Proper Palmar Digital Artery Research Articles

Impact of single versus dual arterial supply on perfusion and function in finger replantation after complex hand injuries

Finger amputations following complex hand injuries (CHI) pose a significant challenge in hand surgery due to severe tissue trauma and neurovascular damage, necessitating precise arterial repair. While restoring arterial perfusion is critical, it remains unclear whether reconstructing both proper palmar digital arteries is required for optimal outcomes. This study evaluates whether restoring one or both arteries in finger replantation after complex injuries impacts perfusion and overall outcomes. In this retrospective, cross-sectional, follow-up study, we investigated patients with finger amputations following CHI admitted to the high-volume regional hand trauma center between January 2013 and December 2020. Perfusion has been assessed using FLIR thermal imaging and laser speckle contrast analysis. Functional outcomes and quality of life scores were measured using standardized questionnaires. Sensory assessments, along with pain and grip strength measurements were also conducted. A total of 31 patients were included in the study. Thermal imaging showed a significantly higher finger surface temperature in patients with two-artery reconstruction. Laser speckle contrast analysis confirmed better perfusion, though not statistically significant. Functional and quality-of-life scores were similar across groups, except for significantly improved temperature sensation in the two-artery group. In conclusion, reconstructing both arteries in finger replantation following CHI isn’t essential for good outcomes if one artery provides adequate perfusion, but dual reconstruction may improve perfusion and temperature sensation.

Repair of a finger pulp or fingertip defect using a palmar rotatory flap pedicled with the perforating branch of the proper palmar digital artery: a retrospective study

BackgroundSoft tissue defects in the hand may result from trauma, oncological procedures, or severe infections. This study aimed to introduce an innovative method for repairing soft tissue defects on the palmar side of the distal segment of the affected finger or fingertip. We explored this surgical method and its curative effect on the volar rotation pedicled flap base on a perforator of the palmar digital artery (VRPF-PPDA) for repairing ventral or fingertip soft tissue defects of the distal segment of the affected finger without impairing its main blood vessels.MethodsBetween June 2019 and January 2021, 13 patients with finger pulp or fingertip soft tissue defects were treated with VRPF-PPDA. Flap survival rate, complication rate, two-point discrimination (2PD), and patient satisfaction were used to evaluate the efficacy of this method. The function of the affected finger was evaluated using the upper limb function evaluation method issued by the Trial Standards for Evaluation of Partial Function of the Upper Extremity of the Chinese Society for Surgery of the Hand of the Chinese Medical Association (CMA) and the Disabilities of the Arm, Shoulder, and Head (DASH) score, 6–12 months after the flap-based operation.ResultsThirteen patients (18 fingers) achieved complete flap survival. The finger pulp flap was full, and no complications occurred. 2PD checks of the flaps revealed that all of them were 4–10 mm in length. According to the Trial Standards for Evaluation of Partial Function of the Upper Extremity of the Chinese Society for Surgery of the Hand of the CMA, hand function was excellent in 12 patients (17 fingers) and good in one patient, with a mean DASH score of 26.05 ± 0.45. Eleven patients selected “excellent” on the subjective satisfaction survey, while the other two selected “good.”ConclusionVRPF-PPDA surgery is a simple, effective, minimally invasive, and reliable method for repairing soft tissue defects in the distal finger pulp or fingertips. Optimal esthetic reconstruction and anatomical and functional repair can be achieved in fingers repaired using the VRPF-PPDA surgical approach.

Median artery persistence in coexistence with a bifid median nerve and interconnections of the median with the ulnar nerve and vice versa

