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AMPUTATION, THUMB

Introduction

Hand injuries continue to be problems that are frequently seen in emergency departments (ED) around the world. In the United States, digital amputations are very common in both the work environment1and in the home.2 Thumb amputations can be partial or complete, and work-related amputations are prevalent in young males (>80%) with limited education beyond high school.1 Most work-related amputations occur during the regular work week, while using machines such as saws, punch presses, food and beverage machines, and printing presses.2,3 The industries where amputations are common include agriculture, forestry, fishing, manufacturing, and construction.1 In many cases, machinery guards and shields are not used by the workers who injure themselves.

The thumb is the most important digit of the hand, accounting for approximately 40% of its function.4 As a result, compared with other fingers, losing the thumb is associated with a much more substantial decline in pinch and grip strength and normal abilities.5 This is why many experts recommend that replantation should be attempted in all cases of thumb amputation to increase the chances of preserving hand function.6

Definitions

A thumb amputation is the loss of any part the first digit, and the lost tissue in this injury may or may not include bone.1 The thumb amputation can be partial or complete.2 With a partial amputation, there may be a skin bridge still connecting the distal part of the thumb to the stump. In complete amputations, there is no visible connection between the amputated part of the thumb and the stump. Amputations may also be defined by the level of the transection. For example, the amputation level may be through the fingertip and fingernail, through the distal phalanx, through the interphalangeal (IP) joint, or through the proximal phalanx.

Related Anatomy

Obviously, complete amputation of the thumb involves all the tissues in the amputated part. Therefore, a thumb amputation involves the skin, veins, extensor tendons, bone, flexor tendons, digital nerves, and digital arteries.

 

Amputation

Replant

Bone
  • Shorten bone to allow for good soft tissue coverage of bone end
  • Debride bone ends and shorten proximal and/or distal to remove tension on microsurgical repairs.
  • Do some type of ORIF for the bone
Flexor tendons
  • Debride and allow ends to retract
  • Do not suture tendon over the end of bony stump
  • Repair flexor tendons
Extensor tendons
  • Debride damaged edge
  • Repair the extensor tendon
Digital arteries
  • Cauterize digital arteries at the stump level
  • Microsurgical repair
Digital nerves
  • Pull digital nerve endings distally, cut sharply and allow ends to retract in surrounding soft tissue
  • Microsurgical repair
Veins
  • Cauterize veins on the stump
  • Microsurgical repair
Skin
  • Maintain healthy viable skin for stump coverage
  • Maintain healthy viable skin for coverage of the circumferential wound.  These wounds do not always require formal closure.
  • There are several classification systems for traumatic thumb amputations, one of which divides them into the following 4 groups:
    • Group 1: amputation at or distal to the IP joint; rarely results in a functional deficit and is termed a compensated amputation
    • Group 2: subtotal amputation of the proximal phalanx with questionable remaining length; results in reduced hand span, difficulty grasping large objects, and fine pinch limitations
    • Group 3: total thumb amputation with preservation of the basal joint; results in substantial impairment 
    • Group 4: total thumb amputation with loss of the basal joint; extremely difficult to treat with few reconstructive options available4

Overall Incidence

  • Conn and colleagues reported that there are >30,000 non-work-related finger amputations annually in the U.S.2 They also identified two high-risk groups: children aged <5 years and adults, usually males, aged >55 years.
    • Of >30,000 digital amputations, 13.6% involved the thumb.
    • Children often get a finger or thumb shut in a door, and adults are usually injured by power saws, snow blowers, and other machinery.
    • Digits were also found to be lost secondary to a cut, crush, bite, or burn.
    • Factors such as alcohol use, fatigue, decreased dexterity, and reflex time and medication use were cited as frequent secondary causes associated with these injuries.
  • Another study used 3 years of data from the National Inpatient Sample of the Healthcare Cost and Utilization Project to identify 9,407 upper extremity amputations.7
    • A total of 1,947 (20.7%) amputations involved the thumb.
    • Approximately 15% of these amputations underwent replantation, including 27% of patients with a thumb amputation. The mean cost of replantation was >$40,000.
  • In the U.S., amputations are very common in the workplace:
    • Amputation rates vary from 1.5-3.7 per 10,000 full-time workers per year.1
    • Single digit amputations occur 81% of the time, and multiple digital amputations in 14%. Of the single digit amputations, the thumb was involved in 10% of cases.1
    • In North Carolina between 2004 and 2006, the amputation rate was 21.3 amputations per one million people. There was no correlation to increased numbers of immigrants.3
  • Another study found that the rate of attempted thumb replantations remained about the same between 2007-2012, decreasing slightly during this period from 37% to 34%.5

