Les traumatismes de la première commissure.Indications chirurgicales

Abstract

Treatment of the first web injuries are based on the concept of one stage repair of the complex injuries of the hand with early motion. Radical debridment is specially important in case of muscular attrition. Fasciotomie of the first web is systematic in case of crush injuries for avoiding compartimental syndrome. For prevention of first web retraction, one or two Kirchner wires are placed in emergency between first and second metacarpal, and later a split in maximal anteposition of the first ray. In case of communited fractures, skeletal stabilisation use inlay internal devices, such the blocked intramedullary nail. First web reconstruction must take into consideration the cutaneous fonctionnal units of the hand, discribed by Michon. Thin and split-thickness grafts are rarely used for covering skin defects of the first web space, because their ability of retraction. Exposition of bone or tendons leads to the realisation of a flap. Soft tissue coverage must be achieved in emergency or after a second loock within the first 48 hours. The kite flap is the most useful local flap for the first web space. The interosseous flap is the best choice among the regional pedicled flap. The use of the Chinese flap must be very careful, because the possibility of contusion of the radial pedicle in these types of injuries. It is only in case of contra-indication of the interosseous flap that free flaps can be realised, as the lateral arm flap or the parascapular flap. The groin flap keeps few indications for aesthetic reasons, or when regional flaps and microsurgery are contra-indicated.