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Background: Restoration of joint congruity is an important factor for the prevention of subsequent arthritis in patients with Bennett's fracture. Surgical treatment of Bennett's fracture is thus generally recommended for displaced intra-articular fractures to the proximal aspect of the thumb metacarpal. Fluoroscopic examination is used to evaluate the adequacy of closed reduction after pinning of Bennett's fracture. The purpose of this study was to determine the accuracy of fluoroscopy to determine the reduction of Bennett's fractures.Methods: A model was created, to mimic a Bennett's fracture utilizing ten fresh-frozen cadaveric hands. An oblique cut was made in the proximal aspect of the thumb metacarpal using an oscillating saw. The small oblique fragment involved 1/4-1/3 of the joint surface was then shifted in position creating a step-off or gap at the fracture site. An anatomical reduction model, gap models (1 mm, 2 mm, 3 mm), and step-off models (1 mm, 2 mm, 3 mm) were created using percutaneous fixation with two 1.0 mm Kirschner wires for each cadaveric hand. Fluoroscopic assessment then took place and was reviewed by 2 attending hand surgeons blinded to the actual position. Their estimated fluoroscopic position was then compared to the actual displacement.Results: The step-off and gap on fluoroscopic examination showed a significant difference compared to the step-off and gap from direct visualization. The frequency of underestimation for the 3 mm displacement models from the fluoroscopic examination was 60%. The frequency for overestimated was 9% for the models in which displacement was within 2 mm (0, 1, 2 mm).Conclusions: The assessment of articular gap and step-off using PA (postero-anterior), AP (antero-posterior), and lateral view of fluoroscopic examination is not accurate as compared to the examination by direct visualization. Surgeons need to be aware that PA, AP and lateral view of fluoroscopic examination alone may not be sufficient to judge the final position of a reduced Bennett's fracture. Other methods such as live fluoroscopy in multiple different planes, 3-dimensional fluoroscopy or arthroscopic examination should be considered. [ABSTRACT FROM AUTHOR]

The traditional management of Manske 3B and 4 thumbs is index finger pollicization. Recently, the transfer of composite tissues from the foot to reconstruct the thumb or the carpometacarpal joint has allowed the preservation of a five-digit hand. Concerns remained about the donor site and also the limited functional and cosmetic outcomes that could be achieved. This article challenges the existing dogma in the management of hypoplastic thumbs, that pollicization should always be the reference standard. We describe the evolution of techniques with free vascularized metatarsal transfer, our refinements and our proposal for a new classification system that accommodates these modifications. With increased experience, acceptable outcomes that are comparable with pollicization can be achieved. [ABSTRACT FROM AUTHOR]

We treated 16 patients with 17 hypoplastic thumbs (eight Type IIIB and nine Type IV) using a non-vascularized fourth metatarsal transfer with a rotational flap and multi-staged reconstruction. The average age at the first operation was 24 months. The average follow-up time was 46 months. All patients achieved reasonable hand function and were able to use the reconstructed thumb to grip small and large objects. The operated thumb achieved an average Kapandji score of 6.7 and average pinch strength of 0.9 kg. There were two cases of graft nonunion. All parents are satisfied with the function and appearance of the reconstructed thumb and donor foot. We conclude that non-vascularized fourth metatarsal transfer is a feasible reconstruction method for patients with Types IIIB and IV hypoplastic thumbs. The reconstruction allows for the preservation of a 5-digit hand with reasonable function and appearance and minimal donor site morbidity, although long-term growth of the metatarsals still need to be monitored. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Pollicization of index finger is the main weapon in the hand of hand surgeons for aplasia and severe hypoplasia of the thumb. It is so popular method especially in the western world ( Figs. 1–3 ). However, the parents (including the grandparents) in the East Asia area are too stubborn to choose this method, they insist on maintaining the “useless floating thumb” always, even after the surgeon show them the “beautiful” pictures after pollicization, and introducing the advantages of the pollicization method in detail, such as it is a one-stage method and provides a very good function. Because of this cultural difference, we tried several methods in practice to reconstruct the first metacarpal and maintain the hypoplastic thumb, such as harvesting half metatarsal et al. However, the good results were obtained in few cases. On account of this reason, we designed the composite second metatarso-cutaneous flap transfer for Type 3B/4 hypoplastic thumb from 2013. For the donor site, we used a half vascularized third metatarsal transfer to reconstruct the second metatarsal. The preliminary result is very good, no flap failure occurred. All parents are satisfied with both the appearance and the function of the new “thumb”. The complication at the donor site is minimal, foot function is almost normal. Compare with the other traditional methods, second metatarso-cutaneous free flap is a kind of time-consuming and technique demanding procedure, however, according to our experiences, it is really a valuable method and a useful weapon in the armamentarium of the hand surgeons, especially in the East-Asia area. [ABSTRACT FROM AUTHOR]