Dorsal Digital Nerve Research Articles

A novel nerve block technique for nail surgery.

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Chirurgie percutanée de l’hallux valgus : étude anatomique de son innocuité et de son efficacité

Background and hypothesisAlthough percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies. Patients and methodsTwenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified. ResultsThe medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet. ConclusionsThe structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures. Level of evidenceV, Cadaveric study.

Reverse homodigital dorsal wraparound flap for reconstruction of distal thumb

Reconstruction of degloving injury or amputation of distal thumb with no indication of replantation has always been a challenging problem for hand surgeons. In this study, a reverse homodigital dorsal wraparound flap innervated by the dorsal digital nerve was devised to repair degloving injury or amputation of distal thumb in 20 consecutive cases. In nine cases of thumb amputation, we skeletonized the phalanxes of the amputated part as a free cortical bone with Kirschner wires. All flaps survived uneventfully. The radiographs showed bone healing in all the patients of thumb amputation within 6 weeks postoperatively. At final follow-up, the appearance of the reconstructed thumb was acceptable and flap sensation and range of joint motion were satisfactory. This flap is a simple and reliable alternative method for degloving injury or amputation of distal thumb when replantation is impossible and patients refuse to donate tissues from toes. Type of study/level of evidence Therapeutic IV.

Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness

Background and hypothesisAlthough percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies. Patients and methodsTwenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified. ResultsThe medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet. ConclusionsThe structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures. Level of evidenceV, Cadaveric study.

First dorsal metacarpal artery flap with dorsal digital nerve with or without dorsal branch of the proper digital nerve produces comparable short-term sensory outcomes

BackgroundThe first dorsal metacarpal artery flap, including dorsal digital nerves with or without dorsal branches of the proper digital nerves, can be used to reconstruct thumb pulp defects with good results. However, it is still unclear whether there are differences in the sensory outcomes between preserving or not preserving the dorsal branches of the proper digital nerves.MethodsThis retrospective cohort study included 137 thumb pulp defect patients who underwent first dorsal metacarpal artery flap reconstruction procedure from October 2015 to June 2019. Patients were divided into two groups according to whether the dorsal branches of the proper digital nerves were preserved. In the non-preservation group (n = 80), the dorsal digital nerves were included in the flap for sensory reconstruction. In the preservation group (n = 57), the dorsal digital nerves and the dorsal branches of the proper digital nerves of the index finger were included in the flap. The stump of the proper digital nerves in the defect was coaptated to the donor nerves of the flap using the end-to-end fashion. At the last follow-up, static two-point discrimination, Semmes–Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction in both groups were compared.ResultsAll patients were followed up for at least 17 months. No significant differences were found regarding pain of thumb pulp, static two-point discrimination, Semmes–Weinstein monofilament score, cold intolerance in the injured finger, and patient satisfaction. The non-preservation group presented slightly shorter operative times (p < 0.05).ConclusionThere are no differences at 2 years in postoperative clinical outcomes when dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves in the first dorsal metacarpal artery flap.Level of evidence: Level III, retrospective comparative study.

Regional anaesthesia on the finger: Traditional dorsal digital nerve block versus subcutaneous volar nerve block, a randomized controlled trial

To identify the most comfortable digital nerve block by comparing painfulness and efficiency of two commonly used digital nerve blocks: the volar subcutaneous nerve block and the traditional dorsal nerve block. Patients, age ≥ 18 years, presenting with an injury of the finger requiring regional anaesthesia were included. Patients were blindly randomized in receiving the one-injection subcutaneous volar nerve block (intervention group) or the two-injection traditional dorsal digital nerve block (control group). Primary outcome measure was discomfort of the injection. Secondary outcome measures were extent of anaesthesia in different regions of the finger, complication rate and satisfaction of the clinician. In total, 409 patients were randomly allocated to the intervention group (N=209) or control group (N=200). Discomfort of the injection was not different between both anaesthetic techniques. The mean pain score (Numerical Rating Scale - NRS) of the intervention group was 4.57 (range 0 - 9, CI 4.27 - 4.87, SD 2.18). The mean pain scores of the control group were 4.63 for the first injection (range 0 - 10; CI 4.28 - 4.99, SD 2.36) and 4.51 for the second injection (range 0 - 10; CI 4.14 - 4.87, SD 2.44). The traditional dorsal digital nerve block was better in anesthetizing the dorsal side of the finger. The subcutaneous volar nerve block was better or equivalent in terms of extent of anaesthesia on the volar side of the finger. In patients requiring digital anaesthesia in the Emergency Department, the anaesthetic technique affects both the discomfort of the injection and extent of anaesthesia. The traditional dorsal digital nerve block is preferred for dorsal injuries. The subcutaneous volar nerve block is preferred for volar injuries.