PurposeThis report describes a bilateral persistent median artery (PMA) originating from the ulnar artery and terminating at different levels of the upper limb. The PMA coexisted with a bilateral bifid median nerve (MN) and two bilateral interconnections (ICs characterized with the symbol -) of the MN with the ulnar nerve (UN) (MN-UN) and a unilateral reverse IC (UN-MN). Emphasis was given to the artery’s developmental background.MethodsThe PMA was identified in an 80-year-old formalin-embalmed donated male cadaver.ResultsThe right-sided PMA terminated at the wrist, posterior to the palmar aponeurosis. Two neural ICs were identified: the UN joined the MN deep branch (UN-MN), at the forearm’s upper third, and the MN deep stem joined the UN palmar branch (MN-UN), at the lower third (9.7 cm distally to the 1st IC). The left-sided PMA ended in the palm giving off the 3rd and 4th proper palmar digital arteries. An incomplete superficial palmar arch was identified by the contribution of the PMA, radial, and ulnar arteries. After the MN bifurcation into superficial and deep branches, the deep branches formed a loop, that was penetrated by the PMA. The MN deep branch communicated with the UN palmar branch (MN-UN).ConclusionsThe PMA should be evaluated as a causative factor of carpal tunnel syndrome. The modified Allen's test and the Doppler ultrasound may detect the arterial flow and the angiography may depict the vessel thrombosis in complex cases. PMA could also be a "salvage" vessel for the hand supply, in radial and ulnar artery trauma.

Anatomical observation and CT three-dimensional reconstruction of Five-shu acupoints of Shaoyin Heart Meridian in rabbit's forelimb

To investigate the location and anatomical structure of "Shaochong"(HT9), "Shaofu"(HT8), "Shenmen"(HT7), "Lingdao"(HT4) and "Shaohai"(HT3) in the rabbit's forelimb. Sixteen rabbits (half male and half female) were used in the present study. By referring to the national standards on the location of acupoints in the human body and the literature about the location of acupoints in the rabbit, and by using the method of comparative anatomy, the location and needling operation of the Five-shu acupoints of Shaoyin Heart Meridian on the rabbit's forelimb were defined, and these acupoints were needled and CT three-dimensional reconstruction were conducted. Then, the rabbits were killed, and intravascular perfusion was performed, followed by inserting acupuncture needles into these five acupoints for observing the anatomical relationship between the inserted acupuncture needle and the structure of surrounding tissues. HT9 is located at the medial side of the little finger of forelimb, about 1 mm beside the nail root, and is adjacent to the superficial flexor tendon of the finger, the dorsal branches of the proper palmar digital artery and vein, and the endings of dorsal branch of palmar digital proper nerve of the ulnar nerve on the fifth finger side. HT8 is located at the palm side of the forelimb, horizontally parallel to the proximal end of the 5th metacarpophalangeal joint and between the 4th and 5th metacarpal bones, and is adjacent to the lumbricalis, the 4th and 5th interossei, and common palmar digital artery and vein and the palmar digital proper nerve of the ulnar nerve. HT7 is located at the medial margin of the extensor carpal tendon on the ulnar side, between the distal end of the ulna and the ulnar carpal bone, and is adjacent to the tendons of flexor carpi ulnaris and extensor carpi ulnaris, ulnar artery, ulnar vein and ulnar nerve. HT4 is located at the medial border of the ulnar flexor tendon, about 1.5 cun superior to HT7, and is adjacent to extensor carpi ulnaris, flexor carpi ulnaris, flexor digitorum superficialis, flexor digitorum profundus, ulnar artery, vein and ulnar nerve. HT3 is located at the depression, medial to the condyle of humerus when the elbow is bent at 90°, its neighbor structure is composed of pronator teres, biceps brachii, brachial artery and vein, radial collateral artery, radial collateral vein, medial antebrachial cutaneous nerve and median nerve. In the rabbit, there is a close relationship between HT9, HT8, HT7, HT4 and HT3 regions and brachial vascular and its branches, cephalic vein and its branches, medial antebrachial cutaneous nerve, median nerve and ulnar nerve, which is the morphological basis of the Five-shu acupoints of Shaoyin Heart Meridian for treating some related clinical disorders.

Ultra-high frequency ultrasound for digital arteries: improving the characterization of vasculopathy in systemic sclerosis

