Anatomical basis for a vascular pedicled island flap from the dorsal area of the wrist.

We explored the cutaneous vascularity of the dorsal wrist area to examine the possibility of using reverse island flaps from this area for reconstruction of the hands and fingers. Four dominant arterial branches including the dorsal branches of the ulnar and radial arteries and terminal branches of the anterior and posterior interosseous arteries, which supplied the dorsal skin over the extensor retinaculum, were explored. The location, number, and diameter of skin perforators from these arteries were examined. The dorsal branches of the radial and ulnar arteries that passed along the dorsal cutaneous nerves gave off 2-4 skin perforators (diameter 0.1-0.2 mm) at the level of the carpal bone and always connected distally to perforating arteries from the palmar arterial system at the metacarpal head. Skin perforators from the anterior and posterior interosseous arteries were found passing through the extensor retinaculum in the second and third and fifth and sixth intercompartmental areas. The terminal branches of the anterior and posterior interosseous arteries always continued to the dorsal carpal arch, and lay over the distal carpal row. It may be anatomically possible to raise two different island flaps from the dorsum of the wrist.     

The anatomic basis of the fourth dorsal metacarpal flap: a cadaveric dissection

PURPOSE: To study the vascularization of the fourth dorsal intermetacarpal space and to determine the contribution of the dorsal metacarpal artery and the interosseous muscle fascia to flap viability. The fourth dorsal intermetacarpal space is considered to be less reliable as a donor site because of previously reported vascular variations. METHODS: We performed 15 cadaver dissections. The vascular tree was injected with black latex through the radial and ulnar arteries at the forearm. The skin paddle was designed within the fourth intermetacarpal space. The proximal border was placed at the wrist joint line. The distal border was located 1 cm proximal to the head of the fourth and fifth metacarpal. The width of the skin paddle was based on whether the donor site could be closed directly. A zigzag incision was performed from the distal end of the skin paddle to the volar edge of the interdigital web. The borders of the skin paddle were outlined down to the fascia of the dorsal interosseous muscle. Once the fourth dorsal metacarpal artery was identified each vascular connection was dissected and recorded. RESULTS: The fourth dorsal metacarpal artery was identified in all specimens under the dorsal interosseous muscle fascia. The distal recurrent branch consistently entered the base of the flap superficial to the extensor digitorum communis tendon of the small finger and the dorsal interosseous muscle fascia. Cutaneous perforators branching off the dorsal metacarpal artery were not found consistently. CONCLUSIONS: Reliable flaps can be raised from the fourth dorsal intermetacarpal space based solely on the distal recurrent branch, excluding the dorsal metacarpal artery and interosseous muscle fascia.     

以掌背动脉为蒂尺骨远段背侧骨瓣移位术的应用解剖

目的 为以掌背动脉为蒂的尺骨远段背侧骨瓣移位修复第３、４、５掌骨头缺损提供解剖学依据。方法 在３０侧成人上肢标本上解剖,观察腕背动脉网的构成及分支。结果 腕背动脉网由桡动脉及尺动脉腕背支及与骨间后动脉终末支,骨间前动脉腕背支吻合形成,由该网发生第２、３、４掌背支,第２、３、４掌背动脉由掌背支与掌深弓所发深支吻合而成。结论 以第３、４掌背动脉为蒂的尺骨远端背侧半片骨瓣,可修复第３、４、５掌骨头缺损。     

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.     

The posterior interosseous flap: a review of 81 clinical cases and 100 anatomical dissections--assessment of its indications in reconstruction of hand defects.

Based on our experience of 100 cadaveric dissections and a series of 81 clinical cases, we have assessed the indications for the posterior interosseous flap in reconstruction of the hand. Large fasciocutaneous island flaps can be harvested, even when the radial or ulnar pedicles are damaged, sacrificing only vessels of secondary importance to the perfusion of the hand. Compound flaps can be dissected based on muscular, musculoperiosteal and fascioperiosteal branches. The primary indications for using this flap are dorsal hand defects up to the metacarpal joints, reconstruction of the first web space up to the interphalangeal joint of the thumb and extensive lesions on the ulnar border of the hand.     

