~s recorded a
it.
that they have
~o comments in
~ne tumors in the
pie reported a car
chondroblastoma
¯ In myseries of
¯ pal involvement.
ladelphia. J. B. Lip
: Surg., 35-A: S88-893~)
Flynn, pp. 1027-103
as, 1957.
¯ 43-A: 861-864, Se
:!roma of Bone. Arch.
nts. pp. 169-195.
s and Feet. Radiology~;’
. A Case Report. Bull.
9-148, 1937.
scano, 1957.
v of 110 Cases. J.
Pollicization of the Index Finger
~’:
METHODANDRESULTS IN APLASIA AND HYPOPLASIAOF THE THUMB
BY DIETER BUCK-GRAMCKO,
M.D.’~,
HAMBURG.GERMANY
Fromthe Departmentof HandSurgery and Plastic Surgery,
Berufsgenossenschaftliches Unfallkrankenhaus Hamburg
Children with congenital absence or marked hypoplasia of the thumb usually
skillful in the use of their hands. Despite this natural dexterity, the important
pul?<o-pulp pinch is missing (Fig. 1), so that the choice of a profession in the later
years is restricted. Therefore, reconstruction of a thumb, if it provides not only better function but also an improvement in the appearance of the hand, wilt have a positive influence on the child’s future, and all the obvious implications, economic and
;social, on the child and his family should not be underestimated.
The high incidence of congenital malformations of the thumb in the years from
1959 to 1962--mostly resulting from the thalidomide tragedy--has led to a widespread interest in their surgical treatment. The progress in the field of surgery of the
hand led to technical modifications of previously used procedures for pollicization,
~ and better results followed. A good result, however, requires that one use a refined
teci,,nique. Unfortunately, this has not been practiced in all cases of pollicization and
: disappointing results may be obtained, particularly
by inexperienced surgeons (Fig.
i 2). These bad results may be responsible for some low estimates of the value of this
’: procedure, published in the last few years, for example, that, "at best, pollicization
gives a hand that is cosmetically distasteful
and functionally
disappointing"
~.
White ~,~4 stated that "a transposed index finger can never be made into a thumb
especially in the congenital cases," and "that no transplant can emulate the thenar
muscles and that flexion and extension may be the~nly worthwhile movements." The
!.
Fro. 1
Impossibility of performing pinch and its compensationin two patients with high-grade hypoplasia of the thumb.
AND JOINT
SURGERY
* Read at the Annual Meeting of the AmericanSociety for Surgery o~ the Hand, San Francisco. California, March6, 1971.
"~ Bergedorfer Strasse 10, 205 Hamburg80, Germany.
1605
VOL.53-A, NO.8, DECEMBER
1971
1606
DIETER BUCK-GRAMCKo
FIG.
(Fig.
vide!
:~
Figs. 2-A and 2-B: Disappointing result
of a trial
to pollicise
the index finger performed else~
where.Anosteotomyof the metacarpaland resection of the proximalinterphal~ngealjoints was
done,but the essential features of shorteningmusclestabilization, and adequaterotation were
lacking.
,
results presented in this paper showthat these statements are not correct if small but
important details of technique are observed.
The technique of pollicization in congenital cases is based on the procedure:
evolved for the reconstruction of the thumb in traumatic amputations. Fromthe fas
cinating literature concerning this problem, I would emphasize the contributions in
operative technique by Gosset, Hilgenfeldt, and Littler 10,11, whodeveloped
fundamental principles for pollicization in cases of aplasia and hypoplasia of the
thumb. Other authors such as Harrison z, s and Riordan 12 also have made important
contributions.
’
From 1959 to the present I have performed 114 pollicization operations, and
of this number100 were in congenital cases. The experience with this large number
of pollicizations has led to modifications in the operative technique with improvement of the results z,3,4. Twenty-oneof the seventy-three patients had unilateral
problems, with normal contralateral upper extremities. In sixteen there were ot
THE JOURNALOF BONE AND JOINT suRGERY
POLLICIZATION OF THE INDEX FINGER
1607
lformations of the other hand which did not require pollicizations with the excepof nine in whomthe procedure will soon be done. This leaves twenty-seven pa..ntsTwelve
whohad
the patients
procedurewho
done
bilaterally.
of the
had
pollicization also had a radial club hand on the
~ide operated on, and six of them had the condition bilaterally; but I did not pollicize the index finger in any patient with bilateral involvement. However,I did perform a centralization procedure on the contra[ateral hand in two of the six patients
ith bilateral involvement. In this procedure the hand was centralized over the end
’ the ulna.
