe trauma resulting in amputations of their
thumb or ngers or for children with congenital
absent digits, due to symbrachydactyly, congenital constriction ring syndrome, or transverse and longitudinal deciencies. From the
rst experimental microsurgical toe-to-hand
transfer performed by Buncke etal. (Br J Plast
Surg 19:332–337, 1966), the procedure has
subsequently evolved to minimize the harvest
of tissues from the foot and to customize the
appearance of the great toe similar to that of the
thumb. Great toe and second toe transfers for
posttraumatic reconstruction of amputations of
the thumb, and single second toe, simultaneous
double second toe transfers (O’Brien, Hand
10:232–240, 1978; Coskunrat et al., Plast
Reconstr Surg 115:1064–1069, 2005), and
combined second and third toe transfers (Wei
etal., Plast Reconstr Surg 84:651–661, 1989)
for posttraumatic reconstruction of multiple
digital amputations have subsequently evolved
N. Jonesn
e-mail: nfjones@uci.edu
C. Parolo (*)
Department of Hand Surgery and Rehabilitation,
San Giuseppe Hospital IRCCS MultiMedica,
Milan University, Milan, Italy
e-mail: chiara.parolo@multimedica.it
for specic indications. Indications for post-
traumatic microsurgical reconstruction of the
thumb and ngers in children may be classied
exactly similar to the classication of congeni-
tal absent digits (Jones and Kaplan, Hand
7:391–399, 2012; Jones and Clune, Hand
11:77, 2016). The optimal age for performing a
toe transfer to reconstruct a congenital hand
difference has not been dened. Generally, the
earlier that a toe transfer is performed, the bet-
ter the chance of cortical integration.
Preoperative counseling of the parents with the
opportunity to meet and speak with other fami-
lies and children who have undergone a toe
transfer is absolutely vital.
Keywords
Toe-to-hand transfer · Microsurgical toe
transfer · Congenital absent digit · Finger
amputation · Hand trauma · Hand
reconstruction
31.1 Introduction
Miraculous improvement in hand function can be
achieved by microsurgical toe-to-hand transfers,
either for children who have sustained severe
trauma resulting in amputations of their thumb or
ngers or for children with congenital absent digits, due to symbrachydactyly, congenital constriction ring syndrome, or transverse and
longitudinal deciencies.
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_31
377
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N. Jones and C. Parolo
Buncke [1] performed the rst experimental
microsurgical toe-to-hand transfer in a monkey in
1964, and this was followed by the rst microsurgical second toe-to-thumb transfer in a human by
Yang in 1966 [2]. Cobbett [3] performed the rst
great toe-to-thumb transfer based on the plantar
arterial system, and Buncke et al. [4] performed
the rst great toe-to-thumb transfer based on the
rst dorsal metatarsal artery system. Great toe
transfers have subsequently evolved to minimize
the harvest of tissues from the foot and to customize the appearance of the great toe similar to that of
the thumb, using the Morrison “wrap- around” ap
[5] and the “trimmed toe” transfer [6, 7]. Great toe
and second toe transfers for posttraumatic reconstruction of amputations of the thumb and single
second toe, simultaneous double second toe transfers [8, 9], and combined second and third toe
transfers [10] for posttraumatic reconstruction of
multiple digital amputations have subsequently
evolved for specic indications.
31.2 Conventional Reconstruction
ofAmputations inChildren
Fortunately, severe amputations of the thumb and
ngers are relatively rare in children. For sharp
amputations, replantation should be attempted if
at all possible, if necessary using vein grafts (performed on a back table) from the dorsal radial
artery or even from the brachial artery at the
elbow. Ectopic replantation in the groin or axilla
may be considered in very unusual circumstances
such as gross contamination. Conventional
reconstruction of amputations or failed replantations includes pollicization of a normal or injured
nger for thumb reconstruction [11, 12] and distraction lengthening for thumb and nger reconstruction [13–17].