Effects of three kinds of proximal pedicled flaps of hand for relaying repair of degloving injuries of fingertips and the soft tissue defects in the donor sites

Objective: To investigate the effects of the dorsal branch of digital artery pedicled flap combined with V-Y advancement flap for repair of degloving injury of fingertip and reverse dorsal metacarpal recurrent artery pedicled island flap for relaying repair of the soft tissue defects in the donor sites of the proximal dorsum. Methods: A total of 21 patients with degloving injuries of fingertips at the 2nd to 5th fingers were hospitalized in the Department of Hand Surgery of the Second Hospital of Tangshan from June 2016 to January 2019, including 14 males and 7 females aged 24-60 years. The retrospective clinical follow-up study was conducted. The areas of wounds after debridement ranged from 2.0 cm×1.5 cm to 3.5 cm×2.2 cm. The dorsal branch of digital artery pedicled flaps with dorsal branch of the proper digital nerve and dorsal digital nerve were designed in the proximal dorsum of the affected fingers to repair dorsal wounds in the distal dorsum of the affected fingers, and the sizes of the flaps ranged from 1.6 cm×1.5 cm to 2.6 cm×2.4 cm. The V-Y advancement flaps in the palmar side of the affected fingers were designed to repair palmar wounds in the distal segment of the affected fingers, and the sizes of the flaps ranged from 0.8 cm×0.6 cm to 2.0 cm×1.5 cm. The reverse dorsal metacarpal recurrent artery pedicled island flaps were used to repair the soft tissue defects in the donor sites of proximal dorsum, the sizes of the flaps ranged from 1.8 cm×1.7 cm to 2.8 cm×2.6 cm, and the donor sites of the flaps in back of hand were sutured directly. The survivals after the operation and the blood supply and appearance during follow-up of the three flaps were observed. At the final follow-up, the static two-point discrimination distance of the three flaps was measured, the satisfaction degree of patients for the appearance of hand was evaluated based on Michigan Hand Function Questionnaire, and the total active range of motion of the injured finger joints was assessed by the trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association. Results: All the flaps survived after operation. Tension blisters appeared on the surface of one dorsal branch of digital artery pedicled flap, and the wound healed after removing the stitch at the pedicle and changing dressings. During follow-up of 6-20 months, with an average of 12 months, the three kinds of flaps had good appearance, soft texture, and similar color with surrounding tissue, and with only linear scars in donor sites of the dorsal hand. At the final follow-up, the static two-point discrimination distances of V-Y advancement flaps, dorsal branch of digital artery pedicled flaps, and reverse dorsal metacarpal recurrent artery pedicled island flaps were 4-7 mm, 5-10 mm, and 8-15 mm, respectively. Sixteen patients were strongly satisfied with the appearance of hand, and the remaining five patients were satisfied with the appearance of hand. The total active range of motion of the injured finger joints was evaluated as excellent in 17 cases, good in 4 cases. Conclusions: The operation is simple and reliable for dorsal branch of digital artery pedicled flap combined with V-Y advancement flap to repair the degloving injury of fingertip, and reverse dorsal metacarpal recurrent artery pedicled island flaps to repair the soft tissue defects in the donor sites of the proximal dorsum, and the appearance and function of the affected fingers recover well, with minimal injury.

