Finger

Amputations of the
Hand
Chapter 14
James H. Calandruccio
Considerations for
amputation ............................ 639
Principles of amputation of
the ngers ............................. 641
Amputations of ngertips ..... 641
Free skin graft ............................ 643
Cross nger aps ........................ 647
Amputations of single
ngers .................................... 650
Index nger ................................

Middle or ring nger ray
amputations .............................
Ring nger avulsion injuries ...............
Little nger amputations ............
650
652
655
655
Amputations of the thumb ... 655

Amputations of multiple
digits ...................................... 656
Reconstructions after
amputation ............................
Reconstruction after
amputation of the hand ..........
Reconstruction after
amputation of multiple
digits .......................................
Reconstruction of the thumb ....
658
658
660
660
Painful amputation stump .... 658
In selected instances, acute traumatic incomplete and complete amputations may be salvaged by emergency microsurgical treatment. For these techniques and their
indications, see Chapter 60. Amputations between the tip
of the nger and the lunula of the nail usually cannot be
salvaged by microvascular techniques and usually require
amputation completion and soft-tissue coverage. The distal
tip in ngers other than the thumb can be reattached to
the nger, however, and the ngertip buried in the ipsilateral palm. The nger is removed from the pocket 16 to
20 days after surgery. The results in 13 of 16 patients
according to Arata et al. were completely successful. In
children, we have observed that merely resuturing the
defatted ngertips back in place usually results in a satisfactory result.
Surgical amputation through the ngers or metacarpals
is a reconstructive procedure to preserve as much function
as possible in injured and uninjured parts of the hand.
Efforts to preserve severely damaged structures can delay
healing, increase disability, and prolong a painful series of
surgical efforts. Primary amputation may be the procedure
of choice in many individuals. In general, every effort
should be made to maintain the skin sensation, joint mobility, and digital length. Achieving supple soft-tissue
coverage of the ends of the thumb and ngers is
essential. In amputations of several digits, pinch and grasp
are the chief functions to be preserved.
CONSIDERATIONS
FOR AMPUTATION
Amputations may be considered for a variety of conditions
in which function is limited by pain, stiffness, insensibility,
and cosmetic issues. A request for amputation of an injured
part by a patient usually is the culmination of a critical
thought process and usually is justied. The only absolute
indication for a primary amputation is an irreversible loss
of blood supply to the part. More often, other factors must
be considered in deciding whether amputation is advisable.
The ultimate function of the part should be good enough
to warrant the time and effort required of the patient if it
is not amputated.
An analysis of the ve tissue areas (skin, tendon, nerve,
bone, and joint) is sometimes helpful in making the decision to amputate. If three or more of these ve areas
require special procedures, such as grafting of skin, suture
of tendon or nerve, bony xation, or closure of joint,
amputation should be strongly considered. Frequently, the
function of the remaining ngers is compromised by survival of a mutilated nger. In children, amputation rarely
is indicated unless the part is nonviable and cannot be made
viable by microvascular techniques.
Even if amputation is indicated, it may be wise to delay
it if parts of the nger may be useful later in a reconstructive procedure. Skin from an otherwise useless digit can be
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[UnitedVRG] - Medical Release Group
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Part IV Amputations
Chapter 14 Amputations of the Hand
employed as a free graft. Skin and deeper soft structures

can be useful as a lleted graft (see Chapter 62); if desired,
the bone can be removed primarily and the remaining ap
suitably fashioned during a second procedure. Skin well
supported by one or more neurovascular bundles but not
by bone can be saved and used as a vascular or neurovascular island graft (see Chapter 65). Segments of nerves can
be useful as autogenous grafts. A musculotendinous unit,
especially a exor digitorum sublimis or an extensor indicis
proprius, can be saved for transfer to improve function
in
640
a surviving digit (e.g., to improve adductor power of the

thumb when the third metacarpal shaft has been destroyed
or to improve abduction when the recurrent branch of the
median is nonfunctional). Tendons of the exor digitorum
sublimis of the fth nger, the extensor digiti quinti,
and the extensor indicis proprius can be useful as free grafts.
Bones can be used as peg grafts or for lling osseous
defects. Under certain circumstances, even joints can be
useful. Every effort should be made to salvage the thumb
(Fig. 14-1).
Fig. 14-1 Reconstruction of thumb. A, Failed thumb replantation after saw injury with concomitant primary ray amputation of index nger and partial amputation through middle nger.
B-D, Metacarpophalangeal joint level thumb disarticulation and neurovascular island transfer
of proximal phalanx segment of middle nger for thumb reconstruction. E, Radiographic
appearance of transfer of middle nger proximal phalanx to thumb complex tissue. F, Example
of functional hand use restored after sensory innervated composite thumb reconstruction.
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Part IV Amputations
641
PRINCIPLES OF AMPUTATION
OF THE FINGERS
Whether an amputation is done primarily or secondarily,
certain principles must be observed to obtain a painless and
useful stump. The volar skin ap should be long
enough to cover the volar surface and tip of the osseous
structures
and to join the dorsal ap without tension. The ends of
the digital nerves should be dissected carefully from the
volar ap, gently placed under tension so as not to rupture
more proximal axons, and resected at least 6 mm proximal.
Neuromas at the nerve ends are inevitable, but they should
be allowed to develop only in padded areas where they are
less likely to be painful. The digital arteries should
be cauterized. When scarring or a skin defect makes the
fashioning of a classic ap impossible, a ap of a different
shape can be improvised, but the end of the bone must be
padded well. Flexor and extensor tendons should be drawn
distally, divided, and allowed to retract proximally. When
an amputation is through a joint, the ares of the osseous
condyles should be contoured to avoid clubbing of the
stump. Before the wound is closed, the tourniquet should
be released and bleeding controlled because hematomas are
painful and may delay healing.
AMPUTATIONS OF FINGERTIPS
Amputations of the ngertips vary markedly depending on
the amount of skin lost, the depth of the soft-tissue defect,
and whether the phalanx has been exposed or even partially amputated (Fig. 14-2). Proper treatment is determined by the exact type of injury, and whether other digits
also have been injured.
Injuries with loss of skin alone can heal by secondary
intention or can be covered by a skin graft (Fig. 14-3). If
the soft-tissue defect is deep and the phalanx is exposed,
however, deeper tissues and skin must be replaced.
Several methods of coverage are available. Reamputation
of the nger at a more proximal level can provide ample
skin and other soft tissues for closure but requires
shortening the nger. If other parts of the hand are
severely
injured or if the entire hand would be
endangered by keeping a nger in one position for a
long time, amputation is indicated. This is especially
true for patients with arthritis or for patients older than
age 50 years. Children usually do not require
reamputation because secondary intention wound closure
covers the variable amounts of exposed bone in a
remarkably short time. A free skin graft can be used for
coverage, but normal sensibility is never restored. A splitthickness graft often is sufcient if the bone is only slightly
exposed and its end is nibbled off beneath the fat. Such a
graft contracts during healing and eventually becomes
about half its original size. Sometimes a full-thickness graft
1. Shorten bone to
joint and close
2. Possible dorsal
flap if length
essential
Free
split
graft
1. Shorten to close
2. Cross finger,
thenar, or Kutler
flap
B
1. Shorten to close
2. Remove exposed
bone to below
pulp and cover
with split graft
3. Atasoy sliding
graft
4. Cross finger
flap
Fig. 14-2 Techniques useful in closing amputations of ngertip. A, For amputations at more distal levels, free split
graft is applied; at more proximal levels, bone is shortened
to permit closure, or if length is essential, dorsal aps can
be used. B, For amputations through brown area, bone can
be shortened to permit closure, or cross nger or thenar ap
can be used. C, For amputations through brown area, bone
can be shortened to permit closure, exposed bone can be
resected and split-thickness graft applied, Kutler advancement aps can be used, or cross nger ap can be applied.
In small children, ngertips commonly heal without grafts.
is available from other injured parts of the hand, but the

fat should be removed from its deep surface. Occasionally,
the amputated part of the ngertip is recovered and
replaced as a free graft. This procedure seems to be more
successful in children than in adults. The medial aspect
of the arm just distal to the axilla, volar forearm and
wrist, and hypothenar eminence are convenient areas
from which skin grafts can be obtained. Free grafts should
be secured by a stent dressing tied over the end of the
nger.
If deeper tissues and skin must be replaced to cover
exposed tendon and bone, various aps or grafts can be
used. Frequently used distal advancement aps include the
Kutler V-Y and Atasoy triangular advancement aps (Figs.
14-4 and 14-5). These aps involve tissue advancement
Fig. 14-3 Abrasion injury to left hand treated by secondaryintention healing. A, Volar view soon after injury with
2 cm 2 cm full-thickness pulp skin loss of middle and
ring ngers. B, Same ngers with local wound care at
4 weeks. C, Result at 8 weeks with no operative
intervention.
C
A
B
Fig. 14- 4 Kutler V-Y advancement aps. A, Advancement
aps over neurovascular pedicles carried down to bone.
BD, Fibrous septa are dened (B) and divided (C),
permitting free mobilization on neurovascular pedicles
alone (D). E, Flaps advance readily to midline. (From
American Society for Surgery of the Hand: Regional review
courses in hand surgery, 15th ed, Englewood, Colo, 1995, The
Society.)
6436
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Part IV Amputations
643
excellent distal coverage and utility for dorsal and volar

defects (Fig. 14-8). Donor site morbidity may be reduced
in retrograde island pedicle aps that use the subdermal
elements only (Fig. 14-9).
Composite soft-tissue transfer to the small nger may
be accomplished by use of an ulnar hypothenar ap. This
retrograde ow ap is based on the ulnar digital artery and
may be used to supply sensation when the dorsal sensory
branch of the ulnar nerve is included in the skin ap (Fig.
14-10).
C
A
Free Skin Graft