Theoretical Concepts
In creating a new thumb from the index finger with stability and optimumposi.tion. the reduction of the length of the bones is important. For attaining the same
nun:L)er of bones and joints as in a normal thumba shortening of the over-all length
of the ray is necessary: the second metacarpal is removedwith the exception of its
head which acts as the new trapezium. However, the metacarpal should not be allowed to continue to grow much; for this reason the epiphysis must be resected. The
metacarpophalangeal joint will then become the new carpometacarpal joint. The
~roximal phalanx of the index will becomethe first metacarpal and the proximal interphalangeal joint the metacarpophalangeal joint of the new thumb, and so forth
(Fig. 3).
A rotation of the index finger on its longitudinal axis is also performedto provide proper axial alignment. Rotation of only 90 degrees, as is often done, will not
giv.= good oppositio~.,:The result will be a type of key grip against the long finger.
The index finger has to be initially rotated about 160 degrees during the operation
so that it is opposite the pulp of the ring finger. This position changes somewhat
during the suturing of the muscles and the skin, so that at the end of the operation
there is rotation of about 120 degrees.
In addition to the shortening and rotation, an angulation of about 40 degrees of
palmar abduction should be obtained. In this way, the new thumb is then well placed
to later movein opposition as well as in adduction and-abduction-
performed
mgeal joints was
.re rotation
DIP
.~ct if small
the
From the
retributions in
developed
oplasia of
ade important
perations, and
large number
~vith improvehad unilateral
~re were other
JOINT sURGERy
Ext. ind. <propr.} ~ Ext. poll.
long.
¯ Abd poll long¯
Ext.digit. II
¯ Add. port.
Interosseus patm. I
~, Abd.poll. brev.
Interosseus dors. I
Fro. 3
Diagram of the reduction of bones and joints;
is shown.
VOL. 53-A,
NO. 8,
DECEMBER 1971
on the right the change in function of muscles
1608
Photographs showing a long (left)
finger.
DIETER BUCK-GRAMCKO
FIG. 4
and a short thumb (right)
after pollicization
of the index
Operative Technique
For the pollicization operation there are four basic principles of equal importance, relating to the following: (a) the neurovascular pedicle; (b) the skeletal
readjustment with preservation of the metacarpophalangeal joint; (c) the muscular
stabilization; (d) the skin incision.
The first, the technique of fashioning the neurovascular pedicle, is now well
known. The freeing-up of the neurovascular bundle between the index and the long
finger is obtained by ligating the artery to the radial side of the long finger. The commondigital nerve is then carefully separated into its componentparts for the two
adjacent fingers. This ensures that no tension will be present after the index finger is
rotated. Sometimesan anomalousneural ring is fot]nd around the artery 5. This ring
Diagram of reduc
the metacarpal head
is split very carefully so that angulationof the
artery after transposition of the finger will
not occur. The radial digital artery to the index finger is occasionally absent. In such
cases it is possible to perform the
tion on a vascular pedicle of only one
Onthe dorsal side at least one of the great
veins must be preserved.
~.
For skeletal fixation after bonereadjustment, the length of the index finger is of considerable importance. If the phalanges are
relatively short, the base of the metacarpal
must be retained in order to obtain the right
length of the new thumb. The metacarpal
head is fixed to its base by meansof one or
two Kirschner wires. If the phalanges are
normal length, the whole metacarpal is reFro. 5
sected with the exception of its head. A
Roentgenogram of a hyperextension
short thumbis desirable, as it is functionally
deformity with dorsal subluxation of-the
former metacarpophalangeal joint.
and esthetically better than a long one, which
bears too close a resemblance to a finger
(Fig. 4). The metacarpal head is fixed by sutures to the joint capsule and the carpal
be,~es, whichin ,.
not essential. Fit:
good function.
