Dorsal Hand Defects Research Articles

Application of Reversed Radial Forearm Flap for Reconstruction of a Dorsal Hand Soft Tissue Defect: А Clinical Case

Worldwide, surgical techniques for soft-tissue hand defects have made use of the reversed radial forearm flap. Generally, has been used in dorsal hand defects. In this case report, we showed the outcome of a case where the reversed radial forearm flap was applied to treat the dorsal hand defect. A 45-year-old patient who was injured in November 2020 as a result of stacking the right hand in the rotational mechanism. The injury was received 3 days before admission to the hospital. The first stage of surgical treatment was performed - necrectomy of the wound of the right hand. Afterwards, therapy using vacuum-assisted closure (V.A.C) was administered for 18 days. Once granulations had formed in the wound, the patient underwent the second phase of surgical intervention. The reversed radial forearm flap was turned and placed in order to close an opened, exposed bones and tendons in the dorsum of hand. There was no complication with flap viability in the postoperative period. Patient’s joint range of motion and vital functions were acceptable. This case showed that the Reversed Radial Forearm Flap can also be used in dorsal hand defects.Keywords: flap, pedicled flap, soft tissue injuries, hand injuries

“Posterior interosseus artery flap for hand reconstruction: anatomical basis and clinical application”

SummaryFlap options for upper limb reconstruction have increased due to better understanding of its vascular anatomy. The posterior interosseus artery flap (PIAF) is used to cover defects of the wrist, hand, proximal thumb, and first web space. This flap has many advantages but requires good knowledge about the anatomy of the posterior interosseus artery (PIOA) and its perforators.MethodsTwenty upper extremity cadaveric specimens were injected with red latex, Fine dissection of the PIOA and its perforators took place; the perforators were counted, measured, described and photographed.Twenty patients with dorsal hand defects, had PIAF. Cases have Post-operative care and followed up for 6 months post-operative.ResultsThe PIOA was constant in all cadaveric dissections and gave off 4–8 septocutaneous perforators along its course between the extensor carpi ulnaris (ECU) and extensor digitorum (EDM) muscles.The mean distance of the distal most perforator in the middle third forearm from the ulnar styloid was 10.39 ± 1.54 cm. The anastomosis between the PIOA and the anterior interosseus artery (AIOA) was there in all specimens.Venous congestion occurred in 10% of the cases and was managed conservatively. Necrosis of the distal third of the flap was inevitable in one case; excellent results were obtained in the other cases 90%.ConclusionsThe posterior interosseus artery flap is an excellent perforator flap for hand reconstruction preserving the ulnar and radial artery; but it has a possible complications such as venous congestion or partial flap necrosis that could be managed conservatively.Level of evidenceII.

Sequential posterior interosseous artery perforator flap for reconstruction of dorsal hand defects.

Dorsal hand defects accompanied by exposure of bones and tendons remain a huge challenge for plastic surgeons. The pedicled perforator flaps have unique advantages in resurfacing the defects. This study aimed to investigate the clinical efficacy of the sequential posterior interosseous artery perforator flap for repairing dorsal hand defects. This study was composed of an anatomical study and clinical application. Anatomically, 30 adult upper limb specimens injected with red latex were dissected, the perforators from the branches of the posterior interosseous artery were observed in the dorsal forearm, and the sequential flap based on them was designed based on the anatomical characteristics. Clinically, nine cases of soft tissue defects on the dorsum of the hand were treated by this flap. Anatomically, the posterior interosseous artery divided into an ascending branch and a descending branch, and the descending branch traveled 1.0 ± 0.3cm down to divide into the ulnar and radial terminal branches. The ulnar terminal branch presented constantly, and the radial terminal branch had an occurrence rate of 93.33%. Clinically, all flaps survived completely and possessed a soft texture and satisfactory appearance, as well as a nonbloated pedicle, and the donor region had a natural color and appearance with only a linear scar left behind. The sequential posterior interosseous artery perforator flap could become a useful option for repairing dorsal hand defects, as it has the advantages of being easy to perform without sacrificing the main vessels and avoiding donor area skin grafting.

