Case of the Week
Department of Plastic, Hand and
Reconstructive Microsurgery
Microsurgical Reconstruction of Metacarpal Hand by Great and Second Toe Transfers
A 16 year old labourer while at work lost all the five fingers of his
right hand with skin on the dorsum (outer aspect)of the hand, when his hand accidentally
got caught in a machine. The fingers
could not be retrieved and hence there was no possibility of replantation. He
was brought to the Department of Plastic, Hand and Reconstructive Microsurgery,
For
any hand to be useful, a person needs the thumb and at least one finger on the other
side for the thumb to meet. Transferring of toes to the hand to serve as
fingers by Microsurgery is a good method of reconstruction of missing thumb and
fingers. The selection of technique depends
on the patient’s functional need, appearance of the reconstructed thumb and
fingers and donor site morbidity. In general, great toe makes better thumb and
second toe is ideal for finger reconstruction.
A
pedicled groin flap (tissue from the lower abdomen) was raised to reconstruct
the soft tissue loss on the dorsum of the hand on arrival. Three months later
the thumb was reconstructed by transferring the great toe form his right foot
by Microsurgery. The surgery took about
6 hours. The great toe was transferred
along with its blood vessels, nerves and tendons which are helpful to move the
joints. In 3 months time his “new
thumb” was fully integrated in its new place. He could feel and move it very well. Now he needed a finger for the ‘new
thumb’ to meet so that he could pickup things. The second toe form his other foot was transferred
to the hand in the place of the middle finger. He can pick up things and in
course of time can expect to do almost all the things he was doing before. It has given the patient a new lease of
life.
The Reconstruction Sequence
|
The Hand on arrival.
All fingers are amputated and the skin loss on the dorsum extends up to the
wrist |
Before giving the
flap a K wire spacer is used to keep the first web open |
The hand after the
groin flap cover |
|
The hand after the
groin flap cover as seen on the
palmar side |
The harvested great
toe |
The new ‘thumb’
in place |
|
The harvested second
toe |
The only
disadvantage usually expressed by the patient – ‘Not able to wear
‘ |
The hand in use –
A New life indeed. Thanks to Microsurgery |
Technical Tips
- When faced
with a major mutilating injury, it is important to make a full plan on day
1 and discuss it with the patient. Only
then are they able to cooperate with the initial stages
- When a flap
cover is done for a metacarpal hand, we find it useful to put in a K wire
spacer to keep the first web open. In
the absence of the thumb it takes only a few weeks for the web to
contract.
- Great toes
make Great thumbs. When there is
major mutilating injury it is great toe transfer is always preferable to
second toe for thumb reconstruction.
- It is good to
give a gap of a few months between the great toe and the second toe
transfer. This period is useful for
us to decide the position of the second toe. A thermoplastic splint is made and
adjusted to find the meeting point of the new thumb
- A single second
toe transfer is functionally as useful as multiple toes for most of the
activities.
|
The Microsurgery Team Dr. S. Raja
Sabapathy |
Anaesthesiologists Dr. V.
Ravindra Bhat |