Thumb reconstruction by free microvascular transfer of an injured index finger

Thumb reconstruction for amputation at the metacarpal phalangeal level was accomplished by microneurovascular transfer of the contralateral damaged index finger ray, including metacarpal phalangeal joint. This transfer accomplished a successful thumb restoration and removed a cumbersome index finger amputation stump, improving function in both hands. This case emphasizes the merits of spare part transfer in hand reconstructive surgery made possible by microneurovascular techniques.     

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.     

Thumb reconstruction with a sensory flap from the dorsum of the index finger.

The dorsal skin of the index ray is very useful (1) for a one-staged thumb lengthening procedure after amputation, (2) for covering the stump of an avulsed thumb with sensory skin, and (3) for expanding the first web space. The flap may be transferred as a rotation flap, or the dorsal vasculature and nerve supply to the index may be carefully dissected free as a pedicle to permit its use as a neurovascular island flap. We believe that considerably more sensory skin can be transferred by this flap than by the ring finger neurovascular island flap, and that the technical risks and surgical time are less with the index finger flap.     

Pollicization

Congenital absence or traumatic amputation of the thumb is a major disability profoundly disturbing the function of the hand, as the thumb represents an estimated 50% of total hand function. The methods for thumb reconstruction utilizing the index finger were developed some twenty years ago, and progress has been made in the last several years with emphasis on intrinsic muscle reconstruction as emphasized by Buck-Gramcko. The method, technique and anatomy of index pollicization is discussed, and representative cases presented for congenital absence of the thumb and for traumatic amputation of the thumb.     

Normal values for total hand length, palm length and middle finger length in Malaysian newborns from 34-42 weeks of gestation.

Early identification of a syndrome at birth is of paramount importance for genetic counselling and possible prevention. Often malformation of the hands and fingers are cardinal manifestations of recognizable syndromes. As there are no published standards for hand and finger size for Malay newborn infants, this study was undertaken to establish normal values for hand, middle finger and palmar lengths, and their indices. A cross-sectional study was done on 509 consecutive newborn Malay babies between 34 and 42 weeks of gestation. Measurements were made on the right hand according to the recommended guidelines of Bergsma & Feingold (1975). The mean values for the measurements did not differ significantly between boys and girls, or change with gestation. For the whole group the mean value for total hand length was 64.4 +/- 3.42 mm, middle finger length 37.1 +/- 2.91 mm, palmar length 27.4 +/- 2.15 mm, finger index 0.425 +/- 0.03 and palmar index 0.58 +/- 0.03. A comparison with published measurements for newborns of different racial origin shows significant differences for the total hand length, middle finger length and palm length from Indian and Jewish infants, but not from Japanese infants. The indices were similar in Malay, Indian, Jewish and Japanese newborn infants.     

Finger length and distal finger extent patterns in humans

The fingers in the adult human hand differ in length and in distal extent. The literature agrees that in the clear majority of males, the distal extent of the ring finger tends to be relatively greater (using the middle finger as standard) than the index finger. However, the results for females vary considerably, with some studies reporting that females show a similar pattern to that of males, while others suggest that the prevalence of a longer index finger is relatively or absolutely more common in females. We provide a review of the literature, and a set of data for both finger length and distal fingertip extent of the finger for a contemporary cohort of young adult females and males (n = 502). Finger length measures favor the ring finger of both sexes, with smaller between-finger differences for females than for males. However, while the distal fingertip extent favors the ring finger of both hands in males, in females the left hand shows no significant differences, and the right hand shows a small index finger advantage. Thus, the sexual dimorphism in finger measures is more strongly expressed in the distal extent of fingertips than in the length of fingers. The sex differences in distal fingertip extent derive from the index finger only, with a lesser distal extent of the index finger, relative to the middle finger, in males than in females.     

Rehabilitation process and functional results of patients with amputated fingers

Digit amputation is a physical and psychological trauma that can influence the daily living of a person. The rehabilitation of patients with digit amputation is a complex process and should take into consideration all influencing factors, such as the functional, emotional, social, and professional profile of the patient. This study was conducted to evaluate the functional level of patients with amputated fingers and to understand the factors that influence their rehabilitation. Fifty patients (42 male and 8 female with an age ranging from 7 to 84 years) who had digit amputation(s) between January of 1990 and December of 1998 at the level of the metacarpus or distal to it and who had at least 6 months of follow-up were examined. The patients were divided into three different study groups: patients with distal amputation were compared with patients who had proximal amputation, patients with one finger amputation were compared with patients who had multiple finger amputations, and patients who suffered finger amputations caused by work-related accidents were compared with those who suffered amputations caused by other incidents. In addition, the time lapse from the amputation was checked as an influencing factor for different functional levels. The results showed that patients with distal amputation reached a higher motor and sensory functional level than patients with proximal amputation. Patients with one-finger amputation reached higher motor, sensory, and activities of daily living functional levels than patients with multiple amputations, and the level of motor and sensory function of patients with finger amputations caused by work-related accidents was lower than that of patients who suffered amputations in other incidents. Time was proven to be an important factor in the process of motor and emotional recovery.     