前臂背侧嵌合骨皮瓣的应用解剖学研究

目的为前臂背侧嵌合骨皮瓣的设计提供解剖学基础。方法在22例成人上肢标本上解剖,观测骨间后动脉皮支分布,支配尺侧腕伸肌神经支与血管交叉点血管的外径及骨间后动脉与前动脉吻合情况。同时观测尺骨茎突近端5cm范围内,尺骨背侧骨膜血管支数目及血运来源。结果骨间后动脉沿途发出6-10个皮支,在深筋膜浅层形成丰富血管网吻合。可分为两种类型,Ⅰ型：间隔1-2cm发出皮支（15例）;Ⅱ型：分远、近两组（7例）。支配尺侧腕伸肌神经支与血管交叉点动脉外径（1．4±0．2）mm。在尺骨茎突近侧（2．4±0．5）cm处骨间后动脉与前动脉腕背支形成恒定吻合。尺骨茎突近侧5cm范围内,骨间后动脉向尺骨远段发出（3．0±0．8）支骨膜支（19例）;骨间后动脉发出2支骨膜支,骨间前动脉背侧支发出1支骨膜支（2例）;骨间前动脉背侧支发出2支骨膜支（1例）。结论以骨间后动脉为蒂可切取前臂背侧皮瓣、尺骨远端骨瓣形成嵌合组织瓣,修复手部皮肤缺损合并小块骨组织缺损。     

The first dorsal interosseous muscle: an anatomic study

The anatomy of the first dorsal interosseous muscle, with particular reference to its vascular and nerve supply, was studied in ten fresh cadaveric hands. A constant dorsal and palmar blood supply is identified from four major branches of the radial artery and deep palmar arch. The ulnar nerve innervates the muscle in a pattern that parallels the palmar blood supply. This information provides a basis for the use of the muscle as a local transposition flap.     

Anatomic study of distally based pedicle compound flaps with nutrient vessels of the cutaneous nerves and superficial veins of the forearm

The purpose of this study was to describe the anatomic basis for a distally based neurovenovascular pedicle compound flap, with nutrient vessels of the cutaneous nerves and superficial veins of the forearm. In this study, the origins, branches, and anastomoses of nutrient vessels of the cutaneous nerves and superficial veins of the forearm and their relationships with the blood supply of adjacent muscle, bone, and skin were assessed in 96 adult cadavers by perfusion of red gelatin into the superior limb arteries. The results showed that the nutrient vessels of cutaneous nerves and superficial veins of the forearm were found to have multiple origins, consisting of six longitudinal vascular plexuses and one transverse vascular plexus of the forearm, as follows: 1) the anterior-lateral vascular plexus from cutaneous branches of the radial artery; 2) the anterior-medialis vascular plexus from cutaneous branches of the ulnar artery; 3) the dorso-lateral vascular plexus from radial osteal and cutaneous branches; 4) the dorso-medialis vascular plexus from ulnar osteal and cutaneous branches; 5) the radial vascular plexus from osteal and cutaneous branches of the radial artery, cutaneous branches of the radial artery in the upper wrist, recurrent branches of the styloid process of the radius, and the radialis vascular plexus of cutaneous branches of the tabatière anatomique (anatomical snuffbox); and 6) the ulnar lateral vascular plexus from cutaneous branches of the ulnar artery in the upper wrist and osteal and cutaneous branches. The transverse vascular plexus is composed of dorsal branches of the ulnar and radial arteries. These perforating branches give fascial branches, cutaneous branches, periosteal branches, and nutrient vessels of cutaneous nerves and superficial veins. These results suggest that nutrient vessels of the cutaneous nerves and superficial veins of the forearm have the same origins as those of the nutrient vessels of adjacent muscles, bones, and skin of the forearm, which can be designated as five types of distally based pedicle flaps with nutrient vessels of cutaneous nerves and superficial veins of the forearm, whose rotation point is at the wrist joint. This flap can be applied to repair tissues of distal parts of the hand.     

