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10.5 Reconstruction ofType V Defect oftheThumb
165
10.5.6 Case Description
tion. The reconstructed nger survived successfully. Regular
follow-up was conducted to guide functional exercise. The
Case 1 A 31-year-old male patient was admitted to hospital
in emergency for 6h due to the right thumb defect with pain
appearance and function of the reconstructed nger were satisfactory (Fig.10.33).
and bleeding caused by heavy object injury. Physical examination: He was in good general condition, with stable vital
signs, traumatic loss of the right thumb from the rst metacarpal, irregular wound, bleeding, comminuted fractures,
and loss of soft tissue. The other ngers were normal.
Debridement and nger reconstruction by the left second toe
transplantation were performed in emergency under general
anesthesia, and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped
with the sterile cotton, bulked, and stuffed with the broken
cotton gauze around, and he returned to the ward safely.
Routine reconstruction treatment was given after the opera-
Case 2 A 28-year-old male patient was admitted to hospital
for 6 weeks after stump repair due to the right thumb defect
caused by cutting injury. Physical examination: He was in
good general condition, with stable vital signs and type V
defect of the right thumb. After admission, routine preoperative preparation for reconstruction was given. The thumb
was reconstructed by free second toe transplantation of the
left foot under general anesthesia selectively and the donor
site was sutured directly. The operation was successful and
the patient returned to the ward safely. Routine reconstruction treatment was given after the operation. Four months
after the operation, the reconstructed nger survived suc-
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Fig. 10.33 Reconstruction of Type V defect of the right thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative design. (c) The reconstructed thumb after the operation. (d) The appearance of the reconstructed thumb 6 months after the
operation. (e) Flexor function of the reconstructed thumb 3 months after
the operation. (f) Opponens function of the reconstructed thumb 6
months after the operation. (g) Opponens function of the reconstructed
thumb 6 months after the operation
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10 Reconstruction ofThumb Defects
Fig. 10.34 Reconstruction of type V defect of the right thumb by free
second toe transplantation. (a) Preoperative palmar view of thumb
defect. (b) Preoperative X-ray. (c) Preoperative dorsal view of thumb
defect. (d) Preoperative design. (e) The removed second toe. (f) The
cessfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the
reconstructed nger were satisfactory (Fig.10.34).
Case 3 A 32-year-old female patient was admitted to hospital for 5 weeks after stump repair due to the right thumb
defect caused by machine injury. Physical examination: She
was in good general condition, with stable vital signs and
type V defect of the right thumb. After admission, routine
preoperative preparation for reconstruction was given. The
thumb was reconstructed by free second toe transplantation
of the left foot under general anesthesia selectively and the
donor site was sutured directly. The operation was successful
reconstructed thumb 14 days after the operation. (g) The appearance of
the reconstructed thumb 4 months after the operation. (h) Holding function of the reconstructed thumb 4 months after the operation
and the patient returned to the ward safely. Routine reconstruction treatment was given after the operation. Five
months after the operation, the reconstructed nger survived
successfully. Regular follow-up was conducted to guide
functional exercise. The appearance and function of the
reconstructed nger were satisfactory (Fig.10.35).
Case 4 A 35-year-old female patient was admitted to hospital for 6 weeks after stump repair due to nger defect
caused by machine injury. Physical examination: She was
in good general condition, with stable vital signs, stump
repair view of the left hand, and loss of the second metacarpal bone, the thumb, and the index nger. After admis-
10.5 Reconstruction ofType V Defect oftheThumb
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167
Fig. 10.35 Reconstruction of type V defect of the right thumb by free
second toe transplantation. (a) Preoperative palmar view of thumb
defect. (b) Preoperative dorsal view of thumb defect. (c) Preoperative
design. (d) Dissociation of the second toe. (e) The palmar view of the
sion, routine preoperative preparation for reconstruction
was given. The thumb was reconstructed by free second
toe transplantation of the left foot under general anesthesia
selectively and the donor site was sutured directly. After
the tourniquet relaxed, the reconstructed nger was ruddy
with moderate tension, wrapped with the sterile cotton,
bulked, and stuffed with the broken cotton gauze around,
and she returned to the ward safely. Routine reconstruction
treatment was given after the operation. Regular follow-up
was conducted to guide functional exercise. The appearance and function of the reconstructed nger were satisfactory. The donor site healed in the rst stage, and the
patient was satised with the appearance and function
(Fig.10.36).
reconstructed thumb. (f) The dorsal view of the reconstructed thumb.