The physiol~
especially in the
myearlier cases /
deformity is now
so that its palma
phalanx is broug
head. The norma
Sl~0nis possible.
creased the stabil
observed.
For muscle
trinsic mechanis~
intrinsic muscles
for the mobility,
than mobility fo~
necessary to sho~
monthsto the sh:
degree. Oneof t:.
is severed at thc
metacarpal resec
first metacarpal)
proprius tendon
~
The intero.
of the thumb, q
lateral bands of
partially strippc
necessity.
THE JOURNALOF BONE AND JOINT SURGERY
VOL.53-A, NO.8, D1
1609
POLLICIZATION
:ationof the ind,
es of equal
(b) the skeletal
c) the muscular,
:.le, is nowwell
iex and the long(
inger. The comz
arts for the two
e index finger
tery 5. This rin
mgulatic
¯ the finger wil
artery to the in’
~bsent. In such
,’n the
only one
,ne of the
ljus
finger is of
phalanges
the metacarpal
obtain the ri
7he
~eans of one
halanges are
~tacarpal is re)f its he~id.
:is functionally
ong one, which
Ice to a
: and the carpal)
OF THE INDEX FINGER
Fta. 6
Diagram
of reduction,rotation, and angulationof the indexfinger: in the circle the turningof
the metacarpalheadfor preventionof the hyperextension
deformityis shown.
bones, which in young children can be pierced with a sharp needle. Bone union is
not essential. Fibrous fixation of the head to its new surroundings is sufficient for
good function.
The physiologically wide range of movementof the metacarpophalangeal joint,
~ecially in the child, was the reason that hyperextension deformity developed in
myearlier cases (Fig. 5). It was moredisturbing esthetically than functionally. This
deformity is now prevented by turning the metacarpal head about 70 to 80 degrees
so that its palmar side becomes proximal (Fig. 6)."In other words, the proximal
~halanx is brought into a position of hyperextension in relation to the metacarpal
head. The normal joint looseness is markedly reduced and hardly any further extenis possible. This procedure, combinedwith the new muscle attachments has inicreased the stability of the thumb. No further tendency to hyperexten~ion has been
:i bbserved.
For muscle stabilization,
the adjustment of the extensor tendons and the inmechanismis one of the most important steps of the operation (Fig. 7). The
muscles and the long extensor and flexor tendons are responsible not only
for the mobility, but also for the stability of the digit. Stability is more important
than mobility for good function of the thumb. Experience has shownthat it is not
to shorten the flexor tendons. They adapt themselves in the course of a few
months to the shortening of the ray and will then flex the new thumbto the required
’ee. One of the two extensor tendons, that of the extensor digitorum communis,
is severed at the metacarpophalangeal level; its proximal end is sutured, after the
metacarpal resection, to the base of the former proximal phalanx (now acting as
first metacarpal), to becomethe new abductor pollicis longus. The extensor indicis
proprius tendon is shortened and then resutured by end-to-end anastomosis.
The interosseus muscles of the inde, x finger are also important for stabilization
of the thumb. They should first be detached from the proximal phalanx and the
lateral bands of the dorsal apone-urosis. Their origins from the metacarpal bone are
partially stripped subperiosteally. Careful preservation of nerves and vessels is a
necessity.
VOL. 53-A, NO. 8, DECEMBER
1971
1610
DIETER
BUCK-GRAMCKO
betwc
ons (100).
The main
on took
tee weeksof
uld moveju~"
dren gained th~
:and some coul~
the sixth to
!the operation.
There
FtG. 7
Diagram of the muscle stabilization
by the two interossei resutured to the separated
bands of the dorsal aponeurosis. The extensor communis tendon is fixed to the base of the new:¯
metacarpal as an abductor polticis longus; the extensor indicis proprius tendon is shortened.
After osteotomy and resection of the second metacarpal, the head of the second
metacarpal must be set in the aforementioned position between the muscles in
a way that they hold the bone well. The stabilization of the ray will be ensured
resuturing the tendinous insertions of the two interossei to the lateral bands of the
dorsal aponeurosis. These lateral slips will have been separated from the middle;
band the entire length of the proximal phalanx. The slips are woven through
distal parts of the muscles and turned back to form a loop. In this way, the
palmar interosseus will becomean adductor pollicis, and the first dorsal
an abductor brevis.