Effect of venous anastomosis of the pedicled digital artery dorsal branch island flap in repairing fingertip or pulp defects of the same finger

Objective: To explore the effect of venous anastomosis of the pedicled digital artery dorsal branch island flap in repairing fingertip or pulp defects of the same finger. Methods: From February 2016 to September 2018, a total of 56 emergency cases (67 fingers) with fingertip or pulp defects in 2-5 fingers were admitted to the Second Hospital of Tangshan (hereinafter referred to as the author's affiliation), and the prospective research was conducted. The patients were divided into venous anastomosis group of 29 cases (35 fingers) and non-venous anastomosis group of 27 cases (32 fingers) by drawing lots. There were 18 males and 11 females in venous anastomosis group, aged 17 to 62 years, with wound area of 1.6 cm×1.3 cm-3.1 cm×2.4 cm after debridement. There were 17 males and 10 females in non-venous anastomosis group, aged 20 to 59 years, with wound area of 1.7 cm×1.2 cm-3.0 cm×2.4 cm after debridement. According to the location and size of the fingertip or pulp defect of patients in the two groups, the flap was designed on the dorsum of the middle or proximal phalanx of the injured finger. During the operation, the epineurium of dorsal branch of the proper digital nerve or the dorsal digital nerve carried by the flap was anastomosed end-to-end with the stump of proper digital nerve in the wound. One or two superficial vein (s) carried by the flap was/were interrupted end-to-end anastomosed with the superficial veins on the dorsum or palm of the wound surface in venous anastomosis group, and the venous anastomosis was not performed in non-venous anastomosis group. The flap size resected ranged from 1.8 cm×1.5 cm to 3.4 cm×2.6 cm in venous anastomosis group, and that ranged from 1.9 cm×1.4 cm to 3.3 cm×2.6 cm in non-venous anastomosis group. The donor site wounds in the two groups were resurfaced by free full-thickness skin graft harvested from the proximal forearm or the medial side of the upper arm. The blood circulation of the flap of patients in 2 groups was observed after operation. During follow-up after operation, the patients' satisfaction for the appearance of the flap was evaluated by Michigan Hand Function Questionnaire, the flap color was observed by the chief physician of the Department of Hand Surgery in the author's affiliation, and the incidence of flap pigmentation was calculated. Data were statistically analyzed with t test and chi-square test. Results: All the flaps of patients survived without tension blister in venous anastomosis group after operation. Tension blisters occurred in 6 cases (6 fingers) in non-venous anastomosis group due to venous reflux obstruction, and the flaps survived after removing some sutures of the pedicle and changing dressing. During follow-up of 8-20 months, with an average of 15 months, the patients' satisfaction score for flap appearance in venous anastomosis group was (4.6±0.5) points, which was obviously higher than (4.3±0.6) points of non-venous anastomosis group (t=2.482, P<0.05). The incidence of flap pigmentation in venous anastomosis group was 9% (3/35), which was significantly lower than 31% (10/32) of non-venous anastomosis group (χ(2)=5.498, P<0.05). Conclusions: The pedicled digital artery dorsal branch island flap with venous anastomosis repairs the same fingertip or pulp defects, resulting in unobstructed venous reflux, low incidence of flap pigmentation, good appearance and high patient satisfaction.