Related Injuries/Conditions

  • The majority of upper extremity amputations are secondary to traumatic injuries; however, amputations are also performed surgically to treat severe burns, neoplasms, and uncontrollable chronic infections.
  • Amputations are also the treatment-of-choice for subungual malignant melanomas.8
  • Congenital amputations are very rare: the Centers for Disease Control and Prevention estimates 4/10,000 babies are born with upper limb reductions.9

Differential Diagnosis

  • Traumatic amputation
  • Surgical amputation for tumor, severe burns or infection control
  • Congenital amputation
ICD-10 Codes

  • AMPUTATION, THUMB

    Diagnostic Guide Name

    AMPUTATION, THUMB

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    AMPUTATION, THUMB, TRAUMATIC    
    - METACARPOPHALANGEAL; COMPLETE S68.012_S68.011_ 
    - METACARPOPHALANGEAL; PARTIAL S68.022_S68.021_ 
    - TRANSPHALANGEAL; COMPLETE S68.512_S68.511_ 
    - TRANSPHALANGEAL; PARTIAL S68.522_S68.521_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S68
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Thumb Amputations
  • Left thumb amputation with avulsion component not acceptable for replantation
    Left thumb amputation with avulsion component not acceptable for replantation
  • Right thumb amputation with very little bone left in distal part.
    Right thumb amputation with very little bone left in distal part.
  • Partial amputation secondary to a saw injury with large avascular volar flap.
    Partial amputation secondary to a saw injury with large avascular volar flap.
  • Thumb tip amputation with palm devolving injury treated thinning reattaching of the palmar flap and amputation revision.
    Thumb tip amputation with palm devolving injury treated thinning reattaching of the palmar flap and amputation revision.
  • Thumb amputation through proximal phalanx guillotine amputation.
    Thumb amputation through proximal phalanx guillotine amputation.
Symptoms
History of traumatic amputation, surgical amputation, or birth defect causing a congenital amputation
Bandaged amputation stump
Amputated part frequently arrives with the patient
Typical History

The typical patient is a right-handed, male construction worker aged 24-29 years who injured himself on the job. The man was cutting a 2x4 beam with a miter saw without the safety guard in use when his hand that was holding the beam slipped and placed his thumb in the path of the blade. This resulted in a clean, complete amputation of his thumb just distal to the IP joint. He subsequently preserved the amputated part of his thumb and rushed immediately to the ED.