The new way of attaching the muscles is accompanied by a further change
the skin incision. Previously, an S-shaped incision was made on the radial side
the hand with an oval incision at the base of the index finger. Now,since the
terossei are reattached in the neighborhoodof the proximal interphalangeal joint,
additional dorsal longitudinal incision over the proximal phalanx is needed.
the volume of the space comprising the proximal phalanx has been increased
muscleand tendon transfers, direct closure is not possible. A dorsal skin flap
to close this defect.
In order to obtain this flap, the incision is mademore palmarly than
It also continues as far as the middle of the phalanx (Fig. 8). The distal end
flap is excised.
Follow-up
Each patient was seen routinely during the first year after operation, and
after at two years, four years, and six to eight years. Dependingon the year in
the operation was done, follow-up was as follows: twelve years, one patient;
eight years, seven patients; four to six years, twenty patients; tWOto four
twenty-five patients; one to two years, seven patients, and less than one year,
patients. Manyof the patients had bilateral involvement: this accounts for the
THE JOURNALOF BONE AND JOINT
Diagram of the
facilitate
VOL.53-A NO. 8, D
POLLICIZATION OF THE INDEX FINGER
1 611
crepancy between the numberof patients (seventy-three) and the numberof pollicizations (100).
Results
The main change in the range of motion and in the dexterity of the hand operated on took place during the first two years after the operation. At the end of the
three weeksof immobilizationafter operation, the joints of the pollicized index finger
could movejust a few degrees, usually; but in the next three to six weeks, all children gained the ability to perform pinch between the new thumb and the long finger,
and some could even touch the thumb to the ring finger. Most children could do this
by the sixth to eighth week, and could touch the little finger four to five monthsafter
the operation.
There was no significant difference in the rate of improvementwith different
ted lateral
of the new
.’ned.
le second
s in such
~sured by
ds of the
ough
the first
terosseus"::~:
:hangein i
~.1 side
:e the
joint,
ed. Since’::
radially.
ad of this
in
nt; six
ur
., thirteen
r the
Fro. 8
Diagram of the new incision (above) and suture line at the end of the operation (below).
letters facilitate the orientation for shifting of the different skin flaps.
VOL. 53-A, NO. 8, DECEMBER
1971
1612
DIETER
BUCK-GRAMCKO
ages, except for infants under the age of fifteen months, whocould not cooperate to
demonstrate pinch, but even these infants were able to use the hand operated on in a
natural way and were gripping objects between the new thumb and fingers or between the new thumband the long finger. Active flexion of the pollicized finger sometimes began in the fourth week, but in the majority not before the third month. The
motion increased slowly but steadily during the first year because of slow adaptive
shortening of the flexor tendons, not shortened surgically.
The motion and strength of radial abduction was the greatest variable in the
group of patients. They depended not only on the strength of the extensor muscle,
and on the position of fixation of the metacarpal head relative to the remains of its
base on the carpal bones, but also on the active use, and on the presence of other
anomalies in the extremity. For instance, in the radial club hand, there usually was
little active motion in the interphalangeal joints of the index and long fingers, and.
therefore, after pollicization, little motion existed in the former metacarpophalangeal
joint and none in the interphalangeal joints. In this case, therefore, the digit had to
be fixed in less radial abduction and act moreas a post for the function of pinch.
All of the children used their new thumbs naturally except those with radial
club hand, whofrequently used the side-to-side grip of ring and long fingers for
smaller objects. One other exception was a child with a "five fingered" hand, who
used this methodfor pinch preoperatively and continued to do so because of insufficient power in the intrinsic muscles. None of the new thumbs showed sensory or
vascular deficiency with one exception a hand in which there was anomalous absence of the pahnar arteries and postoperative thrombosis of the metacarpal artery
with necrosis and subsequent loss of the thumb.
It was necessary to add skin grafts in six operations, in three of which scars
from previous operations were the reason. In the other three a small lull thickness
graft was used from the excess skin on the dorsumof the finger. In these the reason
was retention of much of the second metacarpal because of the shortness of the
phalanges.