Finger Pain In A Professional Dog Groomer

HISTORY: A 36-year-old right-handed female professional dog groomer with past medical history of PCOS, presents with a chief complaint of left hand digit 3 and 4 fingertip pain. She reports progressive discomfort for the past 10 months, worsened with tactile touch especially during work, and mildly improves with rest. Describes the pain as sharp electrical sensations rated 10/10 on pain scale, sensitive to cold weather. Outside facility workup included normal hand x-rays, cervical x-rays and a hand MRI. Electrodiagnostic/nerve conduction studies demonstrated mild carpal tunnel syndrome on the left without radiculopathy, for which she has tried a neutral wrist splint without improvement. She has been seen by her PCP, rheumatology, neurology, endocrinology, and orthopedic surgery, all without a confirmatory diagnosis. Her pain is now debilitating and thus she presents to Stanford for a 6th opinion. EXAM: On inspection no swelling or discoloration. Severe tenderness with light touch of digit 3 at the eponychial fold, ulnar side. Limited active and passive digit 3 DIP flexion due to pain. Sensation decreased in dorsal digital median nerve branch digits 3 and 4. Remaining strength and sensation in the hand intact. Phalen’s test at the wrist positive while tinel’s was negative. Spurling’s negative. DIFFERENTIAL: 1. Median or Palmar Digital Branch Mononeuropathy. 2. C7 Radiculopathy 3. Digital Collateral Ligament Injury 4. Tumor 5. Complex Regional Pain Syndrome 6. Mallet Finger 7. Raynaud’s Phenomenon RESULTS: Point-of-care ultrasound significant for digit 3 solitary hypoechoic lesion with clear boundaries and regular shape, and internal abundant hyperemia. Finger MRI showed 4 x 3 x 3 mm circumscribed T1 hypointense T2 hyperintense, enhancing lesion at dorsal aspect of the third distal phalanx. DIAGNOSIS: Glomus Tumor OUTCOME: Initiation of gabapentin, lidocaine cream for symptomatic relief and referral to orthopedics for definitive treatment with plans for left middle finger glomus tumor excision. The patient is currently pending surgery at the time of this submission, additional follow-up to be presented.

Clinical efficacy of dorsal digital nerve fasciocutaneous pedicle flap with superficial vein anastomosis in repair of the type III and type IV of fingertip defects

Objective To analysis the clinical efficacy of dorsal digital nerves fasciocutaneous pedicle flap (DDNFPF) with superficial vein anastomosis in the treatment of the type III and type IV of fingertip defect, and the relationship between the incidence of vein crisis and superficial vein anastomosis. Methods A total of 85 patients with 92 fingers, treated by DDNFPF from February, 2017 to December, 2018, were retrospectively analyzed. The superficial veins of 30 patients with 32 fingers were anastomosed, and 55 patients with 60 fingers were not. The difference of the superior rate and the incidence of venous crisis between superficial vein anastomosis and non-superficial vein anastomosis was compared by Chi-square test. The difference was considered as statistically significant when P<0.05. The regular postoperative followed-up was performed. Results The average followed-up time was (7.0±2.9) months. The incidence of venous crisis in anastomosis group (1/32) was lower than that in non-anastomosis group (13/60). The difference was statistically significant (χ2=4.217, P 0.05) . The repaired fingertips of the 2 groups were in good appearance, wear-resistant, stable holders and two-point discrimination was 5 to 8 mm. Conclusion DDNFPF for the type III and IV type of fingertip defect is safe and effective. A anastomosis of superficial veins in recipient area can significantly reduce the incidence of venous crisis. Key words: Dorsal digital nerve fasciocutaneous pedicle flap; Fingertip defects; Superficial vein anastomosis; Venous crisis

Application of V-Y advancement flap pedicled with dorsal cutaneous branch of digital artery with sensory nerve for repair of middle and distal dorsal finger defects

Objective To investigate the surgical method and clinical efficacy of V-Y advancement flap pedicled with dorsal cutaneous branch of digital artery with sensory nerve for repair of middle and distal dorsal finger defects. Methods From September 2016 to August 2017, proximal or middle segment flaps with dorsal perforator branches of the proper digital artery were harvested. The flaps carried 1 to 2 dorsal digital nerves and/or dorsal branches of one dorsal digital proper nerve. The proximal end of the flaps was designed as V-Y shape. Eight patients with middle and distal dorsal finger defects were repaired by distal advancement. The area of dorsal finger skin defects ranged from 0.5 cm×1.3 cm to 2.0 cm×1.7 cm. All the patients underwent one-stage emergency operation, and the donor sites of the flaps were sutured directly. The area of the flaps ranged from 2.0 cm×1.8 cm to 4.5 cm×1.7 cm. Results All the wounds achieved primary healing and the flaps survived well. The period of follow-up ranged from 3 to 9 months with an average of 4 months. The interphalangeal joint activity was normal and the sensation of dorsal finger flap recovered to S3+. Conclusion The V-Y advancement flap pedicled with dorsal cutaneous branch of digital artery with sensory nerve can obtain satisfactory function and shape for repairing the skin defects of the dorsal middle and distal segments of finger with sensory recovery. The operation is simple and the donor site can be closed directly. It is a good method to repair the dorsal finger defects. Key words: Finger injuries; Surgical flaps; Dorsal branch of digital artery; Dorsal finger defects