31.3 Toe-to-Hand Transfers After
Trauma inChildren
Microsurgical toe-to-hand transfers have revolutionized posttraumatic reconstruction in adults
after amputation of the thumb and/or ngers. Toe
transfers should now be considered as the optimal technique for reconstruction of amputated
ngers and thumbs in children, just as in adults. It
is a single stage procedure that provides greater
length and maintains the potential for growth [18,
19], compared with distraction lengthening. For
thumb reconstruction, it preserves all four ngers
or the remaining ngers compared with
pollicization.
The second toe is always used for nger
reconstruction and is preferred for thumb reconstruction in younger children. The second toe
also provides the most inconspicuous donor site
in the foot and is preferred by cultures requiring
the use of sandal footwear. The great toe and its
variations are preferred for thumb reconstruction in older children, when the appearance of
the new “thumb” becomes more important and
also when multiple ngers are also amputated
since the great toe has a greater area of sensate
pulp. The Morrison wraparound [5] and
“trimmed great toe” [6, 7] variations of a great
toe transfer minimize the harvest of tissues from
the foot and provide the most normal appearance of the reconstructed thumb. The “trimmed
toe” technique allows the potential for growth in
children, but the Morrison wrap-around does
not.
Amputation stumps previously covered with
skin grafts may need to be replaced using a
groin ap or a reverse radial forearm ap, prior
to toe transfers. Similarly, severe thumb-index
nger web space contractures may need to be
released before performing a toe-to-thumb
transfer, utilizing a groin ap, reverse radial
forearm ap, or reverse posterior interosseous
artery ap. Alternatively, the toe-to-thumb
transfer and thumb-index nger web-space
release can be performed simultaneously, using
a small dorsalis pedis artery skin ap based on
the same arterial pedicle or by using a reverse
radial forearm ap to cover the web space and
the proximal radial artery to provide arterial
inow to the toe transfer [20].
Several small series of toe-to-thumb and toeto- nger transfers have been reported for posttraumatic reconstruction of children’s hands with
success rates comparable to adults [21–32].
31 Toe-to-Hand Transfers for Posttraumatic and Congenital Reconstruction in Children: Indications…
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31.4 Indications forToe-to-Hand
Transfers After Trauma
inChildren
Indications for posttraumatic microsurgical
reconstruction of the thumb and ngers in children may be classied exactly similar to the classication of congenital absent digits [22, 33]. Of
the 15 different phenotypes of digital amputations, only 6 are potential candidates for microsurgical reconstruction with toe-to-hand
transfers—R1, R2, R3, R4, R5, and U4R1—with
a further three potential relative indications:
U3R2, C2R2U1, and C3R1U1.
The indications for toe-to-thumb transfers
after trauma in children include the following:
1. Isolated amputations of the thumb, from
distal to the CMC joint out to the accepted
critical functional level at the midpoint of
the proximal phalanx (R1 classication).
Very rarely, an emergency toe transfer may be
indicated for reconstruction of a degloved
thumb with an intact bony skeleton and
tendons.
2. Amputations of the thumb and several other
ngers (R2, R3, and R4 classication).
3. Amputation of all ve digits—the “metacar-
pal hand” [27, 34] or R5 hand [22].
Indications for toe-to-hand transfers for nger
reconstruction after trauma in children include
the following:
1. Complete or partial amputation of multi-
ple or all four ngers, but with an intact
thumb (U4R1 classication)
2. Amputation of all ve digits: the “metacar-
pal hand” [27, 34] or R5 hand [22]
31.5 Conventional Reconstruction
ofCongenital Hand
Dierences
Conventional non-microsurgical reconstruction
of congenital absent digits usually involves pollicization of the index nger for children born
with a hypoplastic or absent thumb [35, 36] and
nonvascularized toe phalangeal bone grafting
[37–45] and distraction lengthening of hypoplastic digits due to symbrachydactyly, cleft hand, or
congenital constriction ring syndrome [13–17,
46–50].