The reattached intrinsic muscles were important for the appearance as well as
for the function of the thumb. They gave to the transposed index finger the appearance of a thumb. They also produced a real thenar eminence, and, after a period
of training, led to relatively normalmobility of the thumb(Fig. 9).
Hyg
years
on th
were
were
rotat~
biliz~:
perf~
Fro. 9
Normal opposition and radial abduction of a pollicised
nence by the described muscle transfer.
index finger with a real thenar emi-
THE JOURNALOF BONE AND JOINT SURGERY
radi:
the ,
ring
pop
vOI
1613
POLLICIZATION OF THE INDEX FINGER
could not cooperate
’. hand operated on in
mb and fingers or
pollicized finger SOme~ the third month. The
:ause of slow adaptive
reatest variable in the
f the extensor muscle,
e to the remains of its
the presence of other
and, there usually was
and l~ng fingers, and,
metacarpophalangeal
efore, the digit had to
function of pinch.
:ept those with radial
and long fingers for
fingered" hand, who
~ so because of insufOs showed sensory or
"e was anomalous abthe metacarpal artery :’
three of which scars
a small full thickness
r. In these the
the shortness of
ppearance as well as
index finger the a
e, and, after a period
9).
ith a real thenar emi-
AND JOINT
SURGERY
Hypoplastic thumb in the left
years later.
Fro. 10
hand in a boy of the age of five; result
of pollicization
three
The quality of the results depended on the preoperative state of the hand, and
the additional anomalies on muscles, tendons, bones, and .joints. The best results
were in hands with a hypoplastic thumb (Fig. 10). The bones of the hypoplasfic digit
were removed, but the intrinsic muscles were left to provide intrinsic power.for the
rotated index finger. These muscles gave the ne_w thumb normal balance ~ind stabilization, which are the prior conditions for goodmobility, as well as the ability to
pinch and normal prehension (Fig. 1 1).
In cases of radial club hand, usually there were several additional anomalies
: and bad mobility of the radial fingers; the postoperative results in these cases were
! not as good as those previously described, but the operation did provide an increase
in function and usefulness of the hand. The correctionof the club hand by centralization of the hand with removal of the lunate and capitate bones and tendon transfers
performedat the first operation, the pollicization at the second(Fig. 12).
In the case of the so-called five-fingers-hand the decision whether or not the
radial finger was to be removedor used for pollicization sometimeswas difficult. If
the radial finger was of about the equal size of a normalfinger, pollicization of this
finger gave a very satisfactory result (Fig. 13). If the finger was too small and hypoplastic, it was better to removeit and pollicise the index finger.
Finally, the optimumage for performance of the operation was the first year of
VOL. 53-A,
NO. 8,
DECEMBER 1971
1614
DIETER BUCK-GRAMCKO
Result three years after pollicization;
normal position in writing and crochet-work.
life. At the beginning, I considered’that the age of two and a half years was most appropriate. However,in the last few years I have operated upon several infants, the
youngest being eleven weeksold, and nowI think that the first year of life is the best
age for pollicization and, incidentally, for someother operations in congenital m-a-l-:
formations of the hand. There are two decisive factors here: The first is that it is
from the age of about six months onward that the so-called thumb feeling is sup-
Result in radial club hand with centralization
FIG. 12
of the hand and pollicization
of the index finger.
THE JOURNAL OF BONEAND JOINT SURGERY
and crochet-work.
xlf years was most ap~n several infants the
year of life is the
~ns in congenital real;
Thefirst is that it is
thumb feeling is
POLLICIZATION OF THE INDEX FINGER
FIG. 13
"Five-fingers-hand" before and after pollicization
1615
of the radial finger.
posed to develop, and, therefore, the new thumbwill be felt as being a normal one.
The second is the fact that the transposed index finger will have the longest period
possible for growth under the influence of its function as a thumb.Several years after
pollicization we have been able to demonstrate a slow transformation of the structures of the pollicized index finger in the direction of a normal thumb. Not only do
th: muscles becomestronger, but also the bones. Especially the new first metacarpal
becomeslarger than the first phalanx of the long finger, to which it was equal in size
preoperatively (Fig. 14).
The operation was not done in the mildest cases of hypoplasia of the thumb,
in which there was only absence of thenar muscles and a slight adduction contracture.
