=====Secondary Thumb Reconstruction in a Mutilated Hand=====

====Abstract====

====Commentary====
  *  thumb needs: length, sensation, stability, and the ability to meet the other digits, ideally in a tripod pinch. (**losss**: **L**ength, **o**pposition, **s**ensation, **s**tability, **s**trategic position)
  *  options
    * toe transfer as standard -- big vs second toe
    * alternatives:
      * osteoplastic
      * pollicization
    * function 
      * tripod pinch {vs key or lateral pinch}
 

> "It is not the full length of the thumb, nor its great strength and movement, but rather its strategic position relative to the fingers and the integrity of the specialized terminal pulp tissue which determines prehensile status."
Littler

=== Lister classification ===
based on the remaining length:
1. Acceptable length with poor soft tissue coverage
2. Subtotal amputation with questionable remaining length
3. Total amputation with preservation of the basal joint
4. Total amputation with loss of the basal joint. {-> pollicization vs contralateral RF transfer}

=== Toe transfer ===
- soft tissue - abdominal/groin flap -- no regional/local flap
- 2nd toe if include MCPJ

=== Lengthening (Matev technique)===
- only 3cm max

=== Problem - "metacarpal hand" ===
  * SRS - even one toe may be useful
  * up to 2-3 toes have been transferred - either individual toes or as a block, either from one foot or multiple
  * abdominal flap delay

=== Choice of flap ===
>"We wish to preserve the options of a posterior interosseous artery flap or reverse radial artery
forearm flap for the reconstruction of the first web space and for the use of the vessels for any
possible future microsurgical procedure."


=== The injury ===
>" A mutilated hand may be an overwhelming presentation for the less experienced hand surgeon. It is
essential to undertake an adequate radical debridement at the index procedure and provide
soft tissue coverage to allow the underlying tendons and bones to glide in a minimally scarred
bed. Leaving a poorly debrided wound or failing to provide adequate soft tissue coverage will ultimately
result in a poor long-term result."

====Source=====
Hand Clin 32 (2016) 533–547
http://dx.doi.org/10.1016/j.hcl.2016.07.005
DavidGrahamMBBS, FRACS(Orth), FAOrthAaPraveenBhardwajMS (Ortho), DNB (Ortho), FNB (Hand & Microsurgery), EDHSbS. RajaSabapathyMS (Gen), MCh (Plastic), DNB (Plastic), FRCS (Edin), MAMSc

====See also====
  * [[md:secondary_surgery_trauma|Secondary surgery]]

====History====
  * 2020-07-12 created in rst
  * 2020-08-08 transcribed to dokuwiki and minor edits