ObjectivesTo provide a full characterization of proper palmar digital arteries (PPDA) in systemic sclerosis (SSc) with ultra-high frequency ultrasound (UHFUS), and to investigate possible relationships between digital macroangiopathy and microangiopathy. MethodsSSc patients without active digital ulcers and healthy controls (HC) were enrolled. Each subject underwent UHFUS 70 MHz evaluation of PPDA from II to V fingers bilaterally, searching for vessel occlusion and measuring the thickness of the three arterial layers and the systolic-diastolic excursion range. Microcirculation was investigated with capillaroscopy and laser speckle contrast analysis (LASCA). ResultsForty-six SSc patients (87% female, mean age 55.5 years) and 15 HC comparable for age and sex were enrolled. UHFUS in SSc revealed the occlusion of 124 (16.8%) PPDA, whereas in HC they were all patent. Considering a finger with at least one PPDA occluded as ultrasonographically pathological, 67.4% patients presented ≥1 pathological fingers. All three arterial layers were significantly thicker and excursion range significantly reduced in SSc than in HC (p<0.001 for all). Seventy-three percent of fingers previously affected by digital ulcers, were ultrasonographically pathological. Disease duration was directly correlated to the thickness of all three arterial layers. No significant correlations emerged between capillaroscopy or LASCA findings and UHFUS features. ConclusionUHFUS allows the characterization of vasculopathic involvement of PPDA in SSc, also showing subclinical vasculopathy. The lack of correlations between UHFUS and capillaroscopy or LASCA likely mirrors non-overlapping vasculopathic processes. UHFUS evaluation of PPDA emerges as complementary to microcirculation assessment for a more accurate and complete characterization of SSc vasculopathy.

Vascular supply of the metacarpophalangeal joint.

To describe in detail the arterial vasculature of metacarpophalangeal joints 2-5 on cadaver specimens and to compare it to ultrasound imaging of healthy subjects. Eighteen hands of donated human cadavers were arterially injected and investigated with either corrosion casting or cryosectioning. Each layer of cryosectioned specimens was photographed in high-resolution. Images were then segmented for arterial vessels of the metacarpophalangeal (MCP) joints 2-5. The arterial pattern of the joints was reconstructed from the segmented images and from the corrosion cast specimens. Both hands of ten adult healthy volunteers were scanned focusing on the vasculature of the same joints with high-end ultrasound imaging, including color Doppler. Measurements were made on both cryosectioned arteries and Doppler images. The arterial supply of MCP joints 2-5 divides into a metacarpal and a phalangeal territory, respectively. The metacarpal half receives arteries from the palmar metacarpal arteries or proper palmar digital arteries, while the phalangeal half is supplied by both proper and common palmar digital arteries. Comparing anatomical and ultrasonographic results, we determined the exact anatomic location of normal vessels using Doppler images acquired of healthy joints. All, except three branches, were found with less than 50% frequency using ultrasound. Doppler signals were identified significantly more frequently in MCP joints 2-3 than on 4-5 (p < 0.0001). Similarly, Doppler signals differed in the number of detectable small, intraarticular vessels (p < 0.009), but not that of the large extraarticular ones (p < 0.1373). When comparing measurements acquired by ultrasound and on cadaver vessels, measurements using the former technique were found to be larger in all joints (p < 0.0001). Using morphological and ultrasonographic techniques, our study provides a high-resolution anatomical maps and an essential reference data set on the entire arterial vasculature of healthy human MCP 2-5 joints. We found that Doppler signal could be detected in less than 50% of the vessels of healthy volunteers except three locations. Intraarticular branches were detected with ultrasound imaging significantly more frequently on healthy MCP 2-3 joints, which should be taken into account when inflammatory and normal Doppler signals are evaluated. Our study also provides reference data for future, higher-resolution imaging techniques.

Effect of dorsal nerve fascial island flap on repairing distal soft tissue defects at the proximal segment of the index, middle, ring, and little fingers

BackgroundTo investigate the effect of the dorsal nerve fascial island (DNFI) flap on repairing finger soft tissue defects at the distal segments.MethodsFifty patients with distal soft tissue defects at the index, middle, ring, or little fingers were treated with a DNFI flap at the proximal phalanx between February 2008 and May 2018. The nutrient vascular chain around the dorsal branch of the proper palmar digital nerves served as the flap axis. The dorsal branch of the proper palmar digital arteries provided blood supply. The fascia pedicle served as the venous system. All patients were followed for 6 months.ResultsAll 50 flaps survived. The appearance, color, and texture of the skin returned to normal. The sensory function was partially restored. The two-point discrimination of the finger flap was 7–10 mm.ConclusionsThe DNFI flap at the proximal phalanges of the index, middle, ring, and little fingers is an effective surgical option. The technique has a high flap survival rate and long pedicle, which can repair different parts of the finger. The flap also restores the sensory function of the finger without damaging the main nerves or blood vessels. The flap treatment is an optimal option for finger soft tissue defects at the distal segments.