Application of modified digital artery island flap for repair of the middle and distal segment wounds of the same finger

Objective To investigate the clinical outcomes of modified digital artery island flap pedicled with metaphysis branch of the middle phalanx for repair of the middle and distal segment wounds of the same finger with the second palmar anastomotic branch injury. Methods From August 2014 to March 2017, 11 cases of soft tissue defects with the second palmar anastomotic branch injury were treated with modified digital artery island flap pedicled with metaphysis branch of the middle phalanx. The dorsal digital nerve of the flap was sutured to the contralateral digital nerve to restore flap sensation. The donor site was covered with free skin graft. Results All the flaps and skin graft survived completely. All the patients were follow-up from 6 to18 months. The flaps had good appearance and supple texture. The two-point discrimination was 7 to 11 mm. The Cold Intolerance Severity Score (CISS) ranged from 5 to 39 with an average of 21. Ten fingers had mild cold intolerance, while 1 finger had moderate cold intolerance. According to the upper extremity function evaluation criteria issued by the Hand Surgery Society of the Chinese Medical Association, the results were rated as excellent in 8 cases, good in 2 cases, and fair in 1 case. Conclusion The application of modified digital artery island flap pedicled with metaphysis branch of the middle phalanx is a simple method with satisfactory sensory recovery and reliable blood supply for repair of the middle and distal segment wounds of the same finger with the second palmar anastomotic branch injury. Key words: Finger injuries; Surgical flaps; Treatment outcome; Proper digital artery

Clinical application of web-space artery perforator and dorsal branch of the proper digital artery network flap for repair of finger pulp defects

Objective To evaluate the clinical efficacy of web-space artery perforator and dorsal branch of the proper digital artery network flap in the treatment of finger pulp defects. Methods From January 2015 to May 2017, 30 cases (36 fingers) of finger pulp defects were treated by web-space artery perforator and dorsal branch of the proper digital artery network flap. The nerve stump and dorsal digital nerve were sutured to reconstruct the flap sensation. The area of finger pulp defects ranged from 1.1 cm×0.8 cm to 2.3 cm×4.0 cm. The donor site was sutured directly or covered with skin graft. Results After the operation, tension vesicles appeared at the distal end of the flap in 3 cases which achieved secondary healing after dressing changes and flaps edge bleeding. Partial skin flap necrosis and scab occurred in 1 case that achieved healing after the decrustation. The rest of the flaps achieved primary healing. All the patients were follow-up for 3 to 24 months with an average of 16.8 months. The texture of skin flap was soft with satisfactory appearance. The skin flap recovered pain and temperature sensation 2 months after operation. And 3 months after the operation, the tactile sensation was restored. The two-point discrimination was recovered at 6 months after operation, with an average of 7.5 mm and an average of 6.2 mm at 12 months postoperatively. The total active movement (TAM) achieved 105° to 230° with an average of 204.6°. The results were graded as excellent in 22 fingers, good in 11 fingers, fair in 2 fingers, and poor in 1 finger with an excellent and good rate of 91.7%. Conclusion Compared with the traditional digital artery island flap, the island flap of web-space artery perforator and dorsal branch of the proper digital artery is used to repair the defects of the finger pulp, lengthening the length of the pedicle and enlarging the indication of the operation. The operation is simple and safe. It is a better method to repair the defect of the finger pulp. Key words: Finger injuries; Surgical flaps; Web-space artery perforator; Dorsal branch of the proper digital artery

Clinical application of dorsal digital nerve fasciocutaneous flap with superficial vein anastomosis for repair of fingertip defects