The techniques for applying free skin grafts are described
in Chapter 62.
Kutler
V-Y
or
Triangular
Advancement Flaps
Fig. 14-5
Atasoy V-Y technique. A, Skin incision and mobilization of triangular ap. B, Advancement of triangular ap.
C, Suturing of base of triangular ap to nail bed. D, Closure
of defect, V-Y technique. (From American Society for Surgery
of the Hand: Regional review courses in hand surgery, 15th ed,
Englewood, Colo, 1995, The Society.)
Kutler V-Y or Atasoy triangular advancement ap ngertip

coverage is appealing because it involves the injured nger
alone. It provides only limited coverage, however, and does
not result consistently in normal sensibility.
TECHNIQUE 14-1
from the injured nger and provide limited coverage. The

dorsal pedicle ap is useful when a nger has been amputated proximal to the nail bed (Fig. 14-6). If further shortening is unacceptable, however, this type of ap can be
raised from the dorsum of the injured nger and carried
distally without involving another digit. Dorsal defects may
be managed by adipofascial turnover aps in which the
proximal subdermal adipofascial tissues are ipped distally
over a vascularized zone of the same tissue (Fig. 14-7).
Advantages of same-digit coverage techniques include no
need for a second operation for ap division (as with a cross
nger ap), prevention of adjacent nger stiffness that
occurs with adjacent nger coverage techniques (especially
in patients with underlying arthritic conditions), and the
opportunity for coverage in patients in whom adjacent
ngers are injured. The cross nger ap provides excellent
coverage, but may be followed by stiffness not only of the
involved nger but also of the donor nger. This type of
coverage requires operation in two stages and a split-thickness graft to cover the donor site. The thenar ap also
requires operation in two stages. It usually does not
cover as large a defect as a cross nger ap and sometimes
is followed by tenderness of the donor site. It does
have the advantage, however, of involving only one
nger directly. A local neurovascular island graft can be
advanced distally and provides a good pad with normal
sensibility. Retrograde island
pedicle aps
require
tedious dissection, but offer
Atasoy
Kutler; Fisher
Local anesthesia is preferred in adults; children may require

general anesthesia. Anesthetize the nger by digital block at the
proximal phalanx, and apply a digital tourniquet.
Fig. 14-6 Dorsal pedicle ap useful for amputations proximal to the nail when preserving length is essential. It may
have two pedicles or, as illustrated here, only one. A, Flap
has been outlined. B, Flap has been elevated, leaving only
a single pedicle. C, Flap has been sutured in place over end
of stump, and remaining defect on dorsum of nger has been
covered by split-thickness skin graft.
Defect
Flap base
Fig. 14-7 Turnover
adipofascial ap. A,
Complex defect. B, Design of adipofascial
ap. Flap base is immediately proximal to the
defect, and ap width is slightly wider than
the defect. C, Development of a distally
based ap by separating it from the underlying paratenon of the extensor tendon. (Intact
paratenon ensures tendon gliding after
surgery.) D, Flap is turned over on itself to
cover the defect and the ap base. E, Flap
covered with thin skin graft. Skin closure is
not performed at base of ap to avoid tension.
(Redrawn from Al-Qattan MM: De-epithelialized cross-nger aps versus adipofascial turnover aps for the reconstruction of small complex
dousal digital defects: a comparative analysis, J
Hand Surg 30A:549, 2005.)
Flap
Incision
Turned over
flap
No skin
closure
at base
of flap
Flap base
Incision along midlateral line

Skin flap
A
Digital artery with
perivascular soft tissue
Dorsal branch of digital nerve proper
C
Fig. 14-8 Reverse digital artery island ap. A, Flap design. B and C, Digital artery is ligated
proximally. Skin ap is elevated along with artery and perivascular soft tissue. Dorsal branch
of digital nerve can be incorporated and microanastomosed with transected contralateral digital
nerve to facilitate innervation of ap. (A and B from Wilson DH, Stone C: Reverse digital artery
island ap in the elderly, Injury 35:507, 2004.)
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Part IV Amputations
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645
Fig. 14-9 Reverse adipofascial ap. A, Skin incision outlining ap

and defect. B, Postoperative result with free skin graft over defect
site. (From Chang KP, Wang WH, Lai CS, et al: Renement of reverse
digital arterial ap for nger defects: surgical technique, J Hand Surg
30:558, 2005.)
Pivot
point
Skin
flap
Ulnar palmar
digital artery
Superficial
palmar arch
Dorsal branch,
ulnar nerve
C
Fig. 14-10
A, Reverse ulnar hypothenar ap design. B, Crush injuries of ulnar digits. Degloved
skin and soft tissue were necrotized in little nger. Ulnar hypothenar fasciocutaneous ap 2 cm
4 cm was transferred to cover defect. Flap was innervated by small branch from dorsal branch
of ulnar nerve and ulnar palmar digital nerve of little nger. Longitudinal donor-site scar was
resolved by multiple skin Z-plasties. C, Appearance 20 months after surgery. (From Omokawa
S, Yajima H, Inada Y, et al: A reverse ulnar hypothenar ap for nger reconstruction, Plast
Reconstr Surg 106:828, 2 000.)
TECHNIQUE 14-1
Kutler; Fishercontd
Dbride the tip of the nger of uneven edges of soft tissue

and any protruding bone (see Fig. 14-4).
Develop two triangular aps, one on each side of the nger

with the apex of each directed proximally and centered in the
midlateral line of the digit. Avoid making the aps too large;
their sides should each measure about 6 mm, and their bases
should measure about the same or slightly less.
Bipedicle Dorsal Flaps

A bipedicle dorsal ap is useful when a nger has been
amputated proximal to its nail bed, and when preserving
all its remaining length is essential, but attaching it to
another nger is undesirable. When this ap can be made
wide enough in relation to its length, one of its pedicles
can be divided, leaving it attached only at one side (see
Fig. 14-6).
Develop the aps farther by incising deeper toward the nail

bed and volar pulp. Take care not to pinch the aps with thumb
forceps or hemostats. Rather, insert a skin hook near the base of
each, and apply slight traction in a distal direction. With a pair of
small scissors and at each apex, divide the pulp just enough
(usually not more than half its thickness) to allow the aps to be
mobilized toward the tip of the nger. Avoid dividing any pulp
distally.
Round off the sharp corners of the remaining part of the

distal phalanx, and reshape its end to conform with the normal
tuft.
Approximate the bases of the aps, and stitch them together

with small interrupted nonabsorbable sutures; stitch the dorsal
sides of the aps to the remaining nail or nail bed.
TECHNIQUE 14-3
Beginning distally at the raw margin of the skin and
proceeding proximally, elevate the skin and subcutaneous tissue
from the dorsum of the nger.
At a more proximal level, make a transverse dorsal incision to

create a bipedicle ap long enough, when drawn distally, to
cover the bone and other tissues on the end of the stump.
Suture the ap in place, and cover the defect created on the

dorsum of the nger by a split-thickness skin graft. The ap can
be made more mobile by freeing one of its pedicles, but this
decreases its vascularity.
Frequently, closure of the proximal and lateral defects is

impossible without placing signicant tension on the aps. In
such instances, the sides of the triangular aps should be left
without sutures and heal satisfactorily by secondary intention.
Apply Xeroform gauze and a protective dressing.
Adipofascial Turnover Flap

The adipofascial turnover ap is a deepithelialized ap that
may be used to cover distal dorsal defects 3 cm in
length.
TECHNIQUE 14-4 (see Fig. 14-7)
Under tourniquet control, repair the traumatic defects as
TECHNIQUE 14-2
Atasoy et al.
Under tourniquet control and using an appropriate anesthetic,

cut a distally based triangle through the pulp skin only, with the
base of the triangle equal in width to the cut edge of the nail
(see Fig. 14-5).
Develop a full-thickness ap with nerves and blood supply

preserved. Carefully separate the brofatty subcutaneous tissue
from the periosteum and exor tendon sheath using sharp
dissection.
Selectively cut the vertical septa that hold the ap in place,

and advance the ap distally.
Suture the skin ap to the sterile matrix or nail. The volar

defect from the advancement can be left open and left to heal
by secondary intention if closure compromises vascularity. A few
millimeters of the phalanx can be removed to the level of the
sterile matrix. The base of the ap may be difcult to suture to
the sterile matrix or nail, and a 22-gauge needle can be used as
an intramedullary pin in the distal phalanx to keep the ap in
position.
indicated, such as extensor tendon repair and fracture xation.
Outline the planned ap with a skin pen. Make the width 2 to

4 mm wider than the traumatic defect. The base-to-length ratio
should be 1 : 1.5 to 1 : 3. The ap base should be 0.5 to 1 cm
in length and is made just proximal to the defect. The ap
length should be at least this much longer than the defect.
Develop the adipofascial ap supercial to the extensor

tendon paratenon from proximal to distal.
After the ap is detached proximally and along its sides to the

ap base, ip it over and suture it distally.
Do not place sutures at the turnover site to avoid tension on

the vascular pedicle.
Use a split-thickness graft to cover the defect at the ap site.

