Clin Orthop Surg.  2012 Mar;4(1):18-35. 10.4055/cios.2012.4.1.18.

Pollicization: The Concept, Technical Details, and Outcome

• Kozin SH

• KMID: 1245396
• DOI: http://doi.org/10.4055/cios.2012.4.1.18

Abstract

Pollicization substitutes a functioning finger for a deficient thumb. The most indication is thumb hypoplasia with absence or instability of the carpometacarpal joint. However, there are additional causes that may negate thumb function, such as trauma, macrodactyly, multi-fingered hand, and a mirror hand. The technique of pollicization represents a consolidation of contributions from surgeons over the last 100 years. A meticulous stepwise approach from incision to closure is necessary to optimize outcome. Following pollicization, cortical plasticity and motor relearning play a pivotal role in function following pollicization with connections and adjacent sprouting from nearby cortical and/or subcortical territories. Occupational therapy is necessary to encourage large object acquisition followed by smaller objects and ultimately fine pinch. Pollicization is more reliable in patients with isolated thumb hypoplasia and a mobile index finger with robust extrinsic and intrinsic muscle-tendon units compared to and patients with radial forearm deficiencies and diminished index mobility.

Keyword

Pollicization; Thumb hypoplasia; Macrodactyly; Ulnar deficiency; Mirror hand

MeSH Terms

Fingers/abnormalities/*surgery
Hand Deformities, Congenital/rehabilitation/*surgery
Humans
Orthopedic Procedures/*methods/rehabilitation
Reconstructive Surgical Procedures/*methods/rehabilitation
Thumb/abnormalities/*surgery

Figure

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  Fig. 1 Volar skin design (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 2 Dorsal skin design (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 3 Isolation of radial and ulnar neurovascular bundles (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 4 Volar dissection of a type IIIB thumb hypoplasia with tracing of the single vessel to radial neurovascular bundle of the index finger (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 5 Microdissection of the common digital nerve between the index and long (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 6 Ligation of the proper digital artery to the long finger (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 7 Incision of the first annular pulley of the index finger (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 8 Elevation of dorsal incision with preservation of dorsal veins (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 9 First dorsal interosseous released from the extensor hood. (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 10 Sutures placed for later transfer of the first dorsal and first palmar interossei (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 11 Distal cut of index metacarpal through the physis (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 12 Metacarpophalangeal joint sutured into hyperextension using a non-absorbable (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 13 Thumb positioned and secured with interosseous sutures (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 14 Intrinsic reconstruction using first dorsal interosseous (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 15 Skin inset and sutured with absorbable suture (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 16 Three-year-old girl with progressive macrodactyly of the left thumb and index digits (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 17 Volar skin design (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 18 Dorsal skin design (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 19 Enlarged median nerve and superficial arch isolated (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 20 Digital nerves supplying the long finger are separated from median nerve hamartoma (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 21 Amputation of thumb and index finger with preservation of the index metacarpal (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 22 Long finger metacarpal is removed (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 23 The long finger is inset into the base of the index metacarpal with careful positioning (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 24 Final position after the skin is inset (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 25 Three-year-old girl with bilateral ulnar deficiencies and a left hypoplastic thumb with a bifid metacarpal (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 26 Volar skin incision incorporating thumb ablation (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 27 Dorsal skin incision (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 28 Isolation of neurovascular bundles and residual abductor pollicis brevis to be incorporated into the pollicization (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 29 Ligation of the radial digital artery to the long finger (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 30 Amputation of the thumb and its phalanges (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 31 Resection of the radial portion of the bifid metacarpal with preservation of a large base (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 32 Shortening of the index metacarpal for pollicization (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 33 Fixation with two Kirschner wires and abductor reconstruction (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 34 Skin countering of the first web space (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 35 Closure with 5-0 plain suture (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 36 X-ray of 3-year-old girl with bilateral 6 fingered hands (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 37 Clinical examination demonstrates conjoined motion of the two radial digits (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 38 Volar dissection and identification of neurovascular structures (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 39 Incision of A1 pulleys (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 40 Excision of both metacarpals (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 41 Postoperative appearance after intrinsic reconstruction and skin closure (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 42 Subsequent postoperative X-rays following bilateral pollicization (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 43 Left thumb position and pinch function (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 44 Three-year-old girl with mirror hand and seven fingers (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 45 Ablation of the two less mobile radial digits (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 46 Polllicization of the most mobile radial digit (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 47 Appearance after pollicization (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 48 Activities for encouraging pinch pattern include playing with stickers (Courtesy of Shriners Hospital for Children, Philadelphia).

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  Fig. 49 Three-year-old with ulnar deficiency depicted in Fig. 25 (Courtesy of Shriners Hospital for Children, Philadelphia). (A) Left thumb position. (B) Gross grasp pattern. (C) Fine pinch pattern.

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