Handbook on Flaps in Degloving, Avulsion and Crush Injuries of the Hand [1 ed.] 9789351526414, 9351526410

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Handbook on

FLAPS IN CRUSH INJURIES OF THE HAND

Handbook on

FLAPS IN CRUSH INJURIES OF THE HAND

Dhiren Mahida MS (Ortho) Consultant Orthopedic Surgeon Pooja Hospital Udhana, Surat, Gujarat, India

Foreword NV Vachhrajani

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FOREWORD It is with a sense of great pleasure and pride that I take this opportunity to introduce to you this book and its author Dr Dhiren Mahida. I had the opportunity to observe Dr Dhiren Mahida as a resident in orthopedics for about two years, during which he devoted all his efforts to acquire a broad grasp in the field of orthopedics. His breadth of vision and comprehensive view of orthopedics and hand injury in particular is reflected in this book that he has published. I have had occasions to listen his presentations on different platforms and he is always clear and confident on his view points on the topics he presented. Since our country does not provide adequate facilities for continuing research in the multidisciplinary fashion, he must be handicapped in pursuing the work to more fruitful development. The primary purpose of this book is to assist the orthopedic surgeons in the care of traumatized patients in emergency room and deciding the management protocol. Forgoing the often dry recitations, when, where and how has made this book interesting, readable and enjoyable manner. The topics are current and the information is highly useful. Soft tissue coverage is not taught in detail during residency in orthopedics. So there is always an apprehension of taking correct decisions while examining patients in emergency room. Various clinical photographs, schematic diagrams and original illustrations with the detailed explanation have made it easy for orthopedic surgeons and even plastic surgeons to carry out the procedure with ease and confidence. I recommended this book as a must reference book for all trauma and plastic surgeons and must be kept in postgraduate library for ready reference. I feel this book will find a permanent place on your book-shelf as a ready reckoner on hand injury and will be used on regular basis for updating the knowledge on this subject. I must compliment the publisher M/s Jaypee Brothers Medical Publishers Pvt Ltd, New Delhi, India for coming out with such useful and nice comprehensive book. NV Vachhrajani MS (Ortho)

Professor, Department of Orthopedics Surat Municipal Institute of Medical Education and Research Surat, Gujarat, India

PREFACE Injury to the hand and fingers is one of the commonest and most frequently encountered emergency faced by the trauma surgeon, orthopedic surgeon or general surgeon in our industrialized world. Day-in and day-out, one encounters a bewildering array of such injuries. They are both a challenge for the surgeon and a distressing disaster for the patient. Reconstruction of these injuries is many a times bewildering and fraught with uncertainties. Nevertheless for the patient a successful outcome is one of the most satisfying experiences in life. For the surgeon, in addition to the satisfying feeling of a job well done, he has now behind him a patient who will be grateful to him lifelong. In spite of this, the hand is a neglected branch in most surgical units and these injuries are most often delegated to the care of the juniormost resident doctors. Furthermore, lack of training in hand injuries has led to a much higher amount of amputations and, shortening of digits with primary closure is then really necessary. The multiplicity of techniques for the management of fingertip injuries confuses an inexperienced surgeon in selecting the correct technique and management strategy in a particular case. During my residency training, I had always felt the need for a small compact book that would hone my basics in emergency hand surgery. Many of the classic textbooks like ‘Green’s Operative Hand Surgery’ are too voluminous for the beginners. I have attempted to fill up these lacunae and hope that this will inspire the reader to further pursue the voluminous classic textbooks, which are a reader’s paradise, once his interest in the intricacies of hand surgery is awakened. I have drawn heavily from the articles, textbooks by these masters in hand surgery and have attempted to put the salient features of basic surgical procedures in a simple fashion. I express my gratitude to them and beg forgiveness for any omissions and errors in the acknowledgment of their work, if any. At this time, I must not forget C Oberlin, Dr Anil Bhatia and others whose simple but elegant and indepth book on Pedicled Flaps for Coverage of the Limbs gave me the inspiration to perform many of the flaps detailed in this book. I am indebted to my plastic surgeon friend Dr Amar Vakharia who has helped me in executing many of the technically complex flaps illustrated in this book. Special thanks go to Kirit Patel, who has helped immensely in the editing and preparation of this book. Also I must not forget Dr CD Mehta, Professor of Anatomy, Government Medical College, Surat, Gujarat, who graciously allowed me to carry out cadaveric dissection of unusual flaps. Last but not least, my wife Devayani, daughter Hetavi and son Jashpalsinh, whose constant support helped me complete this work. I earnestly hope that this book will help the newly inducted resident, trauma surgeon and the general orthopedic surgeon in selecting and executing the best surgical option for the acutely injured patient. Finally special thanks to Dr Sudhir Warrier and Dr Pankaj Jindal who took special pains to go through my book and offered constructive suggestions in improving the book. Dhiren Mahida

CONTENTS

1. Introduction

1–6

Terminology  1 Aims of Management in Hand Injuries  3 Assessment of Injury  4 Surgical Procedures/Options Available  4



2. Debridement

7–8

Method  7



3. Healing by Secondary Intention 4. Fasciotomy

9–12 13–17

Signs and Symptoms  13 Clinical Features  13 Persistent Pain, that is Progressive and Unrelieved by Immobilization and Increased   by Passive Stretching, is the Hallmark of a Developing Compartment Syndrome 13 Other Investigations  14 Treatment  14



5. Free Skin Grafts

18–20

Split Thickness Graft  18 Full thickness Graft  20



6. Vacuum-assisted Closure 7. Local Flaps (Principles and Techniques)

Principles and Techniques in Flap Coverage 23 Rotation and Transposition Flap  23 Lateral Digital Flap  27 Advancement Flap  27 Rhomboid Flap of Limberg  28 Dufourmental Flap  30 Dorsal Digital Advancement/Regression  31 The Dorsal Reverse Adipofascial Flap for Fingertip Reconstruction  32 Z-Plasty Techniques  35 Simple Z-Plasty of Thumb Web Space  36 Hueston Flap  38 Souquet Flap  40 V-Y Advancement  41 Bilateral Kutler’s V-Y Plasty  43 Venkataswami-Subramanian Flap  45 Palmar Bipedicle Advancement Flap  47 Joshi’s Dorsolateral Neurovascular Island Flap  49 Palmar Digital Monopedicle Flap  52 Distally Based Digital Island Flap  55 Annular flap  58 Local Flaps (Flaps From Adjacent Fingers/Hand/Forearm)  59 The Cross-Finger Flap  59 Classical Laterally Based Flap  59 Distally Based Cross-Finger Flap  63 Proximally Based Cross-Finger Flap (Flag-Flap Variant)  65 Reverse Cross-Finger Flap  66 Radial Sensory Nerve Innervated Cross-Finger Flap  68 Innervated Cross-Finger Flap  71

21–22 23–107

x  Handbook on Flaps in Crush Injuries of the Hand Dual Innervated Cross-Finger Flap  72 Turkish Flap (C-Ring Cross-Finger Flap)  74 Cross Finger Flap Over-Riding A Cross Finger Flap  75 Flap on a Flap on a Flap  76 Dorsal to Dorsolateral Coverage (Dorsal Middle Phalangeal Artery Flap)  80 Results of Cross-Finger Flap  84 Dorsal Metacarpal Artery-Based Flaps  85 Flag Flap  85 Kite Flap  87 Dorsal Metacarpal Flaps: Distally Based 2nd Dorsal Metacarpal Artery Flap  92 Variations Of Dorsal Metacarpal Artery/Flag Flap  95 Reverse Ulnar Parametacarpal Artery Flap  96 Thenar Flaps  97 Reversed Radial Artery Forearm Flap (Chinese Flap)  100 Ulnar Artery Forearm Flap  104 Posterior Interosseous Artery Flap  105



8. Distant Flaps

108–124

Types  108 Random Pattern Distant Flaps  108 Reversed Deltopectoral Flap  108 Deltopectoral Flap  111 Groin flap  113



9. Composite Grafting and Flaps Using Dead Bone as Graft

125–128

Composite grafting  125



10. Interesting Clinical Cases

129–140

Case 1 129 Case 2 131 Case 3: Crushed hand with Extensive Devitalization  134 Case 4: Crush injury of Middle, Ring and Little Finger  136 Case 5  137

11. Amputations

141–158

Indications  141 Principles and Goals of Amputation  141 Digital Tip Amputations  142 Metacarpal Ray Amputation  143 Reconstruction in Amputation  148 Fillet Flaps  148 Phalangization of Metacarpal by Web Space Deepening  149 Phalangization of the Metacarpal Head (Modified)  150 Pollicization of an Index Finger Stump  152 The Gilles Cocked-Hat Flap   157



12. Splints and Fixtures in Crush Injuries Splints 159 JESS Fixtures



159–163

159

13. Microvascular Techniques



164–166

Indications  164 Relative Contraindications  164 Patient Selection  164 Transport of Amputated Part/Preservation  164 Instruments  164 Surgeon Requirements  164 Techniques  165 Other Practical Methods  166 Measures to Salvage a Failing Flap  166

Bibliography 167–169 Index 171–174

1

Introduction

Terminology An understanding of the terms degloving, avulsion, and crush injury is essential before discussing the surgical aspects of hand injury.

tissues and may include skin, fascia, muscles, tendons, bones and neurovascular structures either singly or in combination.

Degloving Injury Degloving (Figure 1.1) involves the skin and fascia. The superficial fascia is completely disrupted and usually deep fascia is also involved. Blood vessels are completely disrupted. Avulsion Injury Avulsion (Figure 1.2) involves deeper tissues, typically as part of a combined degloving/avulsion injury. Part of tendon/muscle belly/nerve is pulled along with skin and deep fascia. Crush Injury Crush injury (Figure 1.3) involves an element of crushing and compressive force that leads to devitalization of

Fig. 1.2: Avulsion

Fig. 1.1: Degloving

Fig. 1.3: Crushed hand

2  Handbook on Flaps in Crush Injuries of the Hand

Flap Terminology • Flap is tissue used in surgical grafting that is only partially detached from its donor site so that it continues to be nourished during transfer to the recipient site. • Skin flap is a full-thickness mass or flap of tissue containing epidermis, dermis, and subcutaneous tissue. A standard technique in skin grafting; based on the part isolation of a graft by creation of a flap which retains its original circulation while becoming established at the new site on the new blood supply. Many types of flap are used, e.g. axial pattern, bipedicle, composite, delayed tube, direct, interpolating, reverse saphenous conduit. • Fasciocutaneous flap is a full-thickness mass or flap of tissue containing epidermis, dermis, and subcutaneous tissue along with deep fascia. • Myocutaneous flap is a compound flap of skin and muscle with adequate vascularity to permit sufficient tissue to be transferred to the recipient site. • Composite flap consists of skin with muscle, bone or cartilage. • Pedicle flap is a flap consisting of the full thickness of the skin and the subcutaneous tissue, attached by tissue through which it receives its blood supply. The proximal segment of a flap that has been entirely inset into the defect is referred as its base. Frequently only the distal segment of the flap may be inset into the defect, its central segment and base remaining unattached. The base is then referred to as the pedicle of the flap and the central segment as its bridge segment the pedicle of a skin flap usually consists like the rest of the flap of skin and subcutaneous tissue but is occasionally reduced to its subcutaneous component. In such circumstances it is the distal segment with a full component of skin and subcutaneous tissue, which is transferred and referred to as an island flap. • Random pattern flaps are not based on any specific blood supply. • Axial pattern flaps are based on a specific arterial supply delineated for that flap. • Rope flap or tube flap is one made by elevating a long strip of tissue from its bed except at its two ends, the cut edges then being sutured together to form a tube. • Rotation flap is a local pedicle flap whose width is increased by having the edge distal to the defect

• •

•

• • •

•

form a curved line; the flap is then rotated and a counter incision is made at the base of the curved line to increase mobility of the flap. Transposition flap is a rectangular flap of skin repositioned to fill a defect like pedicle graft with intact blood supply. Advancement flap or sliding flap is a flap carried to its new position by a sliding technique after release of a portion of tissue and reattachment at an advanced position technique for closing skin wounds where there is a large deficiency of skin. Includes sliding-H flap and Z-flap or Z-plasty. Skin around the defect is separated from its subcutis and the defect repaired by strategic additional incisions and the use of tension sutures. Jump flap is one cut from the abdomen and attached to a flap of the same size on the forearm. The forearm flap is transferred later to some other part of the body to fill a defect there. Free flap is an island flap detached from the body and reattached at the distant recipient site by microvascular anastomosis. V-Y flap is one in which the incision is shaped like a V and after closure like a Y, to lengthen a localized area of tissue. Bipedicle flap is one where the space created by undermining skin between two parallel incisions can be used to reconstruct skin defects, usually onto a distal limb, which is inserted into the space also called pouch flap. Neurovascular island flap refers to flap elevated along with an intact artery and nerve supply. With the advent of microsurgical technique, a better understanding of vascular supply of most flaps and the use of Doppler study that help delineate local vessels most random pattern flaps can now be termed axial pattern.

Indications for Pedicle Flap A pedicle flap is required in the following circumstances namely: • Finger injuries with exposed bone, joints or tendons • Soft tissue padding • Preserve length • Secondary reconstruction anticipated • Improve function and appearance • Facilitate wearing of prosthesis • Bare bone in electrical burns.

Introduction  3

Contraindications for Pedicle Flap • • • • • •

Elderly patient Arthritic or degenerative changes Circulatory problems Scarring on donor area Infection Contused donor skin.

Classification of Degloving Injuries by Different Authors Author Date Thomson 1968

Larrou

1974

Michon 1979 and Merle

Urbaniak 1981 Loda

1983



Classification Type A—Simple laceration Type B—Avulsion of soft tissue + neurovascular injury Type C—Tendon injury + cutaneous avulsion and neuro­ vascular injury Type I—Skin without injury to nerve and vessels Type II—Skin + 1 pedicle Type III—Avulsion + tendon + 2 pedicle Type IV—Avulsion + tendon + 2 pedicle + fracture/dislocation Stage I—Pure cutaneous injury Stage II—Partial vascular injury Stage III Total devascularization Stage IVa—Proximal disarticulation Stage IVb—2nd phalange or distal interphalangeal neck fracture Stage IVc—Cutaneous denuding without skeletal injury Type I—Adequate circulation, treatment of soft tissues Type II—Immediate vascular repair required Type III—Denuded or amputated finger Stage I—Ring compression and pure cutaneous injury Stage II—Dorsal vascular and cutaneous injury Stage III—Palmar vascular and cutaneous injury



Stage IV—Dorsal and palmar vascular and cutaneous injury without amputation Stage V—Complete amputation with fracture or disarticulation (typical degloving injury).

AIMS OF MANAGEMENT IN HAND INJURIES The aim of management in hand injuries requiring skin coverage is four fold: 1. Providing durable cover. 2. Rapid healing and early return to work. 3. Pain free scar and minimizing discomfort. 4. Sensate flap preserving sensation and length. Also remember the 4 Rs of fracture management: 1. Recognition 2. Reduction 3. Retention of reduction 4. Restoration of function. The treatment is directed in ensuring wound healing in the shortest period of time and providing a hand that was almost similar to the uninjured hand, in terms of function, sensation and cosmetics. Different classes require different levels of functional capabilities and this must be carefully assessed before surgery. For example, a manual worker will be highly satisfied with a cross-finger flap over a thumb or index finger tip injury, whereas a pianist or stenographer will find the same to still lack in quality and function in many ways. Order of Priority for Open Wound Management This is as follows: 1. The patient as a person and body as a whole 2. Other injuries, resuscitation 3. History and physical examination 4. Tetanus prophylaxis and antibiotics 5. Debridement 6. Fasciotomy, if required 7. Skeletal stability 8. Restoring adequate blood supply 9. Repair of damaged structures 10. Proper dressing and elevation 11. Appropriate timing of closure or coverage 12. Secondary reconstruction: flap re-implantation, delay of flap, flap release, etc.

4  Handbook on Flaps in Crush Injuries of the Hand

13. Rehabilitation; start as early as possible, preferably while the hand is still in the primary dressing stage. 14. Defattening of flap, release of syndactyly, if one has been created during reconstruction. This is done 6–8 weeks after flap release and defattening of 30–40% is done at a time. ASSESSMENT OF INJURY A good history is essential and includes when, where and how. When?

The time elapsed from injury is important. Many times reimplantation and/or primary closure of wound is dangerous and fraught with complications, especially when the patient presents six hours after injury. Where?

Will indicate the environment and potential level of contamination of open wounds. Clean environment requires less debridement, whereas battlefield and sewage side injuries require extensive debridement. How?

Reveals magnitude of force and degree of tissue damage. For example, crush injury/high pressure injection injury require extensive debridement and compartment release. Glass injury can easily cause tendon and neurovascular damage. Type of Injury The surgical procedure is often dictated by the type of injury. Injury type includes the following: 1. Cutting 2. Slicing 3. Crushing 4. Degloving 5. Avulsion.

Superficial/Deep Fascia

In a clean wound, primary skin grafting can be done on an intact fascia. Fascia has to be released in a developing compartment syndrome. Tendon

An inability to extend fingers indicates extensor tendon injury. An inability to flex a fully extended and stabilized interphalangeal joint indicates flexor tendon injury. Position of ‘hangout’ in unconscious patients and children also indicates flexor tendon injury. Blood Vessels

Distal pulse, capillary refill in nail bed, color of injured tissue is evaluated. Pulse oxymetry and free flow of blood to pin prick help assessment. A white hand implies arterial impairment and blue discoloration indicates venous stasis. Restoration of blood supply has the highest priority in treatment plan. Major arteries and a vein are repaired if deemed necessary. Compartment release is essential to prevent ischemia. Muscles

Look for the extent of cut and crush element and assess the amount of nonviable muscles that have to be excised. Bone

Clinical examination and X-rays help determine bony injury. Fractures can be stabilized by kirchner wires. Nonviable bones devoid of soft tissue attachment are preferably removed. Remember the 4 Rs of fracture management: Recognition, Reduction, Retention of reduction and Restoration of function. Nerves

Anatomical structures involved in isolation or as a group.

Discrimination of dull and sharp sensation to pinprick and two-point discrimination is carried out. Lack of pain indicates nerve damage (psychic problems excluded) and progressively increasing pain indicates developing compartment syndrome.

Skin

SURGICAL PROCEDURES/OPTIONS AVAILABLE

Assess the amount of and extent of cut and crush of the skin edges.

The following procedures are available to treat crush injury in increasing order of complexity. On evaluating

Part of Injury

Introduction  5

the injury any one or a combination of the following will be required in treating hand injuries: 1. Debridement with or without primary closure 2. Healing by secondary intention 3. Fasciotomy, if required 4. Skin grafting 5. Flaps 6. Vacuum-assisted closure 7. Amputations. 8. Stabilization with Kirchner wires/fixators/plates/ sutures, etc.



As a primary or secondary procedure or in combi­ nation with the above.

9. Microvascular repair and reimplantation of pulp/ digits/hand. Majority of the discussion in the following chapters will be restricted to the first six procedures. Stabilization with Kirchner wires/implants/fixators, free flaps and microvascular repair are major topics in themselves and the reader can refer to authoritative textbooks devoted to these topics.

Flow chart 1.1: Algorithm evaluating injury and available treatment options.   Pre-requisites: Clean cut and debrided wound

6  Handbook on Flaps in Crush Injuries of the Hand Flow chart 1.2: Evaluating treatment options for finger tip amputation

Flow chart 1.3: Volar oblique finger amputation

2

Debridement

All open wounds have to be debrided. Debridement decreases contamination and reduces chances of infection. It also facilitates healing of the damaged tissues. Objective is to remove everything detrimental to wound healing and simultaneously preserving all useful tissues essential for good hand function. METHOD Method includes two procedures: Cleaning and excision. Cleaning Depending on the level of contamination, cleaning is done by: 1. Soap and sterile water, povidone-iodine scrub or saline gently but thoroughly.

2. Cetrimide/chlorhexidine solution is used next for residual soap-soluble contaminants. 3. Syringing the wound with a large syringe or rubber asepto bulb removes the embedded particles. 4. Use of pulsating jet lavage from a mechanical pump is next used for removal of firmly embedded particles. The force should be so adjusted to avoid distending tissue space and damaging tissues and, at the same time, strong enough to wash out contaminants and debris. 5. Use of a toothbrush to remove the embedded contamination resistant to removal with the abovementioned procedures. A case study of a severely crushed thumb treated with debridement, K-wire fixation and primary closure showing excellent functional result (Figs 2.1A to D).

A

B

C

D

Figs 2.1A to D: (A) Injury at the time of presentation; (B) Immediate postoperative result after debridement, K-wire fixation and primary closure; (C) Result at six weeks; (D) Result at three months

8  Handbook on Flaps in Crush Injuries of the Hand

Excision • Accurately assess the vascularity of tissues. • Skin edges need not be excised in clean-cut cases. Except for some amount of fat and muscle tissue, everything is essential in the hand and must be judiciously preserved. Conversely, all devitalized tissues must be excised to prevent infection and secondary skin breakdown. When in doubt, preserve tissues, and debride at a second look. 3–4 days later,

in severely crushed cases, multiple debridements are needed. • Clean wounds can be closed primarily and can give the best results. • ‘Delayed emergency’ or ‘staged wound closure’ can be done where wound condition, soft tissue availability and reconstructive needs have to be addressed. When in doubt, it is safer to leave the wound open.

Healing by Secondary Intention Healing by secondary intention is a good treatment option for small fingertip injuries with skin loss but intact pulp. With growth, scar heals well, shrinks to a small size, similar to STG shrinkage. In view of established remarkably good results of spontaneous healing, a surgeon must assess the need to go in for complex surgery. Remember the dictum ‘DO NO HARM’. In selected cases of dry gangrene, one can opt for selective inactivity and wait for the line of demarcation. Remarkable amount of length can be salvaged. When to wait in established gangrene? A wait-and-watch attitude can be undertaken under the following circumstances:

A

B

C

D

3

1. No signs of infection. 2. Pulp feels firm to touch. 3. No mummification effect/shrinkage in the involved finger. 4. Eschar peeling off and not causing any constriction band. Example 1 Example 1 (Figs 3.1A to D) illustrates how remarkable length can be gained by selective inactivity and waiting for natural line of demarcation. Note that underlying tissue beneath black eschar is firm to touch without any shrinkage or mummification. There are no signs of active infection that would demand early intervention.

Figs 3.1A to D: Example 1: ( A and B) Illustrates crush injury with dry gangrene and eschar; (C and D) End result with eschar peeling off completely and complete preservation of length and good functional result

10  Handbook on Flaps in Crush Injuries of the Hand

Example 2 Selective inactivity’ in case of avulsion flap injury of the palm. In the absence of infection, selective inactivity with careful mobilization of joints can go on for months. Final line of demarcation at four months.

A

C

B

D

E

Figs 3.2A to E: (A) Avulsion flap injury; (B) Debridement and closure over corrugated drains to evacuate hematoma; (C) Final line of debrevation at four weeks; (D) Eschar has peeled of and underlying healthy granulation tissue remains; (E) Final result with healing by secondary intention

When not to wait? One must not wait under the following circumstances: 1. Active infection/sepsis. 2. Mummified shrunken pulp with contractures (relative indication). 3. Morbidity and time lost do not justify the wait involved in selective inactivity. Spreading cellulitis, foul-smelling odor, blisters, and systemic signs of sepsis indicate the need for immediate intervention. Such a condition is a surgeon’s nightmare in deciding between radical debridement and immediate amputation. Case requiring urgent intervention and multiple debridement before viable stable margins are reached (Fig. 3.3).

Fig. 3.3: Radical debridement of dorsal surface, first debridement

One can perform radical debridement if: i. The vital parameters of the patient are stable. ii. There are no moribund conditions like diabetes mellitus, septicemia, immunosuppressed conditions.

iii. Gram staining of fluid wound does not indicate the presence of rod-like Cl. welchii group of organisms. iv. There is no apparent threat to the life of the patient.

Healing by Secondary Intention  11

Amputation should be considered in • Gas gangrene • Septicemia with rapidly progressive cellulitis, infection not responding to radical debridement and antibiotics • Concomitant morbid condition that increase risk of life • Rapidly deteriorating vital parameters not responding to intensive care • Severely crushed devitalized and mangled hand where reconstruction is deemed unfeasible and unlikely to provide a functional hand. Case 1 In this case, the line of demarcation is complete and distal part has shrunk and is mummified. There will be no advantage in waiting for gangrenous part to fall off naturally. No worthwhile length is expected to be gained. Amputation of nonviable stump is advisable (Fig. 3.4). Case 2 This patient had a simple closed Colles’ fracture that was treated in a tight constricting bone setter bandage and presented four days later with a single

Fig. 3.4: Dry gangrene of finger tips with completely mummified and shrunken finger tips

blister on the exposed dorsum of fingers. Removal of the bandage revealed multiple foul-smelling blisters and skin necrosis that required early extensive debridement. Active infection and devitalized soft tissues were present after excising skin on dorsal and volar surfaces of the above case. Radical debridement is indicated. He required multiple debridement before the viable and stable margins were reached (Figs 3.5A to H).