Cutaneous perforators of the fourth dorsal interosseous space: anatomic study

PURPOSE: Many investigators have studied the vascular anatomy of the dorsal metacarpal arteries but little attention has been paid to the exact distribution of the cutaneous perforators of the dorsum of the hand. We present an anatomic study of the cutaneous perforators within the fourth dorsal interosseous space, which was supposed to have the most inconsistent vascular anatomy. METHODS: Twenty hands were dissected after black latex injection. A skin paddle was outlined along the fourth dorsal metacarpal space. Suprafascial dissection was performed, preserving any vessel piercing the fascia and reaching the skin. Each perforator was traced back to its origin. The location and origin of each perforator was recorded by digital pictures and measured from a reference point. RESULTS: In 17 of the cases (85%) at least 1 perforator was identified within the fourth space piercing the dorsal interosseous muscle fascia and reaching the skin. In 10 hands, a perforator branching off the proximal communicating branch was identified, located a mean distance of 11 mm from the carpometacarpal joint line. CONCLUSIONS: A dissectable perforator was found consistently (17 of 20; 85%) in the proximal third of the fourth dorsal interosseous space branching off the proximal communicating branch. Few perforators branch off the middle third of the dorsal metacarpal artery. The perforator described herein shows the connection between the superficial and deep vascular systems of the ring and small metacarpal spaces, and establishes the anatomic basis for reconstructive flaps.     

第二掌背动脉岛状皮瓣的临床应用

目的：通过解剖学研究，设计第２掌背动脉岛状皮瓣，临床修复手部皮肤缺损，获得成功。方法：对５０只经动脉灌注红色乳胶的成人手标本，在放大镜下观察第２掌背动脉及伴行静脉的起端，皮支、终末支的走行；测量血管各部位的直径。结果：第２掌背动脉终末支分布于第２指蹼、示中指近节皮肤；皮支和其它掌背、掌指动脉间有丰富的吻合支。临床应用８例，顺行皮瓣７例，逆行１例。修复手背、拇指皮肤缺损，皮瓣全部成活。结论：临床应用第２掌背动脉为蒂的岛状皮瓣时，可设计成顺行或逆行皮瓣，均能成活。     

改良掌背逆行岛状皮瓣的临床应用

目的：探讨切取掌背皮瓣的改进方法及其临床应用效果方法：复习相关掌背动脉解剖学研究成果,改进掌背动脉逆行岛状皮瓣的切取方法,以背侧指蹼中点和两掌骨基底部汇合点连线设计为轴线,距指蹼缘近侧约1．5cm为旋转点,在深筋膜下、伸肌腱腱膜浅层解剖皮瓣,保留掌背动脉远端皮支,临床分别应用修复12例食、中、环、小指中、近节皮肤软组织缺损。结果：12例皮瓣全部成活,1例皮瓣术后远端出现张力性水疱,皮瓣远端部分表皮坏死,后创面经换药后愈合。术后随访3～6个月,皮瓣质地、外观满意,手背部外形功能良好。结论：自深筋膜下、指伸腱膜浅面解剖皮瓣,保留掌背动脉远端皮支的掌背动脉逆行岛状皮瓣手术方法操作简便,对供区损伤小,应用于修复手指近、中节皮肤软组织软缺损创面临床效果好。     

Is the reversed fourth dorsal metacarpal flap reliable?

We have carried out a study to determine if a flap based on vessels in the fourth metacarpal space could be used safely. We studied ten fresh cadaver specimens and used the flap in nine patients. In the anatomical study, we confirmed the presence of a suitable artery in nine out of the ten hands, arising from a piercing artery at the metacarpal bases, running distally under the fascia. The pivot point is located at the metacarpal heads, where the artery anastomoses to palmar branches and dorsal digital branches. In the clinical setting, the flap was reliable in eight patients. There was one case of flap necrosis. The flap seems to be reliable but several technical points are stressed to avoid complications.     