Immobilize the digit in a protective splint.
The rst dressing change is 3 weeks

after surgery, and digital motion is begun as wound healing
and other concomitant injuries allow.
AFTERTREATMENT
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Part IV Amputations
Cross Finger Flaps

The technique of applying cross nger aps is described in
Chapter 62.
647
647
large enough to cover the defect and is properly positioned;

pressing the bloody stump of the injured nger against the
thenar skin outlines by bloodstain the size of the defect to be
covered.
With its base proximal, raise the thenar ap to include most of
Thenar Flap
Middle and ring nger coverage can be accomplished by
the use of the thenar ap. Donor site tenderness and proximal interphalangeal joint exion contractures can occur,
and the aps should not be left in place for more than 3
weeks.
TECHNIQUE 14-5
With the thumb held in abduction, ex the injured nger so
that its tip touches the middle of the thenar eminence (Fig. 1411). Outline on the thenar eminence a ap that when raised is
the underlying fat; handle the ap with skin hooks to avoid

crushing it even with small forceps. Make the ap sufciently
wide that when sutured to the convex ngertip it is not under
tension. Make its length no more than twice its width. By gentle
undermining of the skin border at the donor site, the defect can
be closed directly without resorting to a graft.
Attach the distal end of the ap to the trimmed edge of the

nail by sutures passed through the nail. The lateral edges of the
ap should t the margins of the defect, but to avoid impairing
circulation in the ap, suture only their most distal parts, if any,
to the nger. Prevent the ap from folding back on itself and
strangulating its vessels.
Fig. 14-11
Thenar ap for
amputation of ngertip. A,
Tip of ring nger has been
amputated. B, Finger has
been exed so that its tip
touches middle of thenar
eminence, and thenar ap
has been outlined. C, Splitthickness graft is to be
sutured to donor area before
ap is attached to nger. D,
Split-thickness
graft is in
place. E and F, End of ap
has been attached to nger
by sutures passed through
nail and through tissue on
each side of it.
TECHNIQUE 14-5contd
Control all bleeding, check the positions of the ap and nger,
and apply wet cotton gently compressed to follow the contours
of the graft and the ngertip.
Hold the nger in the proper position by gauze and adhesive
Place over the grafts wet cotton carefully shaped to t the

contour of the area to prevent pressure on the neurovascular
bundles.
Apply a compression dressing until suture removal at 10 to 14

days.
tape, and splint the wrist.
Begin digital motion therapy as soon

as the wounds permit.
AFTERTREATMENT
At 4 days, the graft is dressed again

and then kept as dry as possible by dressing it every 1 or
2 days and by leaving it partially exposed. At 2 weeks, the
base of the ap is detached, and the free skin edges are
sutured in place. The contours of the ngertip and the
thenar eminence improve with time.
AFTERTREATMENT
Island Pedicle Flap

The axial-pattern island pedicle ap may be used to
provide sensation or merely composite soft tissue to
adjacent ngers or thumb. The skin paddle size can
vary to suit the defect.
Local Neurovascular Island Flap

A limited area of the touch pad can be resurfaced by a local
neurovascular island graft. This graft provides satisfactory
padding and normal sensibility to the most important
working surface of the digit.
TECHNIQUE 14-7
This procedure is performed as an outpatient, and general
anesthesia is preferred.
Inate the arm tourniquet after using a skin pen to outline

clearly the intended procedure.
TECHNIQUE 14-6
Measure the defect size after appropriate dbridement and

draw a slightly larger ap onto the donor digit.
Make a midlateral incision on each side of the nger (or
Use a midaxial or a volar zigzag incision to expose the
thumb) beginning distally at the defect and extending

proximally to the level of the proximal interphalangeal joint or
thumb interphalangeal joint.
neurovascular bundle of the area of the supercial arch, the

usual pivot point of the ap.
On each side and beginning proximally, carefully dissect the
a given area, it is imperative that the ulnar border of the small

nger and radial border of the index nger not be used as
donors because maintaining or achieving sensation in these areas
is desirable. The skin paddle is ideally centered over the
neurovascular bundle.
neurovascular bundle distally to the level selected for the

proximal margin of the graft (Fig. 14-12A). Here make a
transverse volar incision through the skin and subcutaneous
tissues, but carefully protect the neurovascular bundles (Fig.
14-12B).
If necessary, make another transverse incision at the margin of

the defect, freeing a rectangular island of the skin and
underlying fat to which are attached the two neurovascular
bundles.
Carefully draw this island or graft distally, and place it over the
defect (Fig. 14-12C). Avoid placing too much tension on the
bundles; should tension compromise the circulation in the graft,
dissect the bundles more proximally, or ex the distal
interphalangeal joint, or both.
If a neurovascular island ap is desired to provide sensation to
Under tourniquet control, locate the neurovascular bundle

proximally, and carefully dissect this to its supercial arch origin.
Leave a cuff of soft tissue around the neurovascular bundle
because discrete veins are not readily visible, but exist in the
periarterial tissues. Dissect the bundle deeply and use bipolar
cautery well away from the proper digital artery to control
perforating vessels entering the exor sheath.
Elevate the skin paddle, taking care to ensure the vascular

bundle is reasonably centered under the ap, and divide the
artery distally.
Suture the graft in place with interrupted small nonabsorbable
Use simple 5-0 nylon suture to secure the distal vascular
sutures.
bundle to the distal edge of the skin ap.
Cover the defect created on the volar surface of the nger
Place the paddle over the recipient site to determine the best
with a free full-thickness graft.
path for the pedicle because the pedicle should not be under
649
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Part IV Amputations
649
649
C
Fig. 14-12
A-C, Local neurovascular island graft (see text).
any tension. The skin between the pivot point can be

undermined and enlarged by gently yet liberally spreading a
hemostat in the intended pedicle path. The tunnel must allow
easy passage of the ap. Frequently, a 2- to 3-cm skin bridge
can be left between the proximal donor and recipient incisions. If
any doubt remains in regard to the pedicle tension or
impingement, however, these incisions should be connected.
Deate the tourniquet, and control bleeding.

Draw the 5-0 nylon suture gently through the skin bridge,
taking care not to place shear stress between the pedicle and
ap.
Suture the ap loosely into position, and close the remaining

wounds. Ensure the ap remains well vascularized before placing
a loose dressing and protective splint.
Note: When this procedure is performed as a vascular island

pedicle ap, the proper digital nerve should be carefully
preserved and protected to prevent problematic neuromas.
Transient dysesthesias that commonly occur with this technique
usually resolve in 6 to 8 weeks.
The patient is seen in 5 to 7 days,

and motion therapy is begun as soon as the wounds permit,
usually 2 to 3 weeks postoperatively.
AFTERTREATMENT
Retrograde Island Pedicle Flap

This retrograde homodigital island ap is well suited to
cover dorsal and volar defects distally. The procedure relies
on retrograde ow through the proper digital artery, supplying the proximal composite tissue (see Fig. 14-8).
TECHNIQUE 14-8
After preparing the recipient site appropriately, determine the
donor defect size.
TECHNIQUE 14-9
(see Fig. 14-10)
Outline the ap on the distal half of the hypothenar eminence

to correspond to the recipient defect.
Under tourniquet control and general anesthesia, dissect in the

subfascial plane, beginning on the dorsal side of the hand.
Include the multiple vascular perforators with the ap before
dividing the ulnar palmar digital artery proximally.
Take the distal dissection of the pedicle to the pivot point of

the proximal interphalangeal joint.
Close the wounds loosely after bleeding is controlled, and

apply a bulky soft dressing.
Expose the vascular pedicle using a linear or zigzag incision

over the digit, the length of which is 1 to 1.5 cm larger than the
distance between the proximal defect edge and distal donor
edge.
Dissect from proximal to distal under tourniquet control.
The bulky soft dressing is removed

within 1 week after surgery, and metacarpophalangeal and
proximal interphalangeal joint motion therapy is begun.
AFTERTREATMENT
Separate the proper digital artery proximal to the donor ap

from the underlying digital nerve. Ligate and divide the artery,
and raise the ap carefully with its pedicle. Leave a 1-cm section
of undamaged vascular bundle undisturbed distally to nourish
the ap and act as the pivot point for the ap.
AMPUTATIONS OF SINGLE FINGERS
Deate the tourniquet, and control bleeding with bipolar
Index Finger
cautery.
When the index nger is amputated at its proximal interphalangeal joint or at a more proximal level, the remaining
stump is useless and can hinder pinch between the thumb
and middle nger. In most instances, when a primary
amputation must be at such a proximal level, any secondary
amputation should be through the base of the second metacarpal. This index ray amputation is especially desirable in
women for cosmetic reasons. Because it is a more extensive
operation than amputation through the nger, however, it
can cause stiffness of the other ngers and may be contraindicated in arthritic hands and in men past middle age.
Unless the surgeons knowledge of anatomy and technique
is precise, the branch of the median nerve to the second
web can be accidentally damaged. Improper technique can
result in a sunken scar on the dorsum of the hand or in
anchoring the rst dorsal interosseous to the extensor
mechanism, rather than to the base of the proximal phalanx,
causing intrinsic overpull.
Suture without tension on the recipient site, and close the

remaining wound loosely so as not to compromise the pedicle.
Donor defects typically require a split-thickness skin graft and

a soft nonadherent conforming dressing, such as Xeroform gauze
and glycerin-soaked cotton balls.
Note: This ap can be used as a deepithelialized retrograde

homodigital island to lessen the morbidity associated with the
skin paddle. In such a modication, the skin graft is applied over
the composite graft at the recipient site.
The dressing is removed 7 to 10 days

postoperatively, and motion therapy is begun depending on
wound healing.
AFTERTREATMENT
Ulnar Hypothenar Flap

The ulnar hypothenar ap is a retrograde vascular pedicle
ap that relies on the distal half of the hypothenar skins
vascular supply from the ulnar digital artery. The ap
can be used to cover defects as large as 5 cm 2 cm.
Based on the proper digital artery to the small nger, this
ap may provide sensation by suturing the ulnar digital
nerve to a cutaneous nerve sensory branch that is harvested
with the ap.
Index Ray Amputation

TECHNIQUE 14-10
With a marking pen, outline the planned incisions (Fig.
14-13A). Begin the palmar line in the second web space at the
radial base of the middle nger, and continue this line
proximally to the midpalmar area, being careful not to cross the
palmar exion creases at 90 degrees. Begin a second palmar line
approximately 1 cm distal to the proximal exion crease at the
651
Part IV Amputations
651
Fig. 14-13 Technique for index ray amputation. A, Dorsal skin incisions planned with marking
pen. Palmar skin incision can be outlined in matching zigzag fashion to reduce skin suture
line contracture. B, Flexor digitorum supercialis and exor digitorum profundus tendons
severed proximal to lumbrical origin after isolation and division of appropriate neurovascular
structures. C, First dorsal interosseous retained for insertion into radial base of middle nger
proximal phalanx. D, Appearance after index ray amputation.
radial base of the index nger, and extend this line proximally to
meet the rst incision in the midpalmar area. Zigzag incisions in
the palmar skin may lessen the incidence of longitudinal skin scar
contractures.
Outline the dorsal part of the incision that extends from the
palmar lines to converge at a point on the index carpometacarpal
joint dorsally.
Now make the incisions as just outlined.