A

B

C

D

Figs 3.5A to D: Radical debridement followed by STG/flap in case of severe infection in colles’ fracture treated by tight bone setter bandage: (A) Dorsal view shows multiple blisters, necrosis of skin, and foul-smelling discharge; (B) Volar view shows compartment compression syndrome with skin blisters; (C) Wound after second debridement; (D) Volar view after debridement and carpal tunnel release

12  Handbook on Flaps in Crush Injuries of the Hand

E

F

G

H

Figs 3.5E to H: (E) Extensive STG and K-wire fixation of Colles’ fracture with exposed radius.The same was covered by a groin flap; (F to H) final result of injury

4

Fasciotomy

Fasciotomy is an armament that has to be frequently and judiciously used in hand and upper limb surgeries following compartment compression syndrome. Compartment syndrome is a group of symptoms and signs that result from increased pressure within a limited space compromising the circulation and function of tissues in that space. The following types can be described: 1. Acute compartment syndrome. 2. Subacute compartment syndrome. 3. Recurrent or chronic compartment syndrome. 4. Crush syndrome. 5. Volkmann’s ischemic contracture (sequel of compart­ ment syndrome). Acute compartment syndrome has signs and symptoms associated with compartment syndrome. Subacute compartment syndrome does not have the signs and symptoms normally associated with a compartment syndrome but the sequel of syndrome will appear subsequently, e.g. progressive muscle contracture in the absence of pain. Recurrent or chronic compartment occurs in athletes who experience pain and tight compartment with a particular exercise. Volksmann contracture is the end-point/sequel of the above with contracted functionless ischemic or dead muscles and insensate paralyzed nerves. SIGNS AND SYMPTOMS A high degree of suspicion and alertness must be kept to diagnose compartment syndrome. Muscles can tolerate ischemia for 4 hours, by 6 hours the effect is uncertain and by 8 hours irreversible changes occur. Peripheral nerves can conduct impulses for 1 hour; can survive 4 hours with only neuropraxic damage and after 8 hours irreversible changes occur.

CLINICAL FEATURES 1. Pain on passive stretching. This is the most reliable indicator of a compartment syndrome because spontaneous pain may be modified by analgesics or long-acting nerve blocks. 2. Diminished sensation is the second reliable indicator of nerve ischemia. 3. Weakened and/or diminished muscle function, that is progressive, is an important indicator. 4. Tense and tender compartment on palpation are indicative of developing compartment compression syndrome. PERSISTENT PAIN, THAT IS PROGRESSIVE AND UNRELIEVED BY IMMOBILIZATION AND INCREASED BY PASSIVE STRETCHING, IS THE HALLMARK OF A DEVELOPING COMPARTMENT SYNDROME Differential Diagnosis 1. Compartment syndrome 2. Nerve injury 3. Arterial injury. Documentation of compartment pressure is important in the patients having communication problems, head-injury patients, where vascular injuries produce tissue ischemia and, at the same time, appear to have compartment syndrome. This method must not take precedence over clinical signs and symptoms of compartment because there are many limitations and scope for errors in these measurement techniques. Techniques 1. 2. 3. 4.

Infusion technique of Whitesides Slit catheter technique of Mubarak Continuous monitoring technique of Matsen Intracompartmental pressure monitoring systems.

14  Handbook on Flaps in Crush Injuries of the Hand

Indications for Fasciotomy Fasciotomy is indicated/recommended in: • Normotensive patients with positive clinical findings with intracompartmental pressure greater than 30 mm Hg and when duration of increased pressure is unknown or thought to be less than 8 hours • Uncooperative or unconscious patients with compartment pressure greater than 30 mm Hg for less than 8 to 10 hours • Patients with low blood pressure where compart­ ment pressure is 20 mm Hg below diastolic blood pressure and the duration of increased pressure is less than 8 to 10 hours. OTHER INVESTIGATIONS 1. Intrinsic muscle compartment pressure normally is less than 15 mm Hg. Measurement is not usually reliable. 2. Direct nerve stimulation: Nerve stimulation of a viable muscle produces a muscle response ischemic muscle will not contract, whereas paralyzed muscle will contract. 3. Arteriography: Helps in the evaluation of arterial injury and blockage. It is of no value in the diagnosis of compartment syndrome. 4. Doppler study: Good blood flow and compartment syndrome can coexist and so this study can mislead in the diagnosis of compartment syndrome. 5. Computed tomography: It is of no value in diagnosing acute compartment syndrome. It can tell the extent of necrosis in an established case but not in an acute setting. 6. Magnetic Resonance Imaging cannot measure intracompartmental pressure and can only reveal muscle status. 7. Pulse oxymetry: This is not useful in the diagnosis of compartment syndrome except to know whether the tissues are being perfused or not. TREATMENT (FIGURES 4.1 AND 4.2) Immediate fasciotomy is the treatment of choice in acute compartment syndrome. Ice application, elevation and sympathetic block have no place in the management because maximum vasodilatation is already present.

The releasing incision starts as a carpal tunnel incision, follows the crease of the wrist to the ulnar side of the forearm and then upward toward the elbow in a curvilinear or zig-zag manner. Median nerve is released at the carpal tunnel through a palmar incision in the valley between the thenar and hypothenar eminence, avoiding the palmar cutaneous branch of the median nerve by curving the incision ulnarward at the wrist. Release the ulnar nerve at the Guyon’s tunnel through this incision. Moving proximally curve the incision radially and finally again curve towards the ulna at the elbow. At the elbow, the incision is just radial to the medial epicondyle. This incision avoids cutaneous nerves; helps release both the nerves and prevents contracture at the elbow and wrist. Four interconnected compartments are released: (i) The superficial volar; (ii) the deep volar; (iii) the mobile wad of Henry (brachioradialis and extensor carpiradialis longus and brevis); and (iv) dorsal compartment. The dorsal compartment is released through a straight linear incision. The dorsal and volar interosseous muscles are released through two longitudinal incisions on the dorsum of the hand over the second and fourth metacarpals. Fasciotomy in the finger is now done, if deemed necessary, by releasing incisons on the nondominant side of fingers. This is usually the ulnar side of index, middle, and ring fingers and the radial side of little finger and thumb. A midaxial lateral incision, along the white line, dissection is superficial to the flexor tendon, releasing all the vertical bands. Following the release, the median nerve is covered by tacking the radially based wrist flap over the median nerve. Depending on the severity of swelling, splitthickness skin grafting or delayed closure can be considered. Proper compressive dressing, wrist dorsiflexion, and splintage in functional position of hand are essential. Elevation of limb above the level of the heart postoperatively is helpful in reducing swelling and promoting drainage. But remember that elevation of a nondecompressed arm reduces perfusion and increases tissue hypoxia and, hence, elevation preoperatively before decompression should not be done. Postoperative scars are hypertrophic and have to be treated appropriately but this is a small price to pay for the preservation of hand function. Incision can be curved on the mid-forearm as depicted in Figure 4.2A. instead of using only ulnar incision.

Fasciotomy  15

B

A C

Figs 4.1A to C: (A) Forearm fasciotomy incisions; (B) Dorsal incisions; (C) Finger/hand compartment release

A

B Figs 4.2A and B: (A) Mid-forearm incision; (B) Cross section of arm

16  Handbook on Flaps in Crush Injuries of the Hand

Example 1 (Figs 4.3A to E): It depicts how, on releasing the compartments, soft tissues expand and regain their vascularity. Delayed split thickness grafting was done

after two days once the soft tissue viability was clearly demarcated.

A

B

C

D

E Figs 4.3A to E: (A) Injury with tense compartment compression syndrome; (B) Immediate postoperative status after fasciotomy; (C) Primary split thickness graft done as wound was clean and healthy; (D) Status after one week; (E) Status two weeks after surgery showing graft incorporation and resolving soft tissue swelling with preserved hand function

Fasciotomy  17

Example 2 (Figs 4.4A to F) Compression injury with developing compartment compression syndrome with thermal burns that are commonly encountered in industrial crush injuries in textile industries.

Extensive fasciotomy extending from the wrist to the elbow along with excision of dead non viable tissues and primary skin grafting was done. Primary skin grafting used selectively and judiciously gives the best result because graft have chance for incorporation before bacterial colonization occurs.

A

B

C

D

E

F

Figs 4.4A to F: (A and B) Depict extensive compression injury along with thermal burns following entrapment of hand and forearm in roller machine that also generated heat that led to acute compartment syndrome in volar and dorsal compartments; (C and D) Reveal state after radical debridement and fasciotomy as well as carpal tunnel release; (E and F) Reveal immediate postoperative status following primary split thickness grafting

5

Free Skin Grafts

Free skin grafts are of two types: 1. Split thickness 2. Full thickness. Split Thickness Graft Split thickness graft (STG) can again be subdivided into three, based on the thickness of the graft: (1) Thin; (2) Intermediate: (3) Thick Thickness can be: a. Thin: 0.010 to 0.012 inch, skin looks translucent. b. Intermediate: 0.015 inch, skin looks moderately translucent, onion peel-like appearance. c. Thick: Greater than 0.018 inch, skin looks like cadaveric skin. Properties of STG • Leaves adnexal remnants, pilosebaceous follicles and/or sweat glands apparatus foci on donor surface. • Heals spontaneously • Is good to cover extensive defects • Takes up readily on the surfaces capable of providing initial fibrin anchorage • Rapid vascularization by capillary bud in growth takes place • Thin grafts take up early but have a tendency to contract • Thicker graft take longer to recover. Chances of rejection are increased by: – Hematoma under graft – Poor immobilization – Poor dressing technique – Infection – Graft on exposed joints, cartilage/tendon.

Ideal surfaces: Fascia, muscle, cartilage with perichondrium, bone with periosteum, tendon with paratenon. STG will not take up on bare cartilage, bone, tendon and site that has been irradiated. Sites for taking STG Preferably thigh or upper arm, rarely other parts of forearm or leg. Small defects can be grafted with infiltration anesthesia with 2% xylocaine containing 1:200000 adrenaline. Block of femoral cutaneous nerve, two fingertips inferior and two fingertips medial to anterior superior iliac spine is an alternative to general anesthesia. Instrument required: Humby knife or silver knife or shaving blade. Method of STG The method is better demonstrated than described in words. Humby knife is the commonly used instrument. Graft thickness is controlled by distance between roller and blade. This is decided by keeping gauge on 0.5 mm, visualizing the space with the naked eye and adjusting the pressure while taking the graft. Smooth to and fro movement is required with adequate stretching of skin to provide maximum width of graft. Drawbacks 1. Induration and fissuring of skin is common. 2. Reduced sensibility in the area of graft as well as donor site. 3. Cold sensitivity in 1/3rd of patients treated by STG. 4. Hypoesthesia in 2/3rd of patients treated by STG.

Free Skin Grafts  19

Example 1

B

A

Figs 5.1A and B: (A) Skin loss on dorsum with cut paratenon sheath and partially cut extensor tendon in a clean uncontaminated injury; (B) Result after repair of paratenon sheath, tendon and primary STG

Example 2

A

B

Figs 5.2A and B: (A) Injury with skin loss with exposed tendons but intact paratenon sheath; (B) Debridement with primary STG performed

20  Handbook on Flaps in Crush Injuries of the Hand

Examples 1 and 2 showing skin loss on dorsum of thumb with cut paratenon sheath and partially cut extensor tendon. Repair of extensor tendon and paratenon sheath was followed by primary skin grafting successfully.

• Exposed neurovascular bundle • Dorsum of hand (relative contraindication). Technique of Full Thickness Graft

• Bare tendon, bone denuded of periosteum

• Determine the size of the graft required • Excise oval skin along with subcutaneous tissue in one block, in line of minimal tension • Close wound with buried subdermal sutures and subcuticular sutures. Cutaneous skin sutures may not be applied to minimize cross hatching on skin surface • Defat the graft with fine scisssors • Prepare recipient site by thorough debridement and secure hemostasis. Suture graft on surface without tension. Irrigate out all blood under the graft with saline from a syringe or a flexible catheter. Cover the graft with antibiotic impregnated vaseline gauze followed by a wet saline gauze. Use compressive dressing on convex surface and tie over dressing on concave dressing • Postoperatively remove the dressing at 24th hour if hematoma is expected or there is risk of infection. Drain fluid hematoma by rolling graft with wet gauze or stabbing graft with #11 knife blade. Puncture all blisters. If there is no drainage/foul smell/fever, dressing may be left undisturbed for 7 to 10 days • To prevent contracture, use silicon sheet over the graft under an elastic glove.

A

B

Full thickness Graft (Figs 5.3A and B) Important features include the following ideally: • Thickness is 0.015 inch • Graft leaves no epidermal elements in the donor area except sweat glands located in subcutaneous tissue • Donor area has to be closed by suturing • Uptake is less reliable • It is successful only in optimal conditions. Ideal Donor Sites • • • •

Lower and lateral abdominal areas Volar wrist crease Medial aspect of antecubital fossa Skin from hypothenar area when restoring sensibility is important.

Indication Small defects on palmar aspect of hand on a well vascularized bed early in the evolution of the wound. Contraindications

Figs 5.3A and B: (A) Injury over middle fingertip with intact pulp and no bony injury; (B) Full thickness graft sutured over the fingertip. Note that the grafted skin looks like cadaveric skin

Vacuum-assisted Closure The use of subatmospheric pressure to promote wound healing has gradually found support in the past few years. The vacuum-assisted closure system uses a pump providing a continuous negative pressure of preferably 125 mm Hg, which is distributed over the wound surface by an air tight covered foam. The exact mechanism of vacuum therapy is not yet understood, but clinically soft tissue defects seem to heal faster when subatmospheric pressure is applied. The procedure is based on the work of Argenta and Morykwas, who found that applying negative pressure to the wound surface increases blood flow by 400%, significantly reduces bacterial count and enhances granulating tissue formation. It can also be used over split thickness graft to enhance take of graft. The VAC is a modified dressing consisting of a sponge and suction tubing that is secured to the wound with an occlusive dressing. The split-thickness skin graft is secured to the recipient site using circumferential staples, followed by placement of a nonadherent

Fig. 6.1: Transverse view: Skin graft or non-adherent dressing covers wound. Next VAC sponge cover is applied followed by vacuum tube. Adherent occlusive dressing covers the sponge and tube

6

dressing. The VAC sponge is cut to match the contour of the wound and is secured to the surrounding skin using benzoin spray and an adherent, occlusive dressing. VAC is placed to continuous −125 mm Hg suction. Continuous negative pressure is ensured by clamping the VAC tubing and assessing for an air leak within the dressing. If an air leak was present, the leaking site is identified and repaired with a strip of the adherent dressing. The VAC dressing is left decompressed and clamped while the patient is transported to the recovery room and back to the hospital room. Once in the hospital room, the wound VAC is returned to suction until the dressing is removed. During the postoperative period, attempts are made to keep the affected area immobilized. The dressing is changed every 24 hours in the infected wounds and every 72 to 96 hours in the rest. The procedure is abandoned if increase in discharge and evidence of sepsis is present. In such an eventuality, the wound is examined earlier and debrided (Figs 6.1 to 6.5).

Fig. 6.2: Cross-section view

22  Handbook on Flaps in Crush Injuries of the Hand

Fig. 6.3: Diagrammatic representation of wound covered by VAC dressing and connected to vacuum pump

Fig. 6.4: Simple method of making VAC. The suction cannula from the sealed dressing is attached to a vacumized flask which in turn is attached to a suction apparatus

Fig. 6.5: Clinical example of making a cost effective VAC apparatus. Suction tube from wound goes to vacumized bottle which in turn is connected to a vacuum suction apparatus

Local Flaps (Principles and Techniques)

7

PRINCIPLES AND TECHNIQUES IN FLAP COVERAGE

ROTATION AND TRANSPOSITION FLAP (FIGS 7.1 TO 7.3) It is essential to understand the principles involved in the use of flaps as they are applicable to all flaps of the hand and fingers. The rotation or transposition flap including Z plasty is useful in dealing with contractures especially on volar skin crease. Principles include: • Use the largest possible flap • Primary defect is triangulated and necessary gain achieved by differential suturing • Acute back at 180 degrees relieves tightness and increases flap length

• Excise critical area as burrow’s triangle to facilitate flap rotation • Lengthening decreases tension after transposition. A rotation flap is a local pedicle flap whose width is increased by having the edge distal to the defect form a curved line; the flap is then rotated and a counterincision is made at the base of the curved line to increase mobility of the flap. A transposition flap is a rectangular flap of skin repositioned to fill a defect like pedicle graft.

A

B

C

Fig. 7.1: Rotation flap

Figs 7.2A to C: Secondary defect closure and orientation of random flaps: (A) If a random flap is lifted from the secondary defect and that defect is then skin grafted, the flap will face in the same direction as when it was raised. This can be represented as north in this diagram indicated as the tip of the arrow; (B) If one or the other lateral margins are made longer than their counterparts, then the flap can be made to face either northeast or northwest; (C) By excising a Burrow’s triangle in the upper part of the secondary defect and suturing the defect margin to margin, the flap can be made to face either due east or due west depending on the location of the extension cut

24  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D Figs 7.3A to D: (A and B) If all the lines are equal with S as pivot, SA is the line that will have to stretch 75% to cover primary defect; (C and D) If the flap is made wider three times, stretching of critical line is only 33%

Rotation flaps are used to repair defects that cannot be closed along a single tension vector by an advancement flap. In the classic rotation flap, an arc is extended distally from the base of the defect to a length that represents about one-fourth of a circle. Increasing the curvature of the arc offers greater flap movement. The primary defect is eliminated by flap rotation, which creates a secondary defect along the length of the arc. This donor site is dispersed along the entire suture line and is easily eliminated. Often, dog ear removal is necessary at the flap pivot point. The arc of rotation can be oversized to reduce flap tension and movement restriction at the pivot point. Flap mobility may also be improved by performing a backcut into the flap’s body, but at the risk of compromising the vascular supply of the flap. A transposition flap repairs defects in an area with little skin laxity by utilizing adjacent tissues.

These flaps redistribute vectors of tension resulting in an overall reduction in tension. The use of adjacent skin provides an excellent color and texture match. Transposition flaps are small and produce a less noticeable broken-line scar compared to rotation and advancement flaps. However, this scar may be considered a disadvantage because its orientation makes it difficult to camouflage and place parallel to relaxed skin tension lines. The flap is rotated around a pivot point carefully ensuring that no excessive tension is placed on the pedicle. Rhomboid flap of limberg, dufourmental flap, bilobed flaps are examples of a transposition flap. Adverse Effects (1) Circulation is compromised, (2) Dog ear is created. Figures 7.3A to D illustrating the advantages of using longer/wider flap. Transposition flap techniques that leave a secondary defect requiring skin graft. Transposition Flap Assessment Techniques A simple method to decide the lust available method to cover on dorsum of thumb is illustrated as a line diagram (Figs 7.4A to F). Transposition Flap Techniques: Extension Cut An extension cut has been made from O to Q of the same length at all other lines in this design. Shaded area defect MNP, ML is first cut equaling MN. If second cut of flap is extended to Q, the critical length is lengthened and stretch necessary is reduced to 16% in this equilateral model (Fig. 7.5). Transposition Techniques: Cut Back (Figs 7.6 to 7.8) Cut back can be done to bring pivot point closer to primary defect and reduce flap which is under tension. Drawback: Vascularity compromised. Advances: Releasing tension more important than adherence to 1:1 flap ratio.

Local Flaps (Principles and Techniques)  25

A

B

C

D

E

F

Figs 7.4A to F: Assessment methods to decide the best method of coverage for defect on dorsum of thumb: (A and B) Burrow’s triangle with sliding transposition flap requires tissue to be available in longitudinal axis on palmar surface of wrist; (C and D) Z-plasty by lengthening central limb requires tissue to be around circumference of wrist because lengthening of central limb requires shortening of transverse axis; (E) A rotation flap requires tissue on the opposite aspect of rotation flap on the dorsum of the wrist; (F) A rotation flap was selected

Fig. 7.5: Transposition flap techniques—extension cut: An extension cut has been made from O to Q defect is the shaded area MNP, ML is first cut equaling MN. If the second cut of the flap is extended to Q, the critical length is lengthened and stretch necessary is reduced to 10% in this model

Fig. 7.6: Transposition techniques using cut back: Cut back OR can be done to bring pivot point closer to the primary defect and reduce flap which is under tension

26  Handbook on Flaps in Crush Injuries of the Hand

A

B Figs 7.7A and B: Transposition flap: Injury on index finger tip treated with transposition flap. Secondary defect is covered with split thickness graft

A

B

C

Figs 7.8A and B: (A) Traumatic amputation of middle, ring and little fingers treated with transposition flap; (B and C) Final result of transposition flap in three fingers

Local Flaps (Principles and Techniques)  27

LATERAL DIGITAL FLAP (FIGS 7.9A AND B) Indications

ADVANCEMENT FLAP (FIGS 7.10A AND B) Excision of two burow’s triangles on both sides assist advancement of flap.

1. Damage to the flexor tendon with anterior loss of skin preventing primary closure. 2. Correction of severe dupuytren’s contractures or burns contracture of dorsal web space. Blood supply: Random pattern but the flap is reliable. Technique Neurovascular bundle is identified and left undisturbed. A proximally based arterial digital flap is raised with apex at the center of the middle phalange. Length should be a little longer than the diameter of skin loss and wide enough. But the length should not be greater than three times the width.

A

A

B Figs 7.9A and B: Lateral digital flap

B Figs 7.10A and B: Advancement flap concepts: (A) Burrow’s triangles are excised; (B) Flap is advanced and defect is closed Courtesy: Dr Amar Vakharia, Surat, Gujarat

28  Handbook on Flaps in Crush Injuries of the Hand

RHOMBOID FLAP OF LIMBERG (FIGS 7.11 TO 7.13) In this flap, the defect is turned into a rhomboid. A line is extended that equals the height of the rhomboid. The line is then extended parallel to one of the sides as shown. The flap is elevated and transposed into the defect. The wound can be closed primarily. The classic rhomboid flap, designed by Limberg in 1963, provides a method to fill a primary defect with reduced suture line tension. The primary defect is converted into a four-sided parallelogram of equal lengths and angles of 60° and 120°. The modified defect

A

serves as a template for the flap. An incision is performed from one of the obtuse tips extending parallel to it. At the distal tip of this incision, a second incision with equal length is made parallel to one of the near sides of the rhombus producing a 60° angle. The flap is then lifted and transposed into the defect, redirecting the tension vector by 90°. The initial incision may be extended off either the long or short axis of the rhombus. However, extending off the short axis minimizes the flap size and arc of rotation. Tension may be minimized at the flap tip by lengthening the leading edge of the flap or increasing the angle greater than 120°.

B

C

Figs 7.11A to C: (A) All the dimensions of flap are equal including transverse diagonal SV; (B) Transposition moving pivot point M to promontory U; (C); Transverse diagonal can be of any length. GT, the transverse diagonal is extended to G’ and one of the adjacent sides NT to N’. Angle N’TG’ is bisected by a line equal to length of one side of defect TX. XC is drawn parallel to the longitudinal diameter diagonal UN. Transposition is done by approximating pivot point C to promontory T

Fig. 7.12: Diagrammatic representation of Limberg flap

Local Flaps (Principles and Techniques)  29

A

B

C

D

Figs 7.13A to D: The rhomboid flap of Limberg: A simple technique to cover the skin defect produced by excision of an implantation dermoid of a digit; (A) Infected cyst; (B) Flap outline; (C) Cyst excised; (D) Final closure after flap transposition

30  Handbook on Flaps in Crush Injuries of the Hand

DUFOURMENTAL FLAP (FIG. 7.14) In contrast to the Limberg rhombic flap, the Dufourmental flap utilizes a narrower angle and a shorter arc of rotation. This flap design allows for an easier closure of the donor defect and better allocation of tension between the primary and secondary defects. As with the Limberg flap, the first incision is off the short axis of the flap. It is the same length as the side of the rhombus. In contrast to the Limberg flap, the angle of this incision bisects the angle formed by the line that extends straight out from the short axis of the rhombic defect and the line created by extending a side of the rhombus from the same corner. The second incision is made at the distal tip of this incision and at an angle parallel to the long axis of the rhombus. The orientation of the second incision produces a widened pedicle,

decreased tip volume and a reduced arc of rotation needed to fill the defect. Complications Pincushioning and trapdooring are terms used to describe the elevation of a flap or graft above the surrounding skin. This phenomenon may occur with all transposition flaps. There are many factors that may contribute to these complications, such as contraction of the curved flap edges, excess subcutaneous fat, lymphedema, oversizing the flap design, inadequate flap tailoring and insufficient contact between the underside of the flap and recipient bed. Flap necrosis may be associated with excess suture line tension, postoperative infection, hematoma, desiccation or ischemia associated with smoking.

Fig. 7.14: Dufourmental flap

Local Flaps (Principles and Techniques)  31

DORSAL DIGITAL ADVANCEMENT/ REGRESSION (FIGS 7.15 AND 7.16)

– When the defect is larger, advancement can be combined with a regression flap based distally. The flap is sutured in position. – Donor area can be covered by split thickness graft or left to heal spontaneously. Splint the finger for a week.