七种轴型血管蒂皮瓣修复手部软组织缺损

目的探讨和总结应用轴型皮瓣修复手部软组织缺损的临床疗效。方法根据手部软组织缺损的不N情况分别采用尺动脉腕上支皮瓣、骨间背动脉逆行岛状皮瓣、前臂皮神经逆行岛状皮瓣、指背筋膜岛状皮瓣、掌背动脉岛状皮瓣、指动脉岛状皮瓣、髂腹股沟皮瓣7种方法进行修复。结果临床应用75例,静脉回流障碍6例,局部血运不良部分坏死3例,经处理皮瓣均成活。随访3～36个月,皮瓣质地、感觉好,手功能恢复满意。结论7种轴型血管蒂皮瓣修复手部软组织缺损疗效满意。     

Vascular anatomy of the pronator quadratus muscle-bone flap: a justification for its use with a distally based blood supply

The vascular anatomy of the pronator quadratus muscle and distal radius was studied in 24 cadaveric forearms by dissection under magnification and india ink and latex injection studies. The anterior interosseous artery divides into a muscular branch and a dorsal branch 1 cm to 3.5 cm from the proximal margin of the pronator quadratus muscle, and on its deep surface. Injection studies showed a rich periosteal plexus contributed by the anterior interosseous artery. Retrograde injection through the dorsal branch also showed good perfusion of the distal radius that was confirmed microscopically on bone sections. A muscle-bone graft from the anteromedial cortex of distal radius with an intact anterior interosseous artery has mobility of less than 2 cm. After ligating and dividing the anterior interosseous artery, blood supply to the distal radius bone flap relies on a retrograde flow and the bone flap could then be mobilized distally up to 4 to 6 cm.     

"Distally based dorsal hand flaps": clinical experience, cadaveric studies and an update.

Many developments have taken place in the area of distally based dorsal hand flaps since 1988. This paper reported these developments as well as our clinical experience and cadaveric studies. Thirty-three reverse dorsal metacarpal artery (RDMA) flaps, 11 reverse dorsal digital artery (RDDA) flaps and five extended RDMA flaps done in the Institute for Research and Rehabilitation of Hand, Stanley Hospital, Chennai, India during the period between 1996 and 2002 are reviewed. In our series, we used simple, composite, fasciocutaneous and adipofascial flaps, encountered 4% total loss and 6% partial loss. A series of injected cadaveric hands were studied in the Institute D'Anatomie de Paris. An important anatomical finding in this cadaveric study is the dorsal metacarpal artery terminating at the confluence of common digital artery branching into digital arteries proper to the neighbouring digits in all the eight hands dissected. We undertake a critical review of the literature, highlighting the sequence of developments in the knowledge of relevant anatomy and various flap designs as distally based dorsal hand flaps since their first popular report in 1990.     

Posterior interosseous island forearm flap

The skin of the dorsal aspect of the forearm is supplied by several cutaneous branches of the posterior interosseous artery. This vascular anatomy permits the surgeon to obtain an island flap of the dorsal forearm based on the distal anastomosis between the two interosseous arteries at the distal part of the interosseous space. This flap can reliably be transferred to different skin defects of the hand such as those created by correction of an adduction contracture of the first web space, or on the back or front of the wrist level. Its principal advantages are that it is a thin flap with excellent circulation and that it is possible to close the donor area primarily provided the island flap is not wider than 3 to 4 cm. The procedure has been employed in 25 patients with satisfactory results.     

Die distal gestielte Arteria-interossea-posterior-Lappenplastik zur Defektdeckung am Handgelenk und an der Hand

