Case of the Week
Second
Toe Transfer for Thumb Reconstruction in a 4 year old child
Microsurgeons
get the toe to do a "Thumbs up"
|
The thumb of
4
year old Manjula was crushed accidentally when it got caught in the
wheel of a two wheeler. It was reconstructed using her own second
toe with the help of microsurgery. The amputation was
through the epiphyseal plate (growing end) of the proximal phalanx .
The part was not fit for replantation. Hence the amputation stump
was closed with the available skin.
| Reconstruction
of an amputated thumb in a small child is a challenge since options
like Osteoplastic technique and micro surgical techniques like wrap around
do not have growth capability. That leaves only toe transfer as the
option. The parents of the child were explained about the options of reconstruction
of the thumb. They did not agree for removing tissues from the great
toe. They opted for second toe transfer as it had a better cosmetic donor
defect. Three weeks after injury, she was readmitted for toe transfer. |
Pre
operative view of the Amputated Left Thumb.
 
|
A team of Plastic Surgeons headed by Dr. Raja Sabapathy, carried out this
surgery. First the structures at the base of the amputated thumb
were identified and prepared for joining with that of the toe. Then
the second toe from the right foot was harvested along with its blood vessels,
nerves and tendons which were tagged with minute sutures for identification.
After the toe was totally detached from the foot the defect in the foot
was closed in such a manner that the loss of the toe was not noticeable.
The toe was
then brought to the hand. The bone was fixed with a Stainless Steel wire.
The flexor and extensor tendons (structures which move the joints) were
then repaired. The only difficulty was nerve repair (structures which
provide sensation). During injury the thumb digital nerves were found
avulsed from the median nerve. So there was no nerve to suture to
the toe nerves on the volar side. Hence the radial side digital nerve
to the index finger was split into two and one half was sutured to the
‘ulnar’ (inner) side digital nerve of the toe. A dorsal nerve was
also sutured.
The
toe before removal from the foot.
|
The
dissected toe before transfer to the hand
|
Immediate
post-op
|
The entire
surgery lasted six hours and at the conclusion of the surgery the TOE-TURNED-THUMB
assumed a healthy pink colour signifying the success of the operation.
This new thumb will have sensation, movement and nail growth.
She can now look forward to going back to school and have a normal
childhood.
Toe
3 weeks after thumb reconstruction
 
|
Donor
foot as seen on the front and back
  ..
|
Late
Postop Photographs
Significance
of this surgery can be appreciated if one imagines a hand without the thumb.
The Loss of thumb is very disabling. Though the disability of the
loss of thumb is rated as 40% for calculation of compensation purposes,
its real significance can be felt while doing some of the daily activities
like holding a cup, writing, putting on a shirt button, eating food, etc.,
The only action you can do is push the wall or lift a bag!
| The Surgical
Team
Dr. S. Raja
Sabapathy
Dr. R. Ravindra
Bharathi
Dr. Hari Venkataramani
Dr. K.L. Deepak
Dr. Sandeep
J. Sebastin |
Anaesthesiologists
Dr. V. Ravindra
Bhat
Dr. Venkatesh |
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