FIG. 28-35. One-year follow-up shows excellent pinch and a wide web space.
FIG. 28-36. The patient can pick up large objects and has useful sensation.
FIG. 28-37. The donor site is well healed, and the patient has no gait problems.
A 9-year-old girl had sustained extensive crushing burns after an automobile accident 7 years ago.
FIG. 28-38. The patient's mitten left hand was covered with scarred, unstable skin grafts over the metacarpal stumps.
FIG. 28-39. The preoperative radiograph shows loss of all metacarpophalangeal joints except the thumb, which is subluxed.
FIG. 28-40. First-stage reconstruction was performed with simultaneous transplantation of a second toe and a serratus muscle to rebuild the thenar prominence and resurface the dorsum of the hand. Second toe is next to thumb metacarpal. The unstable skin graft was removed from dorsum and other metacarpal stumps.
FIG. 28-41. Arterial inflow to the two flaps was provided by end-to-end anastomosis of the first dorsal metatarsal artery to the radial artery which perfused the toe. The thoracodorsal artery feeding the serratus was anastomosed to the proximal communicating branch of the first dorsal metatarsal artery which had been mobilized and tied long for this purpose. Outflow was through similar internal shunts to the superficial dorsal veins of the wrist. Mesh graft over serratus.
FIG. 28-42. Seven months later, the second-stage reconstruction to restore pinch was performed by transplantation of a second toe/third toe block from the opposite foot. The two adjacent toes have been isolated from the left foot for transfer to the ulnar neurovascular pedicle.
FIG. 28-43. The recipient ring and small finger metacarpals were hollowed to receive the toes fixed in place with bone pegs from the resected second metatarsal. Models of positional toes. Right, toe in place.
FIG. 28-44. Sensate three-fingered chuck pinch, one of the most sophisticated of hand functions, has been restored.
FIG. 28-45. Patient is tying shoes with her MMVTs, simultaneously and in sequence.
A 37-year-old mechanic caught his right hand in the engine fan of an industrial earthmover. The dorsal injury destroyed his metacarpals, but left him with sensate, vascularized fingers and a badly injured thumb.
FIG. 28-46. Preoperative view following debridement and placement of external fixation.