Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique

Repair of distal thumb degloving injury using combination of reverse dorsoradial flap of the thumb and middle finger proper digital arterial island flap

BACKGROUND

To examine the efficacy of combination of the reverse dorsoradial flap of the thumb and middle finger proper digital arterial island flap for repair of distal thumb degloving injury.

METHODS

Twelve patients with mechanical distal thumb degloving injuries were treated between February 2017 and August 2019. A combination of the reverse dorsoradial flap of the thumb and the middle finger proper digital arterial island flap were used. Semmes-Weinstein (SW) monofilament and static two-point discrimination (S-2PD) tests, active range-of-motion (ROM) of the joints, cold intolerance, visual analog scale (VAS) score patient complications, and patient satisfaction were sequentially evaluated.

RESULTS

Two cases with postoperative flap blisters were treated at time of dressing changes up to successful scab formation. One case with postoperative arterial crisis of finger arterial dorsal branch vessel was successfully released in the pedicle. Ten cases healed by first intention and 2 cases by secondary intention. Twelve patients received follow-up examinations between 3 and 20 months (average 13 months) post-treatment, and all exhibited full, soft flaps with no fingertip pain.

CONCLUSION

The combined use of the reverse dorsoradial flap of the thumb and the middle finger proper digital arterial island flap is a practical and effective approach to surgical repair of distal thumb degloving injuries.

Techniques and survival incidence for revascularization of degloved fingers

We report techniques and survival incidence of three subtotally and nine completely degloved fingers in seven patients. We performed end-to-end arterial repairs in seven fingers, vein graft repairs for arteries in two fingers, arteriovenous anastomoses in three fingers. End-to-end vein anastomosis was performed in all fingers. One finger requred re-exploration. Soft tissues in the eight degloved fingers survived completely, two failed completely, and two were partially necrotic. We conclude from our results that following revascularization, the skin from a completely degloved finger skin will survive in approximately two cases out of three.

LEVEL OF EVIDENCE

IV.

Anatomical Analysis of Cutaneous Perforator Distribution in the Forearm

Background:

Few reports describe the distribution of cutaneous perforators from the radial and ulnar arteries in the forearm. This study aimed to map the location of the cutaneous perforators that arise directly from the radial and ulnar arteries in cadavers.

Methods:

Twenty-nine human cadaveric forearms were dissected. All radial and ulnar arteries cutaneous perforators were analyzed for total number and distribution. To define the distribution of each cutaneous perforator, the forearm was divided into 10 sections, with the sections labeled as 10%, 20%, 30%, and so on, beginning at the wrist.

Results:

From the radial artery, there were a total of 262 skin perforators with an average of 9.03 ± 2.28 (mean ± SD) per limb, whereas the total was 159 from the ulnar artery, with an average of 5.48 ± 1.49 per limb. Additionally, 128 (49%) radial artery cutaneous perforators and 75 (47%) from the ulnar artery were concentrated in the 0–30% section of the forearm. Both the radial and ulnar arteries had many cutaneous perforators in the forearm section labeled 70%, with 32 of 262 (12%) cutaneous perforators of the radial artery and 27 of 159 (17%) cutaneous perforators of the ulnar artery located here.

Conclusions:

There were more cutaneous perforators from the radial artery than from the ulnar artery, and both were concentrated in the distal one-third of the forearm and in the forearm section labeled 70%. This information could be helpful when harvesting forearm flaps.

[Ring finger reconstruction by Colson's flap]

Surgical treatment of complete cutaneous ring finger avulsion is a challenge in hand surgery. When replantation of the avulsed fragment is not technically feasible, the surgeon must consider reconstruction of soft tissue. Many surgical techniques have been described. We report a case of complete avulsion of the cutaneous sheath and nail of the fourth finger with preservation of mobility and collateral nerves. The reconstruction of soft tissue was performed by a Colson flap-graft. This simple and reliable technique of reconstruction allowed to obtain a functional and sensitive finger with a satisfactory cosmetic result.

Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap

BACKGROUND

Our aim was to summarize the treatment of degloving injury involving multiple fingers using combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap.

PATIENTS AND METHODS

Each degloved finger was debrided under microscopic guidance and embedded in the superficial layer of the abdominal fascia. The abdominal skin was sutured to the skin on the back and side of the hand to promote circumferential healing. After removal, the only remaining injured region was on the flexor surface, and this was repaired by multiple dorsal toe flaps, toe-web flaps, and dorsalis pedis flaps to provide blood vessels and sensory nerves. All fingers had proper flap thickness 3-6 months after surgery, and required only lateral Z-plasty modification with web deepening and widening to narrow the fingers and extend their relative length.

RESULTS

We completed flap-graft and finger narrowing for 25 fingers in eight patients. Abdominal skin flaps and dorsal toe flaps were grafted, and resulted in both firmness and softness, providing finger flexibility. The dorsal toe flap provided good blood circulation and sensory nerves, and was used to cover the finger-flexor surface to regain sensation and stability when holding objects. During the 1-8 years of follow-up, sensation on the finger-flexor side recovered to the S3-4 level, and patient satisfaction based on the Michigan Hand Outcomes Questionnaire was 4-5. Flap ulcers or bone/tendon necrosis were not observed.

CONCLUSION

Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap was effective and reliable.

Repair of a degloving injury of the thumb with a combined dorsal great toenail flap and dorsalis pedis flap: a case report

Many methods for the repair of degloving injuries of the thumb have been reported, but none are entirely satisfactory. Herein, we report a method in which the injury is divided into the dorsal and palmar area for repair. A great toenail flap is used to repair the dorsal injury to restore the nail defect, and a dorsalis pedis flap is used to repair the palmar injury. The described technique provides good restoration of morphology and aesthetic outcome, good functional and sensory recovery, and is associated with minimal donor-site morbidity.

Results of replantation of 33 ring avulsion amputations

PURPOSE

Despite microsurgical advances, it is still difficult to achieve satisfactory functional results in cases of replantations following complete ring avulsion amputations. Our aim is to report the experience we have collected since the early 1990s in the treatment of this type of injury.

METHODS

We replanted 33 fingers on 33 patients (age, 15-54 y) with complete ring avulsion amputation injuries. Twenty-eight amputations were distal to the insertion of the flexor digitorum superficialis, and 5 were complete degloving injuries with intact tendons. Vascular transpositions and vein grafts were used, and in all cases, only 1 of the digital nerves was repaired.

RESULTS

The 29 successful cases were tracked over an average follow-up of 89 months. The average total active motion of the reconstructed finger was 185°. Sensibility evaluated by static 2-point discrimination varied from 9 to 15 mm and by moving 2-point discrimination from 8 to 15 mm. Five patients complained of cold intolerance.

CONCLUSIONS

Resection of the avulsed digital artery and vein is the most crucial part of the procedure.Vessels reconstruction can be performed using various methods, but vessel transfers from the middle finger appear to be the most reliable solution. The outcome of the cases demonstrates that replantation should be attempted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.