Ligate and divide the dorsal veins, and at a more proximal
level divide the branches of the supercial radial nerve to the
index nger.
Retract the index extensor digitorum communis and the

extensor indicis proprius tendons distally, sever them, and allow
them to retract proximally.
Detach the tendinous insertion of the rst dorsal interosseous,

and dissect the muscle proximally from the second metacarpal
shaft (Fig. 14-13B). Detach the volar interosseous from the same
shaft, and divide the transverse metacarpal ligament that
connects the second and third metacarpal heads; take care not
to damage the radial digital nerve of the middle nger.
Carefully divide the second metacarpal obliquely from

dorsoradial proximally to volar-ulnar distally about 2 cm distal to
its base. Do not disarticulate the bone at its proximal end.
Smooth any rough edges on the remaining part of the
metacarpal.
Divide both exor tendons of the index nger, and allow them
to retract (Fig. 14-13C).
Ligate and divide digital arteries to the index nger.
Index Ray Amputation

TECHNIQUE 14-10contd
Carefully identify and divide both digital nerves leaving
sufcient length so that their ends can be buried in the
interossei.
Anchor the tendinous insertion of the rst dorsal interosseous

to the base of the proximal phalanx of the middle nger; do not
anchor it to the extensor tendon or its hood because this might
cause intrinsic overpull.
With a running suture, approximate the muscle bellies in the

area previously occupied by the second metacarpal shaft.
Ligate or cauterize all obvious bleeders.

Approximate the skin edges over a drain, and remove the
tourniquet (Fig. 14-13D).
Apply a well-molded wet dressing that conforms to the wide

new web between the middle nger and the thumb and support
the wrist by a large bulky dressing or a plaster splint.
achieve proper rotation and solid bone xation. Union of

midshaft metacarpal osteotomies is more difcult, and we
recommend metaphyseal xation in such instances.
Excising the third metacarpal shaft removes the origin
of the adductor pollicis and weakens pinch. The index
ray should not be transposed, unless this adductor can
be reattached elsewhere. The operation is contraindicated
if the hand is needed for heavy manual labor (Fig.
14-14).
Similarly, when the ring nger has been amputated,
transposing the fth ray radialward to replace the fourth
rarely is indicated. Resection of the fourth metacarpal at
its base or at the carpometacarpal joint and closure of the
skin to create a common web permit a folding-in of the
fth digit to close the gap without transposing the fth
metacarpal. Disarticulation of the ring nger at the carpometacarpal joint allows the small nger metacarpal base to
shift radially over the hamate facet, essentially eliminating
radial deviation of the ray (Fig. 14-15).
Transposing the Index Ray

TECHNIQUE 14-11
Peacock
The hand is elevated immediately

after surgery for 48 hours. At 24 hours, the drain is
removed. Digital motion therapy is initiated at 5 to 7 days
postoperatively.
Plan the incision so that a wedge of skin is removed from the
Middle or Ring Finger Ray Amputations
Curve the proximal end of the dorsal incision slightly toward
In contrast to the proximal phalanx of the index nger,

the proximal phalanx of either the middle or the ring
nger is important functionally. Its absence in either nger
makes a hole through which small objects can pass when
the hand is used as a cup or in a scooping maneuver; its
absence makes the remaining ngers tend to deviate toward
the midline of the hand. In multiple amputations, the
length of either the middle or the ring nger becomes even
more important. The third and fourth metacarpal heads are
important too because they help stabilize the metacarpal
arch by providing attachments for the transverse
metacarpal ligament.
In a child or woman, when the middle nger has been
amputated proximal to the proximal interphalangeal joint,
and especially when it has been amputated proximal to the
metacarpal head, transposing the index ray ulnarward to
replace the third ray may be indicated. This operation
results in more natural symmetry, removes any conspicuous
stump, and makes the presence of only three ngers less
obvious. Transposition of the index metacarpal after partial
middle nger metacarpal amputation is technically challenging and has signicant complications. If this more cosmetic procedure is chosen, great care should be taken to
the second metacarpal base so that the base can be exposed

easily.
AFTERTREATMENT
dorsal and volar surfaces of the hand (Fig. 14-16).
Plot in the region of the transverse metacarpal arch the exact

points that must be brought together to form a smooth arch
across the dorsum of the hand when the second and fourth
metacarpal heads are approximated.
Fashion the distal end of the incision so that a small triangle of

skin is excised from the ring nger to receive a similar triangle of
skin from the stump or the area between the ngers;
transferring this triangle is important to prevent the suture line
from passing through the depths of the reconstructed web.
After the dorsal and volar wedges of skin have been removed
and the aps have been elevated, expose the third metacarpal
through a longitudinal incision in its periosteum.
The index ray is the right length when its metacarpal is moved
directly to the third metacarpal base. With an oscillating saw,
divide transversely the third metacarpal as close to its base as
possible. Excise the third metacarpal shaft and the interosseous
muscles to the middle nger. Take care not to damage the
interosseous muscles of the remaining ngers.
Identify the neurovascular bundles of the middle nger;

individually ligate the arteries and veins, and divide the digital
nerves.
While the wrist is held exed, draw the exor tendons distally
as far as possible, and divide them.
Fig. 14-14
Middle nger ray resection. A and B, Clinical appearance of unsalvageable contracted and stiff middle nger after gunshot wound to hand. C and D, Planned palmar and
dorsal incisions for ray resection. E and F, Cosmetic appearance after partial middle nger
metacarpal amputation.
Retract the extensor tendons of the index nger, expose the

second metacarpal at its base, and divide the bone at the same
level as the third metacarpal.
undue tension on the muscles. Bevel obliquely the second

metacarpal base to produce a smooth contour on the side of
the hand.
From the radial side of the second metacarpal, gently dissect
From the excised third metacarpal fashion a key graft to
the intrinsic muscles just enough to allow this metacarpal to be

placed on the base of the third metacarpal without placing
extend from one fragment of the reconstructed metacarpal to

the other.
653
Fig. 14-15
Ring nger ray amputation. A and B, Palmar and dorsal view
of patients hand after ring avulsion injury. C, En bloc disarticulation of
ring nger carpometacarpal joint with proximal division of exor and
extensor tendons. D, Intermetacarpal ligaments of small and middle
ngers are sutured in overlapped position to prevent splaying of small
nger. E, Radiograph of hand indicating radialization of the small
nger metacarpal base on hamate facet. F and G, Clinical appearance
after ring nger ray resection.
655
Part IV Amputations
Fig. 14-16 Peacock technique of transposing index ray.

Dorsal incision is shown; arrows indicate points along skin
edges that will be brought together. Similar palmar incision
is made (see text).
Transposing the Index Ray

TECHNIQUE 14-11
Peacockcontd
Insert a Kirschner wire longitudinally through the

metacarpophalangeal joint of the transposed ray, and bring
it out on the dorsum of the exed wrist; draw it proximally
through the metacarpal until its distal end is just proximal to the
metacarpophalangeal joint.
With the wrist exed, cut off the proximal part of the wire,
and allow the remaining end to disappear beneath the skin.
Flex all the ngers simultaneously to ensure correct rotation of

the transposed ray, and insert a Kirschner wire transversely
through the necks of the fourth and the transposed metacarpals.
Bony xation with a small plate and screws also can be used.
This requires precise technique and should be applied only after
correct rotational alignment has been determined. Attaching the
plate to the distal fragment rst and exing the metacarpophalangeal joints fully before proximal plate xation is secured
reduces the chance for malrotation.
Close the skin and insert a rubber drain.

Apply a soft pressure dressing; no additional external support
is needed.
At 2 days, the rubber drain is

removed, and at 8 to 10 days, the entire dressing and the
sutures are removed. A light volar plaster splint is
applied to keep the wrist in the neutral position and
support the
AFTERTREATMENT
655
655
656
Part IV Amputations
transposed ray; however, the splint is removed daily for

cleaning the hand and exercising the small joints. At about
5 weeks, when the metacarpal fragments have united,
the
Kirschner
wires
are removed using
local
anesthesia.
Ring Finger Avulsion Injuries
The soft tissue of the ring nger usually is forcefully
avulsed at its base when a metal ring worn on that nger
catches on a nail or hook. The force usually is sufcient to
cause separation of the skin and nearly always damages the
vascular supply to the distal tissue. Fractures and ligamentous damage also can occur, but the tendons seem to be
the last to separate. Attempts at salvage routinely fail unless
the vascular supply can be reestablished. Even with successful microvascular repair, stiffness and abnormal sensation
are unavoidable. Amputation of the fourth ray with closure
of the web is the procedure of choice in a child or woman.
Simple metacarpal amputation rather than resection may be
indicated in a heavy laborer. A report comparing metacarpal amputation with ray resection suggested that, despite
the poor cosmesis and palmar incompetence, metacarpal
amputation preserved greater strength. By resecting the
fourth ray at its base or at the carpometacarpal joint, the
fth ray closes without having to be surgically transposed.
Simple amputation of the nger itself should be done in
656
656
the face of necrosis and infection, and, if indicated, the ray

amputation is done later as an elective procedure.
Little Finger Amputations

As much of the little nger as possible should be saved,
provided that all the requirements for a painless stump
are satised. Often this nger survives when all others
have been destroyed, and it becomes important in forming
pinch with the thumb. When the little nger alone is
amputated, and when the appearance of the hand is important or the amputation is at the metacarpophalangeal joint,
the fth metacarpal shaft is divided obliquely at its middle
third; the insertion of the abductor digiti quinti is transferred to the proximal phalanx of the ring nger just as
the rst dorsal interosseous is transferred to the middle
nger in the index ray amputation already described. This
smoothes the ulnar border of the hand and is used most
often as an elective procedure for a contracted or painful
little nger.
AMPUTATIONS OF THE THUMB