Indications • Indications for dorsal digital advancement/ regression include: – Loss of skin over PIP joint, dorsum of MP joint, small loss on dorsum of middle and distal phalanges – Small defects (1 cm to 2 cm) are closed primarily – More extensive defects can be closed by advanced or recessed or by a combination of both. • Arterial supply – Flap is based on a branch of the digital artery/ arteriole supplying the dorsum and adequate venous return in the skin pedicle. • Method – Flap is raised on the dorsum. As outlined, incision is extended distally and proximally 2 to 3 times longer than the defected skin. The incision keeps paratenon of extensor apparatus undisturbed. A transverse proximal incision distal to the head of metacarpal allows skin conservation in this area.

Fig. 7.15: Modified use of dorsal digital advancement/regression

A

B

C

D

Figs 7.16A to D: (A) Index finger has fracture of distal phalange with loss of skin over extensor tendon; (B) Fracture is stabilized with K-wire; (C) Proximal and distal extension of skin flaps; (D) Closure of defect over extensor tendon with fine sutures. Split thickness graft applied over nail bed of middle finger

32  Handbook on Flaps in Crush Injuries of the Hand

THE DORSAL REVERSE ADIPOFASCIAL FLAP FOR FINGERTIP RECONSTRUCTION

ward, makes no use of the adjacent digit and provides a pleasing and stable cover for the fingertips.

Indications

Method (Figs 7.17A to D)

1. Transverse or oblique amputation at the level of the nailfold from approximately the lunula to the proximal nail matrix (that spares the germinal matrix of the nail). 2. Small dorsal defects on the middle phalange upto the PIP (proximal interphalangeal) joint.

Surgery is performed under local digital anesthesia and rubber tourniquet. A base of 5 mm is drawn proximal to germinal matrix to include the branches of the digital artery originating distal to the distal interphalangeal joint on either side. A flap equal to the defect length plus 5 mm adjacent to the matrix is marked on the dorsal surface of the middle phalange from midlateral line ulnarly to midlateral line radially. A Z-incision is made from the nailfold to the proximal edge of the marked flap. Alternatively, a quadrangular incision can be made on the noncontact surface of the finger. Thin flaps are raised preserving the subdermal plexus. Remove the germinal matrix and nailfold to avoid subungual growth. The adipofascial flap is raised from proximal to distal preserving the paratenon on the extensor tendon and extends upto the marked base. The flap covers the defect. A small split thickness graft covers the flap and is sutured. No specific immobilization is required and active range of motion is started 10 to 14 days later.

Blood Supply • The flap is based on the dorsal arterial branch that originates from the volar digital arteries just distal to the distal interphalangeal joint. • If the flap is used to cover defects on the dorsum of the middle finger, it is a random pattern flap. Advantages The flap uses only the adipofascial tissue over the middle and proximal phalange of the injured finger. It is a one-step operation perfomed easily in the emergency

A

B

C

D

Figs 7.17A to D: (A) Length of exposed bone ‘a’ plus 5 mm gives flap length and is marked on the dorsum; (B) Z or H incision from nailfold to proximal edge of marked flap; (C) Thin adipofascial flap raised preserving paratenon. Germinal matrix and nailfold are removed; (D) Flap covers defect. Small split thickness graft covers the flap

Local Flaps (Principles and Techniques)  33

Adipofascial Flap (Figs 7.18A to H)

A

B

C

D

E

F

G H Figs 7.18A to H: (A) Injury; (B) Dorsal zig-zag incision; (C) Adipofascial flap dissected; (D) Flap released proximally; (E) Flap covers exposed bone; (F) Zig-zag incision closed; (G) Flap covered with full thickness graft and sutured; (H) Dorsal wound closure

34  Handbook on Flaps in Crush Injuries of the Hand

Dorsal Adipofascial Turnover Flap for Dorsal Defects of Finger Injury The same technique can be used for defects on the dorsum of the finger as illustrated in this case.

Figures 7.19A to E (operative technique) demons­ trates a full thickness wound with exposed PIP joint of right index finger.

Reverse Adipofascial Flap on Proximal Interphalangeal Joint

A

B

C

D

E Figs 7.19A to E: (A) Exposed wound on proximal interphalangeal joint. Black curvilinear incision denotes skin incision; (B) Reverse adipofascial flap raised; (C) Flap sututerd in place; (D) Split thickness graft over area; (E) Final result

Local Flaps (Principles and Techniques)  35

Z-PLASTY TECHNIQUES (FIG. 7.20) Z-plasty is a form of transposition flap wherein two triangles are transposed in opposite direction, exchang­ ing their positions. The secondary defect left by one triangle is filled by the other. Indications 1. To prevent contracture by using zig-zag nature of incision over scar to break the straight line effect. 2. To release scar and gain length. 3. To change direction of scars from unfavorable position across the minimal skin tension line to lie along the lines. The classical Z-plasty involves three limbs of equal length and two equal angles. The final outcome depends on the position of the central limb, the angles, length of the limbs and direction of lateral limbs. Gain in length in one direction results in shortening in the other. Theoretically, the larger the angle, the greater is the length gained but in practice transposition of flaps is

difficult with wider angles. Whatever be the angle of the limbs, when transposed, they move through an angle of 90° and the central limb finally lies at right angle to its original position. Standard 60° Z-Plasty Methods • All limbs of Z-plasty are of equal length. • Angle between limbs is 60°. • This is the largest angle at which flaps can be transposed with ease. If the angle is more, flaps will not reach comfortably and if the angle is less the flaps will overhang. 70–75% lengthening is achieved on transposition with a 60° Z-plasty. • Prerequisite is that skin in opposite direction must yield for transposition • Multiple Z-plasties must be planned when skin in transverse direction is inadequate. The net gain in length is a cumulative effect of the Z-flaps but the tension in the opposite direction gets divided between the two.

Fig. 7.20: Z-plasty. A standard Z-plasty with 60° angles. The theoretical gain length is 75%. Source: Germann G, Principles of flap design; Atlas Hand Clin; 1998

36  Handbook on Flaps in Crush Injuries of the Hand

SIMPLE Z-PLASTY OF THUMB WEB SPACE (FIGS 7.21 TO 7.24) Indication Amputation near the mid-portion of proximal phalange of thumb when at least half of proximal phalange remains, skin is minimally scarred, first metacarpal is mobile and there are no muscle contractures. Aim First web space is deepened so that the first metacarpal and the remaining proximal phalanges are relatively lengthened.

A

Method Flap is marked out with the longitudinal axis on the ridge of the first web space. It extends from the proximal digital crease of the thumb to approximately 1 cm proximal to the proximal digital crease of the index finger at a point that corresponds to the radial confluence of the proximal and middle palmar creases. Oblique proximal palmar and distal dorsal limbs are designed with this length corresponding to the longitudinal incision. The flaps are raised carefully, avoiding vascular compromise. If required, partial recession of the distal edge of the web musculature can help achieve more depth. Flaps are reversed and sutured in place.

B

C

Figs 7.21A to C: Simple Z-plasty of the thumb web. (A) Design of Z-plasty. The preferred angles are approximately 60 degrees; (B) Flaps reflected with partial recession of the web space musculature; (C) Appearance of the flaps following reversal and suture. Corner sutures are preferred in the tips of the flaps

A

B

C

D

Figs 7.22A to D: Simple Z plasty of thumb web. (A) Design of the Z-plasty. The preferred angle are approximately 60 degrees; (B) Flaps reflected with partial recession of the web space musculature; (C) Appearance of the flaps following reversal and suture; (D) Corner sutures are preferred in the tips of the flaps

Local Flaps (Principles and Techniques)  37

A

B

C

D

E

F

Figs 7.23A to F: Four-flap Z-plasty of the thumb web: (A and B) Two 120-degree-angle opposing incisions are bisected to form four 60-degree flaps. The theoretical gain in length is 150%; (C) Design of the flaps in the first web space; (D) Incision, elevation and undermining of the flaps; (E) Flap position after interposition; (F) Appearance of the thumb web following interposition of the flaps

Four, five and six flap Z-plasty are some modifications of multiple Z-plasties. In a four-flap model, two 120-degree or 90 degree flaps are taken and bisected at 60 or 45 degree respectively creating four flaps for alternate exchange.

A

B Figs 7.24A and B: Hueston flap + Z-plasty of 1st web space

38  Handbook on Flaps in Crush Injuries of the Hand

HUESTON FLAP (FIGS 7.25A TO C) (Lateral palmar advancement flap) Indications Sensate coverage for the tip of amputated fingers. One stage restoration of thumb’s volar surface by advancement of volar skin and rotational flap from dorsum of index metacarpal. The flap is technically a rotation advancement flap with one neurovascular bundle included at the base of

A

B

the flap. The longitudinal incision 2 to 3 cm long is made volar to the neurovascular bundle. A transverse cut is made across the volar aspect of the finger and the flap is elevated and rotated into the defect. A triangular defect created proximally is covered with a skin graft. Deepening of the first web space using a Z-plasty can be combined with this flap as shown in the clinical example when amputation of distal phalange is present to deepen web space and increase thumb length.

C

Figs 7.25A to C: Hueston flap is a rotation advancement flap with dissection anterior (volar) to the neurovascular pedicle: (A) Outline on the radial border of the thumb; (B) Dissection anterior to pedicle; (C) Flap in place

Local Flaps (Principles and Techniques)  39

A

B

C

D

E

F

G

H

I

J

K

L

Figs 7.26A to L: An example where Hueston flap has combined with Z-plasty of first web space: (A) Dorsal view, incision outlined; (B) Volar view, incision outlined; (C and D) Incision for Moberg advancement also outlined; (E and F) Z-plasty close up; (G and H) Immediate postoperative images; (I and J) Two weeks postoperative images; (K) Final result; (L) Comparison of both the hands. Note the length restored on the injured site

40  Handbook on Flaps in Crush Injuries of the Hand

SOUQUET FLAP (FIGS 7.27A TO C)

flap, the longitudinal incision is made dorsal to the neurovascular bundle. A transverse cut across the volar aspect carefully preserves the vessels as the flap is elevated off the flexor tendon sheath.

The souquet flap is also a rotation advancement flap but includes both the neurovascular bundles. In this

A

B

C

Figs 7.27A to C: Souquet flap: (A) Outline; (B) Dissection; (C) Flap in place

A

B

C

Figs 7.28A to C: Souquet flap used to cover injury of tip of ring finger

Local Flaps (Principles and Techniques)  41

V-Y ADVANCEMENT (FIGS 7.29 TO 7.32) B

Indications

A

• Gullitone amputation with exposed bone, where at least half of nail bed is intact with nail bed supported by bone and skin loss on dorsal and palmar aspect being almost equal • If injury is obliques slicing one with more pulp, then nail single midline V-Y is used. If obliquity of injury leaves less pulp, then nail double V-Y (Kutler lateral V-Y) is used.

C

Contraindication • Completely avulsed nail bed without bony support • Oblique flap with palmar skin loss than dorsal skin loss • Extensive skin loss, poor vascularity of skin, crushing injuries.

Fig. 7.30: Cadaveric dissection in hand showing fingers with: A–Venkataswami-Subramanian flap; B–Hueston flap; C–Atasoy flap

• Flap is based on single known pedicle but can also be a random pattern flap based on random vessels in the subcutaneous tissues.

• Divide all septa that are tight and resist advancement • Apex of V in single V-Y should be at the distal digital crease. Rarely in more proximal amputations apex can be more proximal (see example of amputation at proximal phalange level) • Use of magnification loupe and microscissors is helpful • Gentle tissue dissection is of prime importance.

Important Considerations

Method

• Adequate mobilization of the flap is a must • Only nerves and vessels need to be kept intact.

1. Atasoy-Kleinert V-Y flap 2. Kutler lateral V-Y flap 3. Venkataswami flap for oblique amputations.

Blood Supply

Atasoy-Kleinert V-Y Flap (Figs 7.31A to D)

Fig. 7.29: Drawing of the four flap types: A—Atasoy flap; B—Hueston flap; C—Venkataswami-Subramanian flap; D— O’Brien flap. Flaps (dotted area) are pulled distally onto the injured surface of the finger leaving a gap (lined area). Open arrow— Line of surgical incision, Closed arrow—Proximal margin of flap. Source: Atasoy et al. (1970); Hueston (1965); O’Brien (1968); and Venkataswami and Subramanian (1980)

• Use a tourniquet • Avoid cautery use, especially near the pedicles • Trim the sharp irregular bony edges of the bone, if present, to create a guillotine stump. technique advances a V-shaped flap distally on to the defect, approximating the skin on either side to close the residual pulp defect. The effect is to convert the initial V of the flap into a Y-shaped suture line • Base of triangle should be as wide as nail bed and not wider to avoid flattened appearance. Apex should be at distal interphalangeal digital crease. Incision with knife is made through full thickness of skin only. But at the apex, skin is cut right down to the bone where there are periosteal attachments, but no vessels. Through the base with tenotomy scissors, deep surface of flap is freed from underlying tendon sheath as far as the apex. With skin hooks on

42  Handbook on Flaps in Crush Injuries of the Hand

one lateral margin distracting the flap, the lateral subcutaneous tissues that contain the pedicle of the flap are spread apart with microscissors. Divide any restraining band. The flap with the neurovascular bundle should advance easily. The neurovascular bundle should be carried enbloc without attempting to isolate or define artery/vein/nerves. • In Kutler’s double V-Y, the procedure is carried out on both ends developing two triangular flaps. Two triangular flaps from the mid-lateral aspect of each digit are developed with the incisions made just down to the dermis. Both the triangles are advanced to the midline and sutured together. • If after full release of all septa the flap still does not cover the defect, use a split thickness graft instead of the nibbling bone.

B

• Start closure at the apex creating the vertical stem of the Y. After closure, release tourniquet and assess vascularity which must be present. If color does not return, use warm packs for 20 minutes. Release the distalmost sutures, if required. Drawbacks and Complications • Skin necrosis results if flap is too large. Restrict the length of the pedicle to 1/4–3/8 inch to avoid this complication • Other complaints frequently encountered are: – Coldness, tenderness on percussion, difficulty in grasping small objects, slight hypoesthesia on the operated tip.

C

D

A

Figs 7.31A to D: Atasoy-Kleinert volar V-Y technique

A

B

C

Figs 7.32A to C: (A) Guillotine amputation of thumb with intact nail bed; (B) V-Y plasty. V is converted into Y, flap is transported distally and sutured in place; (C) End result. Outline of V-Y suture line is outlined on the thumb

Local Flaps (Principles and Techniques)  43

BILATERAL KUTLER’S V-Y PLASTY (FIGS 7.33 TO 7.35)

A

B

C

D

E Figs 7.33A to E: Diagrammatic representation of bilateral Kutler’s V-Y plasty: (A and B) Injury; (C and D) Bilateral triangular flap elevated; (E) Closure of wound

A

B Figs 7.34A and B: Clinical example of bilateral Kutler’s V-Y plasty

44  Handbook on Flaps in Crush Injuries of the Hand

A

C

B

D Figs 7.35A to D: Bilateral Kutler’s V-Y plasty: (A) Injury; (B) Triangular V dissected on both sides; (C) Both triangles advanced to the midline; (D) Final result with sutures in place

Local Flaps (Principles and Techniques)  45

VENKATASWAMI-SUBRAMANIAN FLAP (FIGS 7.36 TO 7.38) Indication This is an oblique triangular flap, which is applied in oblique/palmar amputations of the fingertip and thumb. It can be converted into a neurovascular island flap. If more advancement is required, then it can be obtained with a standard flap elevation. Method An oblique triangle is marked as shown in Figures 7.36A to F. The base is equal to the width of the amputated site and one side is longer than the other. The flap is outlined beginning at the mid lateral line and extended 2.5 times the diameter of the wound. The flap may extend beyond the immediate proximal crease to the second proximal crease. The opposite midlateral line is identified and

an oblique incision is made from the distal midlateral wound edge to the proximal margin of the midlateral incision. Two hooks are applied to the base and the flap is separated from the fibrous flexor sheath with blunt-pointed scissors and, thus, avoiding damage to the neurovascular bundle. On the straight side of the triangle, the incision is always dorsal to the neurovascular bundle. After separating the flap from the fibrous flexor sheath, the flap is raised on the straight side incorporating the neurovascular bundle within the flap. On reaching the apex, the neurovascular bundle is freed to permit adequate mobility. Next, the oblique side of the triangle is dissected. Near the base, branches of the neurovascular bundle entering the oblique side can be found and carefully dissected with scissors. All fibrous septa on the oblique side are divided. Lastly, the apex is lifted and the fibrous bands holding it are

A

B

C

D

E

F

Figs 7.36A to F: (A) Top left oblique amputation; (B to D) Top right skin incision center left flap raised from the bone and fibrous flexor sheath neurovascular bundle in straight line is included in flap; (E and F) Left and right final appearance Source: Venkataswami R, Subramanian M, Oblique triangular flap, Plastic reconstructive surgery. August 1980;66(2):296–300

46  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

E

F

Figs 7.37A to F: Venkataswami flap for oblique amputation of fingertip: (A) Oblique amputation, volar view; (B) Dorsal view of injury; (C) Flap outlined; (D) Flap dissection; (E and F) Final result

A

B

C

D

Figs 7.38A to D: Venkatswami flap on fingertip injury with exposed bone: (A) Fingertip injury with exposed bone; (B) Flap to be raised is outlined; (C) Flap is raised with intact vascular pedicle; (D) Flap is sutured in place covering the exposed bone

divided. Because of the thick texture, if sufficient mobility is not achieved, the vessels that enter the oblique side can be divided to create a neurovascular island flap and advanced.

The tourniquet is released and the flap advanced. The base of the flap is sutured to the nail or the nail bed. The raw area on the nail bed is covered by a split thickness graft.

Local Flaps (Principles and Techniques)  47

PALMAR BIPEDICLE ADVANCEMENT FLAP (FIGS 7.39 TO 7.41) (Moberg-O’Brien flap) Indications • Large avulsions of the thumb pad involving approximately 50% of the palmar portion of the distal phalange, particularly the thumb • Blood supply: Axial supply from the digital vessels. Advantages • Well innervated sensate flap • Restores near the normal sensory perception with durable skin and soft tissue • Up to 2.5 cm length defects or approximately 50% palmar skin loss (but not larger) can be covered • Single stage procedure that does not involve other fingers • The advantages of the flap in the thumb are: (i) vascular supply is easily identified. (ii) blood supply to the dorsal aspect is independent of the volar blood supply; (iii) as opposed to the fingers, a flexion contracture of the thumb generally leaves the thumb in a functional position. Disadvantages • Areas more than 2.5 cm cannot be covered • Danger of compromising vascularity of ungual area

A

• Sloughing of bits of bone and nail in immediate postoperative period is known • Flexion contracture of IP joints is possible • In fingers other than the thumb, blood supply distal to PIP joint is jeopardized and can cause dorsal skin necrosis. Hence, this procedure in other fingers should be avoided and best left to the experienced surgeons. Also only small 10 to 15 cm advancement should be done along with ‘breaking down’ of fibrous bands tethering the skin. Technique Tourniquet is used. Necrotic and ragged bone is trimmed from the distal phalange and soft tissue thoroughly debrided. Midaxial incisions are made on ulnar and radial sides of the thumb, extending proximally from the lesion to the proximal thumb crease. Elevate the palmar flap carefully without disturbing the flexor tendon or its sheath. Preserve the neurovascular bundle and subcutaneous tissue by remaining dorsal to the bundle and mobilizing them en masse without trying to isolate the vessels. Check the flap mobility by gentle traction in the flap. Release any tight undermining tissue. Flex the MP and IP joints 30 to 45 degrees to assist closure. The distal edge of the flap is sutured to the remaining nail bed or terminal skin remnant. Radial and ulnar sutures are used to complete the closure.

B Figs 7.39A to C: Palmar advancement flap with proximal releasing incision

C

48  Handbook on Flaps in Crush Injuries of the Hand

A

B

Figs 7.40A and B: Palmar advancement flap without proximal releasing incision

A

B

C

Figs 7.41A to C: Example of palmar advancement without proximal releasing incision. (A ) Injury; (B and C) Final result

A proximal transverse releasing incision between the proximal ends of the two lateral incisions and carefully elevating the proximal edge of the flap helps mobilize the neurovascular bundle. A full thickness graft can be used to cover the proximal donor area.

Compressive dressing is applied and flap and graft inspected at 7 to 10 days. Mobilization is started at 3 weeks. Dynamic splinting may be required to gain full extension.

Local Flaps (Principles and Techniques)  49

JOSHI’S DORSOLATERAL NEUROVASCULAR ISLAND FLAP (FIGS 7.42 TO 7.44) (Described by Dr BB Joshi in 1974) Indications Slicing oblique injury on the distal phalange of thumb that is not suitable for V-Y plasty, specifically: 1. Volar pulp loss obliquely close to coronal plane 2. Lateral oblique pulp loss especially in radial oblique pulp defect of the thumb. Contraindications • Avulsion injury (absolute contraindication) • Conditions predisposing to microangiopathy like diabetes mellitus, and negative • Allen’s test for refilling. Advantage: Sensation can be restored almost instanta­ neously after surgery. Prerequisites: 1. Good dorsolateral skin condition 2. Intact nail bed. Anatomy: Palmar digital arteries supply small branches to the dorsum of the middle phalanx. Three or more arterial arcades enrich the dorsum of the distal phalanx. Veins are inconsistent and drainage of the flap will depend heavily on the periarterial cuff of soft tissue with its deep venous plexus. The terminal branches of the digital nerve innervate lateral aspect of the pulp. Dorsal supply is variable. The dorsum of the middle and distal phalanx is innervated by a dorsal branch arising from the digital nerve just proximal to the proximal digital crease and should be included in the flap to ensure maximal sensory reinnervation of the transposed flap.

A

B

Method • The nonopposing side of the digit is usually chosen as the donor site • The flap is marked out as a rhomboid shape (Figs 7.43C and D). Distally, the incision falls 3 to 4 mm away and parallel to the nail edge to avoid iatrogenic damage to the nail matrix. Dorsally, the flap can be extended up to the mid-line. Proximally, it can reach as far as the middle phalangeal crease. The edge of the wound defect forms the distal palmar margin of the flap • A mid-axial incision is extended proximally to expose the neurovascular bundle. Remain superficial to the flexor tendon sheath. The flap with the neurovascular bundle is raised. A dorsal vein and the dorsal digital nerve should be included in the flap whenever possible. The periarterial cuff of soft tissue is retained as much as possible to provide adequate venous drainage (Figs 7.43E and F). The skin is very adherent to the distal phalanx and the collateral ligament near the nail bed and preservation of sufficient areolar tissue at this region is essential for survival of the skin graft. To avoid damage to the digital vessels ligate the small arterial branch supplying the flexor tendon over the neck of the middle phalange • Flex the finger joints to relieve tension on the vessels if pedicle mobilization is inadequate • Generous mobilization of the pedicle up to the proximal phalange level would usually eliminate the need to do so. Close the wound proximally (Fig. 7.43G) • Extend the wound into the palm, if required. • Release the tourniquet, ascertain adequacy of circulation of the flap and to achieve optimal hemostasis, anchor the flap to the nail with fine sutures (Figs 7.43H and I). Apply full thickness skin graft to the donor defect (Fig. 7.43J).

C

Figs 7.42A to C: (A) Flap demarcation; (B) Flap raising; (C) Flap splitting Source: Modified with permisson from Dr BB Joshi’s book on thumb reconstruction

50  Handbook on Flaps in Crush Injuries of the Hand

Joshi’s Flap in Index Fingertip Amputation

A

B

C

D

E

F

G

H

I

J Figs 7.43A to J: Joshi’s flap in index fingertip amputation: (A) Injury—volar view; (B) Injury—dorsal view; (C) Incision—volar view; (D) Incision— dorsolateral view; (E) Dorsal view of incision; (F) Flap dissection; (G) Proximal primary closure; (H) Flap sutured onto defect raw donor area; (I) Defect covered by flap; (J) Full thickness graft on donor area

Cadaveric Dissection Depicting Dr Joshi’s Flap on the Thumb

A

B

C

D Figs 7.44A to D: Cadaveric dissection depicting Dr Joshi’s flap on the thumb: (A) Injury and outline of flap to be dissected; (B) Neurovascular bundle dissected out; (C) Flap mobilized; (D) Flap cover overexposed bony defect

Local Flaps (Principles and Techniques)  51

Advantages This technique carries several distinctive advantages, and these are: (i) It provides nonglabrous skin coverage of the pulp; (ii) It can be used to cover relatively large defect, upto the whole length and three quarters of the width of the pulp; (iii) It provides immediate sensation; (iv) The vascular anatomy is usually reliable and constant; (v) It restores good contour of the pulp; and (vi) No restriction of finger movement is required in the postoperative period. Drawbacks/Problems Following are the drawbacks/problems of this technique.