Objective To investigate the clinical efficacy of dorsal digital nerves fasciocutaneous flap with superficial vein anastomosis in the treatment of fingertip defects. Methods From January 2016 to February 2017, 25 cases (25 fingers) of fingertip defects were treated with proximal dorsal digital nerve fasciocutaneous flap. After the flap was transferred to cover the wound, the stump of a superficial vein retained at the proximal end of the flap was anastomosed to the stump of fingertip subcutaneous vein for reconstruction of flap venous circulation. Results All the flaps survived uneventfully. The appearance of flaps was good without blisters and purple skin 2 weeks after operation. The postoperative follow-up time ranged from 6 to 8 months with an average of 6.5 months. The flap had good appearance, no obvious bulky shape and soft texture. Some flaps had pigmentation. The skin pain and temperature sensation were restored. The joints of the fingers were in good motion. All the skin grafts survived. Conclusion The dorsal digital nerve fasciocutaneous flap with superficial vein anastomosis for repair of fingertip defects overcomes the shortcomings of the traditional flap with poor backflow, and the survival of the flap is effectively guaranteed. Key words: Surgical flaps; Treatment outcome; Fingertip defects; Fascial pedicle; Superficial vein anastomosis

TOE FIBULAR-DORSAL ARTERY FLAP ANASTOMOSED TO DORSAL DIGITAL ARTERY IN REPAIRING DORSAL SOFT TISSUE DEFECT OF FINGERS

To discuss the effectiveness of free toe fibular-dorsal artery flap anastomosed to dorsal digital artery in repairing dorsal soft tissue defect of fingers. Between May 2010 and September 2015, 28 patients with dorsal soft tissue defect of fingers were treated, including 17 males and 11 females with an average age of 23.8 years (range, 15-55 years). The reasons of injuries were machine twist (15 cases), heavy pound (4 cases), the sharp cut (5 cases), and hot crush (4 cases). The time from injury to admission was 30 minutes to 12 hours (mean, 1.5 hours). The involved fingers included thumb (3 cases), index finger (8 cases), middle finger (6 cases), ring finger (6 cases), and little finger (5 cases). The area of soft?tissue?defects ranged from 2.0 cm×1.5 cm to 3.5 cm×2.5 cm, and the area of free toe fibular-dorsal artery flap ranged from 2.8 cm×1.7 cm to 3.8 cm×2.8 cm. The blood supply of the flaps were reconstructed by anastomosing the toe fibular-dorsal artery, vein, and nerve to the dorsal digital artery, vein, and nerve, respectively. The donor site was repaired by free skin graft. The operation time was 1.5-5.5 hours (mean, 2.5 hours); the blood loss during operation was 10-50 mL (mean, 30 mL). Vessel?crisis?occurred?in?1 case, and the flap survived after symptomatic treatment. The other flaps survived and the wounds healed with stage I; the skin grafts at donor site survived and the incisions healed with stage Ⅰ. Twenty-eight cases were followed up 6-24 months (mean, 8 months). The appearance of flaps was good, and two-point discrimination was 3.5-12.0 mm (mean, 5.3 mm) at 6 months after operation. The fingers function of grab and pinch recovered. According to the standard functional evaluation issued by Hand Surgery Association of Chinese Medical Association, the results were excellent in 20 cases and good in 8 cases, with an excellent and good rate of 100% at 6 months after operation. The donor sites of toe were smooth and had no depression. The patients had normal gait. Free toe fibular-dorsal artery flap anastomosed to dorsal digital artery in repairing dorsal soft tissue defect of fingers can obtain satisfactory effectiveness in appearance and function of fingers, and has the advantages of modified repair and less injury at donor site.

Anatomical study of the dorsal cutaneous branch of the ulnar nerve (DCBUN) and its clinical relevance in TFCC repair