In partial amputation of the thumb, in contrast to one of
a single nger, reamputation at a more proximal level to
obtain closure should not be considered because the thumb
rarely should be shortened. The wound should be closed
primarily by a free graft, an advancement pedicle ap
(described later), or a local or distant ap.
657
Part IV Amputations
If a ap is necessary, taking it from the dorsum of the

hand or the index or middle nger is preferable. A ap
from one of these areas provides a touch pad that is
stable but that does not regain normal sensibility.
Covering the volar surface of the thumb with an
abdominal ap is contraindicated; even when thin, abdominal skin and fat provide a poor surface for pinch because
they lack brous septa and roll or shift under pressure. Skin
of the abdomen is dissimilar in appearance to that of the
hand and its digits. When the skin and pulp, including all
neural elements, have been lost from a signicant area
of the thumb, a neurovascular island graft (see Chapter
65) may be indicated. The defect should be closed
primarily by a split-thickness graft; the neurovascular
island graft or, if feasible, a local neurovascular island graft
or advancement ap as described for ngertip amputations
(see Technique
14-1) is applied secondarily.
If the thumb has been amputated so that a useful segment
of the proximal phalanx remains, the only surgery necessary, if any, except for primary closure of the wound is
deepening the thumb web by Z-plasty (see Chapter 61).
When amputation has been at the metacarpophalangeal
joint or at a more proximal level, reconstruction of the
thumb may be indicated (see Technique 14-15).
Advancement Pedicle Flap for Thumb

Injuries
Advancement aps for ngertip injuries usually survive
if the volar ap incisions are not brought proximal to
the proximal interphalangeal joint. In the thumb, the
venous drainage is not as dependent on the volar ap,
however, and this technique is safer, and the ap can be
longer (Fig.
14-17).
TECHNIQUE 14-12
Using tourniquet control and appropriate anesthesia, make a
midlateral incision on each side of the thumb from the tip to the
metacarpophalangeal joint (Fig. 14-18A).
Elevate the ap that contains both neurovascular

bundles without disturbing the exor tendon sheath
(Fig.
14-18B).
Flex the joints to allow the ap to be advanced and

carefully sutured over the defect with interrupted sutures (Fig.
14-18C).
657
657
The joints should be maintained in

exion postoperatively for 3 weeks. This large ap is
used only when a large area of thumb pulp is lost.
AFTERTREATMENT
658
Part IV Amputations
1 2 3
4
5
6
Fig. 14-17
Thumb tip amputation levels. Acceptable procedures by level are: 1, split-thickness graft; 2, cross nger ap
or advancement ap; 3, advancement ap, cross nger ap,
or shorten thumb and close; 4, split-thickness skin graft; 5,
shorten bone and split-thickness skin graft, advancement
ap, or cross nger ap; 6, advancement ap or cross nger
ap; 7, advancement ap and removal of nail bed remnant.
AMPUTATIONS OF MULTIPLE DIGITS
658
658
In partial amputations of all ngers, preserving the remaining length of the digits is much more important than in a
single nger amputation. Because of the natural hinge
action between the rst and fth metacarpals, any remaining stump of the little nger must play an important role
in prehension with the intact thumb; this hinge action can
be increased about 50 % by dividing the transverse
metacarpal ligament between the fourth and fth rays. In
partial amputation of all ngers and the thumb, function
can be improved by lengthening the digits relatively and
by increasing their mobility. Function of the thumb can
be improved by deepening its web by Z-plasty (see
Chapter
61) and by osteotomizing the rst and fth metacarpals and
rotating their distal fragments toward each other (Fig. 1419), while, if helpful, tilting the fth metacarpal toward
the thumb. If the rst carpometacarpal joint is functional,
but the rst metacarpal is quite short, the second metacarpal can be transposed to the rst to lengthen it and to
widen and deepen the rst web.
In complete amputation of all ngers, if the intact thumb
cannot easily reach the fth
metacarpal head,
phalangization of the fth metacarpal is helpful. In
this operation, the fourth metacarpal is resected, and the
fth is osteoto- mized, rotated, and separated from the rest
of the palm. Lengthening of the fth metacarpal also is
helpful. In complete amputation of all ngers and the
thumb in which
657
657
Part IV Amputations
657
657
Fig. 14-18 Advancement pedicle ap for thumb injuries. A, Deep thumb pad defects exposing
bone can be covered with advancement pedicle ap. B, Advancement of neurovascular pedicle.
C, Flexion of distal joint of thumb is necessary to permit placement of ap (see text).
the amputation has been transversely through the metacarpal necks, phalangization of selected metacarpals can
improve function. The fourth metacarpal is resected to
increase the range of motion of the fth, and function
of the fth metacarpal is improved further by osteotomy
of
the metacarpal in which the distal fragment is rotated

radialward and exed. The second metacarpal is resected
at its base, but to preserve the origin of the adductor pollicis, the third metacarpal is not. The thumb should not be
lengthened by osteoplastic reconstruction, unless sensibility
can be added to its volar surface. When the amputation has
been through the middle of the metacarpal shafts, prehension probably cannot be restored, but hook can be accomplished by exing the stump at the wrist. This motion
at the wrist can be made even more useful by tting an
arti- cial platform to which the palmar surface of the
stump can be actively opposed.
Phalangization of Fifth Metacarpal

TECHNIQUE 14-13
Over the fourth metacarpal, make dorsal and volar longitudinal
incisions that join distally.
Expose and resect the transverse metacarpal ligament on each

side of the fourth metacarpal head.
Divide proximally the digital nerves to the ring nger, and

ligate and divide the corresponding vessels.
Resect the fourth metacarpal shaft just distal to its carpometacarpal joint. Through the same incision, osteotomize the
fth metacarpal near its base.
Fig. 14-19 In multiple amputations including thumb, function can be improved by osteotomizing rst and fth metacarpals and rotating their distal fragments toward each other
(see text).
it toward
Slightly the
abduct
and Fix
exthe
thefragments
distal fragment,
rotate
thumb.
with a and
Kirschner
wire.
Phalangization of Fifth Metacarpal

TECHNIQUE 14-13contd
Cover the raw surfaces between the third and fth
metacarpals with split-thickness grafts, creating a web at the
junction of the proximal and middle thirds of the bones. Ensure
that the padding over the fth metacarpal head is good and, if
possible, that sensation is normal at its point of maximal contact
with the thumb.
PAINFUL AMPUTATION STUMP

Revision surgery is a frequent elective procedure for the
management of painful amputation stumps, especially those
resulting from traumatic injuries. A neuroma located in an
unpadded area near the end of the stump is the usual cause
of pain. A well-localized area of extreme tenderness associated with a small mass, usually in line with a digital nerve,
is diagnostic. Some painful neuromas can be treated by
padding and desensitization, although surgical excision frequently is required. The neuroma is dissected free from
scar, and the nerve is divided at a more proximal level.
Another neuroma will develop, but should be painless
when located in a padded area. Suturing the radial and
ulnar digital nerves end-to-end (compared with proximal
resection as mentioned previously) has not been shown to
reduce resting pain, cold intolerance, or perceived tenderness. Reduction in tenderness is achieved by this end-toend nerve union, however, at the expense of touch
sensibility.
Pain in an amputation stump also can be caused by bony
prominences covered only by thin skin, such as a splitthickness graft, or by skin made tight by scarring. In these
instances, excising the thin skin or scar, shortening the
bone, and applying a sufciently padded graft may be indicated. Amputation stumps that are painful because of thin
skin coverage at the pulp and nail junction can be improved
by using a limited advancement ap as described in the
section on thumb amputations. In the nger, proximal dissection to develop these aps should not extend
proximal to the proximal interphalangeal joint.
Finally, painful cramping sensations in the hand and
forearm can be caused by exion contracture of a stump
resulting from overstretching of extensor tendons or adherence of exor tendons; release of any adherent tendons is
helpful.
RECONSTRUCTIONS AFTER
AMPUTATION
Reconstruction after Amputation
of the Hand
Amputation of both hands is extremely disabling. In
selected patients, the Krukenberg operation is helpful. It
converts the forearm to forceps in which the radial ray acts

against the ulnar ray. Swanson compared function of the
reconstructed limb with the use of chopsticks. Normal
sensibility between the tips of the rays is ensured by proper
shifting of skin during closure of the wound. The operation is especially helpful in blind patients with bilateral
amputation because it provides not only prehension, but
also sensibility at the terminal parts of the limb. It also is
helpful in other patients with similar amputations, especially in surroundings where modern prosthetic services are
unavailable. According to Swanson, children with bilateral
congenital amputation nd the reconstructed limb much
more useful than a mechanical prosthesis; they transfer
dominance to this limb when a prosthesis is used on the
opposite. In children, the appearance of the limb after
surgery has not been distressing, and the operation does
not prevent the wearing of an ordinary prosthesis if
desired.
TECHNIQUE 14-14
Krukenberg; Swanson
Make a longitudinal incision on the exor surface of the

forearm slightly toward the radial side (Fig. 14-20A). Make a
similar incision on the dorsal surface slightly toward the ulnar
side, but on this surface elevate a V-shaped ap to form a web
at the junction of the rays (Fig. 14-20B).
Separate the forearm muscles into two groups (Fig. 14-20C

and D): The radial side comprises the radial wrist exors and
extensors, the radial half of the exor digitorum sublimis,
the radial half of the extensor digitorum communis, the
brachioradialis, the palmaris longus, and the pronator teres; the
ulnar side comprises the ulnar wrist exors and extensors, the
ulnar half of the exor digitorum sublimis, and the ulnar half of
the extensor digitorum communis. If they make the stump too
bulky or the wound hard to close, resect as necessary the
pronator quadratus, the exor digitorum profundus, the exor
pollicis longus, the abductor pollicis longus, and the extensor
pollicis brevis. Take care not to disturb the pronator teres.
Incise the interosseous membrane throughout its length along

