Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers

Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results

PURPOSE

Although the palm is spared mostly in severe burn injuries, it often is affected in children and requires radical excision of contracting scar tissue to allow normal hand development. Since alternatives are limited for palmar coverage, we primarily use a reverse-perfused, neurocutaneous dorsal ulnar artery flap. We report here our long-term follow-up results.

METHODS

We reviewed the long-term results of 10 postburn palmar contracture release and flap coverage procedures in 10 children. The applied flap was based distally on the dorsal branch of the ulnar artery and harvested along the ulnar aspect of the hand and wrist. The pivot point of the flap was located dorsally, close to the 4th and 5th metacarpal base. Patients were followed for a median period of 6 years (range, 4-20 years).

RESULTS

Flap size ranged from 60-130 mm in length and 20-35 mm in width. This variation in flap dimensions resulted from different hand sizes, because of the various patient ages at surgery. All flaps survived, donor site healing was uneventful, and marginal flap necrosis occurred only once. Satisfactory restoration of range of motion without secondary contractures was observed. Moreover, we detected adequate progressive growth, adaptability and sensory recovery in all flaps. Over time, the flaps mostly become hairless and progressively flattened without debulking.

CONCLUSIONS

The importance of this flap lies in the potential for considerable tissue mobilization to cover palmar defects without sacrificing any major vascular axis. The adequate progressive growth of the flap facilitates functional hand development in children. The predictable vascular anatomy, wide range, and durable, thin, and pliable skin make the reverse neurocutaneous dorsal ulnar artery flap an appealing option for soft tissue reconstruction of the palm in children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

A different option in vascular bone grafts in the hand and wrist region: Use of a dorsoulnar artery-based osteo-fascio-cutaneous flap: A case series

Objectives

This study aims to describe our surgery technique and discuss patients treated through the dorsoulnar artery (DUA)-based technique of osseous and osteo-fascio-cutaneous vascularized ulnar bone grafting.

Patients and methods

Between January 2011 and January 2015, six male patients (median age: 22.5 years; range, 20 to 24 years) who underwent surgery during which the technique of DUA ulnar bone graft was utilized. One patient with scaphoid nonunion, three patients with Kienböck’s disease, and two patients with a traumatic metacarpal defect were retrospectively evaluated. The joint range of motion (ROM), grip strength, Disabilities of the arm, shoulder and Hand (DASH) questionnaire score and Visual Analog Scale (VAS) score, and radiographies before and after surgery were examined. Scintigraphy was performed at 12 weeks postoperatively to monitor the viability of the bone graft.

Results

All patients showed improvements in the ROM, grip strength, VAS, and DASH scores. According to the radiographic examination, bone union was achieved in all patients and the scintigraphy revealed that vascularization was detected in the bone tissue.

Conclusion

The advantages of DUA-based vascularized bone graft are good bone quality and quantity and versatility due to its long pedicle. The osteo-fasio-cutaneous DUA flap seems to be effective in the treatment of traumatic metacarpal bone defects accompanied by skin loss. The DUA-based vascularized ulnar bone may be a source for scaphoid and lunate biological bone reconstruction.

The reconstruction of the mutilated hand

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

The use of reverse-flow dorsal metacarpal artery flaps after postburn metacarpophalangeal joint flexion contracture release

When thermal injuries of the hand are managed inappropriately, complex hand contractures are inevitable. Patients with hand contractures may have many difficulties in their daily life because of this deformity. These patients are challenging to reconstructive surgeons. In this study we evaluated reverse-flow dorsal metacarpal artery flaps for the defects occurred after metacarpophalangeal joint contracture release of different fingers. Nineteen patients with defects on the volar surface of metacarpophalangeal joint were reconstructed by the reverse-flow dorsal metacarpal artery flaps. All operations were successful and flap losses were not seen. The DMCA flaps provide one stage coverage and permit primary closure of the recipient site. The aesthetic and functional results are satisfactory without sacrificing main arteries. The only drawback is the residual scar on the dorsum of the hand, which can be treated by conservative means and may improve over time.

Versatility of the reverse dorsoulnar fasciocutaneous flap in coverage of hand defects: clinical experience with 36 cases

PURPOSE

Local flap reconstruction is often required for soft tissue defects of the hand. The optimal reconstruction method should provide thin, supple, well-vascularized tissue with minimal donor-site morbidity. Short operating time and a sizable pedicle for microsurgical anastomosis are helpful. In this study, outcomes of hand defects after reconstruction with a reverse dorsoulnar flap were retrospectively analyzed.

METHODS

Between 2001 and 2008, 36 patients were evaluated (28 men, 8 women). Twenty-seven pedicle flaps and 9 free flaps were used. Nineteen patients had flexion contractures in their palms and fingers after burn injuries, 14 patients had traumatic soft tissue loss, and 3 patients had defects after tumor exicision. In 26 cases the defects were on the palm site, and in 10 cases the defects were on the dorsum of the hand. Mean follow-up was 12 months.

RESULTS

The success rate was 100%, with satisfactory cosmetic results. Functional recovery of the hands showed good results as well as acceptable donor healing without complication.

CONCLUSIONS

The dorsoulnar flap as either pedicle or free flap provides good and reliable skin cover for substantial soft tissue defects on the palm, dorsum of the hand, and the fingers.

Contractures in burn injury part II: investigating joints of the hand

This study prospectively examines the incidence and severity of hand contractures after burn injury and determines predictors of contracture development. Data were collected prospectively from 1993 to 2002 for adult burn survivors admitted to a regional burn center. Demographic and medical data were collected on each subject. Primary outcome measures include presence of contractures, number of contractures, and the severity of contractures at each of the hand joints at hospital discharge. The metacarpal-phalangeal, proximal inter-phalangeal (PIP), and distal inter-phalangeal joints of all digits and the wrist joints are included in this study. Regression analysis was performed to determine predictors of the presence, severity, and number of contractures. Of the 985 study patients, 23% demonstrated at least one hand contracture at hospital discharge. Those with a contracture averaged ten contractures per person. Most contractures were mild (48%) or moderate (41%) in severity. The wrist was the most frequently affected joint (22%). Statistically significant predictors of contracture development include concomitant medical problems, total body surface area grafted and presence of hand burn and hand grafting (P < .05). Predictors of the number of contractures include length of stay, concomitant medical problems, burn size and presence of hand burn and grafting (P < .05). Contractures of the hand are a significant complication of burn injury. Clinicians can use the contracture predictors to help target interventions for those patients most at risk of developing hand contractures. Given the functional importance of the hand in daily living, the burn care community is challenged to find new ways of preventing and treating hand contractures.