Preoperative MRI Evaluation of Hand Vessels in Children With Congenital Syndactyly Malformation by a Contrast-Enhanced Three-Dimensional Water-Selective Cartilage Scan.

BackgroundIt is crucial to preoperatively assess the arteries of the hands in congenital syndactyly malformation (CSM) patients because this information can affect the therapeutic outcome and prognosis.ObjectiveTo investigate the value of a contrast-enhanced three-dimensional water-selective cartilage scan for the preoperative evaluation of CSM in children.Materials and MethodsContrast-enhanced three-dimensional water-selective cartilage scan 3.0 T magnetic resonance imaging (MRI) performed in 16 clinically diagnosed CSM patients with 17 affected hands. The arteries of the hands were displayed with a focus on the bifurcation position of the common palmar digital arteries (CPDAs) and the maturity of the proper palmar digital arteries (PPDAs). The MRI results were interpreted by consensus between two experienced pediatric radiologists with 10 years of MRI experience each. The MRI findings were compared with the operation results.ResultsOf 51 CPDAs in the 17 affected hands, MRI showed that 30 had an abnormal bifurcation position and 20 had a normal position, and of the 102 PPDAs, 14 were shown to have an abnormal maturity and 85 a normal state, which were confirmed by surgery. The accuracy, sensitivity and specificity for determining the bifurcation position of the CPDAs based on MR maximum intensity projection reconstructed images were 98.04% (50/51), 96.77% (30/31) and 100% (20/20), respectively. The maturity of the PPDAs was judged by MR maximum intensity projection reconstructed images with an accuracy, sensitivity and specificity of 97.06% (99/102), 82.35% (14/17) and 100% (85/85), respectively.ConclusionContrast-enhanced three-dimensional water-selective cartilage scan has excellent performance in displaying the bifurcation position of the CPDAs and the maturity of the PPDAs and is of high value for the preoperative evaluation of CSM in children.

Color Doppler Ultrasonography of digital arteries and digital ulcers development in systemic sclerosis

BackgroundThe aim of this study was to evaluate the role of Color Doppler Ultrasonography (CDUS) of proper palmar digital arteries (PPDA) as predictive marker of new digital ulcers (DUs) in systemic sclerosis (SSc) patients during 5 years follow-up. Methods36 SSc patients were examined using nailfold videocapillaroscopy (NVC) and CDUS of PPDA. ResultsFourteen (38.9%) patients had chronic or acute occlusions (C and D pattern) on CDUS evaluation. Using a cut-off of 0.70, 21 (58.3%) patients had a Resistive Index (RI) ≥0.70. Nineteen (52.8%) patients developed new DUs during the follow-up. The median value of RI was higher in SSc patients with DUs than in SSc patients without DUs [0.73 (IQR 0.70–0.81) vs 0.67 (IQR 0.57–0.70), p < 0.0001].The Kaplan-Meier analysis showed a free survival from new DUs higher (p < 0.01) in SSc patients with Pattern A and B than SSc patients with Pattern C and D. The Kaplan-Meier curves showed that free survival from new DUs is lower (p < 0.001) in SSc patients with increased RI (≥0.70) than in SSc patients with normal RI.In multivariate analysis with two co-variates, RI ≥ 0.70 [HR 5.197 (1.471–18.359), p < 0.01] and NVC late scleroderma pattern [HR 7.087 (1.989–25.246), p < 0.01] were predictive markers of new DUs. ConclusionsRI of PPDA in association with NVC could be used to evaluate SSc patients with increased risk of new DUs development.

Clinical Effectiveness of Dorsal Branch Skin Flap of Proper Palmar Digital Artery with Distal Pedicle in Repairing of Fingertip Soft Tissue Defect: A 1-Year Prospective Study in a Chinese Tertiary Referral Teaching Hospital.