(i) It requires skin grafting of the donor site and has potential donor site morbidity. In most cases, sensation of the donor site never reaches normal, though none of them gives rise to any symptom; (ii) The relative extensive dissection may result in postoperative pain and stiffness; (iii) It theoretically deprives one of the arterial system to the rest of the finger; and (iv) The flap may develop venous congestion postoperatively because of the lack of proper vena comitans. Preservation of periarterial fat, meticulous hemostasis and strict postoperative elevation of the limb are prudent in preventing this complication.

52  Handbook on Flaps in Crush Injuries of the Hand

PALMAR DIGITAL MONOPEDICLE FLAP (FIGS 7.45 TO 7.47) Indications • Exposed bone of distal phalange of a finger • In oblique amputations, the flap is raised on the side where the skin is most abundant and the pulp is less important • In transverse incisions of index and middle finger, the flap is raised from the less important ulnar side. In ring and little fingers, the flap is raised on the radial side. Technique • A long incision extending upto the base of the digit is made between palmar and dorsal skin along the white line. Incision is staggered at the IP crease • Pedicle is raised enbloc to preserve venous return. Dorsal branch of the digital nerve is isolated and split in order to preserve dorsal sensibility. Dorsal veins are coagulated. Flexion of digit due to tone of flexor tendons helps advancement • Flap is sutured in position with good opposition to avoid hypertrophic scar. Proximal part of longitudinal incision is closed and distal part left open to heal by secondary intention. This result is better than skin grafting.

A

B

D

Postoperative • No immobilization is required. Light dressing is changed after 24 hours • Early mobilization restores extension within a week • Dressing continues for 4–5 weeks for healing by secondary intention. Advantage Good functional and cosmetic results. Disadvantages • Scar contracture results if lateral incision is not placed accurately dorsally and mistakenly has a palmar deviation • Grafting of secondary donor defect is not advisable and, hence, dressing continues for 4 to 5 weeks. This is annoying to the patient and he must be counseled of this before surgery. Clinical Application in a Middle Finger Distal Phalange Amputation See Figures 7.46A to F.

C

E

Figs 7.45(i) (A to E): Modified from pedicled flaps for coverage of the limbs Source: Modified from C Oberlin ,B Bastian ,P Greant and Anil Bhatia with permisson from the book Pedicled flaps for coverage of the limbs.

Local Flaps (Principles and Techniques)  53

A

B

C

D E Figs 7.45(ii) A to E: Cadaveric dissection depicting palmar digital monopedicle flap: (A) Injury to finger tip; (B) Neurovascular bundle dissected; (C) Flap cover on the defect; (D and E) Dorsolateral and volar views

A

B

C

D

E F Figs 7.46A to F: Palmar digital monopedicle flap: (A and B) Injury; (C) Flap outlined on ulnar side; (D) Flap dissected and elevated with neurovascular bundle; (E) Final result—volar view; (F) Final result—dorsal view (Courtesy: Dr. Amar Vakharia)

54  Handbook on Flaps in Crush Injuries of the Hand

Fig. 7.47: Palmar digital neurovascular advancement island flap; Multiple zig-­zag incisions can be used to cover fingertip injuries without skin grafting to achieve primary closure as depicted in this method (Courtesy: Dr Vitrag Shah)

Local Flaps (Principles and Techniques)  55

DISTALLY BASED DIGITAL ISLAND FLAP Indication Loss of skin on the dorsum of middle or distal phalange, as far as the proximal nail fold. Blood Supply Flap is pedicle island flap with reversed arterial blood flow based on digital artery. Similar to the chinese forearm flap in the forearm. Reversed arterial blood flow is based on the anastomoses between two principal digital arteries at the level of IP Joints and at the distal arcade in the pulp. Venous return is via the dorsal venous llexus and virtually no significant vein accompanies the artery. Digital nerve accompanying the artery lies anterior to it. Method Flap is taken from the lateral side of the proximal phalange with equal extensions on palmar and dorsal sides. Size is approximately 3 cm in length and 2 cm in width. Assess retrograde flow adequacy by clamping the artery with microvascular arterial clamps. Subcuticular skin incision

A

B

C

D

are made. The artery ligated proximally but the nerve is preserved alongwith venous plexus by performing dissection in periarterial fat. Venous plexus by performing dissection in periarterial fat. Dissection is continued up to the pip joint. A small arteriole at the volar plate needs to be coagulated. Flap is rotated at the pip joint level and sutured donor. Donor area is covered with split thickness graft. Postoperative Venous engorgement occurs. If severe partial de epidermalization may be necessary. Advantages • Excellent cosmetic result with skin of same texture is transferred. • Flap being taken from same digit, another digit is not damaged to provide skin cover. Disadvantage A digital vessel is sacrificed and second vessel must be adequate to perfuse the finger.

Figs 7.48A to D: (A) Distally based digital island flap from proximal phalange for defect on dorsumof middle phalange and DIP joint; (B) Flap is outlined; (C) Digital artery is ligated proximally; (D) Flap is sutured in defect. Full thickness graft covers donar defect Source: Modified from C Oberlin, B Bastian, P Greant and Anil Bhatia with permisson from the book “Pedicled flaps for coverage of the limbs

56  Handbook on Flaps in Crush Injuries of the Hand

A

B

D

C

F

G

E

H

I

Figs 7.49A to I: (A) Injury wound on volar surface; (B) Injury—dorsal view—intact nailbed; (C) Flap outlined and dissected on proximal phalange; Observe the pedicle on the middle phalange; (D and E) Flap is elevated distally; (F and G) Flap being transported onto defect; (H and I) Flap sutured into defect. Flap is slightly larger than defect but resultant dog ear is not excised at present. It can be excised at three weeks. Donor defect is covered with full thickness skin graft

Local Flaps (Principles and Techniques)  57

Distally Based Digital Island Flap (From Dorsum of Middle Phalange to Cover Defect on Volar Surface of Distal Phalange; Figs 7.50 to 7.52)

Fig. 7.50: The anatomy of the arterial system and innervation of the long fingers. The flap is designed on the dorsum of middle phalanx according to the size and shape of the fingertip or the pulp defect. 1—The flap; 2­—The superficial sensory nerve branch of the flap; 3— The dorsal digital nerve and artery; 4­—The dorsal branch of digital nerve; 5—Fingertip or pulp defects; 6­—The EDBA (Exterior distally based artery); 7—Dorsal branches of the digital artery; 8­—A collateral digital nerve; 9­—A collateral digital artery

Fig. 7.51: The flap and its pedicle are dissected and the two suitable superficial sensory nerve branches passing to the flap are cut off at the initial point; 10— Pedicle

Fig. 7.52: The flap is transposed to the recipient area. A tension-free epineurorrhaphy is performed between the two sensory nerves of the flap and both cut ends of the digital nerves at the recipient wound. The flap is sutured to the defect and the donor site is covered with a full-thickness skin graft using tie-over dressing; 11­— Skin graft

58  Handbook on Flaps in Crush Injuries of the Hand

ANNULAR FLAP

Method

Indication Defects on the thumb at the level of proximal phalange that requires sensory tissue cover. Occasionally used for the ring finger. Contraindication Disruption of one or both neurovascular bundles.

A

B

• Goumain described a tetrapedicled homodigital island flap • A circular area is outlined 2 cm proximal to the edge of the soft tissue defect. Only the skin and soft tissues are dissected. The neurovascular bundle is freed proximally to allow the annular flap to advance distally 10 to 12 mm. The distal wound can, thus, be closed and the proximal wound is either grafted or allowed to heal by secondary intention.

C

Figs 7.53A to C: Annular flap: (A) Amputation with protruding bone; (B) Dissection and advancement; (C) Distal closure

Fig. 7.54: Example of annular flap in thumb and STG in the index finger

Local Flaps (Principles and Techniques)  59

LOCAL FLAPS (FLAPS FROM ADJACENT FINGERS/HAND/FOREARM)

THE CROSS-FINGER FLAP (FIGS 7.55 AND 7.56) Pedicle flap taken from the adjacent finger is called a cross-finger flap. Indications A pedicle flap in general and a cross-finger flap in particular is indicated in: • Finger and thumb injuries with exposed bone, joints or tendons • To provide soft tissue padding • To preserve length of fingers, especially the index finger • Where secondary reconstruction is anticipated • To improve function and appearance • To facilitate wearing of a prosthesis • To cover bare bone in selected cases of electrical burns. Contraindications The cross-finger flap should be avoided in the following: • Elderly patients • Patients with arthritic and degenerative changes • Circulatory problems, e.g. Raynaud’s phenomenon • Scarring on donor area • Infection • Contused donor skin. Blood Supply: It is of a random-pattern flap. Following varieties of cross-finger flaps are possible:

1. Classical laterally based flap. 2. Distally based flap. 3. Proximally based (similar to flag flap): a. Dorsal to dorsal coverage. b. Dorsal to volar coverage .



4. Innervated cross-finger flap. 5. Dual innervated cross-finger flap. 6. Radial sensory innervated cross-finger flap. 7. Reverse cross-finger flap. 8. Turkish flap (C-ring cross-finger flap). 9. Flap over-riding a flap (two or more fingers involved). 10. Flap over-riding a flap along with an axial pattern flap (delto-pectoral/groin/loin, etc.). Surgical Techniques Under suitable anesthesia, and tourniquet control if deemed desirable, surgery is carried out. In co-operative patients, surgery is carried out under digital or wrist block supplemented with local infiltration with 2% xylocaine over thigh to take a small postage stamp-sized split thickness skin graft. Full technical details are described with individual flaps. CLASSICAL LATERALLY BASED FLAP (FIGS 7.57 AND 7.58) Indication Coverage of volar soft tissue defects of adjacent fingers. Technique • A pattern of the primary defect is outlined on the dorsum of the donor finger • A full thickness flap is raised from the adjacent finger, preferably the dorsal aspect of the middle phalange and tailored to the primary defect, thus avoiding excision of normal skin from the injured digit. Wound margins may be trimmed to make defect a square or a rectangle but is not always necessary because this leads to excision of sensate skin. Incision can extend from midlateral line to opposite mid–lateral line and from

60  Handbook on Flaps in Crush Injuries of the Hand

Fig. 7.55: Laterally based cross-finger base

A

B

C

D

Figs 7.56A to D: Cross-finger flap from the index finger to the thumb: (A) Large defect involving most of the distal pulp of the thumb; outline of the cross-finger flap on the proximal phalanx of the index finger; (B) Placement of the flap on the thumb defect; (C and D) Position of the thumb and cross-finger flap with a free graft covering the donor defect

Local Flaps (Principles and Techniques)  61

A

B

C

D

Figs 7.57A to D: Classical laterally based cross-finger flap: (A) Loss of pulp of tip of index finger. There is also superficial abrasion on dorsum of the index finger; (B) Cross-finger flap from middle finger; (C) STG applied on donor area and sutured with fine sutures; (D) Flap is divided at three weeks. Final result at three months

A

B Figs 7.58A and B: Five year follow-up of a cross-finger flap on thumb

62  Handbook on Flaps in Crush Injuries of the Hand

proximal extension crease of distal interphalangeal joint (DIP) to the distal extension crease of the proximal interphalangeal joint (PIP). Achieve good hemostasis and coagulate multiple longitudinal veins encountered • The paratenon sheath is carefully preserved while turning over the flap on the hinge. Apply a split or full thickness graft, taken from the thigh, over the donor area • Suture the flap to the recipient site • Flap is divided at three weeks.

• • • •

• • •

Dos’ and Don’ts of Surgery • Gentle soft tissue handling and secure careful hemostasis • Give meticulous attention to surgical detail

•

Preserve volar digital neurovascular bundle Avoid distal segment near nail bed Do not cross midlateral white line Flap size should be a little larger than the defect – if 1:1 ratio, can be located anywhere on proximal or middle segment – if 3:1 ratio, pedicle attachment must be proximal on donor digit. For the thumb, middle finger may be better than index finger as donor site Cut Cleland ligaments to extend flap cover In an amputation stump, make extent of proximal transverse cut more palmar than distal transverse incision In longer, more palmar defects, when considerable flexion of injured finger is necessary, make the distal transverse cut more palmar.

Local Flaps (Principles and Techniques)  63

DISTALLY BASED CROSS-FINGER FLAP (FIGS 7.59 AND 7.60) • •

Indication To preserve length of a finger, especially in guillotine injury to index finger tip. Blood Supply Reversed arterial flow from palmar digital arteries and their anastomosis.

• •

Technique

of dorsal and volar skin, indicating the neurovascular position Avoid encroaching on the nail bed Elevate the flap leaving extensor expansion covered with paratenon. Secure hemostasis. Cover the donor area with split thickness graft and use tie over sutures over dressing. Next suture the flap over exposed digit, usually the tip of index finger In spite of being distally based, this flap is extremely safe and easy to perform Flap is divided at three weeks

• Outline a distally based flap on the middle phalange remaining dorsal to the white line marking transition

B

A

D

C

E

Figs 7.59A to E: Distally based cross-finger flap

64  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

Figs 7.60A to D: (A) Exposed distal phalange of index finger; (B) Distally based cross-finger flap lifted and sutured to the defect; (C) The patient; (D) The immediate postoperative result at three weeks

Local Flaps (Principles and Techniques)  65

PROXIMALLY BASED CROSS-FINGER FLAP (FLAG-FLAP VARIANT) In the thumb, cross-finger flap is more comfortable to take from the middle finger than the index finger. This

A

D

flap is a variation of the flag flap. If the dorsal metacarpal artery is incorporated in the flap after locating with a Doppler, the flap is a flag flap/dorsal metacarpal artery flap. If elevated as a random pattern flap, it is a crossfinger flap.

B

C

E Figs 7.61A to E: (A) Injury; (B and C) Proximally based flap from middle finger to defect on thumb; (D and E) Final result

66  Handbook on Flaps in Crush Injuries of the Hand

REVERSE CROSS-FINGER FLAP (FIGS 7.62 AND 7.63)

A

B

C

D

Figs 7.62A to D: Reverse cross-finger flap: (A) Design of the flap; (B) Raising a full-thickness skin flap; (C) Raising a full-thickness subcutaneous flap in the opposite direction; (D) Suturing the reversed flap along the defect

Indication Small primary defects on the dorsum of the finger where dorsal digital advancement or adipofascial flap is not possible. Technique This flap is useful for dorsal to dorsal cover but is technically demanding. With a knife, a thin layer of skin at the subdermal (deep dermis) layer above the layer of subcutaneous veins below the hair follicles is removed. The underlying subcutaneous tissue is then raised in the same manner as a standard cross-finger

flap, swung 180 degrees to cover the defect. Now its superficial surface lies on the primary defect and the deep surface becomes superficial. A split thickness graft or full thickness graft is laid on the flap and the secondary defect. Flap is divided at 3 weeks. Another way of doing the reverse cross-finger flap is to first gently raise the thinnest possible full thickness flap in the direction opposite to the cross-finger flap. Now a full thickness subcutaneous flap is raised in the opposite direction and sutured to the defect. The reversed flap is now re-sutured using additional STG over the recipient defect that is now covered by the reversed subcutaneous flap.

Local Flaps (Principles and Techniques)  67

A

B

C

D

E

F

Figs 7.63A to F: Reverse cross-finger flap: (A) Raw area on dorsum of index finger with tendon loss and exposed bone; (B) Thin epidermal layer of skin from dorsum of middle phalange removed or turned over as a flap; (C) Classical laterally based flap raised from middle finger of the deepithelized skin. Now deepithelized surface touches exposed bone and raw undersurface of flap faces upward; (D) STG or full thickness flap covers raw area of both donor and recipient sites. If initially flap was created, this covers the donor area; (E) Result at 3 months. Note foul smelling cheesy white discharge from undersurface of graft due to remnants of epidermal skin left behind; (F) Undersurface was elevated and surface was scrapped to remove epidermal remnants and the excellent final result

Complication/Disadvantage Sebaceous cyst-like discharge from the grafted area. Flap necrosis is also a possibility. In the second variation,

first a thin epidermal layer is shaved off from the donor area, then a regular laterally based cross-finger flap of the subcutaneous flap is performed as shown in the clinical example.

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RADIAL SENSORY NERVE INNERVATED CROSSFINGER FLAP (FIGS 7.64 AND 7.65) Indication

•

Providing a sensate flap on the volar surface of the thumb. Relative Contraindication

•

When full length of thumb is maintained, because sensation deteriorates due to traction exerted on the nerve by extension and abduction of thumb. Method • Block the radial nerve at the wrist to delineate its dermatome • A suitable flap is designed on the dorsum of the proximal phalange of the index finger with the base just palmar to the mid lateral line • Flap can be extended over the MP joint for larger defects • An oblique incision from base of flap to mid portion of thumb web is designed and a large sensory branch of radial nerve is mobilized and transported from dorsum of index ray to recipient thumb area via an ulnar thumb incision • The flap is raised with a proximal or radial base, preserving branches of the radial nerve. At the

•

•

time of division, the radial nerve branch is isolated and dissected back through an incision extending proximally to a point close to the snuff box A large sensory branch of the radial nerve is dissected and carefully mobilized to the proximal aspect of the index incision sacrificing the smaller branches The flap is carefully elevated to the peritendinous tissue over the extensor tendon and mobilized close to the thumb. A connecting incision is made along the ulnar border of the thumb and carried proximally to the previous oblique incision extending from the flap The nerve is carefully transposed from the index finger to the ulnar thumb incision after undermining the skin to provide a tension free trough. Flap is carefully sutured and donor area is covered by a split thickness flap Flap is divided at three weeks.

Drawbacks/Complications 1. Damage to the sensory radial nerve. 2. Patient continues to interpret thumb sensation as being that of the dorsal index finger. 3. In a study (by Bralliar and Horner) two-point discrimination was poorer compared to a standard cross-finger flap in a majority.

Local Flaps (Principles and Techniques)  69

A

C

B

D

Figs 7.64A to D: (A) Flap is marked on dorsum of index finger and extension upto base of defect on thumb is made over first web space; (B) Flap is elevated, transporting sensory branch of radial nerve; (C) Flap along with nerve is transported and sutured to dorsal area; (D) STG on donor area and suturing of incision first web space

70  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

E

F

Figs 7.65Ato F: Radial sensory nerve innervated cross-finger flap: (A) The partially amputated thumb with loss of part of distal phalange; (B) Subcuticular incision identifying sensory branch of radial nerve; (C) Incision is extended on radial side of 2nd metacarpal tracing the nerve proximally upto the 1st web space. Through another incision on the ulnar and dorsal side of the wound, the incision is extended to meet the previous one; (D) Flap along with nerve is transported; (E) Completed transport with STG sutured in place. Note that the suture line after transport of nerve with flap is complete; (F) End result. Note the hypertrophied scar line which can cause a problem

Local Flaps (Principles and Techniques)  71

INNERVATED CROSS-FINGER FLAP

Innervation of a standard cross-finger flap.

joined to the proper digital nerve of the injured finger on the side opposite to the donor digit. Thus, the ulnar dorsal digital branch of the middle finger will be joined to the radial digital nerve of the index finger.

Technique

Disadvantage

A classical laterally based flap is performed. The dorsal branch of the proper digital nerve of the donor finger, on the side away from the injured finger, which supplies the dorsum of the middle phalange, is divided proximally in the course of raising the free margin of the flap. It is then

Complexity of procedure limits its use to those skilled in microvascular techniques. Also standard cross-finger flap too has two-point discrimination of up to 8 mm in 70% patients compared to two-point discrimination up to 2 mm in 53% with this complex surgery.

Indication

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DUAL INNERVATED CROSS-FINGER FLAP (FIGS 7.66 AND 7.67) The flap is transposed with the dorsal sensory radial nerve branch and inset radially. By microneurorrhaphy,

the palmar ulnar digital nerve of thumb is sutured to the more distal dorsal sensory nerve branch of the transposed flap.

A

B

C

D

Figs 7.66 A to D: Dual innervated cross-finger flap: (A) The dorsal sensory branch of the index radial digital nerve predictably innervates the distal dorsal aspect of the index proximal phalanx; (B) Elevation of an index-to-thumb cross-finger flap with joining incisions for transposition of the dorsal sensory branch of the radial nerve; (C) Microneurorrhaphy of the thumb ulnar digital nerve (UDN) to the dorsal branch of the index radial digital nerve (RDN); (D) Appearance of the flap at closure

Local Flaps (Principles and Techniques)  73

A

B

C

D

E

F

Figs 7.67A to F: Dual innervated cross-finger flap after transport of dorsal sensory branch of the radial nerve and microneurorrhaphy of the thumb ulnar digital nerve (UDN) to the dorsal branch of the index radial digital nerve (RDN)

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TURKISH FLAP (C-RING CROSS-FINGER FLAP) (FIG. 7.68)

Fig. 7.68: Steps for elevation of C-ring cross-finger flap

Indications

Method

Coverage of relatively large defects of volar and dorsal skin of the fingers and sometimes to cover degloved stumps.

The flap is based on the digital vascular bundle and can be based distally or proximally. The flap is based on the dorsal skin but can include volar skin of the middle phalange. The digital nerve is not included. The plane of dissection is superficial to the paratenon. It can be made into an island flap to allow more mobility. In degloving injuries, the flap is sewn to itself on the degloved defect. Full thickness graft covers the donor site. Flap is divided at three weeks.

Contraindication An abnormal Allen’s test.

Local Flaps (Principles and Techniques)  75

CROSS FINGER FLAP OVER-RIDING A CROSS FINGER FLAP (FIGS 7.69 A TO C) Flap on a Flap When two or three adjacent fingers are involved with skin/pulp/bony loss on the volar surface, a flap riding on a flap is used. Though taking a flap from the dorsal side of a finger having skin loss on its volar surface seems dangerous, in selected cases, excellent end result can be obtained. Results are better compared to bulky deltopectoral or abdominal flaps. In injuries involving index, middle and ring fingers, flap on index finger is from dorsum of middle finger,

A

B

flap on middle finger from dorsum of ring finger, and flap on ring finger is from dorsum of little finger. In injuries involving little, ring and middle fingers, flap on the little finger is from dorsum of ring finger, on ring from dorsum of middle finger and on middle finger from index finger. STG is stitched to the donor area as in cross-finger flap. Flap division is at three weeks. Two fingers involved Cross-finger flap on the middle finger is taken from the ring finger. Flap on index finger taken from dorsum of middle finger. Though taking a flap from an injured finger seems risky, this procedure is safe and comfortable for the patient with excellent long-term results.