The aim of this study was to define a detailed description of the dorsal cutaneous branch of the ulnar nerve (DCBUN) in particular in relevance to triangular fibrocartilage complex (TFCC) repairs. In 20 formalin-embalmed arms, the DCBUN was dissected, and the course in each arm was mapped and categorized. Furthermore, the point of origin of the DCBUN, that is, from the ulnar nerve in association with the ulnar styloid process, was defined. Finally, the distance between the ulnar styloid process and the branching of the radial-ulnar communicating branch (RUCB) and the first branch of DCBUN was measured. The distance between the origin of the DCBUN in relation to the ulnar styloid process ranges from 55 to 111mm (mean 87mm; STD 14mm). The distance between the ulnar styloid process and the RUCB ranges from 1 to 54mm (mean 19mm; STD 12mm). Finally, the distance between the ulnar styloid process and the lateral distal branch shows a range of -6 to 28mm (mean 10mm; STD 9mm). In general, three dorsal digital nerves (medial, intermediate, and lateral branch), run at the dorsal ulnar aspect of the hand. The RUCB is often less abundant and shows a large amount of variation. No complete safe zone could be identified; the course of the DCBUN suggests a longitudinal incision for the 6R portal. In fact, a more dorsal incision also prevents damage to the main branches of the DCBUN.

Heterodigital flaps for severe pulp defects

Heterodigital flaps for severe pulp defects

Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects.

Background:Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip.Materials and Methods:Six cases (six fingers) of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches) towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site.Results:Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale) and the two point discrimination was 3-8 mm.Conclusion:Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.

Does nerve repair influence the outcome of reconstruction of a digital nail defect using a free composite flap taken from the great toe?

We describe reconstruction of a nail unit defect in the finger using a free composite flap taken from the great toe, comparing the outcome in patients in whom neurorrhaphy between the dorsal digital nerve of the great toe and the dorsal branch of the proper digital nerve of the injured finger was performed to those in which no nerve repair was made. From January 2002 to March 2009, 47 patients with traumatic fingernail defects were treated. Twenty-two patients before February 2005 had no nerve repair and subsequently 25 patients had nerve repair. The mean size of the germinal matrix and sterile matrix defects was 9 × 8 mm, and the mean size of the nail bed flaps was 9 × 9 mm. The mean length of the arteries used for the flap was 2.2 cm. Outcomes were rated. In the nerve repair group, full flap survival was achieved in 24 patients. At the mean follow-up period of 25 months, there were 12 excellent, seven very good, four good, and two fair results. In the comparison group without nerve repair, there were seven excellent, four very good, four good, five fair, and two poor results. Donor site morbidities were similar in both groups. The use of a free composite flap taken from the great toe is a useful technique for reconstructing nail unit defects in the finger. Innervated nail flap reconstructions tended to show better outcomes than those in which no nerve repair was performed. There is no difference in function or donor site between those in whom the nerve was repaired compared with those in whom it was not repaired.

The Dorsal Homodigital Island Flap Based on the Dorsal Branch of the Digital Artery

Soft-tissue reconstruction in the finger continues to evolve. This study reports reconstruction of small to moderate finger defects with the dorsal homodigital island flap and compares the results between the innervated and noninnervated flaps. A retrospective study was conducted of 166 patients who had soft-tissue defects of the finger treated with the dorsal homodigital island flap (187 defects in 187 fingers in 166 patients). Mean defect size and flap size were 2.2 × 1.9 cm and 2.4 × 2.1 cm, respectively. When return of sensation was important, the dorsal branch of the digital nerve or the dorsal digital nerve was attached with the flap to restore neurosensory function. The main outcomes were static two-point discrimination and Semmes-Weinstein monofilament scores of the flap, fingertip pain, and joint motion. A significant difference was found between the innervated and noninnervated flaps in two-point discrimination, Semmes-Weinstein monofilament, and fingertip pain. The dual-innervated flap presented better discriminatory sensation on the flap and a lower incidence of fingertip pain than the noninnervated and single-innervated flap. In addition, the innervated flap obtained better Semmes-Weinstein monofilament scores than the noninnervated flap. For flaps harvested from the middle phalanx, the mean active motion arc of the distal interphalangeal joint was 69 degrees (range, 35 to 90 degrees). The contralateral side measured 73 degrees (range, 45 to 90 degrees) (significant difference, p = 0.041). Maximum amplitude losses of 15 degrees were seen in 10 percent of patients in the distal interphalangeal joint. The dorsal homodigital island flap is an alternative for tissue reconstruction in the finger. Therapeutic, III.