its ulnar attachment, taking care not to damage the interosseous
vessel and nerve.
The radial and ulnar rays can be separated 6 to 12 cm at

their tips depending on the size of the forearm; motion at
their proximal ends occurs at the radiohumeral and proximal
radioulnar joints. The opposing ends of the rays should touch;
if not, osteotomize the radius or ulna as necessary. Now the
adductors of the radial ray are the pronator teres, the supinator,
the exor carpi radialis, the radial half of the exor digitorum
sublimis, and the palmaris longus; the abductors of the radial ray
are the brachioradialis, the extensor carpi radialis longus, the
extensor carpi radialis brevis, the radial half of the extensor
digitorum communis, and the biceps. The adductors of the ulnar
ray are the exor carpi ulnaris, the ulnar half of the exor
digitorum sublimis, the brachialis, and the anconeus; the
659
Part IV Amputations
659
659
Triceps m.
Biceps m.
Brachialis m.
Supinator m.
Pronator teres m.
Brachioradialis m.
Palmaris longus m.
Flexor carpi
ulnaris m.
Flexor carpi
radialis m.
Ulnar
Ulnar
Radial
1/2 Flexor
digitorum
sublimis m.
1/2 Flexor
digitorum
sublimis m.
Radial
Ulnar
Radial
Volar
Dorsal
Triceps m.
Brachioradialis m.
Anconeus m.
Extensor carpi
radialis longus m.
Volar
Extensor carpi
ulnaris m.
Extensor carpi
radialis brevis m.
Extensor digiti
quinti proprius m.
1/2 Extensor
digitorum
communis m.
1/2 Extensor
digitorum
communis m.
Radial
Ulnar
Ulnar
Radial
Ulnar
Radial
Dorsal
Volar
Dorsal
Krukenberg operation. A, Incision on exor surface of forearm. B, Incision on

dorsal surface (see text). C and D, Forearm muscles have been separated into two groups (see
text). E, Closure of skin on exor surface of forearm; the area yet to be closed indicates location of any needed split-thickness skin graft. F, Closure of skin on dorsal surface (see text).
(Modied from Swanson AB: The Krukenberg procedure in the juvenile amputee, J Bone Joint
Surg
46A:1540, 1964.)
Fig. 14-20
abductors of the ulnar ray are the extensor carpi ulnaris,

the ulnar half of the extensor digitorum communis, and the
triceps.
Excise any excess fat, rotate the skin around each ray, and
Remove the tourniquet, obtain hemostasis, and observe the
Excise any scarred skin at the ends of the rays, and if
circulation in the aps.
close the skin over each so that the suture line is not on the
opposing surface of either (Fig. 14-20E and F).
necessary to permit closure, shorten the bones; in children, the
TECHNIQUE 14-14
Krukenberg; Swanson
contd
skin usually is sufcient for closure, and the bones must not be
shortened because growth at the distal epiphyses would still be
incomplete.
Preserve any remaining rudimentary digit. Next, suture the ap

in place at the junction of the rays, and apply any needed splitthickness graft.
Insert small rubber drains, and, with the tips of the rays
separated 6 cm or more, apply a compression dressing.
The limb is constantly elevated for 3

to 4 days. The sutures are removed at the usual time. After
2 to 3 weeks, rehabilitation is begun to develop abduction
and adduction of the rays.
AFTERTREATMENT
Reconstruction after Amputation

of Multiple Digits
Several reconstructive operations are useful after
amputation of multiple digits at various levels. After
soft-tissue stabilization is achieved, digital lengthening by
callotasis is an option. Thumb pollicization may be
required when transposition of remaining digits permits.
Restoration of opposition by sensate opposable digits
often necessitates a protracted reconstructive course that
challenges the cre- ativity of the surgeon and patience of
the patient.
Reconstruction of the Thumb

Traumatic or congenital absence of the thumb causes a
severe deciency in hand function; such an absence usually
is considered to constitute a 40 % disability of the hand
as a whole. When the thumb is partially or totally
absent, reconstructive surgery is appealing. Before any
decision for surgery is made, however, several factors
must be considered, including the length of any
remaining part of the thumb, the condition of the rest of
the hand, the occupa- tional requirements and age of the
patient, and the knowledge and experience of the
surgeon. If the opposite thumb is normal, some surgeons
question the need for recon- structing even a totally absent
thumb; at least reconstruction here is not mandatory.
Function of the hand can be improved, however, by a
carefully planned and skillfully executed operation,
especially in a young patient.
Usually the thumb should be reconstructed only when
amputation has been at the metacarpophalangeal joint or
at a more proximal level. When this joint and a useful
segment of the proximal phalanx remain, the only surgery
necessary, if any, is deepening of the thumb web by Zplasty (see Chapter 61). When amputation has been through
the interphalangeal joint, the distal phalanx, or the pulp of
the thumb, only appropriate coverage by skin is necessary,

unless sensibility in the area of pinch is grossly
impaired; in this latter instance, a more elaborate
coverage, such as by a neurovascular island transfer, may
be indicated (see Chapter 65).
A reconstructed thumb must meet ve requirements.
First and most important, sensibility, although not necessarily normal, should be painless and sufcient for recognition of objects held in the position of pinch. Second, the
thumb should have sufcient stability so that pinch pressure
does not cause the thumb joints to deviate or collapse or
cause the skin pad to shift. Third, there should be sufcient
mobility to enable the hand to atten and the thumb to
oppose for pinch. Fourth, the thumb should be of sufcient
length to enable the opposing digital tips to touch it.
Sometimes amputation or stiffness of the remaining digits
may require greater than normal length of the thumb to
accomplish prehension. Fifth, the thumb should be cosmetically acceptable because if it is not it may remain
hidden and not be used.
Several reconstructive procedures are possible, and the
choice depends on the length of the stump remaining and
the sensibility of the remaining thumb pad (Figs. 14-21 and
14-22). The thumb can be lengthened by a short bone graft
or distraction osteoplasty. Sensibility can be restored by
skin rotation aps, with the nonopposing surface skin
grafted as in the Gillies-Millard cocked hat procedure.
Another possibility is pollicizing a digit. A promising possibility is microvascular free transfer of a toe to the hand.
In this procedure, sensory restoration is never normal. The
osteoplastic technique with a bone graft and tube pedicle
skin graft supplemented by a neurovascular pedicle is now
rarely recommended.
For congenital absence of the thumb, pollicization of the
index nger is the most used technique. Congenital absence
of the thumb frequently is associated with other congenital
Provide padding
and sensibility
No reconstruction needed for length
Provide padded painless tip
a. Deepen web
b. Add bone length when coverage
with local sensitive skin possible
a. Pollicization
or
b. Toe transfer when indicated
Pollicization when indicated
Fig. 14-21
Thumb reconstruction at various levels. Basic
needs are sensibility, stability, mobility, and length.
661
661
Part IV Amputations
661
661
Fig. 14-22
Moberg advancement ap. A, Thumb pulp defect with ap outlined. B, Flap raised
on bilateral neurovascular pedicles. C, Flap advanced 1.5 cm. D, Flap sutured into position with
hypothenar free full-thickness skin ap at ap base.
malformations, such as congenital absence of the radius,

and occasionally with metabolic disorders, including blood
dyscrasias. These latter conditions should be well assessed
before elective procedures for thumb reconstruction are
performed. These reconstructive procedures usually are
done after the rst year or two of life.
The so-called oating thumb, a congenital anomaly
in which the distal segment of the thumb has no major
attachment except a narrow soft-tissue pedicle and
appears to dangle from a skin thread, is not considered
useful enough to attempt reconstruction. The skin of
this digit can be used for a skin graft if it is needed,
but as a rule it should be detached during the rst few
months of life.
Lengthening of Metacarpal and Transfer

of Local Flap
When amputation of the thumb has been at the metacarpophalangeal joint or within the condylar area of the rst
metacarpal, the thenar muscles are able to stabilize the
digit. In these instances, lengthening of the metacarpal by
bone grafting and transfer of a local skin ap may be indicated. The technique as described by Gillies and Millard
can be completed in one stage, and the time required for
surgery and convalescence is less than in some other reconstructions. Disadvantages of this procedure include bone
graft resorption and ray shortening and skin perforation
after ap contraction. This procedure requires that there

be minimal scarring of the amputated stump.
TECHNIQUE 14-15
Gillies and Millard, Modied
Make a curved incision around the dorsal, radial, and volar

aspects of the base of the thumb (Fig. 14-23A).
Undermine the skin distally, but stay supercial to the main

veins to prevent congestion of the ap. Continue the
undermining until a hollow ap has been elevated and slipped
off the end of the stump; the blood supply to the ap is from a
source around the base of the index nger in the thumb web.
(If desired, complete elevation of the ap can be delayed until a
second operation, as described by Gillies and Millard.)
Attach an iliac bone graft or a phalanx excised from a toe to

the distal end of the metacarpal by tapering the graft and tting
it into a hole in the end of the metacarpal.
Fix the graft to the bone by a Kirschner wire, and place iliac
chips around its base. Ensure that the graft is small enough that
the ap can be placed easily over it.
Cover the raw area at the base of the thumb by a splitthickness skin graft (Fig. 14-23B).
The newly constructed thumb is

immobilized by a supportive dressing, and a volar plaster
AFTERTREATMENT
Fig. 14-23
Reconstruction of thumb by
technique of Gillies and Millard, modied. A, Curved incision around dorsal,
radial, and volar aspects of base of
thumb has been outlined. B, Hollow ap
has been undermined and elevated, iliac
bone graft has been xed (this time to
base of proximal phalanx), and raw area
at base of thumb has been covered by
split-thickness skin graft.
A
splint is applied to the palm and forearm. The Kirschner
wire is removed when the graft has united with the metacarpal. Minor Z-plasties may be necessary later to
relieve the volar and dorsal web formed by advancing the
ap.
Osteoplastic Reconstruction and Transfer

of Neurovascular Island Graft
Verdan recommended osteoplastic reconstruction, especially when the rst carpometacarpal joint has been spared
and is functional. It is a useful method when the remaining
part of the rst metacarpal is short. As in the technique of
Gillies and Millard, no nger is endangered, and all are
spared to function against the reconstructed thumb. Transfer
of a neurovascular island graft supplies discrete sensibility
to the new thumb, but precise sensory reorientation is
always lacking (see Fig. 14-1).
TECHNIQUE 14-16
Verdan
Raise from the abdomen, the subpectoral region, or some

other appropriate area a tubed pedicle graft that contains only
moderate subcutaneous fat.
Excise the skin and subcutaneous tissue over the distal end of
the rst metacarpal; make this area for implantation of the tubed
graft a long oval and as large as possible so that the graft can
include many vessels and nerves and will not constrict later
(Fig. 14-24A).
B
Insert into the end of the rst metacarpal an iliac bone graft
shaped like a palette to imitate the normal thumb. Do not place
the graft in line with the rst metacarpal, but rather place it at
an obtuse angle in the direction of opposition. Ensure that the
graft is not too long. Place the end of the tubed pedicle over
the bone graft, and suture it to its prepared bed on the thumb
(Fig. 14-24B and C).
Immobilize the hand and tubed pedicle to allow normal

motion of the ngers and some motion of the shoulder and
elbow.
After 3 to 4 weeks, free the tubed pedicle.