C

Figs 7.69A to C: Flap overriding a flap. Defect on middle finger covered with flap from ring finger and defect on index finger with flap from dorsum of middle finger

76  Handbook on Flaps in Crush Injuries of the Hand

FLAP ON A FLAP ON A FLAP (FIGS 7.70 TO 7.75) Three Cross-Finger Flaps Over Riding One Another Example 1

A

B

C

D

E

F

Figs 7.70A to F: Three fingers involved middle, ring and little fingers with exposed bones. Raw area on middle finger covered with flap from index finger, raw area on ring finger covered with flap from middle finger and raw area on little finger covered with flap from ring finger

Example 2

A

B

C

D

Figs 7.71A to D: Three fingers involved—middle, ring and little fingers. Avulsion of volar surface of middle, ring and little fingers. Cross-finger flap on little finger taken from dorsum of ring finger. Cross-finger flap on ring finger taken from middle finger. And cross-finger flap on middle finger taken from index finger

Local Flaps (Principles and Techniques)  77

Example 3

A

B

C

D

E

F

G

Figs 7.72A to G: Flap overriding a flap (flap on a flap on a flap). (A and B) Volar view of injury; (C) Cross-finger flap on middle finger from index finger, on ring finger from middle finger and on little finger from ring finger; (D) Cross-finger flap on middle finger from index finger, on ring finger from middle finger and on little finger from ring finger; (E to G) Result on flap release

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Example 4

A

B

C

D

E

F

G

H

I

J Figs 7.73A to J: Flap over-riding a flap involving index, middle and ring fingers: Here the fingers involved are index, middle and ring fingers. Cross-finger flap for index finger is taken from dorsum of middle finger, CFF for middle finger is taken from ring finger and CFF for ring finger is taken from little finger. Note the reversal of appearance of three fingers over-riding one another compared to the previous example. Needle has been inserted in one finger to prevent flexion at the IP joint that would hinder flap uptake and also prevent inadvertent joint contracture

Local Flaps (Principles and Techniques)  79

Example 5

Fig. 7.74: Avulsion injuries of index and middle fingertips of both hands. Cross-finger flap done on three fingers and STG applied on right index fingertip. Patient was not happy with the STG on right finger, which experienced frequent breakdown of skin. He was extremely happy with the cross-finger flap results and wanted a CFF on the STG site

Example 6

Fig. 7.75: Completely degloved little finger with volar skin loss in ring, middle and index fingers. Reverse delto pectoral flap in little finger, STG on ring finger, cross-finger flap over-riding a cross-finger flap on index and middle fingers. Compare excellent results of local flaps compared to bulky axial pattern flaps. Thenar flap could have been done on ring finger but was deferred because dressing would have been a problem

80  Handbook on Flaps in Crush Injuries of the Hand

DORSAL TO DORSOLATERAL COVERAGE (DORSAL MIDDLE PHALANGEAL ARTERY FLAP) (FIGS 7.76 TO 7.80)

Fig. 7.76: Dorsal island digital flap (axial). The dorsal digital artery may arise either from the proximal digital artery or from the dorsal interosseous metacarpal artery

A

B

C

D

Figs 7.77A to D: Dorsal middle phalanged finger flap. Illustration of the steps for elevation

Local Flaps (Principles and Techniques)  81

A

D

B

C

E Figs 7.78A to E: (A) Injury on dorsolateral aspect of ring finger with exposed bone on middle phalange; (B) The flap in position; (C) Flap after release at three weeks; (D and E) Functional and cosmetic result at 6 months

Indication Dorsolateral defect on adjacent finger or ipsilateral adjacent defects. Blood Supply Dorsal digital artery In the case illustrated here, dorsal flap from proximal and middle phalange of middle finger is taken to cover dorso lateral defect on ring finger. This is a variant of the flag flap which is classically based on the proximal phalange and incorporates the brach of a proper digital

artery or dorsal metacarpal artery. This flap incorporates the middle phalangeal artery and is elevated from distal to proximal preserving the extensor paratenon. After elevation, the flap is rotated into position avoiding kinking of the pedicle. Donor area is covered with STG. Flaps upto 3 × 3 cm can be easily raised. Advantages of the Cross-finger Flap • Skin available for transfer is thin in texture and superior to that obtained elsewhere. It gives better color, contour and appearance of flap. Pinch and grip action regained is good

82  Handbook on Flaps in Crush Injuries of the Hand

• Functionally protective sensation is present over six months in most cases • Consistently good functional and cosmetically acceptable results are obtained • Short operative time (45 min. to 60 min.) • Can be performed as an OPD procedure in cooperative patients under local block anesthesia. Patient is ambulatory and returns to work early • Immobilization of fingers is simple and comfortable • Minimal scarring of donor area. Split thickness graft is on a “silent” area where it affords excellent permanent cover • Excellent flap viability. Except for rare superficial epidermal necrosis, which heals very well with dressings alone, flap necrosis was not encountered in this series • Secondary defatting of flap is not required • Permanent postoperative stiffness and tenderness is rare. The early commoner post • Operative stiffness resolves easily in 6 to 8 weeks • Mobility of unaffected digits is maintained through­ out the treatment period. Drawbacks and Disadvantages • It is a nonsensate flap. There is loss of good tactile sensation, stereognostic sensation is absent and very fine two-point discrimination over the flap is missing. But crude sensibility and protective function is regained over a period of time • Unavoidable scar on donor area. This can be minimized by using full thickness graft (pinch graft) • Early postoperative stiffness on donor area, especially if area is over interphalangeal joint. This stiffness gradually subsides over a period of time, but some patients experience difficulty in making a fist

• Colour difference due to darker dorsal skin covering fairer volar area • Limited area of skin coverage is possible making it unsuitable for bigger defects • At the time of division, flap is indurated, firm on palpation and not sensate. Gradually, it shrinks, becomes pliable and soft, and some crude sensation returns. Complications (Figs 7.79 and 7.80) • Necrosis of superficial epidermal part of flap • The deeper part usually had a good take and full area epithelised over 3 weeks with regular dressing. Full necrosis of flap is very rare and never encountered by the author • Discharge of Sebaceous cyst-like material from case of reverse cross-finger flap. Three months after surgery, the flap is again elevated, the undersurface is scrapped, after which the discharge usually disappears • Stiff finger in elderly is common and other local flaps should be preferred in the elderly • Superficial infection • This usually resolved with change of appropriate antibiotics • Hair growth on flap occurs in patient reluctant to use finger during work, if flap is taken from dorsal skin having hair follicles • Neuroma formation with resultant painful flaps can rarely occur • This is treated surgically if it does not respond to conservative measures Excision of neuroma using magnifying loupes is carried out.

Local Flaps (Principles and Techniques)  83

Complications

A

B

C

D

Figs 7.79A to D: (A) Infection; (B) Sebaceous cyst-like discharge; (C) Hair growth; (D) Flap necrosis

Complications

A

B

C

D Figs 7.80A to E: Flap necrosis in a 2-year-old child with dorsal to dorsal transfer from index to thumb: (A) Partial flap necrosis. Note exposed bone on dorsum of thumb. (B) Base of flap is elongated and cut after a week, keeping inset of partly surviving flap intact and thus converting the inset into a base for the flap; (C and D) Newly created pedicle is rotated over new inset and flap cut from base is sutured onto defect left due to flap necrosis; (E) Final end result after a month with well-incorporated flap.

E

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RESULTS OF CROSS-FINGER FLAP Majority of the patients are highly satisfied with the results and return to their original vocation, mainly industrial work. Their work requires only crude sensation for resumption of work, resulting in a higher level of satisfactory outcome. Vocations requiring higher levels of fine sensibility may not be equally satisfied with the procedure and, in such cases, other sensate flaps would be preferable. All the patients have permanent hypoesthesia of the grafted area, but this is a small price to pay for the preservation of length of the digit and the maintenance of other functions. Discussion The cross-finger flap is an easily mastered versatile and excellent flap for soft tissue coverage. The skin of the hand has highly developed sensibility, is thin in texture and has less amount of subcutaneous fat. It is also better in terms of color, contour, less bulk, pinch and grip, compared to the bulky cross arm pedicle flaps. Hence, it is superior to skin obtained elsewhere. The flap is technically easy, with excellent viability, comfortable immobilization, minimal scarring, acceptable cosmetic and functional results, with minimal or no hospitalization. The major disadvantage is a permanent loss of good tactile sensation in the reconstructed area. The flap can be done as an OPD procedure under regional local anesthesia, as has been done in a majority of cases by the author. Laterally based flaps are adequate in most cases. To preserve length, especially in the index finger; a distally based flap is preferable. Reverse cross-finger flap can be successfully used to cover dorsal defects avoiding other lengthy and cumbersome procedures, but this flap is technically demanding. A local rotation flap similar to a flag flap can be used to serve the same purpose for dorsal defects over the proximal phalange. Flap over a flap is the answer to multiply injured digits. Plaster or k-wire fixation is rarely needed to immobilize the flap in uncooperative patients. The flap should be avoided in elderly patients, in arthritic hands, circulatory or vascular problems, those with a tendency to finger stiffness and in the presence of active local infection. Also dorsal donor skin should not be contused as skin necrosis is likely. Gentle soft tissue handling and good hemostasis improve outcome. Avoid skin over IP joints and near

nailbeds, unless necessary for width. Instead of a split thickness graft, a full thickness graft can be used to cover donor area. This could not be verified in the present series as only STG was used. Return of sensation needs innervation and growth of axons from its surrounding deep and marginal, and is extremely variable. The severity of injury and quota of nerve fibers in bed determines the outcome. Quality of nerve reinnervation in pinch sites is not adequate in the best of cases but is functionally protective in most. Nevertheless, the patient must be warned to be careful and avoid burning the flap while it lacks sensation. An island pedicle sensate flap would be preferable to the cross-finger flap for distal pulp injuries. But compared to other axial pattern flaps, in the cross-finger flap, reinnervation and two-point discrimination is faster due to higher number of nerve fibers and thinner skin in hand. In spite of not having septal connections, due to the thinner skin and less subcutaneous fat, grip of the flap to bone and pinch action is good. This flap is not unstable like other bulky flaps. A review of the literature reveals that 70% patients had 2-point discrimination of less than 8 mm in a standard cross-finger flap (Kleinert). Nicolai and Hentennar report that 53% have 2-point discrimination within 2 mm of the same pulp in opposite hand. Similar is the experience of this author and a re-emphasis is again made of the importance of severity of injury and size of area to be covered in deciding speed and quality of reinnervation. The radial sensory cross-finger flap provides a theoretical scope of early return of sensation, but, in practice, this is not seen possibly due to stretching of the nerve during transfer. In the two cases, in this series, the results were similar to that of a standard cross-finger flap. Similarly, Brallier and Horner, in their series on radial sensory cross-finger flap, report that 64% have 2-point discrimination of less than 15 mm. Injuries that had smaller soft tissue defects, less amount of crushing and damage to underlying structures had better and earlier return of sensation irrespective of the type of flap used. Unless these parameters are the same in all injuries, which is practically impossible except in a study of injuries produced under controlled laboratory conditions, a comparison would be superfluous and misleading. Hence, no attempt is made to read and interpret too much from these findings except the fact that protective crude sensibility returns in a majority of patients in a year.

Local Flaps (Principles and Techniques)  85

DORSAL METACARPAL ARTERY-BASED FLAPS Flaps can be based on all dorsal metacarpal arteries. Kite flap is based on the first dorsal metacarpal artery. Second dorsal metacarpal artery is larger than the first and is more reliable. The 3rd and 4th metacarpal arteries can also be used.

anastomosis between dorsal metacarpal artery and common digital artery and terminates at the level of PIP joint. Hence, if the flap is raised on middle phalange, supply is essentially random from subcutaneous arterial plexus.

Varieties

Method

1. Flag flap 2. Kite flap: (a) Holevich racquet flap; (b) Foucher kite flap 3. 2nd Dorsal metacarpal artery flap (distally based) 4. Reverse ulnar parametacarpal artery flap.

• Flap is raised from dorsum of proximal phalange of adjoining digit. The flap has a large rectangular distal part and a narrow proximal pedicle which facilitates transfer. Flap comprises of all dorsal skin and has at least one intact dorsal vein in the pedicle. Flap is elevated like a cross-finger flap preserving paratenon of extensor apparatus. Distal portion is sutured and pedicle is left free. Donor site is covered with STG. Pedicle is excised or divided and reinserted at 3 weeks • Palmar defects are covered by rotating the flap through 180 degrees • Flap is raised on dorsum from proximal phalange to cover dorsum of neighboring digit • Flap is rotated through 90 degrees and helps in gaining length as a result of the pedicle. This facilitates flap movement and transfer. A watertight cover is achieved. • An axial flap raised on the dorsum of the middle finger can be rotated to cover defects on the proximal phalange of the index finger or the MP joint of either of the two fingers. • The flap can be passed through the web space to cover defects on the palmar surface of the MP joint of the index or middle finger. • Flap is raised on dorsum from proximal phalange to cover dorsum of neighboring digit. • Flap is rotated through 90 degrees and helps in gaining length as a result of the pedicle. This facilitates flap movement and transfer. A watertight cover is achieved.

FLAG FLAP (FIGS 7.81 TO 7.83) Indication To cover a defect on dorsal or palmar surface of proximal phalange that cannot be covered by a smaller lateral digital flap. Blood Supply Axial blood supply, if raised on the proximal phalange. The dorsal digital artery arises in the web space from

Advantage Area covered is relatively larger compared to a lateral digital flap. Disadvantage Fig. 7.81: The Flap is based on the palmer digital arteries arising from the palmer arch

Prolonged rehabilitation time of donor finger, especially if performed as a two-stage procedure.

86  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

Figs 7.82 A to C: The flag flap can be mobilized proximally to cover dorsal surface of adjacent finger and also palmer surface based on the dorsal digital artery

A

B

Figs 7.83 A and B: Defect on dorsum is covered by flap flag flap from adjacent finger. Note transposed margins ABC after flap cover

Local Flaps (Principles and Techniques)  87

KITE FLAP (FIGS 7.84 TO 7.89) (Foucher Kite Flap and Holevich Kite Flap) Indication 1. Coverage of the dorsum of the thumb. Selected cases of volar surface injury, e.g. partial or complete amputation of distal phalange with volar skin loss. 2. Trophic scarring of the thumb or sensory deficit of the thumb that cannot be corrected by other means. 3. As an island flap with reversed flow, it can cover other fingers. Blood Supply • Axial flap based on the first dorsal metacarpal artery • The first dorsal metacarpal artery arises from the radial artery at the base of the 1st intermetacarpal cleft, and runs along the side of the second metacarpal over the 1st dorsal interosseous muscle. It becomes superficial and divides at the MCP joint level and also anastomosis with the palmar network. This vessel supplies an area on the dorsum of the 2nd metacarpal from the MCP joint up to the PIP joint • The flap uses portions of the superficial branch of the radial nerve to substitute for the lost sensation on the volar thumb. Technique Flap is outlined on the dorsum of the proximal phalange of index finger and MCP joint without failing to include an area over the MCP joint. A linear incision from proximal edge of the flap passing to the base of 1st intermetacarpal space is made. The skin and subcutaneous tissue are incised sparing the venous

A

B

network. A wide bridge of fascia with part of the first dorsal interosseous muscle containing the artery is mobilized and the flap isolated. The medial incision is made along the second metacarpal. At the level of the MCP joint, dissection is more superficial ending in subcutaneous layer over the dorsum of the proximal phalange. The peritendinous fascia is left undisturbed as with all local flaps. The flap can be passed through a subcutaneous tunnel towards the thumb (Foucher kite flap) or through a Z-incision on the 1st web space transported to the dorsum (Holevich flap). Donor area is grafted and when small, can be closed primarily. A small vascularized piece of bone can be taken from the neck of the second metacarpal and used to manage vascular problems in the wrist bones. Advantage Single stage procedure with little scarring. Disadvantages • Poor sensibility makes it a poor choice for pulp loss in the thumb. Also flexion of IP joint makes stiffness more likely • Variable vascularity can lead to flap necrosis. The tunneling (Foucher kite flap) is contraindicated in scarring that causes a tight tunnel and thereby jeopardizing vascularity • It is difficult to reach tip of distal phalange and if such an attempt is made stretching the flap reduces sensibility and increases chances of necrosis. Holevich Flap (Figs 7.84 and 7.85)

C

Figs 7.84A to C: Holevich flap: (A) Skin defect on thumb; (B) Elevation of flap; (C) Flap in place with donor defect skin (grafted)

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A

B

C

D Figs 7.85A to D: Holevich flap: 1st dorsal metacarpal artery flap/kite flap: (A) Injury; (B) Kite flap dissected out; (C) Flap sutured to thumb.STG on donor area and closure of proximal incision; (D) Final result

A

B Figs 7.86A and B: Foucher kite flap: Flap is tunneled through subcutaneous tissue

Local Flaps (Principles and Techniques)  89

A

B

C

D

E

F

G

H

I

Figs 7.87A to I: (A and B) Kite flap on dorsum of thumb; (C) First dorsal metacarpal artery identified; (D) Width of soft tissue mobilization containing radial sensory nerve and accompanying vessels marked; (E) Flap dissection; (F) Kite flap elevated; (G) Flap covers exposed bone; (H) STG covers donor area and intervening area; (I) Final result

90  Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

E

F

G

H

I

J Figs 7.88A to J: Case illustrates conversion of Foucher’s flap to Holevich flap to improve vascularity and relieve tension: (A and B) Injury over thumb with partial amputation and skin loss. (C and D) Kite flap dissected; (E) Tunnel made from thumb to base of flap on to the defect (Foucher’s kite flap); (F and G) Release of tight tunnel; (H) Skin grafting of flap; (I and J) Postoperative condition of flap showing full viability

Local Flaps (Principles and Techniques)  91

A

C

B

D Figs 7.89A to D: First dorsal metacarpal artery flap for ulcer on 3rd metacarpal head (Cadaveric dissection)

92  Handbook on Flaps in Crush Injuries of the Hand

DORSAL METACARPAL FLAPS: DISTALLY BASED 2ND DORSAL METACARPAL ARTERY FLAP (FIG. 7.90) Indications 1. Cover of dorsum of the proximal interphalangeal or metacarpo­phalangeal joints of the index or the middle finger. 2. Treatment of web contracture. Blood Supply The 2nd dorsal metacarpal artery arises at the base of the intermetacarpal space, often from the dorsal carpal arch. The artery runs deep in contact with the interosseous muscles. Distally the artery joins the palmar network at the level of the 2nd metacarpophalangeal joint. It gives three small branches, of which the most proximal emerges between the tendons of the extensors of the index and middle fingers. The supply to the overlying skin is from the branches arising from below the level of the MP joint. Method Flap is outlined on the dorsum of 2nd metacarpal. The point of rotation of the flap is situated at the

level of the metacarpophalangeal joint. The crossing between the 3rd metacarpal and the extensor tendon of the index finger is marked on the skin. The flap is drawn straddling this point extending proximally depending on the distance of the defect from the point of rotation. Skin and subcutaneous tissue is incised and hemostasis secured. Extensor tendons are retracted laterally and proximally deep fascia incised. Vascular pedicle is identified, mobilized and divided proximally. Flap is raised by dissecting the pedicle to the level of metacarpophalangeal joint. Divide the intertendinous junction between the extensors of the index and middle fingers to facilitate movement of the flap. Advantage Complete lack of problems at donor site. Flap can be raised from a damaged finger avoiding taking a flap from the adjacent finger and, hence, avoid damaging an intact finger. Disadvantage Artery is of small caliber and deep. This results in a thicker pedicle and tunneling is difficult, giving a cosmetically inferior result.

Fig. 7.90: Reverse dorsal metacarpal artery flap

Local Flaps (Principles and Techniques)  93

Foucher Kite Flap Flap is tunned through subcutaneous tissue. Complications Encountered

• At this stage, the flap is closed and the donor wound is skin grafted

• The flap had poor free flow on release of tourniquet inspite of no kinking of pedicle and adequate proximal release of flap. Hence, to relieve tension on pedicle, the tunnel was incised converting the flap into a Holevich flap and the additional defect skin grafted to avoid the skin tension associated with a tight tunnel or a primary closure of the wound.

A

B

C

D

Figs 7.91A to D: Reverse dorsal metacarpal artery flap, cadaveric dissection: (A) Defect; (B) Flap along with artery dissected on 2nd metacarpal artery; (C) Flap turned around; (D) Closure and final picture

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Examples of crush injury with amputation of index finger, amputation of middle finger proximal to PIP joint, vertical slicing amputation of ring finger (Figs 7.92A to H)

A

B

D

C

F

G

E

H

Figs 7.92A to H: (A and B) Primary injury; (C to E) Reverse 2nd dorsal metacarpal artery flap on middle finger stump; (F and G) Flap cover on stump, full thickness graft on donor area, deltopectoral flap on ring finger; (H) Final result

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VARIATIONS OF DORSAL METACARPAL ARTERY/FLAG FLAP (FIGS 7.93 AND 7.94) • Cross-finger flap on the thumb is more comfortably taken from the middle finger than the index finger

A

• This proximally based cross-finger can be considered a variant of the dorsal metacarpal artery flap if dorsal metacarpal artery is incorporated.

A

B B

C

C

Figs 7.93 A to C: Flag flap variant: (A) Skin loss on dorsum of amputated middle finger proximal phalange; (B) Flap from ring finger (C) Final result

Figs 7.94A to C: Flag flap on thumb from second dorsal metacarpal artery

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REVERSE ULNAR PARAMETACARPAL ARTERY FLAP (FIGS 7.95A TO C) Indication To provide soft tissue cover for various full thickness soft tissue defects at the base of little finger and adjacent areas on palmar and dorsal aspects. Blood Supply

A

This flap is based on 5th metacarpal artery which arises from the dorsal carpal branch of ulnar artery. It frequently has an anastomosis with 5th ulnar collateral artery at the level of metacarpophalangeal joint. Reverse flow through this anastomosis from the palmar arterial system formed the basis of this flap. Method Skin territory, parallel to the metacarpal bones, supplied by the 5th metacarpal artery is marked and raised based on this pedicle. Soft tissue defect is covered with flap and donor site defect is closed primarily. This flap safely covers the defects at base of little finger on palmar aspect, proximal phalanx, proximal half of middle phalanx, defect at mid-palmar crease and similar defect at dorsal side. Advantages Skin features resemble to those around the defect site. Also scar is along the ulnar border and thus hidden, making it cosmetically more suitable. It is a local option, a single stage procedure, and easy to carry out. Disadvantages Flap cover initially results in dog-ear defects, which were quite prominent. They are not excised to guard against compromise of the blood supply of the flap. That

B

C Figs 7.95A to C: Ulnar para metacarpal artery flap; (A) Wound on volar surface of base of little finger. (B) Reverse Ulnar parameta carpal artery flap delineated based on 5th dorsal metacarpal artery, (C) Wound cover

fifth metacarpal artery is not constantly present. Also the communication between the fourth and fifth dorsal metacarpal arteries and the palmar arterial system is present in 65% only.

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THENAR FLAPS (FIGS 7.96 TO 7.101) Indication Loss of pulp on tips of long fingers, volar or dorsal surface but not extending beyond the PIP joint. Types • Distally based to cover volar defects • Proximally based to cover defects on the dorsum or oblique defects with totally destroyed nailbed • H-shaped, that combines proximally and distally based. Contraindication: Associated tendon or bony injuries. Blood Supply Blood supply is of a random pattern flap. The distally based thenar flap contains perforators from the palmar

digital arteries of the thumb, perforating the fascia at the distal border of the thenar muscles. Method The thenar eminence is selected for index, middle and ring fingers and hypothenar eminence for little finger. Area to be elevated is marked on the donor area. Incision extends up to the fascia overlying the muscle, preserving the radial digital nerve of the thumb. The lateral border of the flap runs parallel and medial to the thumb crease. The medial border runs parallel to the lateral border. Flap is usually of 2:1 length-width ratio. Flap should be longer than defect and 50% wider than primary defect because the contour of the lost pulp is semicircular and taking width 1.5 times the width helps restore the shape. Distal end of flap should be left a little long and should not be sutured to the nailbed.

A

B

C

D

Figs 7.96A to D: (A and B) Distally based thenar flap; (C and D) Proximally based thenar flap

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In a distally based flap (proximal inset thenar flap), distally the flap reaches the edge of the thenar muscles and proximally it has a pointed apex to facilitate primary closure. In proximally based defects, reverse is the case. The flap can be predominantly ulnar for ulnar defects and radial for radial defects. Donor defect is closed primarily if possible or a full thickness graft is applied. Simple dressing is adequate and no immobilization is required. Flap is divided at three weeks.

A

Advantages • Technically simple and easy to perform • Flap is nonsensate but protective crude sensibilities are regained in a few months. Disadvantages • Joint contracture, tender donor areas are possible complications • Stiff fingers can occur in the elderly • Flap is nonsensate and lacks sensibility in the first few months.

B

C

Figs 7.97A to C: H-shaped thenar flap: (A) Defect on index finger with small exposed bone on volar and dorsal surface; (B and C) H thenar flap.Proximally based flap covers dorsal defect and distally based covers volar defect

A

B

C

D

Figs 7.98A to D: (A) Injury on tip of ring finger; (B) H-shaped graft marked; (C) Proximal and distal graft elevated; (D) Distal flap covers volar side and proximal flap cover dorsal defect. Split thickness graft can cover intervening area but is not always essential

Local Flaps (Principles and Techniques)  99

Fig. 7.99: 2-year follow up of thenar flap on middle finger

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C

Figs 7.100A to C: Thenar flap covering middle finger Primary closure was done in ring and little fingers. Immediate result at flap release. Thenar flap on ring fingertip

A

B

C

D

E Figs 7.101A to E: (A and B) Injury to ring finger with volar and dorsal loss; (C) Thenar flap raised; (D and E) Flap covers defect

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REVERSED RADIAL ARTERY FOREARM FLAP (CHINESE FLAP) (FIGS 7.102 TO 7.104) The flap was described in China in 1981 by Guofan, Yuzhi and Baoqui, and, hence, is popularly known as Chinese flap. Indication Used to cover defects of the forearm, dorsum of the hand and wrist hand, especially the thumb. Blood Supply The flap is based on the presence of good retrograde flow through the ulnar artery and palmar arch into the radial artery after proximal ligation of the radial artery. The radial artery arises three finger breadths that distal to the elbow from the brachial. Proximally, it lies superficial to the pronator teres just beneath the anterior margin of brachioradialis. It then lies superficially beneath the skin on the radial head of the flexor digitorum superficialis and the flexor pollicis longus. Then it passes deep to the abductor pollicis longus to reach the anatomical snuff box. Throughout the course, it gives branches to a plexus of vessels in the overlying deep fascia. Similarly, it also supplies the periosteum of the distal half of the radius permitting an osteo-cutaneous flap. Two to three veins accompany the artery and multiple anastomoses between the veins permit reversal of flow in the venae comitantes without valvular obstruction. The artery can thus be divided proximally without valvular obstruction. Method Allen’s test is performed to check the adequacy of reverse flow from the ulnar artery. Course of radial artery and major veins is mapped on the skin with a Doppler and also dominance of vessel is assessed before surgery, if facilities are available. Distance from radial styloid to the closest margin of defect is measured to determine location of the distal edge of the flap. Pattern of primary defect is outlined proximal to this point remembering that flap design will be reversed in the reversed pedicle, i.e keep proximal pattern to distal flap margins. Margins of flap are incised. A zig-zag subcuticular incision extends from flap margin over the course of radial artery up to the defect. Skin is elevated from deep fascia preserving the cephalic vein.

