Wide thumb and the first web reconstruction using a neurovascularised instep free flap

[Treatment of the contracted first Commissure of the Hand: Literature Overview and own Experiences]

The freely movable thumb is of central importance for the function of the human hand. This mobility is necessarily linked to an undisturbed function of the commissure between the thumb and the index finger or, if the index finger is missing, the middle finger. A significant contracture of the first commissure, caused by whatever genesis, inevitably results in a significant loss of function up to almost complete inability to use. The surgical treatment of the first commissure often only affects the contracted skin. In some cases, however, it requires a multi-stage approach to fascia, muscles and joints, at the end of which there is the soft tissue expansion of the interspatium between the thumb and index finger. We mention old insights on the subject, give an overview of the literature, present our own experiences based on 5 cases and - according to the severity of the contracture - make a therapy recommendation.

Reconstruction of fingers after electrical injury using lateral tarsal artery flap

Objective

Electrical injuries to the fingers account for the majority of total severe burns that occur each year. While several types of flaps have been used in covering finger defects, all have limitations or disadvantages. The purpose of this study was to introduce our clinical experiences of using the lateral tarsal artery (LTA) flap to successfully restore fingers after electrical injury.

Patients and methods

From 2005 to 2012, 10 patients with 14 severe electrical burns to their fingers, including six thumbs and four index and four middle fingers, were treated with LTA flap. The wound size ranged from 2.0×3.0 cm to 3.5×5.0 cm. The flap with free tendon graft was used to repair the tendon defect in four cases, free nerve graft was used to repair the feeling defect in two cases, and the flap with nerve was used to repair the feeling defect in two cases. All the patients were followed up for 3 months to 2 years.

Results

All skin flaps adhered successfully and there were no complications. All patients were satisfied with the esthetic appearance and functional outcome of the finger reconstruction.

Conclusion

LTA flap is a reliable method to restore fingers after severe electrical injuries.

Secondary mobilization of the first dorsal metacarpal artery flap for first web space reconstruction in a child: A case report

The authors report the case of an iterative mobilization of a skin flap based on the first dorsal metacarpal artery. This flap was initially associated with a toe-to-hand transfer to provide adequate skin coverage in the reconstruction of a post-traumatic thumb defect in a 5-year-old child. More than 8years after initial surgery, this flap was mobilized again for recovery of the first web space opening, which was retracted. This case illustrates the possibility of remobilizing the first dorsal metacarpal artery flap to reduce donor site sequelae in children.

Treatment of unfavourable results of flexor tendon surgery: Skin deficiencies

We recently reported a small study at the Federation of European Societies for Surgery of the hand, which was entitled ‘What is secondary flexor tendon surgery’? This study concluded that ‘secondary flexor tendon surgery’ was a generic name encompassing a multitude of pathologies. Between 10% and 15% of cases exhibited pathology of the skin and subcutaneous fat and required flap reconstruction of these tissues. Skin replacement may be used prophylactically at primary surgery or become necessary at secondary surgery after release of scar contractures, to achieve cover of vital structures. The long-term problem of skin deficiency relating to flexor tendon function is one of loss of extension from longitudinal scar shortening of the integument, even if the flexor tendons are primarily concerned with bending the digits, not straightening them. This loss of extension can only be tolerated in a hand to a certain degree without significant loss of function. This paper is largely an analysis of the flaps available and suitable for different degrees of skin deficiency and at different places along the course of the flexor system. It attempts to dispel the idea that ‘any flap will do’ provided the flexors are adequately covered.

Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap

BACKGROUND

To evaluate the outcome and highlight the operative tips of using the reverse posterior interosseous artery (PIA) flap in the treatment of severe contractures of the first web space.

METHODS

From 1985 to 2008, the reverse PIA flaps, which included fasciocutaneous flaps in 25 patients and composite flaps in 2 patients were used to cover skin defects over the first web space after release of severe contractures of the first web space. The severe contracture of the first web space was defined as the distance of less than 2 cm between the interphalangeal joint of the thumb and the metacarpophalangeal joint of the index. The flap dimensions varied between 6 cm and 22 cm (average, 13 cm) in length and 3 cm to 9 cm (average, 6 cm) in width. The largest flap was 22 cm × 6 cm and the smallest 6 cm × 3 cm. The length of the pedicle ranged from 2 cm to 10 cm (average, 8 cm). Skin defects of the donor site were covered by split-thickness skin grafts in 26 patients and direct closure in 1 patient.

RESULTS

Twenty-six of 27 PIA flaps survived completely except venous congestion occurred in 1 patient, which led to necrosis of the distal 1/4 flap. Skin grafts over the donor sites survived completely without complications. The follow-up period ranged from 1 month to 2 years. Lipectomy or revision was performed in two patients because of scar contractures or bulkiness. The postoperative distance of the reconstructed web space was 6 cm on average.

CONCLUSION

The reverse PIA flap is suited for defect cover in the treatment of severe contractures of the first web space. A usual pitfall using the reverse PIA flap is that the skin paddle is inadvertently outlined over the proximal 1 of 3 forearm to increase its distal reach, which usually leads to postoperative venous congestion. However, if the distal flap pole is placed at or distal to the midpoint from the lateral epicondyle to the radial side of the ulnar head, choosing the proximal 1 of 2 forearm as the donor site of the skin paddle to increase its distal reach is reliable.