Measurement of pulsatile limb and finger blood flow by electrical impedance plethysmography: Criteria for the diagnosis of abnormal flow

The range of pulsatile arm and finger blood flow, measured by electrical impedance plethysmography, has been investigated in a hospital ward. The range of absolute blood flows, in ml min⁻¹, was found to be too wide to be used as a standard for identifying single blood flow readings as being abnormal. A blood flow ratio was calculated by dividing the blood flow in the right forearm or middle finger by the blood flow in the left forearm or middle finger. This ratio was found to have a clearly defined range. A blood flow in a unilaterally injured or otherwise abnormal arm or finger was considered to be significantly altered if the blood flow ratio fell outside the previously defined normal range. The diagnosis of significantly altered arm and finger blood flow from abnormalities in the blood flow ratio was tested in a series of experiments, in which artificial changes in upper limb flow were created by high elevation of the right hand. The ratio was measured in 11 patients with unilateral upper limb injuries and in 3 patients who required an urgent assessment of the upper limb circulation. Abnormalities in the ratio were identified in 12 out of 18 subjects after high elevation of the hand and in 8 out of the 14 patients.     

Development of a Prototype Over-Actuated Biomimetic Prosthetic Hand

The loss of a hand can greatly affect quality of life. A prosthetic device that can mimic normal hand function is very important to physical and mental recuperation after hand amputation, but the currently available prosthetics do not fully meet the needs of the amputee community. Most prosthetic hands are not dexterous enough to grasp a variety of shaped objects, and those that are tend to be heavy, leading to discomfort while wearing the device. In order to attempt to better simulate human hand function, a dexterous hand was developed that uses an over-actuated mechanism to form grasp shape using intrinsic joint mounted motors in addition to a finger tendon to produce large flexion force for a tight grip. This novel actuation method allows the hand to use small actuators for grip shape formation, and the tendon to produce high grip strength. The hand was capable of producing fingertip flexion force suitable for most activities of daily living. In addition, it was able to produce a range of grasp shapes with natural, independent finger motion, and appearance similar to that of a human hand. The hand also had a mass distribution more similar to a natural forearm and hand compared to contemporary prosthetics due to the more proximal location of the heavier components of the system. This paper describes the design of the hand and controller, as well as the test results.     

Anatomical variations of the extensor tendons to the fingers over the dorsum of the hand: a study of 50 hands and a review of the literature

The extensor tendons to the fingers were studied in dissections of 50 fresh cadaveric hands, and the divisions of the tendons, as well as the communications (juncturae), were analyzed. The pattern of distribution most frequently observed was as follows. The extensor digitorum communis provided one tendon to the index finger, one to the middle finger, two to the ring finger, and none to the little finger. The extensor indicis exhibited one tendon, whereas the extensor digiti minimi exhibited two tendons. The extensor indicis tendon was always observed to lack a junctura tendinum. The extensor indicis was absent in both hands of one cadaver. A tendon slip from the extensor digiti minimi to the ring finger was observed in one hand. All surgeons must bear in mind the existence of these variations when performing common tendon transfers.     

Replantation of fingertip amputation by using the pocket principle in adults

There are several treatment modalities for zone 1 or zone 2 fingertip amputations that cannot be replanted by using microsurgical techniques, such as delayed secondary healing, stump revision, skin graft, local flaps, distant flaps, and composite graft. Among these, composite graft of the amputated digit tip is the only possible means of achieving a full-length digit with a normal nail complex. The pocket principle can provide an extra blood supply for survival of the composite graft of the amputated finger by enlarging the area of vascular contact. The surgery was performed in two stages. The amputated digit was debrided, deepithelialized, and reattached to the proximal stump. The reattached finger was inserted into the abdominal pocket. About 3 weeks later, the finger was removed from the pocket and covered with a skin graft. We have consecutively replanted 29 fingers in 25 adult patients with fingertip amputations by using the pocket principle. All were complete amputations with crushing or avulsion injuries. Average age was 33.64 years, and men were predominant. The right hand, the dominant one, was more frequently injured, with the middle finger being the most commonly injured. Of the 29 fingers, 16 (55.2 percent) survived completely and 10 (34.5 percent) had partial necrosis less than one-quarter of the length of the amputated part. The results of the above 26 fingers were satisfactory from both functional and cosmetic aspects. Twenty of the 29 fingers, which had been followed up for more than 6 months (an average of 16 months), were included in a sensory evaluation. Fifteen of these 20 fingers (75 percent) were classified as "good" (static two-point discrimination of less than 8 mm and normal use). From the overall results and our experience, we suggest that the pocket principle is a safe and valuable method in replantation of zone 1 or zone 2 fingertip amputation, an alternative to microvascular replantation, even in adults.     