Background: Digital island flap remains among the most useful types of providing soft-tissues coverage for defect on the fingertip accompanied with underlying structures exposure. Nevertheless, its trends of functional and aesthetic issues such as the limited length of advancement and the limited flap size are the essential disadvantages. The main objective of the study was to assess the clinical effectiveness of dorsal branch skin flap of proper palmar digital artery with distal pedicle in repairing of fingertip soft tissue defect accompanied with underlying structures exposure. Methods: This is a 1-year prospective study, in which 21 patients (24 fingers) with traumatic fingertip skin and soft tissue defects had undergone emergency repair with dorsal skin flap of proper palmar digital artery with distal pedicle. The starting point of the dorsal proper palmar digital artery which is at the connection of distal interphalangeal joint with the digital midline was selected as the rotation point of the surgical skin flap, with an incision area of 1.1 cm × 1.4 cm-2.7 cm × 2.0 cm, the pedicle of 0.8-1.7 cm and disposition of 90°-120° to cover the fingertip. Results: All flaps had completely healed postoperatively. In 2 cases, tension blisters of the flap and partial necrosis were observed, which survived after change in dressing and rational administration vasodilator medication. Patients were followed up to 6 months. Favorable appearance and function were restored, and satisfactory recovery of the sensory functions of the fingers had been achieved. The two-point discrimination of skin flap with anastomosis of nerve could reach 4.5-9.4 mm (mean, 6.80 mm). Conclusions: Repairing the fingertip skin and soft tissue defect of 2nd-5th finger via primary surgical repair with dorsal distal pedicle or proper palmar digital artery skin flap is a good technique. The high survival rate of the flap, the favorable flap's appearance, and the satisfactory recovery of the sensory functions of the fingers are among the advantages of this reconstructive technique.

Synchrotron phase-contrast imaging applied to the anatomical study of the hand and its vascularization.

Microscopic anatomical study of the hand requires difficult or destructive dissection techniques for each anatomical structure. Synchrotron phase-contrast imaging (sPCI) allows us to study precisely, at a microscopic resolution and in a nondestructive approach, the soft tissues and bone structures within a single 3D image. Therefore, we aimed to assess the capacity of sPCI to study the arterial anatomy of the hand and digits in human cadavers for anatomical purposes. A non-injected hand from an embalmed body was imaged using sPCI at 21-µm pixel size. The vascularization and innervation of the hands were virtually reconstructed at 84-µm resolution, and the medial neurovascular bundle of the third digit at 21µm. The thinner-most distal structures were observed and reported. The diameter and thickness of the vascular and neural structures were defined on 2D computed tomographic axial projections, and using a granulometry method coupled to the 3D reconstructions. The vascularization of the hand was visible from the radial and ulnar arteries to the distal digital transverse anastomoses. The thinnest structure observed was the anastomotic arterial network around the proper palmar digital nerve. The latter emerged from the proper palmar digital artery and vascularized the nerve around its whole length and circumference. The perineural arterioles individualizable at this resolution had a diameter of 66-309µm. In conclusion, sPCI allows both the arterial and neural anatomy of the hand to be studied at the same time, as well as the anatomical interactions between both networks. It facilitates the study of structures that have different sizes, diameters, thickness, and histological origin with great precision, in a noninvasive way, and using a single technique.

Arterial grafts for proper palmar digital artery reconstruction: An anatomical study

Digital ischemia due to arterial defects need urgent surgical management. The traditional treatment consists of vascular reconstruction using a reversed autologous venous graft as a bypass. Very few studies have described the use of arterial grafts for digital artery reconstruction. This cadaver study characterized the forearm perforator arteries to assess the potential feasibility of using them as donor grafts for digital artery reconstruction. Eleven forearms and twenty hands were dissected from freshly injected cadavers. All clinically significant perforators (>0.5 mm) derived from radial or ulnar arteries and digital arteries were evaluated. The digital palmar arteries were measured at three points: metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (PIP) joint. In the 11 forearms analyzed, 5.5 ± 1.3 perforators from radial or ulnar arteries with a diameter of at least 0.5 mm were found per dissection. The mean diameters were 0.9 ± 0.18 mm proximally and 0.8 ± 0.15 mm distally; the mean length was 35.6 ± 11.35 mm. The mean diameters for the dominant and non-dominant arteries were 1.5 and 1.3 mm at the MCP, 1.3 and 1.0 mm at the PIP, 0.8 and 0.7 mm at the DIP, respectively. The forearms are good donor sites as they have large-diameter arteries of suitable length for arterial grafting. These new arterial grafts may be suitable for vascular reconstruction of digital arteries starting from the PIP joint.

