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An underdeveloped thumb with no stable joint at its base cannot be reconstructed in place: there is nothing for pinch to push against. The index finger is instead shortened, rotated and repositioned to become a thumb, keeping its own nerves, vessels and tendons — a pollicisation. The child then has to learn to use that finger as a thumb, which young children do remarkably quickly. The result is measured in the pinch regained: holding a pencil, picking up a cup, doing up a coat.

When a wound leaves bone, tendon or metalwork exposed, it cannot close on its own and a skin graft would not survive. Tissue is instead taken from elsewhere on the body with its own artery and vein, then transferred and reconnected under the microscope to vessels one to two millimetres across. The first days are given over to monitoring the flap’s circulation. The aim is not cosmetic: it is stable cover that lets the bone heal and the hand move.

Arthritis at the base of the thumb makes every pinch painful: opening a jar, turning a key, writing. When a splint, therapy and an injection are no longer enough, the small worn bone beneath the thumb is removed, sometimes with ligament reconstruction or joint replacement. The thing to understand about the result: pain is what goes first, and most reliably. Strength returns over several months, and the hand reorganises how it grips rather than recovering exactly what it had.