Hypothesis: Traumatic amputations of the thumb are fortunately rare in children compared with adults, but hand surgeons remain reticent to consider microsurgical reconstruction. Materials and Methods: Nineteen thumb amputations in 17 children (13 boys and 4 girls) between the ages of 2 and 16 years were referred for secondary reconstruction. Nine were isolated thumb amputations (R1 classification) and 10 were combined thumb and multiple finger amputations (R2-R5 classification). Two children had bilateral thumb amputations due to burns. Of the unilateral thumb amputations, 8 were left thumbs and 7 were right thumbs. Three thumbs were amputated just distal to the carpometacarpal (CMC) joint, 4 through the metacarpal head or metacarpophalangeal (MCP) joint, 7 through the base of the proximal phalanx, 3 through the head of the proximal phalanx, and 2 through the base of the distal phalanx. Three children had previously undergone soft tissue coverage with a pedicled groin flap (2) and a reverse radial forearm flap (1), and 2 children underwent a reverse radial forearm flap simultaneously with their toe transfer. Results: Nineteen toe-to-thumb transfers were performed: 12 second toe transfers and 7 great toe transfers (3 great toe and 2 trimmed and 2 Morrison wrap-around variations). There were no immediate postoperative re-explorations of the microsurgical anastomoses and all toe transfers were successful. All children rapidly regained pinch and grasp function and sensibility. There were no gait problems in the donor foot/feet. Conclusions: Microsurgical toe-to-thumb transfers are the optimal technique for post-traumatic thumb reconstruction in children for any level of amputation from just distal to the CMC joint out to the distal proximal phalanx. Second toe transfers are preferred for younger children because of better growth potential and an inconspicuous donor site, but great toe transfers become more favored for older children because of the better cosmetic appearance and for combined thumb and multiple finger amputations.