In all other cases of hypoplasia, in which there were not enoughgood intrinsic muscles and long flexor and extensor tendons for good function, the dysplastic thumbwas
removed, and the index finger was pollicized. The operation also was not done in
radial club hands where centralization of the hand over the ulna was not possible beof restriction of elbow motion.
Fro. 14
Lion of the index finger.
Roentgenograms of a hand with pollicized index finger four years after operation. Note the
broadening of the base of the new first metacarpal in contrast to the base of the long finger.
~E AND JOINT SURGERY
VOL. 53-A, NO. 8, DECEMBER
1971
1616
DIETER BUCK-GRAMCKO
Su mmary
-
The experiences with 100 operations of pollicization
of the index finger in congenital deformities of the thumb in seventy-three patients are reported on. The operation is indicated in aplasia and in hypoplasia if there is no stable metacarpopha_
langeal joint and there are adduction contracture and poor mobility due to abnormal_
ities of aluscles and tendons. The operative technique was improved by the experiences in twelve years of use. Most important are the bone fixation and the muscle
stabilization.
In transformation of an index finger into a thumb it is necessary to
shorten the ray, to rotate it sufficiently, and to give it the right angle of abduction.
The shortening takes place in the metacarpal bone with preservation of its head:
the metacarpophalangeal joint becomes now the carpometacarpal joint and the metacarpal head the new trapezium. For preventing a hyperextension deformity it is
necessary to rotate the metacarpal head For good muscle stabilization
and good
mobility the two interossei of the index finger have to be detached and to be fixed in
the shortened position on both sides of the new thumb to the mobilized lateral slips
of the dorsal aponeurosis.
This new manner of muscle fixation gives a very good
thenar eminence not only in respect to appearance but also in function with full or
nearly full opposition and abduction. It requires a new skin incision with a dorsoradial skin flap for covering the gap between the wound edges of the former proximal
phalanx broadened by the muscle masses. The excellent results show a surprising ....
adaptation of bones and soft tissues due to function and growth--a reason for an
earl), performance of the operation.
References
1. BROOKS,
DONAL:
In Rehabilitation of the Hand. Ed. 2, pp. 336-348. Edited by C. B. Wynn
Parry. London,Butterworths, 1966.
2. BUCK-GRAMCKO,
DIETER:Operative Behandlung einer Spiegelbild-Deformit~t der Hand.
Ann.Chir. Plast., 9; 180-183,1964.
3. BUcK-GRAMCKO,
DIETER:Daumenrekonstruktion bei Aplasie und Hypoplasie. Kiln. Med.,
21; 325-329, 1966.
4. BUCK-GRAMCKO,
DIETER: Indikation und Technik der Daumenbildung bei Aplasie und
Hypoplasie. Chit. Plast. Reconstr., 5:46-51. 1968.
5. EDGERTON,
M. T.: SNYDER,G. B.; and WEB~,W. L.: Surgical Treatment of Congenital
ThumbDeformities (Including Psychological Impact of Correction). J. Bone and Joint
Surg., 47-A-"1453-1474,Dec. 1965.
6. GOSSET,
J.: La poIIicisation de l’index (Techniquechirurgicale). J. Chir., 65:403-411,1949.
7. HARRISON,
S. H.: Restoration of MuscleBalancein Pollicization. Plast. Reconstr. Surg., 34;
236-240, 1964.
8. HARRISOr~,
S. H.: Pollicisation in Cases of Radial Club Hand. British J. Plast. Surg., 23~
192-200, 1970.
9. HILGENFELDT, OTTO:Operativer Daumenersatz und Beseitigung v0n Greifst6rungen bei
Fingerverlusten. Stuttgart, Ferdinand Enke Verlag, 1950.
10. LITTER,J. W.: The Neurovascular Pedicle Method of Digital Transposition for Reconstruction of the Thumb.Plast. Reconstr. Surg., 12:303-319,1953.
11. LITTLER,
J. W.: Digital Transposition. In Current Practice in Orthopaedic Surgery, Vol. 3,
pp. 157-172. St. Louis, The C. V. MosbyCo., 1966.
12. RIORDhN,
D. C.: Congenital Absence of the Radius. J. Bone and Joint Surg., 37-A:
1140, Dec. 1955.