If the patient is aged <5 years, the typical injury will be a crush injury from the thumb being caught in a house or car door while closing. If the patient is a homeowner, he will likely be aged >55 years, and the amputation will be caused by a power tool like a table saw, skill saw, or lawnmower. Secondary factors may include: alcohol use, fatigue, decreased dexterity, decreased reflex time, and/or medication use.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Thumb Amputation X-rays
  • Thumb amputation through IP joint area (arrow). Note distal phalanx fragments still attached to the volar plate.
    Thumb amputation through IP joint area (arrow). Note distal phalanx fragments still attached to the volar plate.
  • AP X-ray of thumb amputation through IP joint area (arrow). Note distal phalanx fragments still attached to the volar plate.
    AP X-ray of thumb amputation through IP joint area (arrow). Note distal phalanx fragments still attached to the volar plate.
  • X-ray of thumb amputated part through IP joint area. Part x-rays very important when assessing replantation options. Note significant bone loss from the distal phalanx.
    X-ray of thumb amputated part through IP joint area. Part x-rays very important when assessing replantation options. Note significant bone loss from the distal phalanx.
  • Successful thumb IP joint fusion with shortening done during thumb tip replantation.
    Successful thumb IP joint fusion with shortening done during thumb tip replantation.
Treatment Options
Treatment Goals
  • Treatment goals for amputation revision include: (1) preserve stump length; (2) provide a stump with durable soft tissue coverage, intact sensation and minimal neuroma pain; (3) keep salvaged joints mobile; (4) minimize downtime with speedy return to work and vocational activities; (5) when appropriate, provide timely referrals for hand therapy and prosthetic fitting.3,10
  • Treatment goals for replantation of an amputated thumb are similar: (1) save a functional thumb by providing an intact, mobile, pain-free sensate digit; (2) minimize cold intolerance; (3) provide efficient post-operative care, rehabilitation, and early return to work and activities of daily living.7,10
  • Algorithms are available to guide thumb reconstruction decisions, but given the complexities of various patient and technical factors, treatment is often individualized. With initial traumatic thumb amputations, replantation should be the first consideration. If this is not possible, there are several reconstructive options to evaluate, the timing of which can be short or delayed depending on the circumstance, patient factors, and surgeon preference.11
Conservative
  • Usually only limited to distal amputations that occur at the tip of the thumb and have little or no bone exposed are ideal for nonoperative treatment.
  • These distal tip injuries can be treated with a small amount of bone resection if needed, followed by daily dressing changes.
  • Conservative management allows for healing by secondary intent.
  • Typically, this treatment approach provides an excellent coverage and a very good cosmetic and functional result with nearly normal sensation.
  • Allowing an open amputation to heal without surgery by secondary intention may also be needed for amputations performed for infections.
Operative
  • The two primary surgical options for thumb amputations are replantation and amputation revision with closure of the stump.
  • Amputation revision includes rongeuring back the protruding bone to shorten it if needed so that the soft tissues can be sutured over the bone ends without excessive tension.
  • Revision also includes cauterizing the digital arteries and veins distally, gently pulling the digital nerves distally and the resection of the distal nerve sharply and proximally so that the digital nerve can retract into the soft tissues of the stump.
  • This maneuver is performed to minimize neuroma symptoms.
  • If the amputation is at the level of the proximal nail base, then complete excision of the nail matrix on both sides of the nail fold is imperative to prevent the development of nail horns.