Pedicled flap from the first dorsal branch of the proper palmar digital artery of the fingers: An anatomy study

The pedicled flap from the first dorsal branch of the proper palmar digital artery (FBPPDA) of the fingers is an option for reconstructing digital skin defects. It has the advantage of being innervated by the dorsal branch of the proper palmar digital nerve (DBPPDN) associated with the artery. However, no studies on the anatomical variations of the neurovascular pedicle have been performed yet. The objective of our study was to evaluate the anatomical variations in the neurovascular pedicle, determine its relationships with other anatomical structures, describe the dissection technique for the FBPPDA and explore potential indications. We conducted an anatomical study with eight upper limbs from fresh adult cadavers. Twenty-six fingers (6 index, 6 middle, 8 ring, 8 little) were dissected after intra-arterial silicone injection. We found a pedicle composed of the FBPPDA and the DBPPDN in all fingers. The artery arises an average 19mm from the bifurcation of the common palmar digital artery. The DBPPDN's configuration relative to the FBPPDA varied; in the main variant – found in 58% of cases – the nerve was superficial and proximal position to the artery. After its origin, the pedicle ran on the superficial aspect of the extensor hood along an oblique path from proximal to distal and from palmar to dorsal. Its path ended with its penetration into the skin paddle of the flap just upstream the proximal interphalangeal (PIP) joint. The skin paddle corresponded to the functional skin unit represented by the dorsal surface of the middle phalanx and that of the PIP joint. Its average length was 33mm (26–40) and its average width was 21mm (15–30). The arc of rotation was sufficient to reach homodigital and heterodigital cutaneous defects. Based on our findings, this flap is a reliable and reproducible option for finger skin defects. The size of its paddle and its innervation make it an interesting alternative to conventional flaps.

Optimization of the homodigital antegrade island flap for fingertip reconstruction: New dissection sequence based on cadaver study findings

IntroductionThe homodigital antegrade island flap pedicled on the proper palmar digital artery is very useful for covering fingertip defects. However, it has its drawbacks, such as the risk of stiffness due to retractile scars and the need for extensive dissection with long-lasting dysesthesia in some cases. In clinical studies, expanding the skin paddle with V-shaped incisions increases the flap's advancement. We wanted to know whether making these V incisions for paddle expansion would make dissection on the volar side of the proximal interphalangeal joint unnecessary. MethodsA cadaver study was performed with four fresh-frozen upper limbs. Sequential dissection was carried out on 32 flaps, allowing us to compare the advancement obtained and the area of the flap's paddle between each step. ResultsCrossing the palmar crease of the proximal interphalangeal joint provides only 2mm advancement of the homodigital antegrade flap. Adding one or two V-shaped incisions in the flap with limited dissection provides additional advancement of 4.1mm (p<0.05) and 6.9mm (p<0.05) relative to the standard flap. DiscussionOur study shows the possibility of increasing the homodigital antegrade flap's advancement – without having to extend the dissection proximally to the PIP joint – by making V-shaped incisions in the paddle. Based on our findings, we have proposed a new flap dissection sequence.

The replantation of penetrating severed finger with disconnected micro tissue blocks in 16 cases

Objective To explore the method of replanting severed piercing finger micro tissue blocks. Methods From February, 2001 to October, 2016, 16 cases of severed piercing finger micro tissue blocks were replanted with debridement. The trunk or branch of proper palmar digital artery was anastomosed. Vascular collocations were used such as venous arterialization when there was no anastomotic artery available. Regular postoperative followed-up was performed to observe the recovery of tissue survival, appearance, sensation of flap, and joint function. Results One case had partial epidermal necrosis, and healed after change of dressing. The finger-disconnected micro tissue blocks of other 15 cases survived well. After 6 months to 2 years of follow-up, the replanted micro tissue blocks were ruddy in color and recovered from S3 to S4. The appearance of the 16 fingers was good, and the function of joints was restored. Conclusion The finger-disconnected micro tissue blocks should be actively replanted. With skilled microsurgical techniques, the anastomosis of the arterial or venous artery will ensure the success of replantation and survived, as well as to restore good function and appearance. Key words: Penetrating severed finger; Micro tissue block; Precise repair; Replantation

