Non-Vascularized Free Toe Phalanx Transfers in Congenital Hand Deformities – the Great Ormond Street Experience

Many options of varying complexity are available for the management of congenital short digits resulting from aphalangia in symbrachydactyly and constriction ring syndrome. We have used non-vascularized free toe phalanx transfers for these children when a vascularized toe transfer has been contraindicated. We describe our technique and experience with 22 children who underwent a total of 64 transfers of the proximal (35) or middle (29) toe phalanges (average 3 per child). The mean age at initial surgery was 15 months, and the mean follow-up was 5 years. Duration of time until epiphyseal closure could not be determined accurately, but total digital elongation averaged 6 mm. Complications of this technique include joint instability, premature epiphyseal closure and, in one patient, infection and graft loss. Donor site deformity was determined according to measured growth deficit and toe function. This technique is a simple option for digital elongation and, if performed in the appropriate age group in short fingered and monodactylous subtypes of symbrachydactyly, has the potential to allow growth and function with minimal donor site deficit.

Ring avulsion injuries managed with homodigital and heterodigital Venous Island Conduit (VIC) flaps

Ring avulsion injury frequently results in vascular insufficiency (venous or arterial) and soft tissue injury. We report four cases requiring revascularization where venous congestion and dorsal skin cover were achieved using a composite pedicled venous flow-through flap. We have termed this a Venous Island Conduit (VIC) Flap. Two types of flaps, homodigital and heterodigital, were used, depending on the severity of the injury. The techniques and results are discussed. Venous island conduit flaps are ideally suited to the management of ring avulsion injury and have several advantages over the alternatives.

Revascularization of an ischemic replanted thumb using a lateral arm free fascial flap

Digital ischemia and cold sensitivity after replantation are common. Occasionally they are severe enough to warrant intervention, including amputation of an otherwise functional digit. We present a patient with pregangrenous ischemia in a replanted thumb 10 years after multiple digit replantation. Angiography revealed vascular occlusion in the distal radial artery with no patent vessel in the thumb. The option of transposition of a spare neurovascular bundle from the adjacent radial digits was limited by their single-vessel supply resulting from previous replantation. We describe a method of revascularization by introduction of an arteriovenous pedicle, using a free fascial flap harvested from the lateral arm and based on terminal ramifications of the profunda brachii vessels. The flap was buried between the pulp and flexor tendon sheath and anastomosed to the radial artery and a wrist vein. This resulted in successful revascularization of the digit, clinically and radiologically, and 20 months later, the patient remains symptom free.

An epithelial cyst of the suprasellar region

A case of a 26 year old woman with increasing headaches due to a suprasellar cyst is described. Histology was consistent with an epithelial cyst with features resembling both Rathke's cleft cysts and enterogenous cysts. The differential diagnosis and treatment of suprasellar cysts is discussed.