  • The angle of the amputation will dictate to a large extent which surgical options are available to revise and close the amputation stump.
  • Many experts recommend attempting replantation in all thumb amputations to preserve hand function. During replantation, digital arteries are usually chosen for anastomosis, but the procedure can occasionally become difficult when there is severe damage to the digital artery.6  Because of the thumb's anatomical position on the hand, digital artery microsurgical repairs can be diffucult after ORIF  of the bone.  To avoid this problem, some microsurgeons recommend a vein graft which is attached to the thumb digital artery before ORIF of the bone.  After the ORIF the vein graft is finally attached to the radial artery.
  • Other surgical techniques that have been used to maintain length and still provide adequate amputation stump coverage include:
    1. Split-thickness skin grafts12
      • These are sometimes complicated by chronic fissures and decreased sensation
    2. Volar "V-Y" advancement flaps13
    3. Lateral "V-Y” advancement flaps14
    4. Volar Moberg type advancement flaps15. This  flap can be especially useful in the distal thumb amputations.
    5. Cross-finger and reverse cross-finger flaps16
    6. Thenar flaps17
    7. Island flaps18-20
    8. Antegrade and retrograde advancement flaps
    9. Ray amputations21,22
  • The Moberg flap is considered a standard option for medium-sized defects of the thumb pulp. Modifications to lengthen the distal advancement of the flap involve V-Y flaps, bilateral Z-plasties, Burow triangles, lateral triangular flaps at the proximal edge of the flap, or the advancement of an island flap with skin grafting of the secondary defect.23
  • Numerous options exist for reconstructing thumb tip defects, but the semi-occlusive method has evolved into the standard procedure. This technique provides excellent restoration of contour, volume, and sensibility, and is therefore suitable for most small to midsize thumb tip defects.19
  • For larger, complex defects, flap reconstruction is useful. A broad armamentarium of flaps is available for thumb reconstruction, including homodigital flaps, heterodigital (cross-finger) flaps, distant island flaps, metacarpal perforator, and microsurgical free, and the surgeon must decide which of these best meets the patient’s needs.19
  • Toe-to-thumb transfer is another available option that has become an accepted practice for thumb reconstruction after amputation, as the procedure provides length and a digit to the hand. It may be advised for amputations at or proximal to the mid-proximal phalanx, and in some cases of total thumb amputation in which the carpometacarpal (CMC) joint is preserved.11,24
Treatment Photos and Diagrams
Thumb Amputation Revisions and Replantations
  • Successful thumb replantation immediately after surgery.
    Successful thumb replantation immediately after surgery.
  • Thumb amputation through distal proximal phalanx treated by replantation.
    Thumb amputation through distal proximal phalanx treated by replantation.
  • Mangled partial thumb amputation saved by revascularization of volar flap. (arrow)
    Mangled partial thumb amputation saved by revascularization of volar flap. (arrow)
  • Dorsal view of partial thumb amputation saved by revascularization.
    Dorsal view of partial thumb amputation saved by revascularization.
  • Failed thumb replant done for thumb amputation caused by a log splitter accident.
    Failed thumb replant done for thumb amputation caused by a log splitter accident.
  • Revision of failed replantation of log splitter thumb amputation prior to index pollicization.
    Revision of failed replantation of log splitter thumb amputation prior to index pollicization.
  • Adult index pollicization to reconstruct failed replantation of log splitter thumb amputation.
    Adult index pollicization to reconstruct failed replantation of log splitter thumb amputation.
  • Primary revision of a crush avulsion thumb amputation through the proximal phalanx.
    Primary revision of a crush avulsion thumb amputation through the proximal phalanx.
CPT Codes for Treatment Options

