Algorithm-Guided Management of Thumb Amputation: A 20-Year Retrospective Review and Outcome Analysis

Abstract

Background: The thumb accounts for 40-50% of hand function. Traumatic amputation of the thumb results in significant disability and necessitates a structured approach to management. Methods: We conducted a retrospective review of 144 patients treated for thumb amputations between 2004 and 2025 at a specialist hand surgery unit. Over 21 years, an institutional algorithm was developed and refined to guide treatment decisions based on amputation level, injury mechanism and patient factors. Results: Out of the 144 cases, 118 patients underwent replantation, achieving an 82% success rate. Alternative reconstructive procedures included toe-to-thumb transfers (eight cases), index finger pollicisation (six cases) and fourth finger pollicisation (five cases). Functional outcomes showed that 90% of patients returned to work, 83% regained temperature and touch sensation, and 94% could lift a 0.5 L bottle. Conclusions: Implementing a structured treatment algorithm facilitates personalised care and leads to favourable functional outcomes in patients with traumatic thumb amputations.

Keywords: replantation; traumatic thumb amputation.

Figure 1

A case of a 51-year-old patient, manual worker who presented with thumb amputation caused by a circular saw. (a) Amputated part of the thumb. (b) The stump with a sharp cut edge; (c) Presentation of the thumb after the replantation procedure.

Figure 2

A case of a 42-year-old manual worker who had an amputation of the thumb at the interphalangeal joint caused by an axe. (a) The amputated right thumb; (b) The stump; (c) The replanted thumb showing a good blood supply after surgery.

Figure 3

A case of a 37-year-old patient who underwent avulsion amputation of the thumb. As replantation was not possible due to extensive tissue damage, the decision was made to skeletonise the amputated phalanges and cover them with a pedicled radial forearm flap. (a) Amputated thumb; (b) Appearance of the hand immediately prior to covering the defect with a pedicled radial forearm flap following thumb skeletonisation with K-wire fixation; (c) Postoperative result of the thumb one week after the procedure, demonstrating satisfactory healing and coverage.

Figure 4

A case of a 62-year-old patient with an avulsion injury to the thumb above the metacarpophalangeal joint. The tissue defect in the thumb was covered with a pedicled inguinal flap. (a) Skeletonised thumb with preserved tendons and neurovascular bundles; (b) Inset of the pedicled inguinal flap onto the defect; (c) Result after flap division, three weeks after the first stage; (d) Result showing satisfactory healing and coverage, fourteen days postoperatively.

Figure 5

A case of a 44-year-old patient who had undergone amputation of the thumb, including the first metacarpal bone and the thenar muscles. The patient had a postoperative scar at the site of the thumb defect and experienced stiffness in the interphalangeal joints. The patient was admitted to our hospital three years after the injury. It was decided that the second toe, together with the metatarsal bone, would be transferred from the foot to recreate the first ray of the hand and the first webspace. The lack of the TMC joint meant that he was unable to hold a precise grip or key pinch; however, he was able to grip larger objects. Prior to the procedure, the entire scar on the hand was removed and the defect was covered with a pedicled inguinal flap. The procedure to transfer the second toe took place six months after the inguinal flap was detached. (a) Initial presentation of the patient’s hand on admission, before scar removal; (b) Inset showing the pedicled abdominal flap covering the defect after scar removal; (c) Result after the first stage of treatment; (d) Appearance of the hand after transfer of the second toe and second metatarsal bone; (e) Final presentation of the hand, demonstrating satisfactory restoration, 10 months postoperatively, (f) Functional result.

Figure 6

A case of a 24-year-old patient who had their thumb and index finger amputated. The thumb was not suitable for replantation due to the nature of the injury. It was therefore decided to replant the index finger in place of the lost thumb. (a) Presentation of the amputated fingers: the index finger (upper part of the figure) and the amputated thumb (lower part); (b) X-ray taken after the injury; (c,d) Final appearance after surgery, showing functional and aesthetic restoration five months postoperatively.

Figure 7

This is a case study of a 47-year-old patient who had undergone amputation of the thumb and index finger. The thumb was missing its proximal phalanx, so the amputated index finger was used to restore thumb function. The middle phalanx of the index finger was skeletonised and placed in the place of the lost proximal phalanx of the thumb to reconstruct the height and function of the thumb. (a) Initial presentation of thumb injury; (b) parts of index finger: proximal phalanx (below) and soft tissue residue (above); (c) connection of proximal index phalanx with amputated thumb before replantation procedure; (d) postoperative appearance; (e,f) final presentation 6 months postoperatively showing good aesthetic and functional results.

Figure 8

A case of a 25-year-old male manual worker who was admitted for thumb function reconstruction after amputation and treatment at another centre. The patient was offered pollicisation of the distal part of the fourth finger at the level of the proximal interphalangeal joint. (a) Initial presentation of the thumb, three months after amputation; (b) X-ray of the hand on arrival at our centre; (c,d) Final presentation showing a satisfactory aesthetic outcome after the procedure, with the thumb flexed and abducted; (e,f) Functional result showing good grasp and key pinch of the operated limb six months after the described surgical treatment.

Figure 9

Algorithm of management after amputation of the thumb depending on the degree of damage.