31.6 Toe-to-Hand Transfers
forCongenital Hand
Dierences
The rst microsurgical toe transfer to reconstruct a congenital hand difference was performed by O’Brien et al. [51] in 1977 who
successfully transferred a great toe to reconstruct a hypoplastic thumb in two children.
Yoshimura [30, 31] performed second toe transfers in two children with congenital differences.
May [52] reported bilateral great toe-to-thumb
transfers to reconstruct a nine-year-old boy with
bilateral aplasia of his thumb, index, and middle
ngers. After other case reports [53, 54], several
surgeons have reported larger series of microsurgical toe-to- hand transfers to reconstruct
various congenital differences of the hand [23,
24, 55–65].
31.7 Indications forToe-to-Hand
Transfers forCongenital
Hand Dierences
Microsurgical toe-to-hand transfers for reconstruction of congenital hand differences have not
evolved to a similar extent as toe transfers for
reconstruction after trauma and still remain controversial. Firstly, surgeons may be reluctant to
risk the small but potential loss of a toe transfer in
children who are already missing one or more
digits in their hands. Secondly, some pediatric
hand surgeons still maintain that children with
unilateral absence of one or more digits adapt to
their impairment as they grow or can be helped
with a static or functional prosthesis. Finally, parents may be reluctant to accept a very complicated reconstructive procedure that carries a
small risk of ending up with a missing great or
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N. Jones and C. Parolo
second toe as well as more scars on the hand to
show for the failed endeavor.
Very little has been published on the specic
indications for microsurgical reconstruction of
congenital absent digits. Most pediatricians and
even some hand surgeons do not understand
which children should be considered for microsurgical reconstruction. Previous reports of toe
transfers for congenital hand differences have
all been based primarily on the specic embryological diagnoses, according to the classication
of the International Federation of Societies for
Surgery of the Hand [66]. However, it is the
authors’ contention that specic indications for
toe transfers are more logically dened by the
anatomy of the hand difference itself, a concept
that is also much more easily understood by
referring pediatricians and surgeons [33]. From
an analysis of 235 hands in 204 children born
with congenital absent digits over a 15-year
period, Jones and Kaplan [33] developed a simple documentation system, which allows hand
surgeons to describe the morphological or radiographic appearance or the functional status of a
child’s hand with congenital absent digits, based
on which digits are missing and their level of
absence. Each hand can be described by three
letters R (radial), C (central), and U (ulnar) as
well as ve numbers. The rst letter and number
designate which rays are missing and the second
and third letters and numbers designate which
rays are present. Consequently, an absent thumb
would be designated as R1U4, a hand with a
thumb but absent ngers would be designated as
U4R1, and complete absence of all ve digits
would be designated as R5. The spectrum of
radial deciencies includes R1U4, R2U3,
R3U2, and R4U1. There are 15 morphological
phenotypes of congenital absent digits—the
three most common phenotypes being U4R1
(thumb but absence of all four ngers corresponding to the monodactylous type III symbrachydactyly), R1U4 (absent thumb), and R5
(aplastic hand). Unlike most other classications, this documentation system not only facilitates communication between hand surgeons
but also incorporates all the previous subclassi-
cation systems that have attempted to describe
congenital absent digits in radial, central, and
ulnar deciencies, symbrachydactyly, and congenital constriction ring syndrome. However,
most importantly, it has allowed the development of an algorithm which predicts whether
conventional or microsurgical reconstruction is
indicated for each specic phenotype. Of the 15
phenotypes, only 7 phenotypes are potential
indications for microsurgical reconstruction
with toe-to-hand transfers: R1U4, R2U3, R3U2,
R4U1, R5, U4R1, and occasionally C3R1U1.
For a child missing a thumb but with four relatively normal ngers (R1U4), it is intuitive to
reconstruct a thumb to oppose to these ngers,
either by pollicization of the index nger or by a
toe-to-thumb transfer. Similarly for a child
missing all four ngers (U4R1), it is logical to
reconstruct one or two ngers to allow pinch
and grasp to the normal thumb, either by distraction lengthening or by toe-to-hand
transfers.