OBJECTIVE: Coverage of defects on the upper limb with the distally pedicled, fasciocutaneous posterior interosseous artery flap. INDICATIONS: Defects with exposed tendon and/or bony tissue on the palmar and dorsal side of the wrist, the hand upon the proximal interphalangeal joint level and the whole thumb. Coverage of defects on the palmar side of wrist and palm of the hand with exposed median and/or ulnar nerve. Enlargement of the 1st interdigital web space in cases of thumb adduction contracture. CONTRAINDICATIONS: Surgery at the flap harvesting site on the proximal third of the forearm. Surgery at the site of the flap pedicle on the middle and distal third of the forearm upon the distal radioulnar joint. Absence of the distal anastomosis between the anterior and posterior interosseous arteries at the level of the distal radioulnar joint (5% of the cases). SURGICAL TECHNIQUE: Skin markings of the planned island flap and subsequent S-curved skin incision along the flap pedicle upon the level of the distal radioulnar joint; blunt dissection onto the forearm fascia. Incision of the forearm fascia between the extensor digitorum communis and extensor digiti minimi muscles. Dissection of the flap pedicle between the extensor digiti minimi and extensor carpi ulnaris muscles with subsequent identification of the posterior interosseous artery (no dissection!). Skin incision around the flap island. Dissection and ligation of the proximal anastomosis between the anterior and posterior interosseous arteries; mobilization of the flap island and pedicle from the ulnar shaft. Mobilization can be performed until the distal anastomosis of the anterior and posterior interosseous arteries is reached (flap pivot point). POSTOPERATIVE MANAGEMENT: Plaster immobilization of the wrist and/or fingers for 7 days. Start of occupational therapy from the 7th postoperative day. Removal of sutures on the 12th-14th postoperative day. Wearing of compression garments. RESULTS: From November 2005 until June 2007, 25 distally pedicled posterior interosseous artery flaps were performed. With this type of flap, it was possible to successfully enlarge the 1st interdigital web space in two patients and to cover the whole thumb in two cases of degloving injury. In nine patients, the flap was used to cover the median and/or ulnar nerve at the level of the wrist and/or palm of the hand, and in four cases, to cover defects after tumor resection on the palm of the hand. Exposed extensor tendons and/or bony structures were covered with this flap in another eight patients. In two of the 25 flaps, distinct necroses of the most distal edge of the skin island were seen. After surgical debridement and split-skin transplantation, all of these small superficial defects healed well. Absence of the distal anastomosis as well as complete flap failure could not be observed in this series.     

The vascular anatomy of the abductor digiti minimi and the flexor digiti minimi brevis muscles

PURPOSE: The abductor digiti minimi (ADM) and the flexor digiti minimi (FDM) brevis muscles could be used as flaps with their low functional morbidity, especially in severe crushed injuries of the hand. The vascular anatomy of both of the muscles were investigated to classify the muscles according to the Mathes-Nahai classification. METHODS: Nine cadavers embalmed with formaline were dissected under loupe magnification (x4) from the wrist proximally to the proximal phalanx of the small finger distally, delineating the branches of the ulnar artery along the ADM and FDM muscles. RESULTS: The dissections and the microangiography of the muscles revealed 1 major and 2 minor pedicles. Both of the muscles could be classified as type II muscles according to the Mathes-Nahai classification. CONCLUSIONS: The vascular pattern of the ADM muscle has been described previously, this study explored the vascular anatomy of the FDM muscle. The information regarding the vascular supplies of these muscles could be of help to the clinician when manipulating the muscles. The FDM muscle could be a suitable alternative for the ADM muscle in opponensplasty. When the pedicles are preserved the muscles could be used--based proximally or distally.     

Vascular basis of dorsal digital and metacarpal skin flaps

We studied the vascular anatomy of dorsal digital skin flaps and the vascular anastomoses between the dorsal cutaneous branch of the palmar digital artery (PDA) and the dorsal digital branches (the terminal branches) of the dorsal metacarpal artery (DMA) at the level of the proximal phalanx. Eight fresh cadavers (16 hands) were injected with a lead oxide-gelatin mixture. Our radiographic assessment revealed that there were 2 sources of the arterial supply to the dorsum of the digit, the dorsal digital branches of the DMA, and the dorsal cutaneous branches of the PDA. These branches anastomose with each other. A flap including the territory of the dorsal cutaneous branches of the PDA and a part of the territory of the DMA can be harvested on the dorsal aspect of the proximal and middle phalanges. The extended neurovascular island flap, based on the PDA and the dorsal branch of digital nerve, can be transposed to the volar surface of an adjacent finger resurfacing the entire length of the digit.