(g) Opponens function of the reconstructed thumb 5 months after the
operation. (h) Holding function of the reconstructed thumb 5 months
after the operation
Case 5 A 32-year-old male patient was admitted to hospital
in emergency for 1h due to pain, bleeding, and deformity of
the right thumb caused by machine injury. Physical examination: He was in good general condition, with stable vital
signs. The right thumb was crushed, at deformity, accompanied by some soft tissue and bone defects, without the condition of nger replantation. Debridement and stump repair
were performed in emergency, and the wound healed well
before he was discharged. One month later, the patient
returned to the hospital for reexamination and was admitted
to hospital again due to requiring nger reconstruction. After
admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second
toe transplantation of the right foot under general anesthesia
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10 Reconstruction ofThumb Defects
Fig. 10.36 Reconstruction of type V defect of the left thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative design. (c) Dissociation of the second toe. (d) Thumb
reconstruction by free second toe transplantation. (e) The appearance of
selectively and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped
with the sterile cotton, bulked, and stuffed with the broken
cotton gauze around, and he returned to the ward safely.
Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed nger
survived successfully. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed thumb 8 weeks after the operation. (f) Opponens
function of the reconstructed thumb 8 weeks after the operation. (g) The
situation of the donor site 8 weeks after the operation
the reconstructed nger were satisfactory. The donor site
healed in the rst stage, and the patient was satised with the
appearance and function (Fig.10.37).
Case 6 A 23-year-old male patient was admitted to hospital
in emergency due to pain, bleeding, and damaged of the left
thumb caused by heavy object injury. Physical examination:
The wound of the left thumb was seriously polluted, and the
contusion of the nger from the middle part of the metacar-
10.5 Reconstruction ofType V Defect oftheThumb
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169
Fig. 10.37 Reconstruction of type V defect of the right thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Cutting of the second toe. (c) Thumb reconstruction by free second
toe transplantation. (d) The palmar view of the reconstructed thumb 10
months after the operation. (e) The dorsal view of the reconstructed
pal which was at and without blood circulation. No obvious
abnormality was observed in the other ngers. Debridement
and stump repair were performed in emergency, and the
wound healed well 1 week after the operation. So the thumb
was reconstructed by free second toe transplantation of the
right foot under general anesthesia. The operation was successful, after the tourniquet relaxed, the reconstructed nger
was ruddy with moderate tension, wrapped with the sterile
cotton, bulked, and stuffed with the broken cotton gauze
thumb 8 months after the operation. (f) Opponens function of the reconstructed thumb 10 months after the operation. (g) Holding function of
the reconstructed thumb 10 months after the operation. (h) The situation of the donor site 10 months after the operation
around, and he returned to the ward safely with plaster external xation. After the operation, the patient was ordered to
lie in bed absolutely, the nger was irradiated with a roasting
lamp, and blood supply was observed. At the same time, routine triple antitreatment was given. No vascular crisis
occurred after the operation, and the reconstructed nger
successfully survived. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed nger were satisfactory (Fig.10.38).
170
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10 Reconstruction ofThumb Defects
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Fig. 10.38 Reconstruction of type V defect of the left thumb by free
second toe transplantation. (a) Preoperative palmar condition of thumb
defect. (b) Preoperative dorsal condition of thumb defect. (c)
Preoperative design. (d) Preoperative design. (e) Dissociation of the
second toe. (f) Dissociation of the second toe. (g) The blood circulation
of the reconstructed nger. (h) The blood circulation of the recon-
structed nger. (i) The dorsal view of the reconstructed thumb 3 weeks
after the operation. (j) The palmar view of the reconstructed thumb 3
weeks after the operation. (k) Holding function of the reconstructed
thumb 6 months after the operation. (l) Opponens function of the reconstructed thumb 6 months after the operation
10.6 Reconstruction ofType VI Defect oftheThumb
171
10.6 Reconstruction ofType VI Defect
oftheThumb
Type VI defect locates at the wrist or the rst carpometacarpal joint. The defect length is longer, the soft tissue defect is
larger, and the rst carpometacarpal joint is destroyed, which
make less function residual. Therefore, its treatment is more
difcult and the effect is worse than that of type I–V defect.