Reliability of Perforator-based UPM Flap for Coverage of Little Finger and Dorsal Hand Defect

Background:There are different approaches for reconstruction of little finger and dorsal hand defects. The ulnar parametacarpal flap, first introduced by Backhach et al in 1995, is considered a good option for reconstructing such defects. In this study, we elevated this flap on one perforator and applied it as a propeller flap. We then discussed the reliability of this flap and which perforator (the proximal or the distal one) is more reliable.Methods:This study was carried out on 20 patients with different little finger and dorsal hand defects between June 2017 and March 2019. All defects were covered by perforator-based ulnar parametacarpal flaps. Ten flaps were based on the proximal perforator, whereas the other 10 were based on the distal perforator.Results:With a period of follow-up ranging from 6 months to 1 year, all flaps that were raised on the proximal perforator survived completely, whereas two of 10 flaps raised on the distal perforator showed venous congestion and also one flap showed partial necrosis of the distal one-third due to ischemia.Conclusions:The perforator based ulnar parametacarpal flap is a reliable option for reconstruction of little finger and dorsal hand defects. It is more reliable when it is raised on the proximal perforator rather than on the distal one.

ADIPOFASCIAL FLAP FOR BONE DEFECTS COVERAGE IN COMPLEX HAND INJURIES: A CASE REPORT AND LITERATURE REVIEW

Abstract INTRODUCTION Hand injuries are often accompanied by defects in bone, tendon, and neurovascular structures that require complex repairs and an adequate skin coverage. Occasionally, this requires using different reconstructive techniques. Reverse flow adipofascial flaps are an option for the coverage of dorsal defects of the hand and fingers, basically. Its vascular supply allows to prevent, in case of fractures or bone defects, subsequent complications (osteomyelitis, pseudoarthrosis or adhesions). MATERIAL AND METHODS We present a patient with complex saw wounds in hand with extensor tendons injuries of the 4th and 5th fingers and an intercalary bone defect measuring 1.3cm x 0.9cm at the base of the proximal phalanx of the 4th finger, which is stabilized with Kirschner wires and cement. This structure is covered by an adipofascial flap based on 2nd, 3rd and 4th intermetacarpal dorsal perforators. Additionally, literature review was conducted in PubMed database with the search terms "Adipofascial flap AND ostheosynthesis". RESULTS Bone stabilization and coverage is achieved without any problems. Subsequently, bone cement and wires are replaced by an autologous radial graft and by plate and screws. Six articles are reviewed that reported the capability of these flaps to prevent bone infections, adhesions and nonunions. CONCLUSION Adipofascial flaps are a safe, low-morbidity and versatile reconstructive option to take into account for urgent or delayed reconstruction of complex dorsal hand defects. These dońt require microsurgical techniques and resources that may not be available in many centers and dońt sacrifice main vascular axis or future reconstructive options.

Reconstructive options for cutaneous dorsal hand defects.

Moderate to large dorsal hand defects pose reconstructive challenges owing to the small surface area, immobile adjacent finger tissue, and thin, fragile skin. To present reconstructive options for moderate to large dorsal hand defects. First, a brief review of dorsal hand reconstructive options is discussed. Then, three approaches to reconstructing dorsal hand defects are presented based on the amount of available underlying tissue and location of the defect on the hand. In the authors' opinion, for larger defects on the mid-distal 1st-3rd metacarpals, the single arm rotation flap is preferable. For medium-sized defects with underlying soft tissue, a Burow's graft is appropriate. The O-Z flap is best for medium- to large-sized defects on the proximal half of the metacarpals. Defects of the digits are excluded. The O-Z rotation flap, single arm rotation flap, or Burow's graft can be used to reconstruct the majority of moderate to large dorsal hand defects.

Reconstruction of pediatric hand injuries caused by automatic cup-sealing machines in Taiwan

ObjectiveThis study was performed to share our clinical experience and provide treatment strategies for pediatric hand injuries caused by automatic cup-sealing machines in Taiwan.MethodsThirteen pediatric patients with an average age of 3.6 years were included in this retrospective study. Treatment was based on the location and depth of the injury and included full-thickness skin grafts, free or local flaps, and digital replantation. Some patients underwent contracture release during follow-up.ResultsThermal crush injuries affected the left hand in five patients and right hand in eight. Four patients with nine amputated fingers were treated by emergent digital replantation, four were treated by skin grafting, one was treated by nail bed repair, one underwent reconstruction with a local reversed dorsal digital and metacarpal island flap, one underwent reconstruction with a fascia graft for extensor tendon repair and pedicled groin flap coverage, and two underwent reconstruction with free anterolateral thigh fasciocutaneous flaps with a vascularized fascia lata graft for dorsal hand defects. All replanted fingers survived.ConclusionPediatric hand injuries, especially those caused by cup-sealing machines, can be devastating. Aggressive treatments including early reconstruction and rehabilitation should be performed for all pediatric hand injuries to achieve satisfactory functional restoration.

