Hand Defects Research Articles

Reconstruction of burn contractures with free anterolateral thigh flap in various anatomic sites.

Burn contractures that cause a restriction in extremity movements have to be reconstructed. Free microvascular flaps are generally needed in cases of severe contractures. The ideal free flap for severe contracture defects has to have a large skin island without bulk and a long pedicle for preventing recurrence and tension-free adaptation. Anterolateral thigh flap (ALT flap) that meets these features has widely been used for several indications in reconstructive surgery. Usage of ALT flap in burn contracture was described for burn and axillary contractures in literature. In this study, the usage of free ALT flaps in various anatomic contracture sites was reported. Fifteen free ALT flaps were performed in 14 (12 male, two female) patients with a mean age of 36.6. Burn contracture defects in neck, axilla, popliteal, cubital region, plantar foot and hand were reconstructed with ALT flap. No total flap loss was encountered. Distal flap necrosis was seen in one case. All patients had significant improvement in a range of motions. Recurrence in contracture was seen in one patient with hand flexor contracture due to lack of physical treatment. ALT flap can safely be used in various anatomic contracture sites. Suprafascial elevation of the flap can be preferred for better adaptation in the neck, hand and foot and prevention of bulky appearance.

Anatomical basis and clinical application of the dorsal perforator flap based on the palmar artery in the first web.

Soft-tissue defects of the thumb and index finger remain a challenge for plastic surgeons. Our purpose was to observe the morphological characteristics of the cutaneous vessels in the first web, to design a dorsal perforator flap based on the palmar artery in the first web and to propose its clinical application. Thirty preserved hand specimens were dissected to observe the origin, course, branch and anastomosis of the dorsal perforators in the first web, and the dorsal perforator flap based on the palmar artery in the first web was designed. Clinically, seven cases of hand defects were reconstructed using this flap. The blood supply for the dorsum of the first web comprised the dorsal perforators from both the dorsal artery (the branch of the first dorsal metacarpal artery) and palmar artery (the radial palmar digital artery of the index finger and the ulnar palmar digital artery of the thumb). The first dorsal metacarpal artery constantly arose from the radial artery and was divided into the radial, ulnar and medial branches. The palmar artery sent out 1-2 perforators and formed a constant anastomosis with the medial branch of the first dorsal metacarpal artery to supply the dorsal skin of the first web. In clinical application, all the flaps survived completely without contracture of the first web or other complications and the donor regions all healed at the first stage. The dorsal perforator flap based on the palmar artery in the first web is useful to repair soft-tissue defects of the thumb, the proximal phalanx of the index finger and thenar region, leading to a satisfactory appearance and good functional and sensory recovery.

Reconstruction osseuse métacarpienne par membrane induite sans ciment

Hand ballistics traumas often produce complex limb injuries and large segmental bone defects. The induced membrane (IM) technique is a simple and effective procedure for reconstruction of segmental bone defects. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four metacarpal bone reconstructions with the IM technique but without PMMA cement after ballistic trauma in a low-resources setting. Two patients were treated in a forward surgical unit for gunshot wounds of the hand. A 33 years old man presented a 4th and 5th metarcarpal bone fracture with critical bone defect and a 25 years old man presented a 2nd and 3rd metacarpal bone and soft tissue defect. In addition to the surgical initial management, we performed the IM technique with a syringe's body in polypropylene (PP) instead of PMMA cement that was not available in this situation. A thick membrane was observable six weeks after the spacer implantation. We performed the bone graft in one case with an iliac crest and in the other with a tibial cortical and cancelous graft. Bone union was achieved in the two cases for the four metacarpal bones. We report cases treated in an austere environment where PMMA cement was not available. This PP induced membrane technique as first been described in a public communication at the SICOT congress by Mozumder et al. It involved critical bone defects from the lower limb. The IM technique has proven its efficiency in hand and wrist bone defect reconstruction but its success is based on strict compliance with technical execution. Our plastic spacers met the requirements of surgical technique. After six weeks, an IM membrane macroscopically similar to cement's IM was found in all cases. The PP spacer shows interesting characteristics: it does not contain antibiotics, it does not heat the surrounding tissues and it is not expensive and easily available. The use of a PP spacer allowed us to achieve bone union in four critical metacarpal bone defects related to ballistic trauma. This procedure respects the technical execution of the IM technique. It is achievable in very low-resources settings. Further biomolecular studies are necessary to assess the PP IM biological properties.

Application of Dermal Skin Substitutes for Hand and Finger Palmar Soft Tissue Loss.