Reconstruction of adjacent large finger pulps with the modified sensate free proximal ulnar artery perforator flap

Objective To study the surgical techniques and the clinical curative effect of the reconstruction of adjacent large finger pulps with the modified sensate free proximal ulnar artery perforator flap. Methods From February, 2013 to May, 2016, 20 fingers in 10 patients with adjacent large finger pulp defects crossing the DIP joint were reconstructed by the modified senate free proximal ulnar artery perforator flap. All the pulps of every patient were recovered by 1 flap in the first stage and the artificial syndactyly of two digits was divided in 7 weeks after the flap transfer in the second stage. In order to reconstruct the sensation of two pulps in each patient, firstly both of the proximal and distal ends of the cutaneous nerve in flaps were dissected and anastomosed with the most lateral and medial palmar digital nerves of two adjacent fingers respectively, which were divided into 2 groups. Secondly the cutaneous nerve in the middle part of flap was cut and the two ends were anastomosed with the other two palmar digital nerves in the second surgery. There were 8 fingers in 4 patients with the index and middle finger pulp defects, 12 fingers in 6 patients with the middle and ring finger defects. The flap size was from 5.0 cm×3.5 cm to 5.5 cm×4.0 cm, and the perforator artery was anastomosed with the palmar digital artery in 6 cases and with the joint branch of digital artery in 4 cases. Results Nine flaps survived uneventfully except the venous congestion was found in 1 flap which was salvaged successfully by acupuncture bleeding. Also, no congestion or ischemia of all the 20 pulp flaps occurred right after releasing the artificial syndactyly. The time of followed-up was from 11 months to 32 months with the average of 17 months after the second surgery. The static two point discrimination of the 2 groups of the sensate pulp flap was (7.3±1.2) mm and (8.6±2.4) mm respectively. There was no significant difference between groups (P > 0.05). These 20 pulp flaps were also assessed by the Semmes - Weinstein monofilament test with the result of diminished light touch in 14 pulps and diminished protective touch in 6 pulps. The total active motion in all 20 fingers was (248.0±4.5) °. No patients suffered cold intolerance and local pain but 1 had hypersensitiveness in the pulp flap. Conclusion The modified sensate free proximal ulnar artery perforator flap is a practical alternative for the reconstruction of two large adjacent pulps with satisfactory functional and aesthetic outcomes. Key words: Ulnar artery perforator flap; Proper palmar digital artery; Finger injuries; Reconstruction fo sensate

Clinical observation of combined skin flap and abdominal flap for repair of distal finger degloving injury

Objective To compare the clinical effect and operation difficulty of the combined skin flap with reversed proper palmar digital arterial dorsal branch island flap and cross-finger flap and the abdominal flap in the treatment of distal finger degloving injury. Methods Inclusion criteria: ①Soft tissue defect far beyond the level of distal interphalangeal joints. ②The inured finger was from second to fifth. ③Single finger injury. ④ Iniury time within 8 h. Exclusive criteria: ①With tendon injury.② Multiple finger injuries. ③Followed-up time within 6 months. Between February, 2009 and September, 2016, 52 patients (52 fingers) with distal finger degloving injury were reviewed, there were 32 males and 20 females, aged from 18 to 60(36.02±11.00) years. The time from injury to operation was 2.5-8.0 (4.81±1.28) h. Affected fingers included index finger in 15 cases, middle finger in 22 cases, ring finger in 10 cases, and little finger in 5 cases. Twenty patients (20 fingers) were treated by combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap(group combined-flap). The cubital skin was grafted onto the donor sites. Thirty-two patients (32 fingers) were treated by abdominal flap (group abdominal-flap). Results The patients were followed-up 6-25 (9.25±3.97) months. The operation time: group combined-flap was 80-130(98.46±8.34) min and group abdominal-flap was 85-125(107.84±8.63)min. There was no significant difference in two groups(P>0.05). Pedicle division time: group combined-flap was 15-24 (16.75±1.74) d and group abdominal-flap was 24-45(28.31±5.12) d. There was a significant difference in two groups(P<0.05). And the pedicle division time in group combined-flap was much shorter than in group abdominal-flap. Flap function at last follow-up, the excellent and good rate of the flap in group combined-flap and group abdominal-flap was 90.00% and 59.38%, respectively. There was a significant difference in two groups (P<0.05), and the flap function in group combined-flap was much better than in group abdominal-flap. Affected finger function at last follow-up, the excellent and good rate of the affected fingers was 95.00% and 71.88%. There was a significant difference in two groups(P<0.05), and the affected finger function in group combined-flap was much better than in group abdominal-flap. Conclusion The combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap is a simple and high-survival-rate flap, whose texture, appearance and clinical outcome for repair of distal finger degloving injury are much better than traditional abdominal flap. Key words: Degloved injury; Finger; Dorsal branch, proper palmar digital artery; Island flap; Cross finger skin flap; Combined skin flap; Repair