Full-thickness skin grafting for coverage of dorsal hand defect

Full-thickness skin grafting for coverage of dorsal hand defect

Spare-part fillet cross-finger flaps: A series of two cases

IntroductionThe concept of ‘spare-part’ flaps in hand reconstruction is most commonly applied using finger fillet flaps to cover dorsal or volar hand defects. In this paper, we introduce the concept of utilization of spare-part finger fillet flaps in a cross-finger fashion. Case reportsThe technique is demonstrated in two case reports. In both cases, there was one finger that was severely crushed requiring amputation. The bones from that finger were removed and the fillet finger flap was utilized to reconstruct a complex defect in an adjacent digit. Immediate post-operative physiotherapy was employed and flap division was done 17–18 days later. Both patients were satisfied with the outcome and returned back to work as manual workers. DiscussionDifferences between previous techniques / types of cross-finger flaps and the current spare-part fillet cross-finger flap technique are discussed. ConclusionWe introduce the concept of utilization of spare-part finger fillet flaps in a cross-finger fashion.

Repair of a Large Dorsal Hand Defect After Mohs Micrographic Surgery

Wright, David R. MD; Kwak, Young MD; Goldberg, Leonard H. MD; Marrugo, Jaqueline MD* Author Information

Evaluation of versatility of use of island first dorsal metacarpal artery flap in reconstruction of dorsal hand defects

Posttraumatic dorsal hand defects with exposed tendons and/or bones represent a challenge to reconstructive surgeons. Many options are suggested ranging from local, regional, distant up to free flaps. First dorsal metacarpal artery island flap was commonly prescribed for reconstructing the thumb or first web space defects. During a 30 month's period, 23 patients, 15 males aged between 17 and 48 years and 8 females aged between 18 and 36 years presented by posttraumatic dorsal hand defects. Ofthem 18 had both exposed tendons and bones while 5 had exposed tendons only. The defects dimensions ranged between 3×4cm and 4.5×6cm. All defects were reconstructed by using a single stage first dorsal metacarpal artery island flaps. All flaps survived completely without complication during the mean follow up periodof 2 years. All patients were very satisfied both functionally and aesthetically by the procedure. Island first dorsal metacarpal artery flap is a good option for reconstructing mild to moderate dorsal hand defects with acceptable functional and cosmetic results.

Multiple extensor tendons reconstruction with hamstring tendon grafts and flap coverage for severe dorsal hand injuries

Treatment of patients with traumatic loss of skin and multiple extensor tendons on the dorsum of the hand is a challenge. The aim of this study was to assess the outcome after reconstruction of soft tissues and multiple extensor tendons in patients who suffered traumatic loss of skin and multiple extensor tendons. Ten patients were enrolled in the study. These patients underwent single-stage reconstruction with autogenous hamstring tendon grafts for multiple extensor tendon defects and fasciocutaneous flaps for coverage of dorsal hand defects. In total, 25 tendons (2 tendons in 5 patients and 3 tendons in 5 patients) were reconstructed. The semitendinosus tendon was used in all patients and the gracilis tendon was added in five patients for tendon reconstruction. Total tendon length requiring reconstruction was between 9cm and 31cm. Free anterolateral thigh flaps were used in six patients and reverse pedicled forearm flaps were used in four patients. According to Miller's scoring system, 8 fingers had excellent results, 12 fingers had good results and 5 fingers had fair results at the final follow-up. Hamstring tendons can be used satisfactorily for primary reconstruction of multiple digital extensor tendons due to their availability and compatibility, with a fasciocutaneous flap. Level of evidenceIV.

Couverture d’une perte de substance de la face dorsale de la main par lambeau antérolatéral de cuisse : description, cas clinique et revue de la littérature

Reconstruction of hand dorsum soft tissue defect usually requires a flap. The dorsal skin is thin and the underlying structures require coverage by vascularised tissue. We have been using perforator flaps in these cases, especially the anterolateral thigh perforator flap. After a description of the technique, we present a case report in which this flap, in a free version, was used to reconstruct a dorsal hand defect after failure of a posterior interosseous flap. The fascia underlying the flap was used to create a sliding interface for extensor tendons. Postoperative care was without complications. The indications of this flap are numerous but after a review of international literature, we found that its use was seldom reported in France compared to other countries. However, we think that its trophic qualities and minor donor site morbidity make it ideal for coverage of hand dorsum soft tissue defects.