Close the skin over the distal end of the newly constructed
thumb, or transfer a neurovascular island graft from an
appropriate area to the volar aspect of the thumb to assist in
closure and to improve sensation and circulation in the digit
(Fig. 14-24D to G).
A supportive dressing and a volar

plaster splint are applied. The newly constructed thumb is
protected for about 8 weeks to prevent or decrease resorption of the bone graft. If a neurovascular island graft was
not included in the reconstruction, this transfer must be
done later.
AFTERTREATMENT
Pollicization
Because pollicization (transposition of a nger to replace
an absent thumb) endangers the nger, some surgeons
F
Fig. 14-24 Osteoplastic thumb reconstruction. A,
32-year-old woman with traumatic thumb amputation 4 years previously with amputation level just
distal to metacarpophalangeal joint and thumb-index
web space contracture. B, Simple two-ap Z-plasty
web space release allows access to ulnar shaft of
thumb metacarpal. C, Lengthening frame applied
percutaneously from radial side of thumb under uoroscopic guidance before osteotomy. Note web contracture release after Z-plasty. D and E, Palmar and
dorsal view of thumb soon after frame application.
Lengthening begun at 1 week after surgery at rate
of 0.5 mm twice daily. F and G, Lateral radiograph
at 2 weeks and 10 weeks after surgery. H, Lateral
radiograph 5 months after surgery indicating solid
union. No bone graft was required, and metacarpal
manual osteoclasis was done after xator removal to
simulate metacarpophalangeal joint fusion.
664
664
Part IV Amputations
recommend transposition only of an already shortened or

otherwise damaged nger. In this instance, full function
of the new thumb hardly can be expected. Full function
cannot be expected even after successful transposition of a
normal nger. In the hands of an experienced surgeon,
however, pollicization is worthwhile, especially in complete bilateral congenital absence of the thumb or in bilateral traumatic amputation at or near the carpometacarpal
joint. When amputation has been traumatic, extensive scarring may require resurfacing by a pedicle skin graft before
pollicization.
In the following techniques, the index nger is transposed to replace the thumb.
TECHNIQUE 14-17
Littler
In congenital absence of the thumb with absence of the

trapezium or in traumatic amputation proximal to the thumb
trapeziometacarpal joint, the repositioned index nger is xed to
its own metacarpal base as described here rst (see Fig. 14-25D
to F). In these instances, the second metacarpophalangeal joint
serves as the carpometacarpal joint of the new thumb.
Make a racquet-shaped incision encircling the base of the
ulnar lateral band, and then proximally to suture it to the

abductor indicis (Fig. 14-25C).
Resect the redundant part of the extensor indicis proprius

tendon, and suture together the free ends of the tendon under
proper tension.
In traumatic amputation through the rst metacarpal shaft, the

second metacarpophalangeal joint is not needed as a substitute
for the carpometacarpal joint of the thumb. The index metacarpal
(except for its base), the metacarpophalangeal joint, and the
proximal part of the proximal phalanx are discarded, and the
retained part of the proximal phalanx is rotated and xed to the
stump of the rst metacarpal as described next.
Begin the incision dorsally over the junction of the middle and
distal thirds of the second metacarpal, and extend it distally to
the web between the middle and index ngers, then laterally
across the proximal exion crease, and then proximally to the
starting point; from here, continue it to the end of the
amputated thumb, then proximally along the dorsum of the rst
metacarpal, and then slightly ulnarward to permit subsequent
shifting of the skin (Fig. 14-26A). Be careful to protect the dorsal
vein to the index nger.
Reect the volar ap anteriorly to expose the rst dorsal

interosseous, lumbrical, and adductor muscles and the radial
neurovascular bundle (see Fig. 14-26D).
index nger.
Reect distally the triangular ap from the dorsum of the
Extend the handle of the racquet proximally, and gently curve
nger to expose the extensor tendons and dorsal aponeurosis,

the intermetacarpal ligament, and the common volar artery with
its digital branches to the index and middle ngers.
it rst volarly and then dorsally (Fig. 14-25A).
Preserve the dorsal vein of the nger.

Free the neurovascular bundles and exor mechanism of the
nger by dividing the palmar fascia and septa.
Divide the intermetacarpal ligament and interosseous fascia

between the second and third metacarpals and the proper volar
digital artery to the radial side of the middle nger.
Detach the insertion of the abductor indicis muscle that in the

normal hand is the rst dorsal interosseous (Fig. 14-25B).
Expose subperiosteally the metacarpal and divide it obliquely
Divide the lamentous juncturae tendinum and the fascia

between the tendons of the extensor communis of the index and
middle ngers.
By further dissection at the base of the index nger, carefully

isolate the neurovascular pedicles.
To allow radial shift of the nerves, vessels, and exor tendons,

section the compartmental septa of the palmar fascia.
Locate the bifurcation of the common volar artery at the distal
at its base at a right angle to the normal projection of the

thumb.
border of the intermetacarpal ligament; divide and ligate here

the proper digital artery to the radial side of the middle nger
(see Fig. 14-26E).
Section proximally the extensor digitorum communis tendon,
The common volar nerve usually divides more proximally, but if
and separate it distally from the extensor indicis proprius and the
radial lateral band to near the proximal interphalangeal joint.
Resect the metacarpal shaft just proximal to the epiphysis,

preserving a dorsal strut for better xation of the remaining
head to the metacarpal base. The metacarpophalangeal joint is
preserved to act as the carpometacarpal joint of the new thumb.
Fix the metacarpal head to the metacarpal base in the normal

thumb projection.
Fix the tendon of insertion of the abductor indicis at the level

of the proximal interphalangeal joint by passing the extensor
digitorum communis tendon twice through it, then around the
necessary, separate it farther.
Section the rst dorsal interosseous and volar interosseous

muscles at their musculotendinous junctions.
Divide as far proximally as possible the extensor tendons to

the index nger, and reect them distally.
Remove a bone graft from the dorsal surface of the second

metacarpal to be used for medullary xation of the transposed
nger to the rst metacarpal (Fig. 14-26B and C).
Divide the index metacarpal at its base and the proximal

phalanx near its base, and discard the intervening bony
665
Part IV Amputations
Transverse metacarpal arch
a
Recession
665
a'
Volar
interosseus
muscle
Thumb projection
II
I
Epiphysis
a
x
a'
II
x
I
Abductor indicis muscle
Extensor digitorum
communis tendon
Extensor indicis
proprius tendon
Proximal interphalangeal joint

Volar interosseus
tendon
Volar interosseus
muscle
Extensor indicis
proprius tendon
Extensor digitorum
communis tendon
Lateral band
Lateral band
Abductor indicis
tendon
Volar interosseus
muscle
Extensor indicis
proprius tendon
Extensor digitorum
communis tendon
Abductor indicis
muscle
Volar interosseus
tendon
Extensor indicis
proprius tendon
Abductor indicis
muscle
Extensor digitorum
communis tendon
Fig. 14-25
Littler pollicization for congenital absence of thumb or amputation at carpometacarpal joint. A, Skin incision. B, Detachment of abductor indicis, resection of second metacarpal
shaft, and freeing of extensor digitorum communis (see text). C, Readjustment of extensor
mechanism and xation of abductor indicis by extensor digitorum communis tendon (see
text).
665
F
Fig. 14-25, contd D, Left hand after treatment of congenital absence of thumb by limited
repositioning of index nger. E, Left hand after surgery (function improved). F, Right hand
after treatment for same anomaly by Littler technique as described in text (function is much
better than in left hand; note pinch). (Modied from Littler JW: Digital transposition. In Adams
JP, ed: Current practice in orthopaedic surgery, vol 3, St Louis, 1966, Mosby.)
TECHNIQUE 14-17
Littlercontd
segments; resect only enough bone from the proximal phalanx

to make the new thumb of proper length.
Place the bone graft in the medullary canal of the rst

metacarpal, and transx it with a Kirschner wire.
Shift the volar ap ulnarward, and suture it to the soft tissues

at the side of the third metacarpal. Suture the dorsal ap to the
margin of this ap and to the triangular ap on the dorsum of
the transposed nger.
Close the remaining incisions.
Transpose the index nger to the thumb by placing its exposed

proximal phalanx over the protruding medullary graft
in proper pronation; transx it also with a Kirschner wire to
maintain its position after surgery.
Suture the extensor pollicis longus tendon to the extensor

communis tendon of the transposed nger by the end-to-end
method (see Fig. 14-26F).
The hand and newly constructed

thumb are immobilized in the functional position. The
sutures are removed at 2 weeks. Function is resumed
gradually 6 to 8 weeks later. Radiographs of a hand before
and after this type of pollicization are shown in Figure
14-27.
AFTERTREATMENT
Divide the extensor indicis proprius at its junction with the

