Ulnar artery distal cutaneous descending branch as free flap in hand reconstruction

Subcutaneous Dorsomedial Triangle of Forearm: Surgical Anatomy and Clinical Implication

Background The purpose of the study was to provide a practical landmark for localizing the dorsal branch of the ulnar artery and nerve, to approach for microsurgical flaps, for harvesting nerve grafts and also to avoid these nerves during insertion of wrist arthroscopy portals. Material and methods Forty adult cadaveric upper limbs (20 right and 20 left) were dissected for localizing the dorsal branches of the ulnar artery and nerve. The ramification patterns of the nerve were mapped. The wrist arthroscopy portals are located radial and ulnar to the tendon of extensor carpi ulnaris at the level of the wrist joint, and their designated names are '6R & 6U', respectively. The distance of branches of the nerve from the 6U and 6R portals for wrist arthroscopy was recorded. Results The present study has delineated a subcutaneous dorsomedial triangular area in the distal forearm. The construction of this triangle uses palpable landmarks, i.e. pisiform bone, styloid process and subcutaneous border of the ulna. The measure of the sides of the triangle uses proportion rather than absolute measurements and hence is person specific. The dorsal branches of the ulnar nerve and artery are consistently given off in the triangle's upper third and middle third, respectively. Four branching patterns have been mapped, with one dominant pattern in 67.5% of limbs. In three-fourths of cases, one branch of the dorsal branch of the ulnar nerve consistently overlies the 6U portal and hence runs a higher risk of injury. Conclusion The study suggests more practical, accurate, reliable and consistent surface landmarks for the localization of the dorsal branch of the ulnar artery and nerve for reconstructive microsurgery for distal hand defects.

Flap Repair Technique for Soft Tissue Defects of the Hand

ABSTRACT

Repair for the soft tissue defects of hand has been a major challenge of hand or reconstructive surgery. A lot of flaps are used, free or pedicle flap, but there are no comprehensive description of these flaps. In this article, we retrospectively reviewed the repair technique of the fingertip defect, palmar or dorsal defect of the hand, by using different flaps in 14 cases, between June 2010 and December 2014, and the advantages and limitation of each flap are simply stated. We have shown a lot of surgical pictures, with a small amount of text, providing a wide range of ideas for the surgeon to freely choose an easy and effective method for his own technology. Overall, these approaches are simple, safe, and effective for repairing the soft tissue defect of the hand.

A Comparative Study of Finger Pulp Reconstruction Using Free Distal Ulnar Artery Perforator Flaps and Reverse Dorsal Homodigital Island Flaps

PURPOSE

This study aimed to compare and analyze the outcomes of finger reconstruction using free distal ulnar artery perforator (FDUAP) and reverse dorsal homodigital island (RDHI) flaps.

METHODS

The study included 27 patients with finger pulp defects that were reconstructed using FDUAP or RDHI flaps. Standardized assessment of outcomes included objective sensory recovery, duration of operation, range of motion in the repaired fingers, pain at the reconstructed finger pulps and donor sites, and recovery time before returning to work. Subjective assessment of outcomes included the cold intolerance, aesthetic appearance, and functional recovery.

RESULTS

All flaps in the series showed complete survival. The average surgical time for the RDHI flaps was significantly smaller than that for the FDUAP flaps. Sensory recovery was significantly better with FDUAP flaps than with RAHI flaps. No significant differences were detected between the 2 procedures regarding range of motion, cold intolerance, or pain of the injured finger pulps and donor sites. The outcomes of aesthetic result and functional recovery satisfied all patients. Optimal cosmetic satisfaction was obtained in the FDUAP flap group.

CONCLUSIONS

Although both types of flaps offer a satisfactory approach for finger reconstruction with small-to-medium defects, FDUAP flaps are more suitable for such operations because of the better sensory reconstruction and aesthetic results.

The experience of the free superficial palmar branch of the radial artery perforator flap application

PURPOSE

The purpose of this study is to retrospect and summarize clinical efficacy and experience of the free perforator flap base on the superficial palmar branch of the radial artery for tissue defect reconstruction in hand.

METHOD

17 patients who underwent tissue defect in hands reconstruction by the free superficial palmar branch of the radial artery (SPBRA) perforator flaps in our department from July 2014 to October 2018 were reviewed.

RESULTS

All the flaps in our series application were survival uneventful except one, which was necrosis because of venous thrombosis postoperative 5 days, and then the abdominal pedicle flap was executed to recover the defect in second stage. The first dorsal metacarpal artery flap and the arterial venous flap were utilized to cover the defect in one right index finger and one right ring finger due to the absence variation of the SPBRA. 2 cases presented tension vesicle of superficial skin and 1 case occurred venous congestion. All donor sites were closed primarily. The follow-up period means 13.5 months (range, 4-50 months). The static 2 point discrimination test mean 7.53 mm (range, 4-11 mm). All flaps acquire protective feeling at the latest follow-up. The self-assessment of patients: 13 cases in good, 4 cases in fair.

CONCLUSION

The goal of physiological reconstruction and esthetic effect can be achieved for hand tissue defect by the free SPBRA perforator flap, multiple tissues of the flap can be contained according to the defect. Even though the SPBRA is variation, arterial venous flap could be applied thanks to abundant superficial cutaneous veins.