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Common Procedure Name
Pollicization of digit
CPT Description
Pollicization of digit
CPT Code Number
26550
Common Procedure Name
Amputation revision
CPT Description
Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure
CPT Code Number
26951
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Hand Therapy
  • For thumb amputations that are allowed to heal by secondary intention, the hand therapist is an excellent resource to teach the patient proper techniques for soaking the amputated stump and performing daily dressing changes.
  • Patients wirth thumb amputations may also need referral to an orthotist/prosthetist for evaluation, constructing and fitting of a cosmetic or functional prosthesis. 
  • A hand therapist can also help patients recovering from more aggressive thumb amputation treatment in the following ways:
    1. Instruct on how to maintain active range of motion (ROM) in the salvage joint(s)
    2. Decrease finger edema by massage and stump wrapping
    3. Minimize neuroma symptoms by desensitization techniques
    4. Teach prosthetic use and care when appropriate
Complications
  • Symptomatic neuroma and diminished stump sensation
  • Psychological trauma, time off from work and job change or loss1
  • Wound complications such as infections
  • Bone overgrowth at stump end
  • Loss of range of motion in the remaining thumb joint(s)
  • Contractures in the joint(s) of the amputated finger
  • Phantom limb sensation and pain
  • Replant failure and need for secondary amputation revision
  • Cold intolerance from the amputated stump or replanted thumb
  • Fingernail deformity and nail horns10
  • In one study of 36 patients who underwent pulp reconstruction of the thumb, the most common complaints were cold sensitivity and pain, which 36% of patients experienced.23,25
Outcomes
  • Digital replantation procedures achieve an average 86% survival rate of the distal part.20  Guillotine amputations do better than crush type injuries.10,26
  • Active range of motion usually is greater after digital replantation.
  • Digital replantation is usually associated an excellent cosmetic result; however, paresthesias and cold intolerance are present after amputation revision and after successful replantation surgery.27 Pain can be a posttraumatic complaint in both groups.
  • Amputation revision remains a straightforward procedure that is frequently done without hospitalization; rehabilitation and time lost from work is usually shorter for amputation revision surgery than for replantation.
  • Despite this, lost time from work, lost jobs and placement in alternative work remain occurrences that workers often experience after a finger or thumb amputation.1
  • Pulp atrophy and nail deformity occur after replantation surgery at rates of 14% and 24%, respectively.26
  • Despite the fact that multiple reconstructive options are available for thumb amputations, literature regarding outcomes and comparative data is lacking; however, all reconstruction methods have been found to be beneficial compared with no treatment.4
  • Replantation for thumb amputations has been associated with a favorable survival rate of 74-92% and benefits such as adequate range of motion and sensory return. It is also a cost-effective procedure, with the majority of patients being able to return to their previous occupation and their daily living activities. This is why many experts recommend replantation whenever it is clinically possible.5. Another study evaluated long-term subjective and functional scores of thumb replantation, and found that no reconstructive procedure could be compared with a successful replantation. These authors therefore also reinforced that it should be mandatory to attempt replantation in every thumb amputation.28
  • One study compared 21 patients with thumb MP joint amputations, with 16 undergoing toe transfer and 5 not undergoing reconstruction. At 7 years, toe transfer had significantly higher vocational function scores, and the trimmed great toe transfer generally regained better hand function and cosmesis than the second toe transfer.29
  • One study of 21 toe-to-thumb transfers in children found the procedure to be reliable, with no failures and no reexplorations, and excellent long-term functional and psychosocial outcomes. The great toe provided better function and appearance than second toe transfers, and all children regained pinch and grasp function and subjective sensation similar to the contralateral thumb or an adjacent finger.24
YouTube Video
Replantation and Microsurgery
Key Educational Points
  • Thumb tip amputations that involved no bone or minimal bone can be managed effectively by minimal debridement and bone shortening followed by dressing change therapy. This treatment allows stump healing by secondary intention.
  • Amputations to the thumb IP joint that are not amenable to replantation should be revised by removing the cartilage and some bone from the proximal phalanx head to provide a stump that is not overly bulbous.
  • All revision amputations have neuromas, and all replanted thumbs have either neuroma incontinuity or neuroma if the nerves were not repaired.
  • Symptomatic amputation neuromas are complex problems with no simple answer.  Centro-central union of the digital nerves and the stump may decrease these annoying and troublesome symptoms.30
  • Patients with elective and traumatic amputations should be advised early about phantom sensations and/or phantom pain. These patients should be advised to ignore these disrupted perceptions that are caused by the damaged nerve endings sending the brain corrupted messages that are perceived as pain or the feeling that the amputated thumb is still present.
  • Partial or complete amputation of the thumb will leads to considerable impairment in hand function that will often require significant functional adaptations from the patient.23
  • Although local flap coverage has the benefit of preserving the thumb length and is preferred for wound closure after bone shortening, it is not feasible in patients with extremely large defects or in cases where the adjacent tissue is in poor condition.19
  • Although replantation is recommended for most traumatically amputated thumbs, it may not be superior to revision in isolated thumb amputations distal to the proximal third of the proximal phalanx. Hand function is maximized by replantation in certain individuals, but in others, revision of the amputation is the most suitable form of treatment.31
  • Reconstruction of thumb tip amputations and acceptable functional and cosmetic outcomes remain a challenge for the hand surgeon because of the limited availability of local soft tissue. The intrinsic flaps are well established for thumb tip reconstruction in complex defects, but in recent years the methods of reconstruction have changed dramatically.19
  • Thumb replantation remains relatively uncommon in the U.S. compared to other developed countries despite the fact that it’s associated with long-term functional and economic benefits. In 2001, 2004, and 2007 combined, only 27% of thumb amputations were replanted in the United States, and a 2007 survey of hand surgeons indicated that only 56% perform replantation.5
References