Skin margins adjacent to the flap are elevated from the underlying deep fascia, preserving the cephalic vein radially. Deep fascia is incised all around the flap to identify the plane of dissection. Skin and deep fascia are sutured once the plane is identified. Flap is raised dissecting loose areolar tissue beneath the deep fascia, preserving the epitenon over the underlying tendons. Raise the flap radially from brachioradialis and medially from flexor carpi radialis. Identify the radial artery running in the lateral inter muscular septum. Incise the lateral intermuscular septum linearly on both sides of the radial artery and dissect the pedicle up to the radial styloid. Divide the radial artery proximally and transfer the flap to the defect, tunneling it through the intact intervening skin, if required. Suture the flap, Cslose the zig-zag incision wherever possible. Apply split thickness graft over the donor area. Variations 1. In selected cases, where forearm defects are covered by this flap, venous return can be enhanced by rejoining one or more proximal veins. 2. Vascularity can be improved in flap by reconstructing radial artery by anastomosing a vein graft proximally end to end and distally at the pivot point adjacent to the snuff box by end to side microsurgical techniques. 3. To improve appearance of secondary defect, flap consisting only of fascia sparing the skin can be raised. The radial artery fascial flap so created is covered with a full thickness skin graft. Advantages 1. Can cover almost any defect in the hand due to its potential of transporting much of forearm skin. This flap offers unrivalled quality of thin and mobile skin similar to skin of the dorsum of the hand. 2. Assured vascularity increases survival rate of bony grafts used to reconstruct the thumb. 3. Single stage procedure minimizes immobilization and hospital stay. Disadvantages 1. Flap requires sacrifice of one of the major forearm arteries. Good flow is required in ulnar artery and palmar arch. The radial artery may be the only patent vessel in some hands, and in 12% of cases,

Local Flaps (Principles and Techniques)  101

it is the dominant vessel. Acute ischemia and cold intolerance may be a consequence of its use. 2. Unsightly secondary defect occurs. 3. If a vascularized segment of radius is used, chances of fracture are higher. Hence, zroin and lateral arm free flaps are more preferred by microsurgeons. 4. Gradual osteolysis of the bone in the flap occurs especially if the flap is at the tip/distal most part of

the digit. Long term results can be disappointing if the complete bone undergoes osteolysis. This will not occur if bone is interposed in between two viable soft tissue ends. Also this rate of deterioration is less in young patients and in radial artery vascularized grafts compared to groin or loin flaps, possibly due to better vascularity.

A B

C

D

Figs 7.102A to D: Reverse radial artery forearm flap: (A) Diagram indicating maximum area that can be cover red; (B) Diagram indicating flap to be raised for coverage on the thumb alongwith marking of radial artery; (C) Diagram showing elevation of flap along with dissection of radial artery; (D) Flap can be transported to the dorsum of the hand

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A

B

C

D

E

F

Figs 7.103A to F: (A) Injury amputated thumb; (B) Another variety (degloving of thumb) where the flap can be used; (C) Iliac bone graft to reconstruct thumb. Flap has been dissected and mobilized; (D) Immediate postoperative picture. STG applied on donor area. Flap covers thumb; (E) Function (pinch) use of a pen. (F) Function (grip) holding a bottle

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A

B

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D

E

F

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H

I

Figs 7.104A to H: (A) Injury; (B) Iliac bone graft; (C) Flap; (D) Early post operative result; (E to G) Functional result 5 years postoperative; (H and I) Five year postoperative X-ray. Note: Gradual osteolysis of iliac bone graft. This will affect long-term results

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ULNAR ARTERY FOREARM FLAP (FIG. 7.105) Indication Useful in chemotherapy burns to dorsum of hand in elderly women. Also can cover defects around the elbow. At the wrist, it can cover the palmar and dorsal surface of the wrist, the first web space and can also be wrapped around a fibrosed median nerve.

anterior incision of the flap after retracting the flexor carpi ulnaris and flexor digitorum muscles. Protect the ulnar nerve lying immediately deep to the vessel. Postoperative Immobilize the wrist in a splint till wound healing and suture removal.

Blood Supply The dorsal ulnar artery arises from the ulnar artery 2 to 4 cm proximal to the pisiform and a flap can be based on it. Likewise, like the radial artery flap, the ulnar artery flap can be based proximally to cover the elbow and distally to cover the hand.

Advantages

Method Method is similar to radial forearm flap. The origin of the dorsal ulnar artery can be found through the

Most patients experience ulnar nerve dysesthesia owing to proximity of dissection to nerve. This resolves in a few months.

Reliable flap with less hairy skin, less obvious secondary defect. Donor site can often be closed especially in elderly patients. Disadvantages

A

B Figs 7.105A and B: Ulnar artery forearm flap

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POSTERIOR INTEROSSEOUS ARTERY FLAP (FIGS 7.106 AND 7.107) Indication Loss of tissue on the dorsum of the hand or severe contracture of the first web space. Contraindication Defects distal to PIP joint and palmar defects are difficult to cover. Blood Supply This distally based flap is based on the posterior interosseous artery and veins. The vessel emerges in the upper forearm from under the supinator into the intermuscular septum lying between the extensor carpi ulnaris and extensor minimi digiti. It passes distally in the septum reaching the dorsal carpal vascular arch and anasomoses with the anterior interosseous vessels at the wrist joint. The artery has a diameter of approximately 1.7 mm with corresponding small caliber branches. Method Draw a line from the lateral epicondyle of the humerus and the head of the ulna with the arm fully pronated. Mark an elliptical flap outline with the centre of the flap about 9 cm from the lateral epicondyle, the long axis being proximo-distal and width usually not more than 5 cm. (This facilitates primary closure). Dissection is carried from distal to proximal because of ease in identifying superficial distal vessels. Proximally

the vessels are hidden between bellies of ext. carpi ulnaris and ext. digiti minimi. A straight distal incision extends from the flap to the ulnar styloid. Skin is isolated from the fascia and FCU and EDM tendons are identified. Incision is now deepened to the fascia covering the muscle bellies and thereby strip of fascia containing the blood vessels is created. Identify the vessels by incising the deep fascia up to the extensor muscles, and retracting the extensor of the little finger radially. A branch of the radial nerve accompanies the artery. Spare the nerve by ligating the artery a little distally. Raise the flap, septum, and vascular pedicle from the proximal to the distal end. Carefully dissect the flap up to the neck of the ulnar styloid if necessary. Suture the flap to the recipient area and close the donor defect primarily. Apply skin graft if required in larger flaps. Advantages • Excellent quality of thin skin is provided • No major perfusing arterial source is sacrificed • Primary closure of defect improves cosmetics. Disadvantages • Technically demanding and requires skilled dissection • Relative short pedicle restricts use to defects of dorsum of hand but not beyond PIP joint or the palm. If this is attempted, wrist has to be fixed temporarily in hyperextension.

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A

B Figs 7.106A and B: Posterior interosseous artery flap: (A) Lateral epicondyle; (B) Ulnar styloid. Usually 9×5 cm flap is dissected. Artery is ligated proximally and fascia with vascular bundle dissected upto the neck of ulnar styloid

Local Flaps (Principles and Techniques)  107

A

B

C

D Figs 7.107A to D: Line marking of posterior interosseous artery flap

8

Distant Flaps TYPES 1. Random pattern distant flaps • Variations • Random pattern • Bipedicle • Double flap to cover dorsal/palmar areas • Interdigitating flaps to resurface multiple finger injuries • Reversed delto-pectoral flap. 2. Axial pattern distant flaps • Groin flap • Loin flap • Combined groin and loin flap • Deltopectoral flap • Latissimus dorsi flap • Hypogastric, etc. RANDOM PATTERN DISTANT FLAPS (FIGS 8.1A TO C) Blood Supply Random pattern flap derives its blood supply from subdermal or subcutaneous plexus. Ideal Sites Inguinal region in females. In the males, the whole of the torso, the opposite infraclavicular region for selected thumb defects and opposite arm for palmar defects. Method As far as possible, stick to 1:1 ratio for random pattern flaps to guard against flap necrosis. Larger flaps (up to 73% bigger) can be created by performing a delay procedure 10 days previously. Another method is by creating bipedicle flaps with safe length: breadth ratio of 2.5:1. The positioning of the arm must be carefully planned to create a flap that is tension-free and protected from torsional impairment. Preoperatively the position of greatest ease for the patient as well as tension-free elevation of the flap is

assessed. Avoid areola in infraclavicular flap and pubic hair in inguinal flap. Mark the pattern on the donor area by bringing the injured limb to the donor site. Mark the area and endpoints with two sutures if required and elevate the flap as a hinge carrying the incision down to the subcutaneous tissue up to the deep fascia. Defat the flap to the required thickness and suture the flap to the defect. Closure of the donor defect can be done in the following ways: 1. Primary closure by approximating edges and excising dog ear. 2. Excising two triangles from the lateral margin of secondary defect in cases where the flap is wider than it is long. 3. Making one lateral margin of the flap longer than the other by a margin equal to the width of the flap. 4. Skin grafting if tension on suture line is high or the defect is very large. Once the flap is sutured and the donor site closed or grafted, apply strapping to the limb in such a position that the pedicle of the flap is not kinked and the limb is comfortably placed for the patient to exercise his joints. REVERSED DELTOPECTORAL FLAP Indication Degloving injury of a thumb or finger that requires a tubed pedicle flap. Blood Supply Random pattern and from deltoid branch of thoraco acromial artery. Method A random pattern tube pedicle flap with the direction reverse to that of a deltopectoral flap can be taken for small defects involving a finger. This reverse pattern is comfortable to position the flap, both for the surgeon and the patient. Large defects are not suitable for such a flap.

Distant Flaps 109

The circumference of the MP joint of an adult male is 9 cm. The flap is made as a square with 9 cm sides. Defat the flap radically till the subdermal vessels are seen. Make a tube of the flap strarting distally and proceeding towards the base. Graft the secondary defect and suture it over a bolus dressing. Introduce the thumb in the tube, flexing the wrist so that the fingers lie in the axilla. This enables the suture line to come to the midline of the palmar surface of the thumb.

A delay procedure, half way across the base, is carried out at 3 weeks. This is important because the fingertip is revascularized by new vessels that grow from the wound of attachment and this flow is usually very marginal. The tube pedicle is divided at 4 weeks. A neurovascular island flap can be performed at the time of flap division. This flap can be transported through the suture line of the tube pedicle. This has three-fold benefits. Firstly, it brings sensation to the thumb; secondly, it improves circulation of the tip and, finally, the additional skin provided eliminates the need to close the tube under tension. Neurovascular Island Flap of Litter See Figures 8.2A and B and 8.3A to D.

A

A

B

B C Figs 8.1A to C: (A) Degloving injury of the thumb; (B) Reverse deltopectoral flap; (C) End result. 2nd stage neurovascular island flap at six weeks improves the results

Figs 8.2A and B: Neurovascular island flap of litter

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Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

Figs 8.3A to D: Neurovascular island transfer from either the long or ring finger to provide sensate coverage of the thumb. (A) Neurovascular island flap using the ulnar side of the long finger. An extended island flap is designed with an identical defect patterned over the palmar aspect of the thumb; (B) Use of the ulnar aspect of the ring finger, which is designed and transferred in a similar manner, is depicted; (C) Mobilization of the island flap on its neurovascular pedicle and preparation of the recipient bed on the thumb. Note the areas of undermining required between the palmar and thumb incisions (dotted arrow); (D) Completed transfer of the neurovascular island flap with a free graft on the donor area of the long finger. Care must be taken to avoid a longitudinal scar along the palmar aspect of the donor finger

Distant Flaps 111

DELTOPECTORAL FLAP (FIGS 8.4 AND 8.5)

Fig. 8.4: A—Musculocutaneous artery; B—Anterior phoracic perforators; C—Cutaneous branch of thoracoacromial artery; D—Cephalic vein

Indications

Method

Cover of defects on the mastoid, ear, parotid, cheek, mouth, chin and hand.

The outlined flap as per required dimensions of the defect is raised deep to the fascia and stripping the muscles bare as a fasciocutaneous flap. The deltoid branch of thoracoacromial artery is ligated if required. The slack skin available along the anterior axillary fold explains its anomalous pivot point as well as its long reach in an upward direction. The lower border lies along the anterior axillary fold having slack skin, making it longer than the upper border. Consequently, the tension line that develops in transfer is along the shorter upper border. Therefore, in planning, the effective length of the flap should be measured along the upper border with the pivot point at the medial end. The secondary defect is skin grafted, if large. In transfer to the face, a tube is created in the bridge segment. In the hand, this tube can be directly applied to the defect. The flap is divided at three weeks. The deltopectoral flap is very vascular and delay of the flap is advisable, in large flaps in the young as well as elderly, to prevent risk of sudden ischemic necrosis on flap division.

Blood Supply The first three perforating branches of the internal mammary vessels forms the axial vascular basis. The second perforating branch is the most important artery in the flap. The deltoid branch of the thoracoacromial artery also comes in the flap and may have to be ligated. Surface Markings The upper border of the flap runs horizontally along the anterior chest wall from the medial border of the sternum, along the inferior border of the clavicle up to the tip of the shoulder. The lower border runs from the sternal edge to the level of the anterior axillary fold without including the nipple. The flap can be raised up to the midlateral line on the deltoid muscle. Beyond this line, flap viability is unreliable even if preceded by a delay procedure.

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Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

E

F

G

H

I

Figs 8.5A to H: (A) Acutely injured patient with degloving of four fingers up to PIP joint but intact bony architecture; (B) DP flap covering all fingers with skin-grafted donor area at the time of flap division and the syndactyly hand created; (C) Four fingers recreate after second syndactyly release surgery. In first syndactyly release surgery done 6 to 8 weeks after DP flap release. The single syndactylized hand is turned into hand with two syndactylized units. In second syndactyly release, after another interval of 4 to 8 weeks, four fingers are recreated from the two syndactylyzed units. They appear fat, bulky, ugly and grotesque at this stage; (D) Condition after defattening done 6 weeks after the last surgery. 30% to 40% fat can be debulked at one stage with safety. Excessive defattening carries the risk of skin necrosis and it is preferable to carry out staged 30% defattening at 4 to 6 week’s interval three or four times, till the required thinness is achieved; (E to I) Final result three years after injury

Distant Flaps 113

GROIN FLAP (FIGS 8.6 TO 8.9)

A

B Figs 8.6A and B: In line diagram and surface marking of groing flap

Fig. 8.7: Bolster under the buttocks helps in flap elevation

Fig. 8.8: The elevated flap

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Handbook on Flaps in Crush Injuries of the Hand

A

B

C

D

Figs 8.9A to D: Example illustrating how even a 10-year-old motivated child happily accepts and tolerates three weeks, immobilization if the flap is comfortably placed. A small STG was placed proximally over raw area instead of tightly suturing the flap and thereby jeopardizing flap mobility and viability. A posterior interosseous artery flap would have been possible if the area was smaller. Today, a free flap is an alternative available at most major centers

Indications 1. Major skin loss of the hand, wrist and forearm where local flaps are unsuitable or not available or inadequate in providing skin cover and microsurgical expertise is not available. 2. Procedure of choice where secondary reconstruction is anticipated, e.g. index finger transfer by pollicization or toe-to-thumb transfer in amputation. Anatomy The flap is based on the superficial circumflex iliac artery, which is present in 96% angiograms. This artery arises in the femoral triangle directly from the femoral artery or from a common trunk of the superficial inferior epigastric approximately 3 cm distal to the inguinal ligament. Sometimes, it arises from the deep femoral or the deep circumflex iliac artery. The artery

emerges from the femoral triangle by passing over the medial border of the sartorius immediately after giving a deep branch. It runs toward the anterosuperior iliac crest initially below the deep fascia and emerges through it as it crosses the sartorius. It passes below and lateral to the ASIS before becoming superficial and giving two or three terminal branches immediately below the iliac crest. The flap can, thus, be extended safely beyond the ASIS by a distance at least equal to the width of the flap. Venous drainage is to the femoral triangle and lies within the pedicle. There are two networks: 1. Superficial via the superficial inferio and superficial circumflex iliac veins; and 2. A deep network of the satellite veins of the deep circumflex iliac artery. Commonly no re-innervation is done but the 12th thoracic nerve consistently crossing the iliac crest

Distant Flaps 115

5 cm posterior to the iliac crest can be anastomosed with any cutaneous nerve in the hand. Method Outline the surface markings of the flap on the skin. Mark ASIS, pubic tubercle, inguinal ligament and femoral artery. The femoral artery and origin of superficial circumflex femoral artery are noted 3 cm distal to inguinal ligament. A line joining this point and the ASIS constitutes the axis of the flap and the flap overlies 1/3 above and 2/3 below the ASIS, as classically described. The flap is 20–25 cm long and 10–12 cm wide but larger flaps upto 35 × 15 are possible. In larger flaps, superior incision is more medial to include the superficial inferior epigastric artery. Carefully consider: A. location of defect: Dorsal wrist defects are best approached by pedicle around ulnar border. B. resulting configuration of tube pedicle. C. freedom of pronation/supination of the forearm. D. patient comfort. E. presence/absence of kinking, kinked flaps do poorly but gentle stretching helps. F. weight/height ratio of patient. If this is high, flap will be thick and, therefore, must be wide. Considering the above, apply a prepared pattern of the flap and, if necessary, extend a portion to represent a pedicle and check various approaches and positions. Identify the edge of the primary defect that will be closest to the pedicle. The pattern is laid on the skin below and behind the ASIS because the more medial inguinal portion is largely used to construct the tube. Now the midline of the flap is outlined 2 cm inferior and parallel to the inguinal ligament (two-finger breadth in children). The width is outlined up to the ASIS and the distal lateral margin of the flap made to confirm to the distal half of pattern of primary defect. Part covering the defect can be wider than the pedicle. Margin of flap is incised up to superficial surface of deep fascia. Sub-cutaneous plane is made up to ASIS without creating a cave in the mid-portion of the flap. Take sutures if needed. Raise the superficial fascia with its vessels but without disturbing the muscles, as a single layer. Incise the deep fascia at the level of inferior incision and visualize the sartorius, tensor fascia lata and intervening intermuscular septum. Keeping the flap stretched, the deep fascia is divided in line of the fibers of the sartorius from inferior to superior, and at

its lateral border just medial to the septum between tensor and sartorius. This prevents kinking of the superior. Circumflex iliac artery that pierces the deep fascia. Incise the fascia cephaloid up to the origin of the sartorius. Failure of division of the fascia explains necrotic edges of a well-designed flap. Always incise the fascia. Pull the flap caudally and dissect up to the upper margin. If dissection is upto the external oblique aponeurosis, the superficial inferior epigastric artery might be cut. Free the flap up to the ASIS. The incision in the sartorius fascia is located and turned medially to free the deep fascia of the thigh from the inguinal ligament. Identify the lateral cutaneous nerve of the thigh, which is usually deep to the flap vessel. If superficial to the artery, divide the superficial branches, place them deep to the vessel and repair them. Stop dissection at the medial border of the sartorius in preparing a tube pedicle. Margins of flap can be trimmed to excise fat but deep fascia should be left alone. Closure of secondary defect up to 12 cm or less can be done primarily. Skin margins can be undermined but is not advisable because of the creation of dead space. Use heavy sutures for primary closure. Flex the hip to facilitate closure. Tight tense sutures cause inflammation and, if released later, cause secondary infection. Make a tension-free tube working from proximal to distal end of tube. Edges of the tube are now sutured to the defect with tension-free sutures without overlapping of wound edges. Immobilize the limb using adhesive strapping across the limb and torso, taking care that there is no kinking or stretching. Brachial plexus block minimizes chances of immediate postoperative risk of flap disruption. Postoperatively avoid kinking or traction. Most patients can move about after cautioning them about risks of forceful flap disruption due to traction. Gentle shoulder, elbow and wrist movements are allowed and encouraged. Padding is done to see that all skin surfaces are exposed to air and thereby preventing maceration. Regular dressing with local antiseptic ointment/ hydrogen peroxide is dictated by wound condition. Flap is divided at 3–4 weeks on signs of perfect healing of wound and the surrounding skin is supple and unscarred. Delay procedure is preferred when area of division is large or in very vascular flaps or when any problem is anticipated with flap uptake.

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Handbook on Flaps in Crush Injuries of the Hand

Example 1 Moderate Degloving + Fracture Dislocation (Figs 8.10A to L)

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J

K

L Figs 8.10A to L: Moderately degloved hand with fractures/dislocation/extensor tendon injury treated with groin flap. Note healed burns mark on the nonsensate flap as well as boutonnière deformity due to extensor tendon injury. Only index finger was reconstructed free of the syndactylized hand. Note the functional result of grasp (holding a glass) and firm grip (able to ride a bike independently)

Distant Flaps 117

Example 2 Extensive Thermal Burns + Degloving (Figs 8.11A to H)

A

B

C

D

Figs 8.11 (i) A to D: (A and B) Extensive burns and degloving have to be treated conservatively initially till the wound stabilizes and flap cover must be delayed up to 2 to 3 weeks as the situation demands. Eschar that forms has to be gradually excised; (C) Healthy granulation at the end of three weeks; (D) Groin flap performed at three weeks

E

G

F

H

Figs 8.11 (ii) E to H: Syndactylized hand created.The deep fascia acts as a teether preventing flexion contracture along with the continuous skin. On syndactyly release and inadvertent lease of deep fascia at defattening flexion, contracture occurred due to the now dominant flexors

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Example 3 Extensive Degloving + Deep Thermal Burns (Figs 8.12A to G)

A

B

C

D

E

F

G

Figs 8.12A to G: Another example of delayed flap coverage in a more extensive injury involving burns on dorsal surface and compartment syndrome that required carpal tunnel release and fasciotomy along with extensive escharotomy on the dorsum. Groin flap on the dorsum along with split thickness skin grafting of dorsum of forearm. Syndactyly release was deferred in this case.

Distant Flaps 119

A

B

C

D

E

F

G

H

Figs 8.13A to H: Crush injury sustained in ice-cutting machine with extensively cut and crushed radial and ulnar artery but with warm extremity and good capillary refilling. Extensive fasciotomy was performed and both cut vessels were ligated as no micro vascular surgeon was available. In young adults in 30% of cases anterior interosseous artery is large enough to perfuse and save the hand in spite of cut major vessels. The limb survived in this case on an intact anterior interosseous artery. Next day a groin flap was performed over the wrist to cover median nerve and surviving vessels. Major loss of flexor tendons was present but surprisingly the fascial sheath of the groin flap stuck to the tendons and acting as a graft gave useful thumb and finger flexion in the long run. The other areas were covered with STG

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Example 4 Amputation Plus Degloving (Figs 8.14 and 8.15)

A

B

C

D

Figs 8.14A to D: (A and B) Completely avulsed hand; (C) Attempt was made to reconstruct thumb with dead bone in amputated thumb; (D) Flap used to cover avulsed hand and reconstructed thumb. The thumb had to be removed because of gradual osteolysis and subsequent infection

Fig. 8.15: Advised toe-to-thumb transfer

Distant Flaps 121

Example 5 Combined Loin and Groin Flap (Figs 8.16 and 8.17)

A

B

C

D

E

F

G H Figs 8.16(i) A to H: (A and B): Completely degloving of fingers and partial loss in thumb; (C and D) Combined groin and loin flap and local flap for thumb; (E to G) The flap inset in patient and syndactylized hand on release at one month; (H) Release of syndactyly creating two syndactylized units.

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I

J

K

L

M

O

N

P

Figs 8.16 (ii) I to P: (I) Recreating four digits from two units; (J) Extensive defattening leads to soft tissue and skin necrosis; (K and L) Contracture of little finger following secondary healing; (M to P) Final result following contracture release. Patient’s desire and perseverance with treatment and good physiotherapy resulted in this excellent result

Distant Flaps 123

A

B

C

D

E

F Figs 8.17A to G: To shorten the time spent in syndactyly release, in selected cases three local flaps can be taken up as tubed pedicle flaps based on groin, loin flap axial supply: (A and B) The three degloved fingers and the flap raised for the three fingers; (C and D) The flap at the time of release from inset. Note the distal necrosis which fortunately did not affect the final outcome; (E to G) Final functional result at the end of six months

G

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Example 6 Two Tube Pedicles and a Cross Finger Flap (Fig. 8.18)

A

B

C

D

E

F Figs 8.18A to G: (A and B) Degloving injury with amputation involving ring and little finger with pulp avulsion involving index finger; (C and D) Two tubes created for the ring and little finger. After suturing them in place, a cross-finger flap from middle finger onto ring finger status at the time of release; (E) Note partial necrosis of skin in ring finger. This was possibly because flap was released at 3 weeks and without delay procedure; (F and G) Final result with secondary healing on ring finger

G

Composite Grafting and Flaps Using Dead Bone as Graft Composite grafting Simple nonmicro-vascular reattachment of distal fragment gives good results only in children. In adults documented graft survival is less than fifty percent.