Use of a distal ulnar artery perforator-based bilobed free flap for repairing complex digital defects

PURPOSE

To retrospectively evaluate the effectiveness and safety of using a distal ulnar artery perforator (DUAP)-based bilobed free flap (BFF) for the repair of complex digital defects in the hand.

METHODS

We retrospectively studied 15 patients who sustained traumatic digital defects with complicating tendon and phalanx exposure and were hospitalized for repair using a DUAP-based BFF. Main outcome measures included patients' self-assessed physical appearance, total active motion, and 2-point discrimination.

RESULTS

The flaps survived and the wounds healed with primary intention in all patients except one who experienced partial flap necrosis of the distal margin and required treatment with a second skin graft. Patients were observed for a mean of 13 months. The physical appearance and texture of the repaired fingers were assessed as good with minimal scarring. Total active motion and 2-point discrimination were 113° to 255° (contralateral, 255° to 275°) and 6 to 11 mm (contralateral, 5 to 8 mm), respectively.

CONCLUSIONS

Use of the DUAP-based BFF is a feasible, effective, and safe treatment alternative for repairing complex digital defects with favorable aesthetic and sensorimotor outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Vascular anatomy and clinical application of the free proximal ulnar artery perforator flaps

Background:

There is a dearth of detailed published work on the anatomy of ulnar artery perforators. The objective of this study was to fully document the vascular basis of the free proximal ulnar artery perforator flap and report its use in reconstruction of the hand.

Methods:

(1) The ulnar artery perforators were studied in 25 fresh cadavers and 10 cast preparations. Cadavers were injected with lead oxide for 3-dimensional reconstruction. The origin, course, and distribution of the ulnar artery perforators were comprehensively documented. (2) Between August 2011 and January 2013, 29 free proximal ulnar artery perforator flaps were utilized for reconstruction of soft-tissue defects of the hand in 25 patients. Flap size varied from 3.5 × 2.0 cm to 24.0 × 4.0 cm, with a consistent thickness of approximately 3 mm.

Results:

(1) There were 7 ± 2.0 ulnar artery perforators. The average external diameter was 0.6 ± 0.2 mm. Each perforator supplied an average area of 26 ± 7.0 cm². Extensive anastomoses were found between the ulnar artery perforators and multiple adjacent source arteries. (2) All flaps survived. The clinical results were satisfactory after 10.2 ± 5.3 months of follow-up. The flaps were considered cosmetically acceptable by both patients and doctors.

Conclusions:

The main advantage of the proximal ulnar artery perforator flap is that it is a thin flap that is ideal for upper extremity reconstruction, either as proximally or distally based local perforator flap or as a free flap. The donor site is excellent, and the vascular anatomy is very consistent.

Ulnar artery perforator free flap for finger resurfacing

INTRODUCTION

The ulnar forearm flap has been performed by many authors for the reconstruction of finger injuries. This article describes the refinement of the perforator anatomy based on ulnar artery and presents our clinical experience using ulnar artery perforator free flap for finger resurfacing.

METHODS

An anatomical study conducted in 10 cadaver forearms demonstrated the consistent origin of the ulnar perforator from the ulnar artery 40 mm proximal to the pisiform. The diameter of the artery was 0.9 mm and the average length of the perforator from the skin to the origin of ulnar artery was 20 mm. Based on this anatomic knowledge, 5 patients underwent ulnar artery perforator flap operations for finger resurfacing.

RESULTS

All flaps survived without complication, and the patients were satisfied with the aesthetic and function outcome.

DISCUSSION

The ulnar artery perforator flap is thin and pliable and provides nonhairy skin with color and texture matches. In addition, it is a simple and fast procedure with a reliable and constant blood supply. The ulnar artery perforator flap could be an alternative for the resurfacing of finger defects.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Three kinds of forearm flaps for hand skin defects: experience of 65 cases

INTRODUCTION

Reverse radial forearm flap has been proven reliable and effective for hand reconstruction. Here we report our experience with the use of reverse forearm flap that does not contain the radial or ulnar artery for reconstruction of hand defects in 65 cases with soft tissue defects of the hand.

METHOD

Sixty-five patients who sought surgical treatment for soft tissue defects of the hand at our hospital between January 2003 and December 2008 were included in the study. 39 cases had soft tissue defect on the dorsal aspect of the hand and 26 cases on the palmar aspect of the hand. 65 flaps were performed with the posterior interosseous artery flap in 26 cases, island flap supplied by the distal cutaneous branch of the ulnar artery in 23 cases, and the flap based on distally perforator of the radial artery in sixteen cases with the size of the flaps ranging from 5 to 12 cm in length and from 4 to 8 cm in width.

RESULTS

The distal cutaneous branch of the ulnar artery flap showed partial necrosis (25-35% of their area) in two cases. Both the donor and the recipient sites healed successfully in other cases. At 8.4 months of follow up, all patients had insensitivity in recipient sites. No patient complained of cold intolerance, pain, numbness and so on in the forearm and hand. According to the TAM criteria (the total active motion of the finger joint) and DASH (Disability of the Arm, Shoulder, and Hand) score showed that postoperative functions were excellent and symptoms were minor, with no significant differences among the groups (P > 0.05).

CONCLUSION

Our results indicated that the reverse forearm flap preserving the radial and ulnar artery is a reliable and effective method to cover skin defects of the hand.