The cross-hand finger transfer.

This report is of the first successful case we know of transplantation of a ray (finger and metacarpal) from one hand to another. The transfer was accomplished by a two-stage pedicle technique. The tendons and nerves were left long in the donor finger, and were anastomosed at the second stage when the pedicle was divided. Good sensation was obtained. Active tendon function resulted, with excellent power and range of motion in all of the digits of both hands.     

Patient-specific prosthetic fingers by remote collaboration--a case study

The concealment of amputation through prosthesis usage can shield an amputee from social stigma and help improve the emotional healing process especially at the early stages of hand or finger loss. However, the traditional techniques in prosthesis fabrication defy this as the patients need numerous visits to the clinics for measurements, fitting and follow-ups. This paper presents a method for constructing a prosthetic finger through online collaboration with the designer. The main input from the amputee comes from the Computer Tomography (CT) data in the region of the affected and the non-affected fingers. These data are sent over the internet and the prosthesis is constructed using visualization, computer-aided design and manufacturing tools. The finished product is then shipped to the patient. A case study with a single patient having an amputated ring finger at the proximal interphalangeal joint shows that the proposed method has a potential to address the patient's psychosocial concerns and minimize the exposure of the finger loss to the public.     

Independent responses of Pacinian and Non-Pacinian systems with hand-transmitted vibration detected from masked thresholds

This study was designed to identify psychophysical channels responsible for the detection of hand-transmitted vibration. Perception thresholds for vibration (16, 31.5, 63 and 125?Hz sinusoidal for 600?ms) at the distal phalanx of the middle finger and the whole hand were determined with and without simultaneous masking stimuli (1/3 octave bandwidth Gaussian random vibration centered on either 16?Hz or 125?Hz for 3000?ms, varying in magnitude 0 to 30?dB above threshold). At all frequencies from 16 to 125?Hz, absolute thresholds for the hand were significantly lower than those for the finger. Changes in threshold as a function of masker level were used to estimate the thresholds of three psychophysical channels (i.e. P, NP I, and NP II channels). Increased vibrotactile sensitivity of the hand compared to the finger seems to be not entirely due to increased spatial summation via the Pacinian system (P channel); non-Pacinian system (NP I and NP II channels) also contributed to perception. Differing transmission of vibration between the hand and the finger may have also influenced the thresholds.     

Independent responses of Pacinian and Non-Pacinian systems with hand-transmitted vibration detected from masked thresholds

This study was designed to identify psychophysical channels responsible for the detection of hand-transmitted vibration. Perception thresholds for vibration (16, 31.5, 63 and 125 Hz sinusoidal for 600 ms) at the distal phalanx of the middle finger and the whole hand were determined with and without simultaneous masking stimuli (1/3 octave bandwidth Gaussian random vibration centered on either 16 Hz or 125 Hz for 3000 ms, varying in magnitude 0 to 30 dB above threshold). At all frequencies from 16 to 125 Hz, absolute thresholds for the hand were significantly lower than those for the finger. Changes in threshold as a function of masker level were used to estimate the thresholds of three psychophysical channels (i.e. P, NP I, and NP II channels). Increased vibrotactile sensitivity of the hand compared to the finger seems to be not entirely due to increased spatial summation via the Pacinian system (P channel); non-Pacinian system (NP I and NP II channels) also contributed to perception. Differing transmission of vibration between the hand and the finger may have also influenced the thresholds.     