9

K wires. The graft is buried in a subcutaneous pocket to enhance graft survival by imbibation. Contraindications

The amputated fingertips are de-epithelized. The tips are reattached without neurovascular anastomosis with

The procedure is never perfomed in smokers, diabetics or in setting of a crush injury. Late postoperative result of such procedures is poor due to gradual osteolysis and resorption of bone and

A

B

Method

C Figs 9.1A to C: (A) Showing use of intact bony structure of amputated thumb fixed with K-wire to the first metacarpal; (B) Groin flap is performed over bony stump; (C) Immediate postoperative result

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A

B

C

D

E

Figs 9.2A to E: An example of a failed attempt to salvage a late presentation of amputated fingers with flap coverage over bony remnants fixed with K-wires and performing a deltopectoral flap. A syndactylized hand was created followed by syndactyly release. There was gradual osteolysis and resorption of distally based bone grafts. The only saving grace was an increase in digit length due to flap cover

A

B

C

D

Figs 9.3A to D: Traumatic amputation of thumb and 2nd metacarpal in a 60-year-old chronic smoker and alcoholic: (A) The clinical presentation; (B) Bony remnant of amputated thumb fixed with K-wire; (C) The flap outlined; (D) The immediate postoperative result. The flap developed gradual necrosis possibly due to a combination of old age, smoking, alcoholism, distal most dead bone in graft and release of flap at the end of three weeks instead of four weeks

Composite Grafting and Flaps Using Dead Bone as Graft  127

A

B

C

D

E

F

G

H

Figs 9.4A to H: Nonviable hand: (A) Severely crushed and nonviable hand; (B) Nonviable part excised; (C) Bone of the dead stumps debrided free of all soft tissues; (D) Dead bone fixed with K-wire in functional position; (E) Deltopectoral flap elevated; (F) Flap in position, released at one month; (G and H) Claw hand created and functional use

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secondary infection. Clinical experience has shown that bone implanted at the end of a flap like the above example has a poor prognosis and such procedures ultimately fail. But a bone or graft interposed between two viable ends and covered with a flap will survive, possibly due to good vascularity, and adequate venous and lymphatic drainage. Beware of old age, smoking, alcoholism and early flap division. Use delay of flap

technique when in doubt. Gradual osteolysis of distal bone in the flap will ultimately give a poor long-term result. Such procedures are now consigned to the realms of history and mentioned only to be condemned. In the present day of excellent micro-vascular results of toe-to-finger transfer, the above procedure should be consigned to the realms of history.

Interesting Clinical Cases

10

CASE 1 Crushed, avulsed and degloving with deep thermal burns on dorsum and with bony degloved middle, ring fingers lying in the palm

A

B

C

D

E

F

Figs 10.1A to F: (A) Dorsal view of injury; (B) Dorsal view after incising non viable skin; (C) Voalr view of injury; (D) Drain inserted in volar skin after reducing finger into degloved intact skin of digits; (E) Dorsal skin immediately after pulling back degloved skin on to the digits on day one; (F) Dorsal view at one week of injury. Debridement of nonviable necrotic skin done

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G

H

I

J

K

L

M

N

Figs 10.1G to N: (G) Skin graft applied on dorsum; (H) Selective inactivity on volar side; (I) Dorsal side one week after STG; (J) Three weeks postoperative. Note necrosis of tips of finger. Selective inactivity was followed till tips of dry gangrenous digits separated spontaneously, (L, M, N) End result at the end of four months with good functional result inspite of loss of distal tips and some deformity

Interesting Clinical Cases 131

CASE 2 Severely crushed hand but with intact vascular pedicle in index, middle and ring fingers and extensive skin and bone loss in the thumb and involved fingers. At this stage, primary debridement and k-wire fixation was

done as an emergency procedure without sacrificing any finger. This was followed by a groin flap on the volar surface along with corticocancellous bone grafting of the bone defects. Note the useful hand function at the end of treatment .

A

B

C

D

E

F

G

Figs 10.2A to G: (A) Injury volar view; (B) Dorsal view; (C and D) Clinical picture after reducing degloved skin on to finger and soft tissue mobilization; (E and F) Fractures stabilized with K-wires transfixing IP joints ignoring bone loss segments; (G) A groin flap was used to cover volar side of index, middle and ring fingers with a local full thickness flap for the thumb and STG applied on the dorsum of the hand. Corticocancellous bone grafts were interposed over bony defects and fixed with K-wire just before flap application

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H

I

J

K

L

M

Figs 10.2H to M: (H to J) The immediate postoperative results; (K) Late postoperative X-ray; (L and M) K-wires were kept for three months till the grafts consolidated and the flap was ready for syndactyly release

Interesting Clinical Cases 133

N

O

P

Q

Figs 10.2 N to Q: (N) K-wires were kept for three months till the grafts consolidated and the flap was ready for syndactyly release; (O to Q) Final clinical and functional results. The stiff intact fingers are good for his manual work but are a hindrance in fine work

A

C

B

D Figs 10.3A to D: (A and B) Example of deep friction injury with thermal burns and avulsion that will lead to skin loss and require full thickness cover at a later stage; (C and D) Shows end result in a different but similar case

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CASE 3: CRUSHED HAND WITH EXTENSIVE DEVITALIZATION

A

B

C

D

E

F

G

H Figs 10.4A to H

Interesting Clinical Cases 135

I

J

Figs 10.4A to J: (A and B) Extensive crush injury with devitalization of tissues. Volar surface looks badly crushed but dorsal surface deceivingly looks viable on day 1; (C and D) After multiple debridement, only bony remnants remain; (E and F) Hand after flap on remaining bony stumps; (G to J) Gradual bone resorption and osteolysis leave behind a grotesque ugly looking hand. This apparently seemed a big failure of treatment. The patient was nevertheless appreciative of the surgeon’s efforts and persisted with physiotherapy. He demonstrated how he could hold a pen to sign and use the same to kick start a rickshaw that he now drives for his livelihood

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CASE 4: CRUSH INJURY OF MIDDLE, RING AND LITTLE FINGER

A

B

C

D

E

F

Figs 10.5A to F: Reversed DP flap is done on the degloved little finger and flap overriding a flap on the middle and ring fingers. Final result at two years’ follows up. Note how much the wound shrinks and give an excellent long-term result

Interesting Clinical Cases 137

CASE 5

Correction with JESS was not found suitable in view of radial shortening, fixed multiplaner deformity and strong soft tissue contractures. An ilazarow frame was applied, Corticotomy of lower end radius and lengthening along with deformity correction was gradually carried out over four weeks. Frame was removed at 12 weeks. Note the radial lengthening achieved and deformity correction. She will require physiotherapy and tendon grafting to improve thumb function.

A 10-year old girl had sustained a compound epiphyseal crush injury with loss of part of radial epiphysis and loss of thumb extensors and abductors. She was treated with debridement followed by full thickness groin flap on the exposed epiphysis. She was thereafter lost to follow up and presented after 8 years at the age of 18 years with epiphyseal arrest, fixed flexion contracture of 90 degrees and radial deviation of 45 to 50 degrees at the wrist.

B

A

C

A

D Figs 10.6 A to D: Dorsal, volar, radial views before surgery

B Figs 10.7 A and B: (A) X-ray images; (B) CT reconstruction image

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A

B Figs 10.8A and B: CT Images of the deformity

A

B

C Figs 10.9A to C: Clinical picture immediately after ilazarow frame application

Interesting Clinical Cases 139

Fig. 10.10: Images depict gradual correction after corticotomy

Fig. 10.11: Reveals correction in frame

A

B Figs 10.12A and B: Radiological picture at the end of correction

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A

B

C

D Figs 10.13A to D: Clinical picture on fixator removal

Amputations

INDICATIONS 1. Trauma with extensive crushing that leads to nonviable extremity. 2. Severe electrical shock/burns with nonviable distal parts. 3. Elective decision in some congenital deformities 4. Malignancy. 5. Life-threatening infection. PRINCIPLES AND GOALS OF AMPUTATION 1. 2. 3. 4. 5. 6. 7. 8. 9.

Preservation of life and patient as a whole. Preserving functional length. Durable skin coverage. Preserving useful sensibility. Preventing symptomatic neuroma. Preventing adjacent joint contracture. Short morbidity. Early prosthetic fitting. Early return to work. The decision to go in for an elective amputation or an attempt at implantation must be done after considering the pros and cons of both. The possibility of a successful reimplantation and its end result must be tempered with a consideration of the social, economic, psychological aspects following a failed or poor outcome at reimplantation surgery. Elective amputation may be considered in: 1. Laborers who desire a rapid return to work. 2. Heavily contaminated human bite wound. Nail bed injuries are usually related to crush injuries of the distal phalanx. Hematoma formation under the nail plate is usually a sign of an underlying nail bed injury. If the nail plate is damaged, it should be removed to search for injuries to the nail bed by removing the entire nail plate using an elevator between the nail plate and nail bed. The entire undersurface of the plate is freed from the bed

11 with the elevator. Remove the nail plate. Injuries with a subungual hematoma that involves greater than 50% of the space beneath the nail plate have traditionally been managed with nail plate removal and nail bed repair. Simple trephination of the nail plate can give similar long-term results, especially in children. Regardless of the size of the subungual hematoma, if the nail plate and underlying distal phalanx are not fractured, do not remove the nail plate or drain the hematoma unless it is significantly painful for the patient because trephination or nail plate removal with nail bed repair is potentially more harmful than beneficial. Nail bed lacerations are common in crush injuries and are often associated with fractures of the nail plate and/or the underlying distal phalanx removes the nail plate completely. For nail bed lacerations that extend near or beneath the proximal eponychial skin fold, it performs skin incisions at each corner for adequate exposure. The skin is everted proximally, taking care not to injure the underlying germinal matrix of the nail bed or the terminal extensor tendon just proximal to the germinal matrix. It is helpful to suture the skin fold to the proximal dorsal skin of the finger as a means of retraction. Once exposed, the nail bed laceration can be repaired with 4-0 or 5-0 chromic suture. If there is an underlying tuft fracture, suturing the nail bed injury and the surrounding skin and soft tissue injury can provide enough stability. The goal is to prevent the underlying bone from deforming the nail bed. If this cannot be achieved with suture repairs, pinning the fracture with a K-wire or large gauge needle can prevent imminent nail deformities. Complete regeneration of the nail is usually expected within four to five months. However, patients are counseled that it usually takes two to three nail growth cycles before the final appearance and function of the nail will be known.

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Following is a list of procedures that can be performed for various levels and degree of amputations/crush injury. DIGITAL TIP AMPUTATIONS (FIGS 11.1A AND B) A. B. C. D. E. F. G.

Primary closure with or without shortening Split thickness grafting V-Y Plasty, neurovascular advancement Cross-finger flap Thenar flap Dorsal metacarpal artery flap Radial artery flap/postinterosseous flap/ulnar artery flap, etc. H. Reimplantation. All have been discussed previously. Type I Injuries: Transverse Distal Tip Amputation

Type I injuries are transverse distal tip amputations involving only a portion of the nail bed with or without exposed bone. Treatment Injuries without exposed bone or tendon can simply be treated with irrigation and healing by secondary intention. Small amount of exposed bone is trimmed until bone is covered by soft tissue. Maintain enough

distal phalanx length so that the nail bed does not extend beyond the distal phalanx in order to avoid a hook nail. The distal skin can be brought dorsally to be sutured to the distal nail bed but should not be excessively tight such that the nail bed is drawn over the distal end of the phalanx resulting in a hook nail. Those injuries that heal by secondary intention typically have good cosmetic and functional results. Type II Injuries

These injuries involve > 50% of the nail bed and a significant portion of the distal phalanx. Treatment These injuries are usually treated by shortening and closure of the wound. The shaft and base of the distal phalanx is conserved to maintain the insertion points of the flexor and extensor tendons. VY Plasty, thenar flap and cross-finger flap are other options. Type III Injuries: Amputation through DIP Joint

These injuries are amputations through the distal interphalangeal (DIP) joint. In sharp injuries, replantation can be considered at this level though relative risks and benefits should be strongly considered. Consider replantation especially in multiple digits,

Figs 11.1A and B: Amputation levels and treatment options

Amputations 143

thumbs and children. However, at this level, shortening and primary closure can also result in good or excellent results and is preferred for avulsion and crush injuries. If the flexor tendon is resting in its native position, it can be sutured to local tissue such as the volar plate or flexor sheath to try to prevent later development of a lumbrical plus finger and maintain flexion power. A lumbrical plus finger results in paradoxical proximal interphalangeal (PIP) joint extension when the patient attempts to perform fist flexion. This occurs when the flexor digitorum profundus (FDP) tendon retracts excessively and the lumbrical muscle, which originates from the FDP, becomes shortened and tight. A shortened, tight lumbrical leads to excessive tone in the radial lateral band of the intrinsic system. When the patient flexes the digit, the FDP slides proximally and the excessively tight lumbrical, via the radial lateral band, leads to PIP extension. Treatment of lumbrical plus deformity is by section of lumbrical band under local anesthesia. If the FDP is not in its resting position, it should not be pulled out to length and sutured to soft tissue or to the extensor tendon as this may result in a quadregia effect. Since the FDP to the fingers shares a common muscle belly, excessive lengthening of the FDP of the amputated finger prevents the other digits from achieving full flexion excursion. The effect is an inability to make a full fist or weakness of grip for the uninjured digits. Therefore, if the relative length position of the FDP of the injured digit is not clearly apparent, it is better to just transect the FDP proximally and allow it to retract proximally as the risk and detriment of developing a lumbrical plus finger is less than that of creating a quadregia effect. Gently pull the digital nerves distally and use bipolar cautery to cauterize them as proximally as possible within the zone of injury to diminish chances of inevitable neuroma formation. Type IV Injuries

Type IV injuries spare a significant amount of dorsal tissue, with the soft tissue defect involving most of the volar surface of the distal phalanx. Treatment includes: a. Healing by secondary intention: If the area of soft tissue loss is less than 1 × 1 cm and there is no exposed bone or tendon, the wound will usually heal and provide the best result with regard to cosmesis and sensation.

b. Cross-finger or other local flaps can be used to provide full thickness coverage and protective sensation. Split thickness grafts in this area are discouraged, even if there is no exposed bone or tendon without paratenon, due to poor durability and sensation. Amputation through Middle Phalange If amputation is distal to superficialis tendon insertion, shortening and closure of wound is done. Flap cover can be considered if superficialis tendon is exposed but intact and viable. Amputation through Proximal Phalange This is also treated by primary closure. If amputation is at the level of MP joint, dropping of objects from the hand will occur. Consider metacarpal ray amputation or prosthetic replacement. METACARPAL RAY AMPUTATION Indications 1. Elective procedure for disability resulting from previous injury/amputation of a digit. 2. As part of a reconstructive programme to facilitate phalangization of metacarpals. Method Index Finger Ray Amputation (Figs 11.2A to D)

Make a circumferential incision at the mid phalangeal level of the index finger which is continuous with a dorsal incision on the index metacarpal. The skin is kept long to facilitate closure and prevent web contracture. Ligate the dorsal veins, transect the extensor tendons and sub-periosteally divide the 2nd metacarpal at its base. Cut the tendon of the 1st dorsal interosseous and lumbrical on the radial side. Proceed to the volar surface and ligate the neurovascular bundle, stretch and cut the nerve and transfer them into the interosseous space between the 1st and 2nd dorsal interossei. Cut the flexor tendons and allow their retraction into the palm. Cut all attachments of volar plate preosseous bands of palmar fascia and proximal portion of flexor tendon sheath. Close the periosteal tube, secure hemostasis and close the wound with interrupted sutures.

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A

B

C

D

Figs 11.2A to D: Technique of index ray amputation. The index metacarpal is transected at its metaphyseal flare. Special care should be taken to transpose the digital nerves into the interosseous space to prevent the formation of symptomatic neuromas

Index Finger Amputation

Method of ray amputation of middle/ring finger. Complications/Drawbacks: 1. Hyperesthesia interfering with function due to excessive mobilization of radial nerve in more than a third of the patients. The problem can appear 6 to 8 weeks after surgery. 2. Phantom finger sensation in amputated finger in many patients.

3. Intrinsic plus deformity in one-third of cases where second dorsal interosseous was augmented by transfer of 1st dorsal interosseous or long flexor of amputated finger. 4. Carpal tunnel syndrome due to proximal migration of transected flexor tendons into carpal tunnel. 5. Triggering of finger due to proximally migrated long finger lumbrical overhanging the superficial transverse metacarpal ligament.

Amputations 145

Example 1

A

B

Figs 11.3A and B: (A) Injuery with non-viable index fingure. (B) Post-operative status with index finger metacarpal-ray amputation. Note: The excellant functional and cosmetic results after index ray amputation

Example 2

A

B

C

D

E Figs 11.4A to E: Non-viable index finger. Note the excellent functional and cosmetic results after index ray amputation

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A

B

C

D

E

F

Figs 11.5A to F: Transposition of base of index metacarpal to base of middle/ring finger metacarpal (Carroll technique)

Amputations 147

A

B

Figs 11.6A and B: (A) Alternative technique for long finger metacarpal ray amputation, with distal suture of the deep intervolar plate ligaments to close the space between the index and long fingers. Preserving the deep intervolar plate ligaments and suturing them together; (B) Suture of the deep intervolar plate ligaments (with subsequent migration of the fifth metacarpal base radially across the hamate) is a satisfactory procedure for accomplishing ring finger ray amputation

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RECONSTRUCTION IN AMPUTATION FILLET FLAPS Fillet flaps are prepared from well vascularized digits that are otherwise worthless due to extensive damage to bones, tendons, nerves individually or in combination. The skeleton, tendons are removed preserving all soft

A

tissues on an intact vascular pedicle. Usually fillet grafts are used to cover dorsal defects of the hand. Sometimes the adjacent ray of index or little finger is also transposed into the defect. In such circumstances, the fillet is used as a neurovascular island flap by excising palmer skin as required.

B

C Figs 11.7A to C: (A and B) Injury with crushed non-viable index finger and skin loss on thumb (C) Final result at 2 years. Avulsed skin on thumb was sutured back and survived because of intact vascular pedicle. Skin over index finger was used in web space, thenar area and dorsum after excising non-viable index finger ray

Amputations 149

PHALANGIZATION OF METACARPAL BY WEB SPACE DEEPENING Phalangization of metacarpals by web space deepening helps improve intercarpal pinch. This is achieved in the thumb by web space deepening. Indications 1. Partial thumb amputations. 2. Early web space contracture.

A

Method (Figs 11.8A and B) Use a Z-plasty incision over the first web space as described in the section on Z-plasty. Detach the fibres from the third metacarpal attaching over the base of the proximal phalange. This is sufficient for small contractures. When additional web deepening is required, release the sesamoid tendon of the adductor pollicis and reattach it halfway down the shaft of the first metacarpal. If the muscle is markedly fibrotic, release most of the attachment and reinforce the action along with tendon transfer.

B

Figs 11.8A and B: Z-plasty and release of fibers of adductor pollicis from base of proximal phalange of thumb. Sesamoid bone can be released and re-attached proximally

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PHALANGIZATION OF THE METACARPAL HEAD (MODIFIED) Indications • •

Loss of thumb and all digits with intact metacarpals. Procedure attempts first metacarpal phalangization with excision of second metacarpal and majority of third metacarpal. Procedure attempts to provide a cleft space with preservation of adductor and abductor pollicis function and preserving opposable strength and motion of at least one ray and satisfying sensory perception on opposing sides of the pincer that is reconstructed.

Method (Figs 11.9 and 11.10) A linear or zig-zag incision is designed over the second metacarpal starting dorsally at the wrist and continued

palmarly to the base of the thenar eminence. Flaps are planned to interdigitate with the ulnar side of the mobilized first metacarpal. Extensor and flexor tendons, common digital nerve, radial nerve of index and middle finger are dissected and transsected and allowed to retract at the wrist level. Second metacarpal and trapezoid are excised along with fifty percent of the third metacarpal, preserving as much of adductor origin as possible. Close the ulnar side of the first ray. A dorsal rotational flap may have to be created to cover the radial margin of the cleft with a full thickness graft covering the donor area. If phalangeal remnants of 1st, 4th, 5th metacarpals are present, preserve them because they add considerably to the final function achieved. Lengthening of the 1st and 5th metacarpals may add to the function in selected cases.

A

B

C

D

Figs 11.9A to D: Phalangization of the metacarpal hand: (A) Appearance of the metacarpal hand with small proximal phalangeal remnants in the thumb, ring and small fingers. The shaded areas of the second and third metacarpals are to be excised; (B) Zig-zag skin incisions over the proposed cleft between the thumb and ring finger remnants; (C) Phalangization of the first metacarpal with excision of the second metacarpal, trapezoid and distal half of the third metacarpal. The origin of adductor pollicis brevis from the proximal half of the third metacarpal is carefully preserved; (D) Closure of the ulnar side of the first ray and dorsal rotational flap coverage of the first web, with free skin graft coverage of the donor defect

Amputations 151

Fig. 11.10: Clinical example of phalangization of metacarpal head

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POLLICIZATION OF AN INDEX FINGER STUMP (FIGS 11.11 AND 11.12) Indication Injuries that result in loss of thumb with partial destruction of adjacent index finger along with extensor tendon and 2nd metacarpal damage or amputation which creates the possibility of transfer of an injured digit or distal metacarpal to the base of the proximal phalange of the thumb or to the first metacarpal to restore length and sensory perception. Method Perform surgery under tourniquet control. A racquet type incision is used around the base of the index finger starting on the palmar surface at the

proximal digital crease and continuing around the digit to join as a V over the middle of the second metacarpal, curving over the base of the metacarpal and finally sloping laterally to the metacarpal stump area. Carefully raise the flaps. Identify the radial neuron vascular structures to the index finger. Free the flexor tendon, identify the ulnar neurovascular vessels and dissect them out. Identify and divide the radial digital artery beyond the common digital artery. Split the common digital nerve to the index and middle fingers. Mobilize dorsal veins after ligating the tributaries. Cut the transverse intercarpal ligament and separate the interossei. Preserve as much of the extensor tendon as possible. Transversely cut the articular base of the proximal phalange.

A

B

C

D

Figs 11.11A to D: Pollicization of an index finger stump: (A) Incisions used for index stump transposition; (B) Elevation of flaps and mobilization of the second ray identification of a dorsal vein is shown; (C) Diagram depicting the areas of the second metacarpal to be divided and excised (stripes) before transfer of the distal metacarpal and proximal phalangeal stump; (D) The palmar flap with intact neurovascular bundles and flexor tendons following division of the radial digital artery to the long finger

Amputations 153

Ream the medullary cavity of the remnant of 1st metacarpal or trapezium and fix them with the base of the proximal phalange of the index finger. Bones graft the anastomosis with one from excised second metacarpal. Ensure that neurovascular bundle is tension-free and reconstructed digit is in proper abduction, opposition and pronation. Join extensor of index finger to extensor pollicis longus. Shorten the flexor tendon, if required.

Release tourniquet and secure hemostasis. Assess reconstructed thumb viability. Transpose the lateral web flap into the new cleft created between pollicized index finger and long finger. Apply plaster splint for 6-8 weeks. Complications Encountered 1. Complete or partial flap necrosis. 2. Non-union of bony junction.

E

F

G

H

Figs 11.11E to H: (E) Transfer of the index stump to the first metacarpal, again with preservation of a dorsal vein. Fixation by means of a bone peg and crossed K-wires is shown; (F) First and second metacarpal fixation with proximal deletion of the second metacarpal; (G) Wound closure on the palmar surface of the transposed index stump; (H) Use of the palmar flap to create a thumb-long finger cleft

154

Handbook on Flaps in Crush Injuries of the Hand

A

C

B

D

Figs 11.12A to D: Pollicization of an injured index finger: (A and B) Incisions for transfer of the index finger following thumb loss through the proximal part of the metacarpal with damage to the second metacarpal and extensor tendon. Incisions may vary depending on skin conditions; (C) Diagram of bone transfer including the proximal, middle and distal phalanges of the index to the first metacarpal base or scaphoid, depending on the level of thumb loss; (D) Appearance of the reconstructed thumb following pollicization with the lateral flap used to restore the first web

Amputations 155

Example 1 (Figs 11.13 to 11.15)

Fig. 11.13: Amputated thumb at MP joint level and index finger at neck of proximal phalange

Fig. 11.14: Proximal phalange of index finger transferred to top of first metacarpal after partial excision of the second metacarpal

Fig. 11.15: Post-operative clinical picture compared to opposite hand Source: Concepts and strategies in thumb repair and reconstruction: Dr BB Joshi

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Handbook on Flaps in Crush Injuries of the Hand

Example 2: Pollicization of partially amputated index finger on to amputated thumb

A

B

C

D Figs 11.16A to E: (A) Preoperative status; (B) Preoperative X-ray; (C and D) Postoperative status; (E) Postoperative X-ray Courtesy: Dr Pankaj Jindal, Hand Surgeon. Pune, Maharashtra, India

E

Amputations 157

THE GILLES COCKED-HAT FLAP (FIGS 11.17A TO D) Indication Tricortical iliac bone grafting to create a thumb in cases where other alternatives for thumb lengthening are not available. Method Surgery is performed under tourniquet anesthesia. Outline a long curved incision at the level of the neck of the second metacarpal curving proximally around the base of the thumb at the CMC joint level and terminates palmarly just distal to the edge of the thenar muscles.