Since the rst metacarpal and thumb are missing, all the
function of the thumb would be lost, which would seriously
inuence the patient’s daily life. The appearance would also
cause serious psychological impact on the patients, so this
type defect of thumb is the absolute indication for reconstruction. The classic way is free second toe transplantation
with dorsal ap, which is same as type V defect of thumb.
Due to inadequate coverage of dorsal ap, additional pedicled ap or free ap is often required. The difference is a
defect or partial defect of the wrist in type VI.Reconstruction
of the bony structure requires the attachment of the second
metatarsal with trapezium bone, scaphoid, or base of the second metacarpal.
10.6.1 Indications
The donor site:
With the contralateral second metatarsophalangeal joint
as the center, triangular incisions are made on both sides of
the rst and second toe webs, so that they are connected in a
diamond shape, the distal and proximal angles are about 90°,
and the length of the sides is about 3–4cm. The proximal
incision extends in an “S” shape, and the plantar incision is
V shaped.
10.6.3 Surgical Method
The reconstruction method is basically the same as that
of type V defect, so it will not be repeated. Since the first
carpometacarpal joint has been lost, fixation of the second metatarsal with trapezium bone or scaphoid should
be performed after the second toe transplantation
(Fig.10.39).
(1) Adult, young, and middle-aged is better; (2) A severed
thumb that cannot be replanted; (3) The patient has a strong
desire for reconstruction, whose general conditions are good,
and without systemic organic disease; (4) No basic disease,
mental disease, peripheral vascular disease; (5) There is no
history of trauma, surgery, or infection in the donor toe and
the appearance is normal.
10.6.2 Surgical Design
Surgical design is similar to typeV defect. Soft tissue defect
needs to be taken into account, which often requires additional design of forearm reverse pedicle ap or free ap.
The recipient site:
A U-shaped incision is designed on the radial side of the
second metacarpal, with the mouth to distal and the U-shaped
base tip to proximal and lengthened. The U-shaped mouth is
located at the proximal end of the second metacarpophalangeal joint, about 3cm wide. The radial artery and cephalic
vein are exposed by a transverse or longitudinal incision centered on the radial artery in the snuffbox or distal forearm.
Fig. 10.39 Fixation of the second metatarsal bone and trapezium bone
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Fig. 10.40 Fixation of the second metatarsal bone and the second
metacarpal bone
In the absence of these two bones, the second metatarsal
bone can also be used for bony xation with the radial palmar of the middle segment of the second metacarpal bone
(Fig. 10.40); thus, the step of reconstruction of opponens
function can be omitted.
10.6.4 Postoperative Treatment
(a) After the operation, continuous light irradiation should be
given and the peripheral blood supply should be observed;
(b) The patients should be treated with “three anti” therapy;
(c) After the operation, lie in bed for 7 days absolutely, attention should be paid to heat preservation; (d) Smoking is prohibited during the perioperative period. Dressings are
changed every 2–3 days and stitches are removed 2 weeks
after the operation.
10.6.5 Operation Characteristics
(a) The surgeon should exibly design different forms of
dorsal ap to cover the wound and reconstruct the rst nger
web according to the skin defect; (b) The second metatarsal
10 Reconstruction ofThumb Defects
bone should be xed with trapezium bone or scaphoid or the
second metacarpal bone which could omit the reconstruction
of opponens function; (c) Various forms of dorsal foot ap,
plantar-side V-shaped ap and tongue ap on the rst nger
web should be reasonably adjusted among the three aps to
make full use of the effective area of these skin not only to
form the rst nger web but also to eliminate the wound, and
the excess skin should be excised; (d) The injury to the foot
is large, when it is closed we should be careful to avoid causing hallux valgus deformity.
10.6.6 Announcements
(a) The size of soft tissue defect should be measured carefully before operation and pedicle ap or free ap should
be designed accurately; (b) If the forearm pedicle ap is
needed, it should cover the wound without obstructing the
blood circulation of the nger; (c) If the free ap is
removed, the recipient vessels need to be considered; (d)
After the toe transplantation, the bleeding must be stopped
completely to avoid the occurrence of postoperative hematoma; (e) The reconstruction of the rst nger web should
make full use of the composite ap carried by the donor
toe, and attention should be paid to the incision location of
the hand U-shaped ap. Free skin graft can be considered
if there is a large area of scar on the wound surface and the
soft tissue defect is large after debridement; (f) Attention
must be paid to the closure of the foot wound. The surrounding aponeurosis tissue should be protected and the
hemostasis should be complete during the operation; (g) If
the wound cannot be closed directly and free skin graft is
applied, the tightness should be paid attention to, and the
blood circulation of the foot should be observed after the
operation to prevent the occurrence of vascular crisis; (h)
Heat preservation, keeping quiet, strict smoke prohibiting
must be paid attention to, patients absolutely lie in bed for
a week; (i) Postoperative dressing change should be gentle, pay attention to the use of warm disinfectant disinfection and clean scab.