common extensor, withdraw it proximal to the dorsal carpal
ligament, transfer it in line with the extensor pollicis longus, and
suture it to the extensor mechanism under proper tension.
Riordan Pollicization
In the Riordan technique, the index ray is shortened by
resection of its metacarpal shaft. To simulate the trapezium,
Dorsal vein
De
D
V
De
Final
thumb
position
Ve
EPL
II
II
VI
KW
DI
Add
Rotate
and
recess
Rotate
90
S
P
F
Fig. 14-26
Littler pollicization for amputation of thumb through metacarpal shaft. A, Skin incision. Note tenting of incision
in anterior midline and preservation of dorsal vein. Broken line, thumb after repositioning of index nger. Note shortening
of index ray to simulate natural length of thumb. B, Treatment of bone. Remove graft from dorsum of second metacarpal,
discard bone between base of second metacarpal and base of proximal phalanx, and shift index nger. C, Fixation of bone
by graft and two Kirschner wires. D, Reection anteriorly of volar ap to expose rst dorsal interosseous, lumbrical, and
adductor muscles and radial neurovascular bundle. E, Ligation of proper volar digital artery to middle nger and division
of intermetacarpal ligament and deep palmar fascia. F, Closure of skin aps. Note special mattress suture used to snug tips
of triangular aps into position. Suture of extensor digitorum communis to extensor pollicis longus is shown. (Courtesy of
J.W. Littler, MD.)
668
Part IV Amputations
Fig. 14-27
Littler pollicization. A, Before
surgery. B, After surgery. (Courtesy of
J.W. Littler, MD.)
A
the second metacarpal head is positioned palmar to the
normal plane of the metacarpal bases, and the metacarpophalangeal joint acts as the carpometacarpal joint of the
new thumb. The rst dorsal interosseous is converted to
an abductor pollicis
brevis,
and the rst volar
interosseous is converted to an adductor pollicis. The
technique as described is for an immature hand with
congenital absence of the thumb, including the greater
multangular, but it can be modied appropriately for
other hands.
TECHNIQUE 14-18
Riordan
Beginning on the proximal phalanx of the index nger, make a

circumferential oval incision (Fig. 14-28A and B) on the dorsal
surface.
Place the incision level with the middle of the phalanx and on
the palmar surface level with the base of the phalanx. From the
radiopalmar aspect of this oval, extend the incision proximally,
radially, and dorsally to the radial side of the second metacarpal
head, then palmarward and ulnarward to the radial side of the
third metacarpal base in the midpalm, and nally again radially
to end at the radial margin of the base of the palm.
Dissect the skin from the proximal phalanx of the index nger,
leaving the fat attached to the digit and creating a full-thickness
skin ap.
Isolate and free the insertion of the rst dorsal interosseous,

and strip from the radial side of the second metacarpal shaft the
origin of the muscle.
Isolate and free the insertion of the rst volar interosseous,

and strip from the ulnar side of the metacarpal shaft the origin
B
of this muscle. Take care to preserve the nerve and blood
supplies to the muscle in each instance.
Separate the second metacarpal head from the metacarpal

shaft by cutting through its epiphysis with a knife; preserve all of
its soft-tissue attachments.
Divide the second metacarpal at its base, leaving intact the

insertions of the extensor carpi radialis longus and exor carpi
radialis; discard the metacarpal shaft.
Carry the index nger proximally and radially, and relocate

the second metacarpal head palmar to the second metacarpal
base so that it simulates a trapezium (Fig. 14-28C); take care to
rotate and angulate it so that the new thumb is properly
positioned.
Anchor it in this position with a wire suture (Fig. 14-28D).

Anchor the insertion of the rst dorsal interosseous to the
radial lateral band of the extensor mechanism of the new
thumb and its origin to the soft tissues at the base of the digit;
this muscle now functions as an abductor pollicis brevis (Fig.
14-28E).
Anchor the insertion of the rst volar interosseous to the

opposite lateral band and its origin to the soft tissues; this
muscle now functions as an adductor pollicis.
Shorten the extensor indicis proprius by resecting a segment

of its tendon; this muscle now functions as an extensor pollicis
brevis. Also, shorten the extensor digitorum communis by
resecting a segment of its tendon.
Anchor the proximal segment of the tendon to the base of the

proximal phalanx; this muscle now functions as an abductor
pollicis longus.
669
D
Fig. 14-28
Riordan pollicization for congenital absence of thumb, including greater trapezium,
in an immature hand. A and B, Incision (see text). Skin of proximal phalanx (brown area in
A) is elevated as full-thickness skin ap. C and D, Second metacarpal has been resected by
dividing base proximally and by cutting through epiphysis distally, and nger has been relocated
proximally and radially. Second metacarpal head has been anchored palmar to second metacarpal
base and simulates greater trapezium (see text). E, Insertion of rst dorsal interosseous has
been anchored to radial lateral band of extensor mechanism of new thumb and origin to soft
tissues at base of digit; insertion of rst volar interosseous has been anchored to opposite lateral
band and origin to soft tissues.
Trim the skin aps appropriately; fashion the palmar ap so

that when sutured it places sufcient tension on the new thumb
to hold it in opposition.
Suture the aps, but avoid a circumferential closure at the

base of the new thumb.
Apply a pressure dressing of wet cotton and a plaster cast.
At 3 weeks, the cast is removed, and

motion therapy is begun. The thumb is appropriately
splinted.
AFTERTREATMENT
Buck-Gramcko Pollicization
Buck-Gramcko reported experience with 100 operations
for pollicization of the index nger in children with congenital absence or marked hypoplasia of the thumb. He
emphasized a reduction in length of the pollicized digit
trapezium. For best results, the index nger has to be
rotated initially approximately 160 degrees during the
operation so that it is opposite the pulp of the ring nger.
This position changes during the suturing of the muscles
and the skin so that at the end of the operation there is
rotation of approximately 120 degrees. In addition, the
pollicized digit is angulated approximately 40 degrees into
palmar abduction.
670
Part IV Amputations
B
C
A
A
C
B
A
Dorsal
Palmar
E
First PI (AP)
First DI (APB)
EIP (EPL)
EDC (APL)
H
Fig. 14-29
Pollicization of index nger. A and B, Palmar and dorsal skin incisions. C and D,
Appearance after wound closure. E, Rotation of metacarpal head into exion to prevent postoperative hyperextension. F, Index nger rotated about 160 degrees along long axis to place
nger pulp into position of opposition. G, Final position of skeleton in about 40 degrees of
palmar abduction with metacarpal head secured to metacarpal base or carpus. H, Reattachment
of tendons to provide control of new thumb. First palmar interosseous (PI) functions as adductor pollicis (AP), rst dorsal interosseous (DI) functions as abductor pollicis brevis (APB),
extensor digitorum communis (EDC) functions as abductor pollicis longus (APL), and extensor
indicis proprius (EIP) functions as extensor pollicis longus (EPL). (Redrawn from Buck-Gramcko
D: Pollicization of the index nger: method and results in aplasia and hypoplasia of the thumb, J Bone
Joint Surg 53A:1605, 1971.)

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Amputations of the

Index nger ................................

Amputations of the thumb ... 655

Painful amputation stump .... 658

[UnitedVRG] - Medical Release Group

Chapter 14 Amputations of the Hand

employed as a free graft. Skin and deeper soft structures

a surviving digit (e.g., to improve adductor power of the

Chapter 14 Amputations of the Hand

is available from other injured parts of the hand, but the

[UnitedVRG] - Medical Release Group

Chapter 14 Amputations of the Hand

excellent distal coverage and utility for dorsal and volar

Free Skin Graft

Kutler V-Y or Atasoy triangular advancement ap ngertip

from the injured nger and provide limited coverage. The

Local anesthesia is preferred in adults; children may require

[UnitedVRG] - Medical Release Group

Incision along midlateral line

Dorsal branch of digital nerve proper

Chapter 14 Amputations of the Hand

Fig. 14-9 Reverse adipofascial ap. A, Skin incision outlining ap

[UnitedVRG] - Medical Release Group

Dbride the tip of the nger of uneven edges of soft tissue

Develop two triangular aps, one on each side of the nger

Bipedicle Dorsal Flaps

Develop the aps farther by incising deeper toward the nail

Round off the sharp corners of the remaining part of the

Approximate the bases of the aps, and stitch them together

At a more proximal level, make a transverse dorsal incision to

Suture the ap in place, and cover the defect created on the

Frequently, closure of the proximal and lateral defects is

Adipofascial Turnover Flap

Under tourniquet control and using an appropriate anesthetic,

Develop a full-thickness ap with nerves and blood supply

Selectively cut the vertical septa that hold the ap in place,

Suture the skin ap to the sterile matrix or nail. The volar

indicated, such as extensor tendon repair and fracture xation.

Outline the planned ap with a skin pen. Make the width 2 to

Develop the adipofascial ap supercial to the extensor

After the ap is detached proximally and along its sides to the

Do not place sutures at the turnover site to avoid tension on

Use a split-thickness graft to cover the defect at the ap site.

The rst dressing change is 3 weeks

Chapter 14 Amputations of the Hand

Cross Finger Flaps

large enough to cover the defect and is properly positioned;

With its base proximal, raise the thenar ap to include most of

the underlying fat; handle the ap with skin hooks to avoid

Attach the distal end of the ap to the trimmed edge of the

[UnitedVRG] - Medical Release Group

Hold the nger in the proper position by gauze and adhesive

Place over the grafts wet cotton carefully shaped to t the

Apply a compression dressing until suture removal at 10 to 14

tape, and splint the wrist.

Begin digital motion therapy as soon

At 4 days, the graft is dressed again

Island Pedicle Flap

Local Neurovascular Island Flap

Inate the arm tourniquet after using a skin pen to outline

Measure the defect size after appropriate dbridement and

Make a midlateral incision on each side of the nger (or

Use a midaxial or a volar zigzag incision to expose the