Summary:Restoring function after traumatic defects of the palm is a reconstructive challenge, considering the need for flexible, elastic, and resistant skin. Dermal skin substitutes are biologically engineered materials composed of collagen and glycosaminoglycan, devoid of cellular structures. These biodegradable materials act as artificial dermis and stimulate neovascularization: they have been used for many years, mainly on the dorsal side of the hand and fingers, whereas the palmar side of the hand has been generally addressed by local flaps. In this study, we described our experience with dermal skin substitutes in two cases of palmar defects associated with exposed tendinous structures. Coverage of palmar defects in hand and fingers with dermal substitute and split thickness skin graft was performed on two patients. Both patients presented palmar-only loss of tissue (traumatic palmar amputation in the first patient and degloving-type injury in the second patient). Range of motion, functional outcomes, and satisfaction and aesthetical results were evaluated. The resulting skin showed good quality, thickness, pliability, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Additionally, the patients regained full range of motion and reported high satisfaction. The association of split thickness skin graft with dermal substitutes in palmar traumatic hand showed optimal functional and aesthetic outcomes. Although being more adapted to dorsal loss of substance, collagen-based dermal substitutes can also be useful reconstructive tools in palmar defects with exposed structures and could be used to a larger extent in the future.

Reconstruction of complex hand defects using trapezoidal osteocutaneous free fibular flap.

Traumatic defects of multiple metacarpal bones can be addressed using conventional or vascularized bone grafts. When associated with extensive skin and tendon loss, the treatment becomes more challenging. The aim of the study was to describe the results of using free osteocutaneous fibular flap placed in a new fashion for the reconstruction of complex hand defects. Six patients with complex hand defects underwent reconstruction using free osteocutaneous fibular flap placed in trapezoidal fashion with two-stage tendon reconstruction using fascia lata graft. The mean age at the time of injury was 34.7 years (range: 14-54 years). The injury was caused by motor vehicle accident in four patients, machine injury in one patient, and falling from height in one patient. All patients had extensive three or four metacarpal bones defects, segmental loss of tendons, and large skin defect ranging from 6 × 10 cm to 10 × 15 cm. The fibular graft was divided into three segments and positioned in a trapezoidal fashion with the middle bone segment placed transversely to support the bases of the proximal phalanges while the first and third bone segments were placed obliquely along the metacarpal axis converging toward the remaining metacarpal bases and/or carpal bones. At final follow-up visit, the finger range of motion was assessed using the total active motion (TAM) scoring system. Functional outcome was evaluated by the disabilities of the arm, shoulder and hand (DASH) score. Active range of motion (AROM) of the pseudo-metacarpophalangeal (MP) joint was measured. The handgrip strength was measured using Jamar hydraulic dynamometer. The mean length of the harvested fibular graft was 18 cm (range: 17-19). The mean size of the skin paddle was 7.5 × 13.1 cm (range: 6 × 10 cm to 10 × 15 cm). Fibular flaps survived in all patients. The mean follow-up period was 30.8 months (range: 24-40 months). The mean time to achieve bone healing was 3.8 months (range: 3-5 months). The mean TAM was 185° (range: 165-204°) and TAM percentage was described as excellent in two patients and good in four patients. The mean AROM at the pseudo-MP joint was 53.8° (range: 42-70°). The mean injured handgrip strength was 27.3 kg (range: 23-31 kg) and the mean grip strength ratio was 74.8% (range: 69-80%). The mean DASH score was 19.6 (range: 11.67-26.67). Pin tract infection, partial skin paddle necrosis, and wound infection were reported. The fibular osteocutaneous flap arranged in trapezoidal fashion is a viable choice for the reconstruction of complex hand defects, particularly when the metacarpophalangeal joints are not preserved.

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.

Reconstruction of dorsal and palmar defects of hand with anterolateral thigh flaps from one donor site

The anterolateral thigh (ALT) flap is becoming the flap of choice for reconstruction of soft tissue defects with primary donor site closure. The purpose of this report was to review the reconstruction of dorsal and palmar defects of the hand with ALT flaps from one donor site. From 2016 to 2018, seven patients with dorsal and palm defects of the hand were reconstructed with the ALT flaps from one donor site. The cutaneous perforators of the two paddles were from a common vascular supply in five cases. The Michigan Hand Questionnaire (MHQ) score of the function was 37.8 ± 10.0 points, and pain score was 32.9 ± 23.4 points. All of the donor sites healed well in one stage. The use of ALT flaps from one donor site is a good strategy for the reconstruction of dorsal and palm defects of the hand with minimal donor site morbidity and a favorable outcome.