10.6.7 Case Description
Case 1 A 24-year-old male patient was admitted to hospital
for 2 years due to the left thumb, index nger and middle
nger defect caused by machine injury. Physical examination: He was in good general condition, with stable vital
signs, the thenar, thumb, index nger, and middle nger
defect. The thumb was reconstructed by free second toe
transplantation of the right foot under general anesthesia
selectively and the thenar was reconstructed by reversed
10.6 Reconstruction ofType VI Defect oftheThumb
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173
Fig. 10.41 Reconstruction of type VI defect of the left thumb by free
second toe transplantation. (a) Preoperative palmar view of thumb
defect. (b) Preoperative dorsal view of thumb defect. (c) Preoperative
design. (d) Cutting of the second toe. (e) Reconstruction of the thenar.
forearm dorsal interosseous artery pedicle ap. The donor
site was covered by skin graft. The operation was successful
and routine reconstruction treatment was given after the
operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger were improved and the donor site healed in
the rst stage (Fig.10.41).
Case 2 A 34-year-old male patient was admitted to hospital
for more than 3 years due to the left thumb defect caused by
machine injury. Physical examination: He was in good general condition, with stable vital signs, the thenar, and thumb
defect. The thumb was reconstructed by free second toe
transplantation of the right foot under general anesthesia
selectively and the thenar was reconstructed by reversed
(f) The thumb reconstructed by second toe transplantation. (g) The
appearance of the recipient site 3 months after the operation. (h) The
appearance of the recipient site 3 months after the operation. (i) The
situation of the donor site 3 months after the operation
forearm dorsal interosseous artery pedicle ap. The donor
site was covered by skin graft. The operation was successful
and routine reconstruction treatment was given after the
operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed nger were general and the donor site healed in the
rst stage (Fig.10.42).
Case 3 A 20-year-old female patient was admitted to hospital in emergency for 3h due to pain and bleeding of the right
forearm and hand caused by machine injury. Physical examination: She was in good general condition, with stable vital
signs, irregular open wound at distal forearm, exposed bone
fracture and tendons, severe contusion of the right thumb,
soft tissue extirpation, no peripheral blood supply, and the
174
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10 Reconstruction ofThumb Defects
Fig. 10.42 Reconstruction of type VI defect of the left thumb by free
second toe transplantation. (a) Preoperative condition of thumb defect.
(b) Preoperative design. (c) Preoperative design. (d) Dissociation of the
ap. (e) Dissociation of the second toe. (f) The reconstructed thumb. (g)
other ngers were normal. “Right forearm debridement with
internal xation and thumb stump repair” was performed
under general anesthesia in the rst-stage emergency department. The operation was successful and the patient was discharged after good postoperative wound healing. Three
month later, the patient returned to the hospital due to requiring nger reconstruction. The thumb was reconstructed by
free second toe transplantation combined with the great toe
nail ap of the left foot under general anesthesia selectively
and the right radius defect was repaired by free bular ap
transplantation. The operation was successful, after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and
stuffed with the broken cotton gauze around, and she returned
The appearance of the reconstructed thumb 11 months after the operation. (h) Holding function of the reconstructed thumb 11 months after
the operation. (i) The situation of the donor site 11 months after the
operation
to the ward safely. Two weeks after the operation, the reconstructed nger and bular ap survived successfully. Regular
follow-up was conducted to guide functional exercise. The
appearance and function of the reconstructed nger were satisfactory (Fig.10.43).
Case 4
A 28-year-old female patient was admitted to hospi-
tal for 1 month after stump repair due to the left thumb defect
caused by mold crush injury. Physical examination: She was
in good general condition, with stable vital signs and the left
thumb defect. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free great toe transplantation of the right foot
under general anesthesia selectively and the donor site was
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