Finger and thumb replantation: From biomechanics to practical surgical applications.

Finger and thumb amputations, which are always dramatic injuries with major functional and psychological repercussions, remain a surgical challenge. This review on digit replantation develops the underlying biomechanical and surgical aspects as well as practical indications. The different stages from trauma to postoperative monitoring are described. We describe the steps to follow from theory to practice in order to optimize the surgical acts that must as effective possible in terms of management and decision-making efficiency. Indications recognized as standards such as thumb amputation, multi-digit amputations and distal amputations are detailed, as well as the more controversial ring finger replantations. The challenge of successful finger and thumb replantation lies in searching for the best functional and cosmetic outcome and not performing irrelevant microsurgical manipulations.

Complete ring finger avulsion: Review of 16 years of cases at a Hand Emergency Unit.

Replanting complete ring avulsion injuries remains a challenge for hand surgeons. The prognosis depends on achieving satisfactory function. We present the results of our 16 years' experience with managing this type of injury. Our cohort consisted of 83 cases of complete ring avulsion injuries in patients with an average age of 23.5 years, treated in a Hand Emergency Unit between 1998 and 2014. Seventy-two were replanted. A vein graft was used in 57 cases to bridge the arterial injury and direct anastomosis was performed in 15 cases. Forty-one cases were a microsurgical success. Twenty-four patients were reviewed with an average follow-up of 87 months. The mean of total active motion was 164°, with 64° range of motion in the proximal interphalangeal joint on average. The two-point discrimination for sensitivity averaged 6mm. Two cases of severe cold intolerance were noted. Using a graft for vascular repair increases the odds of microsurgical success. The functional outcome depends on the condition of the proximal interphalangeal joint. Cold intolerance and lack of sensitivity have little effect on the functional outcome and patient satisfaction. Replantation of complete digital avulsion injuries should be attempted. Amputation at the metacarpal base is better discussed later on, after the initial surgery.

Thumb reconstruction by pollicization of an index finger stump combined with a wrap-around flap from the big toe.

A finger stump pollicization combined with a thin wrap-around procedure from the big toe for reconstruction of the thumb is described. This technique permits excellent functional and cosmetic restoration, providing length to the new thumb as well as widening the first web. There is joint motion in the reconstructed thumb. Sensibility of the transferred pulp is good and allows fine pinch without pulp shrinkage. This method is indicated in cases of multidigit amputations, for thumb loss near the carpometacarpal joint.

Thenar flap rehabilitated: a review of 20 cases.

The thenar flap is a satisfactory reconstruction technique for the treatment of extensive loss of the distal phalanx of the index and middle fingers. As we observed in this series of 20 patients, this flap is reliable and provides tissue that closely matches the missing finger pulp. Flap sensibility is good (average Weber of 6.5 mm). Transferring a distally based flap prevents proximal interphalangeal joint contracture and allows the surgeon to better reconstruct the outlines of the distal phalanx, thereby reducing the risk of a clawed nail. Finally, we did not observe major postoperative complications at the donor site.

[Reconstruction of digital pulp by pulp tissue transfer of the toe. Apropos of 15 cases]. / Reconstruction de la pulpe des doigts par transfert d'hémipulpe de gros orteil. A propos de 15 cas.

PURPOSE OF THE STUDY: The authors report their experience of digital pulp reconstruction by free toe pulp transfer. Fifteen patients were treated with the lateral great toe hemipulp. MATERIAL AND METHODS: 15 cases of post-traumatic finger tip reconstruction were reviewed including 9 thumbs, 5 index, 2 medius, and one ring finger. There were 6 emergency cases and 9 secondary reconstructions (7 after inconvenient spontaneous healing and 2 after groin flap coverage). RESULTS: We noted 2 partial necrosis, and 4 patients suffered from cold intolerance. The flap sensibility, according to the American Society for Hand Surgery criteria, was excellent in 1 case good in 6 cases, fair in 7 cases and bad in 1 case. The value of the mean two point discrimination test was 10 mm, the mean moving two points discrimination test equalled 9 mm. We had 1 excellent functional result, 6 good, 6 fair and 2 bad. The subjective evaluation found 12 patients satisfied and 3 disappointed. DISCUSSION: A wide range of procedures from spontaneous healing to thenar flap, neuro vascular flap or toe pulp transfer can be proposed to treat digital pulp loss. In the case of moderate thumb pulp avulsion and homodigital volar flap can be proposed; if microsurgery is contra-indicated, an hetero-digital flap from the index can be performed. When the other fingers are concerned, a homodigital flap can be proposed for moderate defects. For more important trauma, the thenar flap is convenient to cover the index and the medius pulp. Ring and little fingers can be treated by a reverse digital artery flap or by a cross finger flap. When a toe pulp transfer is indicated we recommend the lateral great toe hemipulp for the thumb and a second or third toe pulp transfer for the other fingers when digital vascular anastomosis are possible. The great toe hemipulp transfer represented a good indication for complete digital pulp loss reconstruction where the thumb is concerned. Performing this reconstruction during the acute phase may improve the management of those trauma by reducing the time needed for cicatrisation and the length of work inability.

[The contribution of MRI in the study of glomus tumors]. / Apport de l'IRM dans l'exploration des tumeurs glomiques.

The glomus tumors of the finger tip are benign. Their diagnosis is clinic but their precise localization is quite difficult by classic imaging. MRI with gadolinium injection seemed a good method to check exactly this lesion and have been tested on 20 patients suspected suffering of glomus tumor. On 18 glomus tumors surgically and histologically confirmed MRI examination have been positive for 16. In two cases MRI and surgery were negative. A good correlation seems observed with surgery for the size (7 tumor of 2 mm) the localization and osseus extension. Addition of T2 and T1 before and after injection weighted acquisitions improved the results. Precise informations on topography and size seems improved the surgical approach.