Effects of medial upper arm bilobed free flaps in the repair of two skin and soft tissue defects of hand

Objective: To summarize the effects of medial upper arm bilobed free flaps in the repair of two skin and soft tissue defects of hand. Methods: From May 2014 to May 2016, 7 patients of two skin and soft tissue defects of hand with exposures of phalanges and tendons were treated in Xuzhou Renci Hospital, including 5 males and 2 females, aged from 19 to 41 years. Each defect area ranged from 3.0 cm×1.5 cm to 6.0 cm×3.0 cm. The medial upper arm bilobed free flaps were used to repair the defects, and the area of each lobe of the flaps ranged from 4.0 cm×2.0 cm to 8.0 cm×3.5 cm. The donor sites were sutured directly. The survival of the flaps was recorded. During follow-up, the recovery of donor and recipient sites was observed, the two-point discrimination distance of the flaps was measured, and the hand function was assessed by the trial criteria of the upper limb functional assessment of the Hand Surgery Society of the Chinese Medical Association. Results: All flaps survived smoothly, and the wounds and donor site incisions were healed. All patients were followed up, and the follow-up time lasted for 6 to 15 months. The color and texture of the flaps were similar to the surrounding normal skin, and the shape of the flaps was good. There was no obvious scar in the donor site, and the elbow joint function was normal. One patient developed ulnar numbness one month after operation and relieved after 3 months of treatment with neurotrophic drugs and local physiotherapy, etc. Six months after operation, the two-point discrimination distance of the flaps was 5.5-8.0 mm, and the hand function evaluation was excellent in 3 cases, good in 3 cases, and middle in 1 case. Conclusions: The medial upper arm bilobed free flap has both good texture and good appearance, and the scar of donor site is concealed. It is a good method to repair two skin and soft tissue defects of hand.

A classification system for split-hand/ foot malformation (SHFM): A proposal based on 3 pedigrees with WNT10B mutations

SHFM6 (OMIM 225300) is caused by WNT10B pathogenic variants (12q13.12). It is one of the rarest forms of SHFM; with only seven pathogenic variants described in the world literature. Furthermore, it has not been determined if SHFM6 has specific phenotypic characteristics.In this paper, we present a case series of three unrelated families with SHFM6 caused by three novel WNT10B pathogenic variants. The index patient of the first family was homozygous for the nonsense variant c.676C > T (p.Arg226*) in the WNT10B gene. The index case of the second family had a homozygous splice variant c.338-1G > C in the WNT10B gene. Finally, the index case of the third family carried two different variants in the WNT10B gene: A nonsense variant (p.Arg226*), and a missense variant (p.Gln86Pro). The latter represents the first compound heterozygous pathogenic variant related to SHFM6. We also offer a classification system for the hand/foot defects to illustrate the specific phenotypic characteristics of SHFM6. Based on this classification and a review of all previously reported cases, we demonstrate that SHFM6 caused by WNT10B pathogenic variants have the following characteristics: more severe feet defects (compared to the hand defects), polydactyly, severe flexion digital contractures, and phalangeal dysplasia.

Review of the optimal timing and technique for extensor tendon reconstruction in composite dorsal hand wounds

Aim: The management of complex dorsal hand wounds with extensor tendon loss is controversial. Treatment has focused on soft tissue coverage, but there is limited evidence comparing immediate vs. staged tendon reconstruction. This review evaluates existing literature to determine the optimal management of composite hand defects.

Reconstruction of Hand and Upper Extremities Defects by Thin Random Pedicle Abdominal Flaps, Still a Valid Option in Developing Countries: A Cross Sectional Study

Reconstruction of Hand and Upper Extremities Defects by Thin Random Pedicle Abdominal Flaps, Still a Valid Option in Developing Countries: A Cross Sectional Study

Evaluation of the results of functional prosthetics in children with congenital defects of the hand and fingers

Background. Evaluation of the result of functional prosthetics in patients with different upper limb defects is a topical problem of modern prosthetics. Providing patients with non-functional hand stumps with functional prostheses is not wide-scale and refers to atypical and experimental prosthetics. While new functional prosthetic hands appear, there is no algorithm for evaluating the results of prosthetics.
 Aim. This study aimed to evaluate the result of functional prosthetics in children with congenital defects of the hand and fingers by active prostheses.
 Materials and methods. We observed 67 children with congenital hand defects, of which 22 were included in the experimental prosthetics group. Bench test station was used for an objective assessment of the residual function of the hand. The booth imitated the tasks of an international competition for the users of Cybathlon rehabilitation equipment and allowed users to perform a series of tests, for each of which a certain number of evaluation points were awarded. Samples at the stand were supplemented with a subjective assessment of the function of the hand using the DASH questionnaire validated in Russia.
 Results. The best subjective assessment of the supply of an active prosthetic hand was determined in the patients with underdeveloped hand similar to the truncation of the hand proximal to the metacarpophalangeal joints. The lowest functionality score of the active prosthetic hand was obtained in cases of ectrodactyly and hypoplasia of 1–5 fingers, which was associated with a high residual functionality of the hand.
 Conclusions. In addition to training functions, the developed bench test station serves a diagnostic function as it evaluates the results of functional prosthetics in patients with upper limb defects in different levels, including defects on the hand and fingers. The results of the study on the station correlate with the results of the DASH questionnaire.