Reactive hyperemia-peripheral arterial tonometry is useful for assessment of not only endothelial function but also stenosis of the digital artery

BackgroundAlthough reactive hyperemia-peripheral arterial tonometry (RH-PAT) is widely used for assessment of endothelial function, RH index (RHI) cannot be measured in some cases when pulse wave amplitude (PWA) is very low. Decrease in PWA is mainly caused by proper palmar digital artery (PPDA) stenosis. The purpose of this study was to evaluate the relationship between PWA measured by RH-PAT and stenosis of the PPDA measured by digital subtraction angiography and to evaluate the limitation of assessment of endothelial function measured by RHI in patients with PPDA stenosis. MethodsWe measured baseline PWA in 51 fingers including the first to third fingers of both hands in 10 patients who had PPDA stenosis and in 66 fingers that were the first fingers of both hands in 33 subjects who had no PPDA stenosis. Severe stenosis was defined as over 75% by lower percent diameter stenosis between two PPDAs in a finger. ResultsPWA was significantly correlated with stenosis of the digital artery (r=−0.55; P<0.0001). A PWV value of 300mV was the optimal cut-off value for severe stenosis (sensitivity, 84.0%; specificity, 88.5%). Log RHI was significantly lower in patients with PPDA stenosis than in subjects without PPDA stenosis (0.33±0.27 versus 0.73±0.27, P=0.007). ConclusionsRH-PAT may be useful for assessment of not only endothelial function but also PPDA stenosis. RHI may be underestimated in patients with PPDA stenosis. We should pay attention to low baseline PWA when measuring RHI. Clinical trial registration informationURL for clinical trial: http://UMIN; registration number for clinical trial: UMIN000003409.

Aneurysms of the hand: Imaging and surgical technique

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

Blood bridge venous flap to repair finger wound with proper palmar digital artery defect

Objective To explore the application and clinical effect of blood bridge venous flap in finger wound with proper palmar digital artery defect. Methods From February, 2007 to September, 2016, 11 cases of fin- ger wound with artery defect were repaired with forearm vein free flap by the way of bridging blood vessels. The time from injury to surgery was 1.5 to 6 hours (average 2.5 hours) . Vascular defect length was 1.4 to 3.4 cm (average 2.3 cm) . 8 cases were bridged the unilateral digital artery and 3 cases were bridged the both side. The area of skin flap was 1.5 cm × 2.0 cm to 2.2 cm × 3.5 cm and the donor site was sutured directly. Results One case appeared necrosis in marginal part and healed after dressing change. The other flaps and finger survived and the incisions healed well.All the 11 cases were followed up after operation. The follow-up time ranged from 6 to 20 months, aver- aged 10 months. The color and texture were well ,the sensation of temperature, pain and tactile were recovered, and the flap had good contour. According to TAM system evaluation method: 6 cases got excellent results, 4 cases were good, 1 case was poor. The donor site only had a linear scar and the flexion and extension of wrist were not limited. Conclusion Flow bridging venous flap can reconstruct the finger blood and repair the wound simultaneously. To the finger with nerve or tendon defect, bridged with the cutaneous nerve or palmaris longus tendon can also get satisfactory result. Key words: Surgical flap; Venous flap; Finger injuries; Proper palmar digital artery; Microsurgical operation