Dissect at the level of the deep fascia exposing the muscles around the first metacarpal. Reflect the flap over the bony stump carefully mobilizing the skin over it and preserving the digital median nerve branches. Take a 5 cm-long tricortical graft from the iliac crest. Freshen the ends of the metacarpal stump and fix the graft with a kirshner wire. Bring the previously raised flap over the graft, and completely cover the bone with tension-free sutures. Cover the donor area defect with a skin graft. Splint the thumb for 6 weeks. Drawbacks 1. Sensory perception is often marginal. 2. Graft resorption and non-union is known. 3. Cosmetically unsatisfactory web space appearance is often created.

A

B

C

D

Figs 11.17A to D: Gillies’ “cocked-hat” Hap: (A) Outline of the incisions around the base of the thenar eminence; (B) Tricorticocancellous iliac bone graft to elongate the first metacarpal; (C) The flap is reflected and the graft is held in place with crossed K-wire fixation. The graft may be stemmed for insertion into the metacarpal, or a cortical peg may be used to bridge the graft-metacarpal interval, as shown here; (D) The flap brought back to cover the bone graft. A free skin graft covers the thumb defect

158

Handbook on Flaps in Crush Injuries of the Hand

Example 1: Avulsion thermal injury and friction burns with secondary infection that will require full thickness cover (Figs 11.18A to F).

A

B

C

D

E

F Figs 11.18A to F: Crushed and avulsed hand with early wet gangrene of dorsum of hand and fingers that led to amputation at MP joint of all four fingers. The flap creates a hand on which a planned second stage toe-to-hand transfer can be performed

Splints and Fixatures in Crush Injuries

External fixatures have revolutionized the treatment of hand injuries. The topic requires a complete book in itself. But this book will be incomplete without a mention of the role of fixatures in crush injuries of the hand.

12

JESS FIXTURES (FIG. 12.3)

Dr Joshi’s external fixatures that evolved from using discarded electrical switch plugs to the modern JESS system are versatile and user-friendly.

The modern JESS is a versatile and user-friendly external stabilizing system that facilitates fracture manage­ ment, wound healing and soft tissue reconstructive procedures. The reader can pursue the exhaustive and authoritative books on this topic for a better under­ standing of the principles, techniques and indications of this procedure.

A

B

SPLINTS (FIGS 12.1 AND 12.2)

C

D Figs 12.1A to D: Slints like Gawande’s splint can immobilize as well as dynamically align fractures

160  Handbook on Flaps in Crush Injuries of the Hand

A

B Figs 12.2A and B: Example of the early fixature made from the discarded electrical switches

A

C

B

D Figs 12.3A to D: Crush injury with dorsal skin loss and comminuted fracture of phalanges with bone loss stabilized with JESS fixator and K-wires

Splints and Fixatures in Crush Injuries  161

A

B

C

D Figs 12.4A to D: Joshi’s external stabilizing system

JESS fixatures can also be used to distract thumb and fingers contracture that commonly occurs after flap coverage of severe crush injuries. Example (Figs 12.5 to 12.8) JESS fixature used to distract thumb and second metacarpal to create adequate first web space before syndactaly release in case of crush injury hand treated with an groin flap. Fig. 12.5: X-ray depicting crowding and contracture of thumb and other fingers

162  Handbook on Flaps in Crush Injuries of the Hand

A

B Figs 12.6A and B: Immediate postoperative images after JESS application

A

B

C Figs 12.7A to C: Status at the end of distraction and fixature removal. Incision is marked for syndactaly release. Note: The amount of web space widening that could be achieved

Splints and Fixatures in Crush Injuries  163

A

B Figs 12.8A and B: (A) Surgical incision, defatting; (B) Syndactaly release and closure using Z-plasty principles. Multiple defattening and staged syndactaly releases of remnants of amputated fingers will be required

Microvascular Techniques

Indications

1. All amputations at the level of the arm, forearm, carpus and metacarpus. 2. All amputations of thumb proximal to middistal phalanx. 3. In multiple digits replant as many as possible. 4. Most digits amputated distal to proximal phalange. 5. Children. 6. Think about avulsed digits and crushed distal parts. 7. Thumb reconstruction with great toe or 2nd toe transfer. 8. Hemipulp transfer from big toe to reconstruct oblique amputations of soft tissue over the thumb. 9. Morrison wrap around flap for nail and tip reconstruction. 10. Partial transfer of big toe for distal necrosis of the thumb.

Relative Contraindications



1. Severely crushed and mangled hands. 2. Amputations at multiple level. 3. Concomitant serious injuries or disease. 4. Prolonged warm ischemia time, greater than 6 hours for amputation proximal to carpus and 12 hours for digits. Cold ischemia time greater than 12 hours is also a contraindication. 5. Mentally unstable patient. 6. Atherosclerotic vessels. 7. Individual finger amputation in adult proximal to flexor digitorum superficialis insertion.

Patient Selection Factors include: 1. Predicted morbidity of patient.

13

2. Expected chance of survival and function of reimplanted plant. 3. Cost involved. 4. Experience of reimplantation team. Transport of Amputated Part/Preservation 1. Wrap the part in a sterile cloth moistened with ringer’s lactate or saline solution and place the bundle on ice. 2. Immerse the part in ringer lactate or saline solution in a plastic bag or specimen container and placing the bag on ice. Tissues survive 6 hours if the part is not cooled and up to 12 hours if part is cooled. Cooled digits survive longer as there are no muscles in the digits. Instruments • Surgical loupes with 3.5 × 4.5 magnifications for initial exploration. • Operating microscope, preferably with diploscope and 20 × magnification. • Microsurgical instruments including fine needle holder, jewellers, forceps, small tipped tying forceps, microtipped dilator, microirrigator, microclips, small tipped bipolar cautery. Monofilament nylon suture 10-0 and 8-0. Surgeon Requirements Surgeon performing microvascular implantation must consistently have a 90% patency rate in 1 mm vessels in animal laboratory. Reimplantation surgeon must be a competent hand surgeon, microsurgeon and knowledgeable in predicting outcome in patients selected or reimplantation. A well-integrated reimplantation team available round the clock is essential for good outcomes.

Microvascular Techniques  165

A

B

C

D

Figs 13.1A to D: Traumatic amputation of the thumb in an adult: (A) Amputation of thumb, dorsal view; (B) Volar view of injury; (C) Result after reimplantation; (D) Result after reimplantation (Courtesy: Dr Arvind Patel, Plastic surgeon Surat, Gujarat, India)

Techniques Techniques are beyond the scope of this book and the reader is directed to authoritative books on this subject. The operative sequence is merely mentioned for the sake of completeness. 1. locate and tag vessels and nerves. 2. Debride. 3. Shorten and fix the bone. 4. Repair extensor tendons. 5. Repair flexor tendons. 6. Anastomose the arteries. 7. Repair the nerves. 8. Anastomose the veins. 9. Obtain skin coverage. Traumatic Avulsion of Thumb in a Young Girl (Fig. 13.2) Monitoring of any flap postoperatively includes: 1. Observing color of the flap Healthy flap is pink in color.



If arterial supply is inadequate, color is pale with faint blue-grey tinge. If venous drainage is occluded, color is first an angry red, then purple-red and, finally, pupple-blue. In a failing flap cyanosis, blisters and line between surviving and failing flap appear. Initially, a waxy pallor—white tinged with yellow or brown similar to the healthy pink pallor occurs. Induration and blister follow. 2. Observe refill after blanching by fingertip Very slow refill is seen in flap with no flow due to stagnant blood. Swift refill and bluish hue indicate venous engorgement. If caused by kinking, this can be corrected. 3. Measuring temperature with dorsum of hand/ finger will give some indication. Cold indicates impaired flow. 4. Puncturing with a needle and observing bleeding Healthy flap shows the same bleeding/color as normal.

166  Handbook on Flaps in Crush Injuries of the Hand

A

B

C Figs 13.2A to C: Traumatic amputation in a young adolescent: (A and B) Amputation, dorsal and volar view; (C) Immediate postoperative picture with signs of successful reimplantation (Courtesy: Dr Arvind Patel Plastic Surgeon, Surat, Gujarat, India)

No or little bleeding means arterial inadequacy. Dark blood or persistent bleeding indicates venous congestion. OTHER PRACTICAL METHODS 1. Pulse oxymetry. 2. Thermocouple. 3. Photoplethysmograph. 4. Fluorescein injection and evaluation under ultra­ violet light. 5. Assessment of hematocrit and pH from blood from stab wound in flap. Hematocrit was raised by 19% and pH fell by 0.4% in one study. MEASURES TO SALVAGE A FAILING FLAP

1. Seek and eliminate any kinks in the pedicle. 2. Remove single large or multiple small kinks. 3. Check the general condition of the patient.

4. Hypotension, cardiopulmonary impairment and impaired perfusion contribute to flap failure. 5. Hematoma: Evacuate hematoma. Insert drain if hematoma is anticipated or persistent serosanginous oozing from the flap persists. 6. Release tight sutures that impede circulation. 7. Reposition the patient. 8. Moist environment, local and systemic oxygen improve survival. Hyperbaric oxygen at 21% and 100% has been showm to improve survival. 9. Drugs that have been tried are streptokinase, allopurinol, prednisolone, chlorpromazine, calcium antagonist, free radical scavengers, prost­aglandins, antiadrenergics, tropical nitro­ glycerine, ketamine, isoxuprine, etc. 10. Drugs that have been tried but with some reports of failure/ineffectiveness are nitro­glycerin, pento­­ xifylline, chlorpromazine, henoxy­ benzamine, isoxuprine, reseprine, propanol and heparin.

Bibliography

1. Argenta LC, Morykwas M, Rouchard R. The use of negative pressure to promote healing of pressure ulcers and chronic wounds in 75 consecutive patients. Presented at the Joint Meeting of the Wound Healing Society and European Tissue Repair Society, Amsterdam. August 1993. 2. Argenta LC. Vacuum-assisted closure case. Wound Care, 1997:30-31. 3. Argenta LC. Vacuum device can speed healing. Wound Care, 1997:29. 4. Askari M, Fisher C, Weniger FG, et al. Anticoagulation in microsurgery: a review. J Hand Surg [Am] 2006; 31:836-46 5. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated finger tip with a triangular volar flap. A new surgical procedure. J Bone Joint Surg Am 1970;52A:921-26. 6. Atasoy E, O’Neill E. Local flap coverage about the hand. Atlas Hand Clin 1998;3(2):179. 7. Atasoy E. Reversed cross-finger subcutaneous flap. J Hand Surg [Am] 1982;7A:481-483. 8. Becker C, Gilbert A. Lambeau antebrachial des branches distales de l’artere cubital. Paris: Expansion Scientifique Francaise, 1990. 9. Blackburn JH, Boemi L, Hall W, et al. Negative pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;40;453-7. 10. Braun RM, Rechnic M, Neill-Cage DJ, et al. The retrograde radial fascial forearm flap: surgical rationale, technique, and clinical application. J Hand Surg [Am] 1995;20A:915-22. 11. Chang TS, Wang W. Application of microsurgery in plastic FIGURE 28. Radial forearm fascial flap. (A) Skin and tissue loss over dorsum of forearm and hand. (B) Identification of fascial radial forearm flap on volar surface of forearm. (C) Fascial flap tunneled under skin, set into defect and covered with a split-thickness skin graft. Local hand flaps z chao et al 43 and reconstructive surgery. J Reconstr Microsurg 1984;1:55-63. 12. Chase RA, (Ed.) Atlas of Hand Surgery. Philadelphia: Saunders, 1970. 13. Chase RA. Historical review of skin and soft tissue coverage of the upper extremity. Hand Clin 1985;1:599-608. 14. Chen HC, Tang YB, Chuang D, et al: Microvascular free posterior interosseous flap and a comparison with the pedicled posterior interosseous flap. Ann Plast Surg 1996; 36:542-50. 15. Chen KT, Mardini S, Chuang DC, et al: Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120:187-95. 16. Chuang DC, Jeng SF, Chen HT, et al: Experience of 73 free groin flaps. Br J Plast Surg 1992; 45:81-85. 17. Conrad MH, Adams Jr WP: Pharmacologic optimization of microsurgery in the new millennium. Plast Reconstr Surg 2001; 108:2088-2096. 18. Cronin T. The cross finger flap: a new method of repair. Am Surg 1951;17:419-25. 19. D Imran, C Koukkou, L C Bainbridge. J Bone Joint Surg [Br] 2003;85-B:860-2. 20. De Franzo AJ, Marks MW, Argenta LC, et al. Vacuum-assisted closure for the treatment of degloving injues. Plast ReconstrSurg. 1999.104:2145-2148 21. Dorsal adipofascial flap: Sabah Hassan Naji, Al-Wasiti Teaching Hospital, Baghdad, Iraq. Medical Journal of Babylon vol 8 no 1 2011 22. Dr BB Joshi concepts and strategies in thumb repair and reconstruction Green’s textbook of hand surgery, 4th Edition 23. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr Surg 1979;63:344-9. 24. Foucher G, Norris RW: The venous dorsal digital island flap or the “neutral” flap. Br J Plast Surg 1988; 41:337. 25. Foucher G, Van Genechten F, Merle N, et al: A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap. Br J Plast Surg 1984; 37:139-148. 26. Germann G. Principles of flap design for surgery of the hand. Atlas Hand Clin 1998;3(2):33. 27. Gilbert A. Pedicle flaps of the upper limb. Philadelphia: Lippincott, 1992. 28. Goumain AJ, Baudet J, Massard JF. Our experience with recent thumb mutilations. Revue de Chirurgie Orthopedique et Reparatrice de l’Appareil Moteur 1972;58:563-74.

168  Handbook on Flaps in Crush Injuries of the Hand 29. Graham B, Adkins P, Scheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg [Br] 1992; 17:189-92. 30. Green DP, Hotchkiss R, Pederson WC. Green’s operative hand surgery. Vol 2. London: Churchill-Livingstone, 1998. 31. Hentz VR, Pearl RM, Grossman JAI, et al. The radial forearm flap: a versatile source of composite tissue. Ann Plast Surg 1987; 19:485-98. 32. Hirase Y, Kojima T, Matsuura S. A versatile one-stage neurovascular flap for fingertip reconstruction: the dorsal middle phalangeal finger flap. Plast Reconstr Surg 1992;90:1009-15. 33. Hirase Y, Kojima T, Matsuura S. A versatile one-stage neurovascular flap for fingertip reconstruction: the dorsal middle phalangeal finger flap. Plast Reconstr Surg 1992;20:1006-15. 34. Holevich J. A new method of restoring sensibility to the thumb. J Bone Joint Surg Br 1963;45B:496-502. 35. Ho PC, Hung LK, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong. 36. Hueston J. Local flap repair of fingertip injuries. Plast Reconstr Surg 1966;37:349-50. 37. Innervated Reverse Island Flap based on End Dorsal Branch of Digital Artery 38. Jones G, Jurkiewicz, MJ, Bostwick J, et al. Management of the infected wounds The Dorsal Reverse Adipofascial flap for fingertip reconstruction Dimitrrio. H Laoulakos, American Journal of plastic and reconstructive surgery, 2003. 39. Joshi BB. A local dorsolateral island flap for restoration of sensation after avulsion injury of fingertip pulp. Plast Reconstr Surg 1974;54:175-82. 40. Joshi’s dorsolateral neurovascular island flap Dr BB Joshi, India and Ho PC, Hung LK, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, the Chinese University of Hong Kong. 41. Katsaros J, Tan E, Zoltie N, et al. The use of the lateral arm flap in upper limb surgery. J Hand Surg [Am] 1991; 16:598-604. 42. Kojima T, Tsuchida Y, Hirase Y, et al. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290-95. 43. Kojima T. Reverse vascular pedicle digital island flap. Br J Plast Surg 1990;43:290-95. 44. Koshima I, Nanba Y, Tsutsui T, Takahashi Y. New anterolateral thigh perforator flap with a short pedicle for reconstruction of defects in the upper extremities. Ann Plast Surg 2003; 51:30-36. 45. Kutler W. A new method for fingertip amputation. J Am Med Assoc 1947;133:29-30. 46. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg 1989;22:495-500. 47. Limberg A. Mathematical principles of local plastic procedures on the surface of the human body. Leningrad: Medgis,1946. 48. Lister G. The theory of the transposition flap and its practical application in the hand. Clin Plast Surg 1981;8:115-127. 49. Marks MW, Marks C. Fundamentals of plastic surgery. Philadelphia: Saunders, 1997. 50. Martin D, Bakhach J, Casoli V, Pellisier P, Ciria-Llorens G, Khouri RK, et al. Reconstruction of the hand with forearm island flaps. Br J Plast Surg 1990;43:290-95. 51. McCarthy JG, ed. Plastic Surgery. Vol 7. Philadelphia: Saunders, 1989. 52. Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am 1964;46A:817-25. 53. Mullner T, Mrkonjic L, Kwasny O, et al. The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum-sealing technique. BrJ Plast Surg. 1997;50:194-9. 54. O’Brien B. Neurovascular island pedicle flaps for terminal amputations and digital scars. Br J Plast Surg 1968;21:258-261. 55. Pedicled flaps for coverage of the limbs :a practical guide : C Oberlin, D. Bastian, P .Greant, Anil Bhatia 56. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat 1986;8:209-215. 57. Reinisch JF, Winters R, Puckett CL: The use of the osteocutaneous groin flap in gunshot wounds of the hand. J Hand Surg [Am] 1984; 9:12-17. 58. Shepard GH. The use of lateral V-Y advancement flaps for fingertip reconstruction. J Hand Surg [Am] 1983;8A:254-9. 59. Smith PJ, Foley B, McGregor IA, Jackson IT. The anatomical basis of the groin flap. Plast Reconstr Surg 1972; 49:41-7. 60. Snow JW. The use of a volar flap for repair of fingertip amputations: a preliminary report. Plast Reconstr Surg 1967;40:163-8. 61. Song R, Gao Y, Song Y, et al. The forearm flap. Clin Plast Surg 1982; 91:21-26. 62. Souquet R. The asymmetric arterial advancement flap in distal pulp loss (modified Hueston’s flap). Ann Chir Main 1985;4:233-238. 63. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 1984; 37:330. 64. Timmons MJ, Missotten FE, Poole MD, Davies DM: Complications of radial forearm flap donor sites. Br J Plast Surg 1986; 39:176178. 65. Tranquilli-Leali L. Ricostruzione dell’apice delle falangi ungueali medianti autoplastica volare peduncolata per scorrimento. Infort Traum Lavoro 1935;1:186-93. 66. Turkish C ring cross finger flap. Christine M Klienert Institute for Hand and Microsurgery, Iowa ortho journal, 2011. 67. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique amputations of the fingertip and thumb. Plast Reconstr Surg 1980;66:296-300.

Bibliography  169 68. Weinzweig N, Chen L, Chen ZW. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical approach. Plast Reconstr Surg 1994;94:675-84. 69. Yan-Feng Li, MD, MSc, JiangSu, China, Shu-Sen Cui, MD, PhD, JiLin, China. Department of Orthopaedic Surgery,Second Affiliated Hospital, SooChow University, 1055 SanXiang Rd,SooChow, Jiang Su 215004, PR China 70. Yan –Feng Li, Shu Sen Cui, China, The Journal of Hand Surgery 2005, American Society for Surgery of the Hand, Department of Orthopaedic Surgery, Second Affiliated Hospital, SooChow University, Soo Chow, JiangSu, and Department of Hand Surgery, the Third Clinical Hospital, University of JiLin ChangChun, Peoples republic of China 71. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg [Br] 1988;13B:130-5.

index Page numbers followed by f refer to figure A Adipofascial flap 33, 33f Advancement flap 2, 27, 27f Amputation 11, 141, 143 reconstruction in 148 Annular flap 58, 58f Anterior thoracic perforators 111f Arterial system and innervation of long fingers, anatomy of 57f Arteries of hand 85f Arteriography 14 Atasoy-Kleinert volar V-Y technique 42f Avulsion 1f flap injury 10f Axial pattern distant flaps 108 B Bilateral Kutler’s V-Y plasty 43, 43f, 44f Bilateral triangular flap 43f Bipedicle flap 2 Blood vessels 4 Blue discoloration 4 Bone 4 Burrow’s triangles 27f C Cadaveric dissection 91f Carroll technique 146f Cephalic vein 111f Chinese flap 100 Combined loin and groin flap 121 Compartment syndrome 13 acute 13, 17f chronic 13 recurrent 13 sequel of 13 subacute 13 Composite flap 2 Composite grafting 125 Computed tomography 14 C-ring cross-finger flap 74 Cross-finger flap 59 advantages of 81 over-riding cross finger flap 75 results of 84 reverse 66 Crush injury 1 examples of 94 splints and fixatures in 159 Crush syndrome 13

D Deep fascia 4 Deep thermal burns 118 Deformity, CT images of 138f Degloving injury 1 classification of 3 of thumb 109f Degloving of thumb 102f Deltopectoral flap 108, 111 Developing compartment syndrome, hallmark of 13 Digital tip amputations 142 Direct nerve stimulation 14 Distal interphalangeal joint 62 Distant flaps 108 Doppler study 14 Dorsal adipofascial turnover flap 34 Dorsal digital artery 81 Dorsal incisions 15f Dorsal interosseous metacarpal artery 80f Dorsal island digital flap 80f Dorsal metacarpal artery 85, 92, 95f flap 92f, 93f variations of 95 Dorsal metacarpal flaps 92 Dorsal middle phalangeal artery flap 80 Dorsal middle phalanged finger flap 80f Dorsal zig-zag incision 33f Dorsum of thumb, kite flap on 89f Dual innervated cross-finger flap 72, 72f Dufourmental flap 30, 30f E Elevated flap 113f Extensive thermal burns 117 F Fasciocutaneous flap 2 Fasciotomy 13 indications for 14 Fillet flaps 148 Finger injury, dorsal defects of 34 Fingertip amputation 6 dry gangrene of 11f injury, Venkataswami flap on 46f oblique amputation of 46f Flag flap 85, 95 Flap 2

172  Handbook on Flaps in Crush Injuries of the Hand demarcation 49f dissection 50f observing color of 165 on flap 75, 76 overriding flap 75f, 77f raising 49f Forearm fasciotomy incisions 15f Foucher kite flap 87, 88f, 89f, 93 Four-flap Z-plasty of thumb web 37f Free skin grafts 18 Full thickness graft, technique of 20 G Gilles cocked-hat flap 157 Groin flap 113 Guillotine amputation of thumb 42f H Hand injuries 3 Holevich flap 87, 87f-89f H-shaped thenar flap 98f Hueston flap 37f-39f, 41f I Index finger amputation of 94, 144 ray amputation 143 stump, pollicization of 152, 152f Index radial digital nerve, dorsal branch of 73f Index ray amputation, technique of 144f Injured index finger, pollicization of 154f Injury 33f assessment of 4 over middle fingertip 20f types of 4 Interosseous artery flap, posterior 105 Intrinsic muscle compartment pressure 14 Island flap 2 J Jess fixtures 159 Joshi’s dorsolateral neurovascular island flap 49 Joshi’s external stabilizing system 161f Joshi’s flap in index fingertip amputation 50, 50f Jump flap 2 K Kite flap 87 L Lateral digital flap 27, 27f Lateral palmar advancement flap 38 Limberg, rhomboid flap of 28, 28f, 29f Lumbrical plus finger 143 M Magnetic resonance imaging 14 Metacarpal hand, phalangization of 150, 150f

Metacarpal ray amputation 143 Microvascular techniques 164 Middle finger amputation of 94 distal phalange amputation 52 Mid-forearm incision 15f Moberg-O’Brien flap 47 Muscles 4 Musculocutaneous artery 111f Myocutaneous flap 2 N Neurovascular island flap 2, 109, 109f Non-viable index finger 145f P Palmar advancement flap 47f, 48f Palmar bipedicle advancement flap 47 Palmar digital monopedicle flap 52, 53f Palmar digital neurovascular advancement island flap 54f Pedicle flap 2 contraindication for 3 indications for 2 Plus degloving, amputation 120 Proximal interphalangeal joint 34, 34f, 62f Proximal primary closure 50f Pulse oxymetry 4, 14 R Radial artery forearm flap, reversed 100 Radial nerve and microneurorrhaphy of thumb ulnar digital nerve, branch of 73f Radial sensory nerve innervated cross-finger flap 68, 70f Random pattern distant flaps 108 Ring finger, vertical slicing amputation of 94 Rope flap 2 Rotation flap 2, 23, 23f, 24 S Skin 4 flap 2 Sliding flap 2 Small fingertip injuries 9 Souquet flap 40, 40f Splints 159 Split thickness graft 18 STG, method of 18 Superficial fascia 4 T Tendon 4 Thenar flap 97, 97f Thoracoacromial artery, cutaneous branch of 111f Thumb, traumatic avulsion of 165 Transposition flap 2, 23, 24, 26f techniques 24, 25f

Index  173 Traumatic amputation of thumb 126f, 165f Tube flap 2 Turkish flap 74 U Ulnar parametacarpal artery flap 96, 96f V Vacuum-assisted closure 21 Venkataswami-Subramanian flap 41f, 45, 46f Volar oblique finger amputation 6

Volkmann’s ischemic contracture 13 V-Y flap 2 W White hand 4 Wound, closure of 43f Z Z-plasty 35f, 37 design of 36f incision 149f techniques 35