Repair of resurfacing soft tissue defect of hand with radial collateral artery polyfoliate perforator flap

To explore the feasibility and effectiveness of radial collateral artery polyfoliate perforator flap in repair of resurfacing soft tissue defect of hand. Between September 2017 and September 2018, the radial collateral artery polyfoliate perforator flaps were transplanted to repair 5 cases of two adjacent wounds of hand and wide or irregular wounds. All patients were male, aged from 27 to 52 years, with an average of 42.5 years. The time from injury to admission was 4 hours to 3 weeks, with an average of 7.3 days. Causes of injury included traffic accident in 2 cases, crushing injury in 2 cases, and paint injection injury in 1 case. The wounds were located at the dorsum of hand in 3 cases, the dorsum of finger in 1 case, and the thumb and thumb web in 1 case. The area of wound ranged from 8 cm×6 cm to 10 cm×8 cm. The area of skin flap ranged from 6.0 cm×3.0 cm to 11.0 cm×4.5 cm, all of which carried the posterior cutaneous nerve of the arm, and the donor site was closed directly. All flaps survived and healed by first intention. All patients were followed up 3-11 months (mean, 6.5 months). The patients were satisfied with the appearance of hands. The flaps were not bulky, and the color and texture were similar to the hand. There was only linear scar in the donor site, no radial nerve injury occurred, and elbow joint function was not affected. One patient underwent finger-splitting and skin flap thinning at 6 months after operation. The radial collateral artery polyfoliate perforator flap is a good method for repairing two adjacent wounds and wide or irregular wounds of hand.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Full-thickness skin grafting for coverage of dorsal hand defect

Full-thickness skin grafting for coverage of dorsal hand defect

An Anatomical study of Cleft hand in North – East population of Assam

Introduction: Cleft hand or Ectrodactyly or Split Hand is a rare form of congenital hand disorder in which there is deficiancy of one or more central rays of the hand. The hand presents with a V-shaped gap situated in the centre of the palm. The condition may occur alone or maybe associated with anomalies of foot, syndactly, polydactyly, triphalangeal thumb, transverse bones in the hand or maybe part of Ectrodactyly Ectodermal dysplasia Cleft (ECC) Syndrome. Aims and Objectives: To find out the sex ratio and incidence of laterality (unilateral or bilateral) of cleft hand in North East population of Assam. Subjects and Methods: This study included 31 children between age group of 3 years to 8 years with hand deformities who were brought to the Plastic Surgery Department, Gauhati Medical College, Guwahati for aesthetic correction within a time span of 2 years. Only those cases who had central defects of hand were included & those with other syndromic anomalies were excluded. For this detailed clinical and radiological examination was done to evaluate the extent of bone or tissue involvement and to find out any syndromic association of the condition. Results: Out of 31 cases, 10 cases were had Unilateral and 21 cases had Bilateral Cleft Hands. It was seen that out of 31 cases, 22 were males and only 09 were females indicating that male to female ratio of the deformity is 2.44 .Thus, males were more affected than females. Conclusion: Most of the cases presented with absence of the middle finger and central tissue of the affected hand since birth. The embryological basis has been highlighted to throw light into such a catastrophe where both males and females were affected and showed unilateral or bilateral involvement of the hand leading to cosmetic and functional debility. Therefore, the study revealed that males were more affected than females and bilateral involvement of the hands were common than unilateral involvement.

The use of chimeric musculocutaneous posterior interosseous artery flaps for treatment of osteomyelitis and soft tissue defect in hand.