An Anthropomorphic Robot Hand Developed Based on Underactuated Mechanism and Controlled by EMG Signals

When developing a humanoid myo-control hand,not only the mechanical structure should be considered to afford a highdexterity,but also the myoelectric (electromyography,EMG) control capability should be taken into account to fully accomplishthe actuation tasks.This paper presents a novel humanoid robotic myocontrol hand (AR hand Ⅲ) which adopted an underac-tuated mechanism and a forearm myocontrol EMG method.The AR hand Ⅲ has five fingers and 15 joints,and actuated by threeembedded motors.Underactuation can be found within each finger and between the rest three fingers (the middle finger,the ringfinger and the little finger) when the hand is grasping objects.For the EMG control,two specific methods are proposed:thethree-fingered hand gesture configuration of the AR hand Ⅲ and a pattern classification method of EMG signals based on astatistical learning algorithm-Support Vector Machine (SVM).Eighteen active hand gestures of a testee are recognized ef-fectively,which can be directly mapped into the motions of AR hand Ⅲ.An on-line EMG control scheme is established basedon two different decision functions:one is for the discrimination between the idle and active modes,the other is for the recog-nition of the active modes.As a result,the AR hand Ⅲ can swiftly follow the gesture instructions of the testee with a time delayless than 100 ms.     

Balancing a force on the fingertip of a two-dimensional finger model without intrinsic muscles

A slightly flexed human middle finger can balance an external force on the fingertip. Internal stabilization is also possible, which means that the externally unloaded finger can be kept stiff. We want to analyse whether in these situations the intrinsic hand muscles are needed. Distances from tendons to flexion axes are taken from the literature and are substituted in the moment equilibrium equations of a two-dimensional finger model. Diagrams illustrate the statically indeterminate problem of solving tendon forces. The possibilities for equilibrium without intrinsics appear to depend mainly on four tendon-to-joint distances. These distances determine to which of two groups a finger belongs: (1) one in which intrinsics are not necessary for internal stabilization nor for balancing a force on the fingertip in any direction in the sagittal plane; (2) one in which, without intrinsics, internal stabilization is impossible and only dorso-distally directed forces on the fingertip can be balanced.     

The natural history of the growth of the hand: I. Hand area as a percentage of body surface area

The use of a patient's own hand as a tool to estimate the area of burn injury is well documented. The area of the palmar surface of one hand has been estimated to be 1 percent of the body surface area. The area of the palmar surface of the hand was measured to test the accuracy of this estimate and then compared with the body surface area as calculated by formulas in common use. This study also sought to determine the natural history of the growth of the hand to permit development of a readily available, bedside means of estimating hand area and body surface area. Bilateral hand tracings were obtained from 800 volunteers ranging in age from 2 to 89 years. The area of each tracing was determined using an integrating planimeter. The height and weight of each individual were measured, and his/her body surface area was calculated. The palmar hand's percentage of body surface area was determined by calculating the quotient for hand area divided by body surface area. Additionally, the width of the hand was measured from the ulnar aspect at the palmar digital crease of the small finger to the point where the thumb rested against the base of the index finger. The length of the hand was measured from the middle of the interstylon to the tip of the middle finger. These two figures were multiplied together to obtain a product which approximated the area of the hand. Based on the most commonly used DuBois formula for calculating body surface area, the area of palmar surface of the hand corresponds to 0.78 +/- 0.08 percent of the body surface area in adults. The percentage varies somewhat with age and reaches a maximum of 0.87 +/- 0.06 percent in young children. Multiplying the length of the hand by its width overestimates the area of the hand as determined by planimetry by only 2 percent. A patient's own hand may be used as a complementary, readily available template for estimation of burn area or other areas of disease or injury. In adults, the area of tracing of the outline of the hand is 0.78 percent of the body surface area, whereas in children, this number tends to be slightly higher. In the emergency room or on the wards, a simple product of length multiplied by width of the hand will closely approximate the area as determined by planimetry. This method allows a more accurate determination of the area of the palmar surface of the hand than the 1 percent estimate, which may lead to an overestimation of the size of a burn wound in adults.     

Morphological observations on the congenital malformation of limbs in the Japanese monkey

Congenital malformation of limbs is found in many troops of the Japanese monkey. The author morphologically examined more than ten monkeys with such malformations by means of palpation and Röntgenographing. Anatomical dissection was performed on two of these monkeys. Malformation manifests a considerable variety of forms, from the reduction or absence of fingers to almost total lack of limbs, and is prone to occur in the region of the third finger, the center of malformation, occasionally showing a “split” or “cleft” hand or foot. The latter tendency is more conspicuous in the hand than in the foot. In a word, most of the malformations are characterized by congenital amputation, though the degree varies considerably. The occurrence of supernumerary digits was not found and fusion between fingers was rare. One of the most interesting anatomical results found may be the continuation or fusion between muscles which are normally opposed to each other in action. The occurrence of malformation is more frequent in the male than in the female, and in the hand than in the foot. Little is known about the causes of such malformations, except that they do not occur, at least, according to dominant inheritance.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.