13. WroTE,W. F.: Pollicisation for the Missing Thumb,Traumatic or Congenital. The Hand,
1: 23-26, 1969.
14. WHITE,W.F.: FundamentalPriorities in Pollicization. J. Boneand Joint Surg., 52-B: 438443, Aug. 1970.
DISCUSSION
.DR. J. W. LITTLER, NEW YORK, N. Y.: Through a tragic pharmacological mishap
Buck-Gramcko
has gathered this unprecedented series (100 cases) of thumbaplasia. His paper
a splendid one and therefore a pleasure to discuss: its clarity is refreshing, the surgical approach
is exact, and the functional rewardfor these little patients is superior. His outstanding contribution gives great authority to this particular procedure.
Several points, however, deserve emphasis. First: the surgical timing. For manyyears I
have resisted transposing the radial digit into thumbposition during infancy, believing that the
THE
JOURNAL
OF BONE
AND JOINT
SURGERY
:.
POLLICIZATION OF THE INDEX FINGER
1 617
ically unmolested child, possibly with another anomaly, would better tolerate the operation
i later. Never, however, have I hesitated to encourage the removal, relatively early, of any rudi-
index finger in con:eported on. The o
;table metacarpopha_
e
tity
due to abnormal,
,roved by the experi_,
ttiorl and the muscle
nb it is necessary to
¯ angle of abductiot
:rvation
of its head:
11 joint and the meta~sion~deformity it is
~bilization
and
ed and to be fixSd in
.obilized lateral slips
n gives a very good
function with full or
cision with a dorsothe former proximal
:s show a surprising
th--a reason for an
Edited
~. i:;!~:!~;.i
rnentary, functionally and hopelesslyblighted first pre-axial digit.
It is acknowledged that the thumbless child will endeavor to force his independent index
finger as an opponent of the other digits. What we attempt with our surgery is to complete that
!!~:!l(i
~
endeavor. Both Dr. Buck-Gramcko and Dr. Riordan now firmly believe that the digital transposition should be done during infancy. This may or may not be true for the best result. It is my
!i!i~, opinion that a non-existing thumb has no special cortical representation; any oppositional function resides in the next most independent digit, regardless of the time of any transposition.
Heretofore, I have awaited the age of from two to four, but perhaps my approach is too cautious, despite parental pressure.
Certain technical aspects are most important and of these the incision is of primary concern, for finally the closure must have allowed the digit to be shifted into proper position, providing an adequate cleft and a sufficient proximal phalangeal skin envelope to house the bulk of
the intrinsic
muscles advanced to encompass the recessed proximal phalanx (now acting as the
metacarpal).
Though it is not carefully documented in this paper, the head of the epipyseal-arrested
metacarpal fails to develop, but as shown in some of the illustrations,
the hypertrophic proximal
phalanx has taken on the characteristics
of a thumb metacarpal. It also shows good projection
(despite an incomplete carpal arch) and has a firm fibrous base to meet the oppositional demands. In the words of Sir Charles Bell:
"On the length, strength, free lateral motion and perfect mobility of the thumb, depends
thepower of the human hand. The thumb is called Pollex because of its strength;
and that
strength is necessary to the power of the hand, being equal to that of all the fingers."
It must be admitted that to bring the thumb-deprived primitive hand into a more advanced
state, the pre-axial finger can be substituted through careful surgery and that ~vith time and use,
though imperfect, its appearance and function will approach quite nearly that prime digit which
faiied to develop.
by C. B. Wynn
Deformit/it
der Hand.
ypoplasie.
Klin. Med.,
:tung bei Aplasie und
,atme~it of Congenital
~). J. Bone and Joint
:.. 6~: 403-411, 1949. :21 ?~
st. Reconstr. Surg., 34:
;sh J. Plast. Surg., 23:
m Greifst6rungen
nsposition
bei
for
~aedic Surgery, Vol. 3,
int Surg., 37-A:
7ongenital.
The Hand,
;0int Surg., 52-B:
~cological mishap Dr.
,b aplasia. His paper "
. the surgical approach
; outstanding contribu-
ncy believing that the
: ANDJOINT SURGERY~ ~i~,~ VOL. 53-A, NO. 8, DECEMBER
1971