Free transfer of a large sensory flap from the first web space and dorsum of the foot including the second toe for reconstruction of a mutilated hand

A 19-year-old man sustained a mutilating crush injury in August, 1978, in an 80-ton punch press. The injury resulted in transmetacarpal amputations of the index through little fingers. The thumb was revascularized by microvascular anastomoses. The replanted index to the little finger position failed. A free transfer of the patient's second toe to the fifth metacarpal was done to provide a post to oppose the thumb. The first web space of the toe was used in expanding the contracted single cleft of the hand. The innervated dorsal foot flap provided coverage for the dorsal surface of the hand. Anatomically, the entire composite transfer was supported by the dorsalis pedis artery anastomosed to the radial artery. The nerve sutures were between the plantar digital nerves and sensory fascicles of the median nerve and the deep peroneal to the dorsal branch of the radial. The extensor and flexor tendons were also repaired. This procedure differs from the neurovascular island transfer of the first web described by Strauch and Tsur¹ by inclusion of the second toe in the free transfer.