When replantation of an amputated thumb is not feasible, toe-to-hand transfer should be considered as a reconstructive option. In this review we report our success with immediate great toe transfer in selected patients with non-replantable thumb avulsions. During the past five years, six hand trauma patients underwent great toe-to-hand transfer during initial post-injury hospitalization at our tertiary medical center. The overall results of these thumb reconstructions were retrospectively evaluated after patients were contacted. Objective and subjective scores to quantify patient satisfaction and clinical success were tabulated. All of our patients were laborers who suffered work-related thumb avulsions and a spectrum of associated extremity injuries. No surgical complications, transfusions or reoperations were reported during initial hospitalization, which lasted an average of 12 days (range 6 to 18). Time to reconstruction averaged 5.7 days post-injury (range 1 to 11). Donor site morbidity was minimal, with one patient reporting mild gait disturbance. Follow-up averaged 8.4 months (range 2 to 13). Four of the six patients have returned to work, averaging 130 days of disability. All patients that followed up after six months (4 of 6) had intact protective sensation in their reconstructed thumbs. Subjective and objective outcome scores (rated 1 to 5) at most recent follow-up each averaged 4.4, reflecting agreement between patient satisfaction and functional outcome. Post-hospitalization complications included one hand infection, one first web space contracture and one patient with moderate cold sensitivity. Additionally, one patient required soft tissue debulking. The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. Reduced length of hospitalization and surgical recovery time expedites return of function and may allow patients to return to work sooner. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating patients with non-replantable thumb amputations.