Imaging the Posterior Interosseous Artery With Computed Tomographic Angiography

Although the posterior interosseous artery flap has been used extensively for the coverage of dorsal hand defects, anatomic variations in the artery have been widely described. These variants have led to reports of flap failure or conversion to alternative salvage procedures. Preoperative imaging has been suggested in the past prior to posterior interosseous artery flaps as a result of these anatomic variations, particularly with Doppler ultrasound. We describe a new technique for imaging the posterior interosseous artery preoperatively, the use of computed tomography angiography, a highly accurate, noninvasive technique that can highlight the anatomy and allow safe planning for alternative reconstructive options in complex cases. A unique case is described where the posterior interosseous artery was completely absent throughout its course, and in which preoperative imaging was able to potentiate a good outcome.

The Radial Artery Pedicle Perforator Flap: Vascular Analysis and Clinical Implications

The purpose of this study was to determine the location, size, and vascular territory of the radial artery cutaneous perforators. Twenty-six human cadaveric forearms were dissected. All cutaneous radial artery perforators were analyzed for total number, orientation, location, and external diameter. A cluster analysis was performed to determine the overall distribution of perforators. The cutaneous territory of a distally based pedicled perforator flap was determined using methylene blue injection and three-dimensional computed tomographic angiography in five flaps. Six hundred thirty-nine perforators (399 perforators smaller than 0.5 mm compared with 240 perforators 0.5 mm or larger) were dissected in 26 forearms. Of the 639 radial artery perforators dissected, 328 (51 percent) were radially distributed and 311 (49 percent) were ulnarly distributed. There are two main clusters of clinically relevant perforators at a relative distance of 17.6 percent and 61.7 percent along the radial styloid-to-lateral epicondyle interval. In all cases, two or more perforators were found within 2 cm proximal to the styloid. Dye injection of the most dominant distally based perforators revealed a cutaneous territory ranging from 104 cm2 to 333 cm2. The case presented is of a patient with a dorsal hand defect, which was resurfaced with a pedicled perforator flap based on a distal perforator proximal to the radial styloid. There are two main clusters of clinically significant radial artery perforators. Increased knowledge of size, location, and cutaneous territory of the radial artery perforators can lead to expanded use of the radial artery forearmflap based on cutaneous perforators alone, without sacrificing the radial artery.

The Use of Mitten-Shaped Thin Abdominal Flap for the Coverage of Extensive Compound Dorsal Hand Defect in a Pediatric Patient

Background: Severe hand trauma in small children has special social, psychological, aesthetic and functional implications that mandate comprehensive treatment strategies. Because of the miniaturized size of the limbs and the incautiousness of the little kids, the injury tends to have a substantial severity and extent. Moreover, the physicians will encounter considerable difficulties while attempting the reconstructive task and implementing the post operative care, also owing to the tiny structural components and the uncooperativeness of the toddlers. Aim and Objectives: To reconstruct the severe hand injury in Pediatrics by using the abdominal flap was an efficient and safety method. Materials and Methods: This report describes an 18-month-old boy who sustained 3rd degree contact burn over his left dorsal hand with multiple extensor tendon loss, joint and bone exposure, and large skin defect due to autonomic cup-sealing machine injury. He received abdominal flap transfer for wound coverage in conjunction with immediate tendon and lateral bands reconstruction using tensor fascia lata graft. A whole body spica was used to prevent premature detachment of the limb from the abdomen donor site during the two weeks period of immobilization. A special ”mitten like” flap design was utilized, which served to ensure a stable limb anchorage and enable maximal contact surface between the two parties with minimal enrollment of unnecessary donor tissue. An optimal thinning of the flap thickness can be achieved without safety concern. The flap was divided two weeks later and two more surgeries were conducted subsequently to separate the syndactylous fingers. A reasonable final functional result was obtained without significant donor site morbidity. The rational and technical details as well as the special measure of postoperative immobilization were described in this article. Results: No flap partial necrosis or total necrosis was found in each surgery including of reconstructive and division operation. No donor site co-morbidity was noted. Three hundred eighteen days after abdominal flap surgery, or 155 days following complete flap division, no significant complication related either to the donor or recipient sites and an acceptable functional performance is achieved. Conclusion: The method of traditional abdominal flap transfer, is easy to execute, highly accountable, vastly flexible and versatile in flap design, and would be particularly valuable for young aged individual.