New and Cited Articles

  1. Boyle, D, Parker, D, Larson, C, et al. Nature, incidence, and cause of work-related amputations in Minnesota. Am J Ind Med 2000;37(5):542-50.PMID: 10723048
  2. Conn, JM, Annest, JL, Ryan, GW, et al. Non-work-related finger amputations in the United States, 2001-2002. Ann Emerg Med 2005;45(6):630-5.PMID: 15940097  
  3. Gavrilova, N, Harijan, A, Schiro, S, et al. Patterns of finger amputation and replantation in the setting of a rapidly growing immigrant population. Ann Plast Surg 2010;64(5):534-6. PMID: 20395810
  4. Graham, DJ, Venkatramani, H and Sabapathy, SR. Current Reconstruction Options for Traumatic Thumb Loss. J Hand Surg Am 2016;41(12):1159-1169.PMID: 27916148
  5. Mahmoudi, E, Huetteman, HE and Chung, KC. A Population-Based Study of Replantation After Traumatic Thumb Amputation, 2007-2012. J Hand Surg Am 2017;42(1):25-33. PMID: 28052825
  6. Cho, SH, Bahar-Moni, AS and Park, HC. Thumb Replantation Using the Superficial Palmar Branch of the Radial Artery. J Hand Microsurg 2016;8(2):106-8. PMID: 27625540
  7. Friedrich, JB, Poppler, LH, Mack, CD, et al. Epidemiology of upper extremity replantation surgery in the United States. J Hand Surg Am 2011;36(11):1835-40. PMID: 21975098
  8. Martin, DE, English, JC and Goitz, RJ. Subungual malignant melanoma. J Hand Surg Am 2011;36(4):704-7. PMID: 21277700
  9. Upper and lower limb reduction defects. Centers for Disease Control and Prevention2018-4-20. Retrieved 2018-09-12.
  10. Jebson PL, Louis DS, Bagg M. Amputations. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery 6thEdition, Philadelphia. Elsevier Churchill Livingstone, 2010.
  11. Engdahl, R and Morrison, N. Traumatic thumb amputation: case and review. Eplasty 2015;15:ic18. PMID: 25834698
  12. Moynihan, FJ. Long-term results of split-skin grafting in finger-tip injuries. Br Med J 1961;2(5255):802-6. PMID: 13773383
  13. Atasoy, E, Ioakimidis, E, Kasdan, ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am 1970;52(5):921-6. PMID: 4920906
  14. Kuyler, W. A new method for fingertip amputation. JAMA1947;133(1):29. PMID: 20277556
  15. Snow, JW. The use of a volar flap for repair of fingertip amputations: a preliminary report. Plast Reconstr Surg 1967;40(2):163-8.PMID: 5340493
  16. Johnson, RK and Iverson, RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am 1971;53(5):913-9. PMID: 4934075
  17. Smith, RJ and Albin, R. Thenar "H-flap" for fingertip injuries. J Trauma 1976;16(10):778-81. PMID: 792463
  18. Foucher, G and Khouri, RK. Digital reconstruction with island flaps. Clin Plast Surg 1997;24(1):1-32. PMID: 9211025
  19. Germann, G, Rudolf, KD, Levin, SL, et al. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am 2017;42(4):274-284. PMID: 28372640
  20. Henry, M and Stutz, C. Homodigital antegrade-flow neurovascular pedicle flaps for sensate reconstruction of fingertip amputation injuries. J Hand Surg Am 2006;31(7):1220-5. PMID: 16945731
  21. Carroll, RE. Transposition of the index finger to replace the middle finger. Clin Orthop 1959;15:27-34. PMID: 13807969
  22. Peimer, CA, Wheeler, DR, Barrett, A, et al. Hand function following single ray amputation. J Hand Surg Am 1999;24(6):1245-8.PMID: 10584948
  23. Baumeister, S, Menke, H, Wittemann, M, et al. Functional outcome after the Moberg advancement flap in the thumb. J Hand Surg Am 2002;27(1):105-14. PMID: 11810623
  24. Jones, NF and Clune, JE. Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers. J Hand Surg Am 2018. [Epub] PMID: 30292715
  25. Pierrie, SN, Gaston, RG and Loeffler, BJ. Current Concepts in Upper-Extremity Amputation. J Hand Surg Am 2018;43(7):657-667.PMID: 29871787
  26. Sebastin, SJ and Chung, KC. A systematic review of the outcomes of replantation of distal digital amputation. Plast Reconstr Surg 2011;128(3):723-37.PMID: 21572379
  27. Hattori, Y, Doi, K, Ikeda, K, et al. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg Am 2006;31(5):811-8.PMID: 16713848
  28. Haas, F, Hubmer, M, Rappl, T, et al. Long-term subjective and functional evaluation after thumb replantation with special attention to the Quick DASH questionnaire and a specially designed trauma score called modified Mayo score. J Trauma 2011;71(2):460-6. PMID: 21206290
  29. Chung, KC and Wei, FC. An outcome study of thumb reconstruction using microvascular toe transfer. J Hand Surg Am 2000;25(4):651-8.PMID: 10913205
  30. Belcher, HJ and Pandya, AN. Centro-central union for the prevention of neuroma formation after finger amputation. J Hand Surg Br 2000;25(2):154-9.PMID: 11062573
  31. Goldner, RD, Howson, MP, Nunley, JA, et al. One hundred eleven thumb amputations: replantation vs revision. Microsurgery 1990;11(3):243-50.PMID: 2215196

Reviews

  1. Germann, G, Rudolf, KD, Levin, SL, et al. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am 2017;42(4):274-284.PMID: 28372640
  2. Graham, DJ, Venkatramani, H and Sabapathy, SR. Current Reconstruction Options for Traumatic Thumb Loss. J Hand Surg Am 2016;41(12):1159-1169. PMID: 27916148

Classics

  1. Hughes NC, Moore FT.A preliminary report on the use of a local flap and peg bone graft for lengthening a short thumb. Br J Plast Surg1950;3(1):34-9. PMID: 15411503
  2. Stefani AE, Kelly AP Jr. Reconstruction of the thumb: a one-stage procedure. Br J Plast Surg1962;15:289-92. PMID: 13916515
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