There is growing evidence of the superior ability of muscular tissue to clear bacterial bone infection. Unfortunately, in the hand, there are almost no small local muscular flaps, and muscular transfers to the hand are mainly microsurgical free transfers. In this report, we present the results of the use of a chimeric posterior interosseous flap including part(s) of the forearm muscles to treat osteomyelitis and soft tissue defect of hand from a series of patients. Four male patients with an average age of 32 years (range 20-46 years), were affected by acute osteomyelitis in hand. Previous fracture fixation with percutaneous K-wires was the cause of bone infection in three case. In one case, the osteomyelitis was a consequence of an open fracture. The bones affected were four metacarpals and one proximal phalanx, all with a minimal cortical defect (from the K-wire) obscuring a larger medullary infection, which required extensive bone and overlying soft tissue debridement, leaving a soft tissue defect to be reconstructed of size ranging from 2 x 4 cm to 5 x 7 cm. The soft tissue defects were due to concomitant superficial infection and consequent debridement. All patients were treated with bone debridement and a chimeric posterior interosseous flap, which included part of the extensor digiti minimi and/or extensor carpi ulnaris to fill the intramedullary canal of the bones. No fixation of bone was necessary. The skin paddle of the flaps ranged from 2 x 5 cm to 5 x 6 cm, replicating the defect area, plus a teardrop tail of skin circa 1.5 cm wide and as long as the pedicle of the flap. The muscular components of the flaps used to fill the intramedullary canals ranged from 1 x 1 x 1.5 cm to 1.5 x 1.5 x 4 cm. All flaps survived and osteomyelitis resolved in all cases without major complications. At the final follow-up at 16 months (range 12-26 months), assessment of the hands using TAM, Power Grip and Key Pinch Strength measurements and, where appropriate, Kapandji scores, demonstrated satisfactory hand function. The chimeric posterior interosseous flap including part of the muscles of the forearm may be a robust solution for augmenting the flap bulk and may be used in cases of severe osteomyelitis of the hand.

A Case of Two Stage Reconstruction of Soft Tissue Defect in Hand with Infection

A Case of Two Stage Reconstruction of Soft Tissue Defect in Hand with Infection

First dorsal metacarpal artery flap a workhorse for reconstruction of selected small defects of the hand

Background: The first dorsal metacarpal artery (FDMA) flap is used mainly for reconstruction of thumb defects. We share our experience of this flap for various defects of thumb and also its use to cover other defects. Materials and Methods: Case records of 15 patients with FDMA flap between October 2015 and February 2018 at our center were analyzed retrospectively. Data were analyzed for etiology, associated comorbidities, interval between injury and operation, site of defect, harvesting technique, and inclusion of dorsal interossei muscle cuff, complications, donor-site morbidities, and postoperative sensory recovery. Results: Of 15 patients, 13 were male and 2 were female. Eleven patients had a posttraumatic defect, 2 had post-electric burn defect, 1 had a firecracker injury, and 1 had a post snakebite defect. Of 15 patients, 12 patients had thumb defects, 1 patient with defect of first web space, 1 on volar aspect of palm, and 1 on the dorsum of hand over the head of third metacarpal. All patients showed protective sensations and 6 patients with 12-month follow-up showed minimum of 9 mm of two-point discrimination with no donor-site morbidity. Conclusions: The FDMA flap has a constant anatomy, easy dissection, and shows good functional and esthetic results. FDMA flap is the first treatment of choice for defects of the thumb, but it can be used for selected small defects of hand due to its wide arc of rotation.

Evaluation of dorsal metacarpal artery perforator flaps in the reconstruction of hand soft-tissue defects

Objective Evaluation of the dorsal metacarpal artery perforator (DMAP) flaps in the reconstruction of hand soft-tissue defects. Background The DMAP flap is a nonconventional solution for treating hand and finger defects. We present our experience in resurfacing a variety of soft-tissue defects of hand and fingers with this single-stage flap, reducing the need for other conventional flaps which may need more than one stage for reconstruction. Patients and methods This study was done on 20 patients (18–65 years) with soft-tissue defects of the hand and fingers, following trauma in 15 patients, postburn deformity reconstruction in four patients, and in one patient for post-tumor excision, presented at the Menoufia University Hospital and Kafr Al-Shaikh General Hospital over a 1-year period. Results The average flap size was 6 × 2.5 cm; raised from the dorsum of the hand as an island elliptical flap. Twelve flaps were used to resurface defects between metacarpophalangeal and proximal interphalangeal joints; three flaps were used to resurface defects between proximal and distal interphalangeal joints; one flap was used to resurface defect beyond the distal interphalangeal joint; and four flaps were used to resurface web space defects. The donor site closed primarily in all cases. Complications were distal necrosis in two flaps and congestion in two flaps. Wound dehiscence of the donor site occurred in two cases. Conclusion DMAP flap is a reliable alternative for treating defects on the hand and fingers. The flap offers the surgeon simple, single-stage, and fast procedure with minimal donor site morbidity and with preservation of functional and esthetic outcomes.