Reverse-Flow Posterior Interosseous Flap—A Review of 68 Cases

We are reporting our 10-year experience with 68 patients. Sixty-six flaps were of fasciocutaneous type and two were of osteofasciocutaneous type. These flaps were used for volar and dorsal traumatic hand defects, first web space reconstruction, thumb reconstruction, and repair of congenital anomalies. Sixty flaps (88.24%) had complete uneventful take-up. Four flaps developed partial necrosis, whereas four flaps suffered complete necrosis. The single most important factor for flap survival in our experience has been inclusion of at least two perforators to supply the skin pedal. The proximal flap dissection has a learning curve and all of our poor results were in the early part of our experience. We believe that posterior interosseous fasciocutaneous flap (PIF) is a versatile and reliable option for the challenging problems of hand soft-tissue coverage.

A bilobed groin flap for coverage of traumatic injury to both the volar and dorsal hand surfaces

There are many methods available for coverage of both the volar and dorsal hand surfaces in traumatic injury. All of these surgical procedures allow for ample coverage of the defect, but have the major drawback of needing multiple donor sites. In the present report, a case of a complex crush injury to the hand in which both volar and dorsal surfaces received traumatic injury is presented. A bilobed groin flap pedicled on the superficial circumflex iliac artery was fashioned to cover the entire defect. Like many other described flaps, the bilobed groin flap resulted in a favourable functional and cosmetic result for the patient, but with the unique advantage of requiring a single donor site. A bipedicled groin flap was raised from distal to proximal, and the flaps inset onto both the dorsal and volar hand defects. The patient regained adequate function of his hand, and was able to return to work full-time as a manual labourer. The bilobed groin flap appears to be a valuable option for covering complex hand injuries involving both the volar and dorsal surfaces of the hand.

Distal radial and ulnar arteries perforator‐based adipofascial flaps for covering hand traumatic defects

The clinical value of adipofascial flaps based on distal ulnar or radial-artery perforators is demonstrated in a series of 14 patients with severe hand injuries and significant soft tissue defects requiring coverage. There were 10 male and 4 female patients, aged between 23 and 72 years. The defects were 7 dorsal, 4 palmar, 1 combined dorsal-palmar, and 2 with thumb or total digit amputation. In the patients with a dorsal defect, the extensor tendons were intact in 2 cases, reconstructed in 2 cases, and reconstructed in 3 cases using silicon rods. Following debridement, a fascial flap based on a distal ulnar (12) or radial (4, 2 primarily and 2 secondarily) artery perforator was fashioned and used to cover the defect. A split thickness skin graft was used to cover the defect and the hand was immobilized for 2 weeks. All cases were followed up for at least 6 months. The donor and recipient sites healed uneventfully, and the functional result was very good in terms of wrist and hand joint range of motion, which approximated the normal rates. The extension or flexion deficit was less than 25 degrees. The esthetic result was satisfactory. Two ulnar flap partial (involving approximately 35% of the area) necroses have been treated using reversed radial-distal perforator flaps. The described fascial flaps offer several advantages over other local flaps, and are rather easy to perform and cover effectively both dorsal and palmar hand defects without causing significant functional deficits to the upper limb.

Free Thin Anterolateral Thigh Adipofascial Flap for Reconstruction of Hand Dorsum Defect

There are many flap choices for reconstruction of dorsal hand defect with extensor tendon exposure. Free flap, such as superficial temporal fascia flap or dorsalis pedis flap, is an optional choice because it provides thin, pliable coverage and good gliding surface for extensor tendons. The anterolateral thigh flap is an another alternative, however, thick and bulky of flap lead to unfavorable results. We modified the anterolateral thigh flap with only including adipofascial layer to reconstruct the soft tissue defect of hand dorsum. A 60 year-old of female patient suffered from metastatic Transitional Cell Carcinoma of the bladder. The extravasation of the chemotherapeutic agents led to skin necrosis over her right dorsal hand. We reconstructed the defect of her right dorsal hand by the free thin anterolateral thigh adipofascial flap. The result of the right dorsal hand was satisfactory after 3 months follow-up. The anterolateral thigh adipofascial flap provided vascularized, thin, and gliding coverage. The donor side can be closed primarily. However, it still bears the disadvantages of needing for skin graft and risk of skin graft failure due to fatty necrosis.