CASE REPORT Type II Metacarpal Hands: Reconstruction Planning Revisited

Abstract

Objective: Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgical planning. Effective transplantation involves 3 main considerations: residual hand function, functional needs and desires of the patient, and optimal surgical management to maximize outcome and minimize patient morbidity.

Methods: The following is a clinical example of the metacarpal hand in which the patient underwent initial reconstruction at an outside hospital and was referred to our institution. This demonstrates how the initial planning and surgical management could have been further optimized to minimize functional deficits and donor-site morbidities as well as reduce the number of subsequent revisional surgeries and rehabilitation time.

Results: Several important points in metacarpal hand reconstruction are described given specific level of amputation and residual function after the injury-the timing and sequence of operative strategy depending on the type of injury, the selection of donor-site digit transfers, and the overall treatment strategies for thumb and finger reconstruction.

Conclusion: It is important to follow proper treatment algorithms in order to determine appropriate timing and sequence of toe-to-digit transfers, multi-stage versus 1-stage, as well as define the reconstructive goal to achieve a tripod pinch for a unilateral or a dominant hand injury or a pulp-to-pulp opposition for nondominant injury in bilateral cases. If adequate planning is performed, unnecessary and additional surgical procedures as well as increased patient suffering and prolonged rehabilitation time can be prevented or optimized.

Figure 1

Initial presentation to our institution (6/27/03) post—latissimus dorsi myocutaneous flap and right great toe-to-thumb transplantation. The thumb was malpositioned with excessive length.

Figure 2

Appearance after second and third toe-to-finger transplantation (8/6/03). Given the initial length and positional discrepancies of the transplanted thumb, the patient is unable to use the reconstructed fingers to form an effective tripod pinch.

Figure 3

Appearance and function after corrective osteotomy of the transplanted thumb and after a series of debulking and revisioning surgeries (2/18/04 to 9/29/04). The patient now has the correct length to produce a tripod pinch.