The following are four indications for considering microsurgical reconstruction of an absent
thumb [60]:
1. Isolated absence of the thumb with four
normal or relatively normal ngers, in
which the carpometacarpal joint and base
of the thumb metacarpal and thenar muscles are preserved (R1U4). This is usually
seen in congenital constriction ring syndrome
or occasionally transverse failure.
Reconstruction of these thumbs with a toe
transfer is superior to index nger pollicization, distraction lengthening, or nonvascularized toe phalangeal bone grafting, because it
provides greater length and the potential for
growth and preserves the full complement of
ngers. A second toe transfer in a 2–3-yearold child will provide almost 5cm length of
the bone and soft tissue compared with only
13–17 mm length of a nonvascularized toe
phalangeal bone graft or 3 cm that can be
achieved by distraction lengthening, albeit
with a secondary bone graft procedure. If the
thenar muscles are poorly developed, an
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opposition tendon transfer using the exor
digitorum sublimis from the ring nger can be
performed at a secondary procedure.
However, if there is an isolated absence of
the thumb and four relatively normal ngers,
but the carpometacarpal joint is absent, pollicization of the index nger remains the gold
standard of reconstruction [36], although
there are two reports of toe transfers for reconstruction of Blauth type IV and V hypoplastic
thumbs [67, 68].
2. Absence of the thumb as well as the index,
middle, and ring ngers, but with one or
two ngers remaining on the ulnar side of
the hand (R2U3, R3U2, and R4U1). This is
usually seen with severe radial longitudinal
deciencies or the monodactylous type III
atypical cleft hand variant of symbrachydactyly [69]. A second toe can be transferred to
reconstruct the absent thumb with minimal
donor site morbidity, but the modied “wraparound” [5] or trimmed great toe [6, 7] techniques can occasionally be considered in
older children to provide both an excellent
functional result and a “thumb” very similar
in appearance to the contralateral normal
thumb. If the carpometacarpal joint is absent
in these severe radial deciency phenotypes,
the second toe metatarsal can be xed to the
scaphoid or spliced into the radial styloid as
described by Vilkki [25] and by Yu [32]. Very
rarely, a similar morphological deformity
also occurs in one or both feet (cleft hand
and cleft feet), and the abnormal great toe is
sometimes amputated to facilitate the tting
of shoes. In these situations, the abnormal
great toe is a “free spare part” that can be
transferred to reconstruct the absent thumb
[18, 19].
3. Unilateral (or extremely rarely bilateral)
absence of the thumb and all four ngers
(R5). This is usually seen with the adactylic
type IV symbrachydactyly [69] or with transverse failure of formation.
4. Finally, there are very rare cases in which the
thumb or radial side of the hand becomes
totally enveloped by a rapidly growing vascu-
lar malformation which is unresponsive to
embolization or sclerotherapy or by progressive macrodactyly. This situation can potentially be salvaged by radical resection of the
thumb but preserving the carpometacarpal
joint and base of the thumb metacarpal and
thenar muscles, followed immediately by a
second toe transfer [56, 70].
The following are two indications for considering toe transfers to reconstruct absent ngers
[60]:
1. Absence of all four ngers (from the car-
pus out to the base of the middle phalanges), but with a normal thumb (U4R1).
This is usually seen with the monodactylous
type III symbrachydactyly, transverse failure of formation, congenital constriction
ring syndrome, or severe ulnar longitudinal
deciency. The location into which the toe
transfer is positioned depends on the anatomy. Microsurgical reconstruction of a nger can be accomplished by a single second
toe transfer into the middle, ring, or small
nger position (Figs. 31.1 and 31.2).
Placement of the toe transfer on the ulnar
side of the hand allows both grasp of large
objects and tip-to-tip pinch. An alternative
option, if the parents are agreeable, is to
transfer two second toes, either simultaneously or sequentially, into the middle and
Fig. 31.1 Toe transfer in U4R1 hand Post op
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