第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损

目的报道第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损的临床效果。方法2005年8月-2012年10月,采用第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损35例,术后随访3-24个月。结果本组35例皮瓣成活良好,外观满意,两点辨别觉达6-10mm,无虎口挛缩,拇食指的对捏、对掌功能恢复良好。结论第一掌背动脉皮瓣修复拇、食指皮肤软组织缺损操作简单,供血血管变异率低,无需再次手术断蒂,也可制成带血运的掌骨、伸肌腱复合组织瓣,且能携带掌背皮神经重建感觉,值得临床推广。     

The innervated first dorsal metacarpal artery island flap for reconstruction of post-traumatic thumb defect

Background

Various surgical techniques contribute to repair distal defects of the fingers, especially the thumb as traumatic loss diminishes or eliminates the thumb prehensile abilities and may affect overall hand function.

Methods

Ten innervated first dorsal metacarpal artery (FDMCA) island flaps were performed and evaluated postoperatively. The function of the thumb and the cosmetic appearance were documented for all patients.

Results

The flap survived with good cosmetic results in all cases. Grasping and pinching activity as well as cortical orientation was achieved for all flaps.

Conclusion

It appears that the FDMCA flap is one of the best solutions for cover of simple or complex skin loss of the thumb. Its technical performance is easy, and it gives durable, sensate, and stable skin cover. Level of Evidence: Level 4, therapeutic study.     

第1掌背动脉皮瓣一期修复儿童拇指软组织缺损

目的探讨第1掌背动脉皮瓣一期顺行修复儿童拇指软组织缺损的临床效果。方法选取自2009-06—2012—06收治的拇指皮肤组织缺损息儿11例,行急诊清创、残端修整及伴肌腱断裂的修补,骨折患者给予克氏针内固定,11例均予一期第1掌背动脉皮瓣修复拇指组织缺损。结果术后组织瓣全部成活,供区、受区伤口均一期愈合,质地与色泽较好。随访时间为3。24个月,平均10个月,无继发性感染发生,感觉恢复S3一S4,肢体外形与功能满意。结论儿童拇指软组织缺损应用第1掌背动脉皮瓣移植修复、重建软组织,可以避免儿童患拇指功能障碍。采用该皮瓣技术血供可靠、操作简单,是一期修复儿童拇指皮肤缺损理想的治疗方法。     

Flap within a first dorsal metacarpal artery flap for recurrent thumb injury

Thumb pulp defects are commonly due to avulsion injuries. It is important to reconstruct these defects using sensate. A very good option for these defects is the islanded first dorsal metacarpal artery flap (FDMA). We present a patient, a carpenter by occupation, who had initial thumb pulp injury which was reconstructed with islanded first dorsal metacarpal artery flap. At 6-month follow-up, he had near normal sensation and two-point discrimination of 2 mm. The same patient represented after 1 year with similar injury to the same reconstructed thumb. This time, VY advancement flap was designed within the remnant of the previous FDMA flap. Flap within a flap is not a new concept. In the present scenario, it worked as a great indigenous solution as it was a simple alternative. It preserved the sensation and avoided the need of other complex reconstructions. The procedure was performed under local anaesthesia, and patient could return to his normal activities within 2 weeks post-op. This is a rare case report of making use of the concept of flap within a flap for recurrent thumb injury which was reconstructed previously with FDMA flap. VY advancement design aided the necessary movement required to cover the defect yet preserving the regained sensation making it a useful tool before embarking upon complex reconstructions.Level of Evidence: Level V, therapeutic study.     

Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb

Finding an appropriate soft-tissue grafting material to close a wound located over the distal phalanx of the thumb, especially the pulp region, can be a difficult task. A sensate first dorsal metacarpal artery flap, mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap, can be useful for this purpose. The pedicle includes the ulnar branch of the first dorsal metacarpal artery, the dorsal veins, and the cutaneous branch of the radial nerve. Although this tiny artery is anatomically variable, safe dissection can be achieved by including the radial shaft periosteum of the secondary metacarpal bone and the ulnar head fascia of the first interosseous muscle.This approach has been used for 8 individuals with extensive pulp defects of the thumb over the past 3 years. Skin defects in all patients were combined with bone, joint, or tendon exposure. All flaps survived completely. This 1-stage procedure is reliable and technically simple. It provides sensate coverage to the pulp of the thumb but also avoids nerve repair or more complicated microsurgery.     

Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap

PURPOSE: This study investigated the quality of sensibility from innervated first dorsal metacarpal artery (FDMCA) island flaps in younger and older patients and evaluated the donor site morbidity at the index finger. METHODS: Twenty-five patients with an innervated FDMCA island flap to restore sensibility of the thumb were divided into groups according to age (>50 or <50 years). Sensory recovery and cortical reorientation were tested with Semmes-Weinstein monofilaments, a calibrated 2-point discrimination tester, and needle prick testing. Donor site morbidity was evaluated for range of motion, aesthetic appearance, pain, and problems with injuries. RESULTS: The mean age of the patients was 48.3 years and the mean follow-up period was 3 years. The 14 patients older than 50 years had a static 2-point discrimination (s2-PD) of 10.9 mm compared with 10.8 mm of the 11 patients younger than 50 years. The average loss of s2-PD of the flap compared with the donor area averaged 2.7 mm in all patients. Complete cortical reorientation occurred in 7 patients older than 50 years and in 5 patients younger than 50 years. Total loss of range of motion of all donor finger joints was 14 degrees (4.4%) compared with the contralateral index finger. Twenty-two patients were satisfied with the result. CONCLUSIONS: There were no age-related differences in the surgical results of the innervated FDMCA island flap and the donor site morbidity was negligible.     

第一掌背动脉皮瓣联合大鱼际皮瓣修复拇指末节皮肤脱套伤

【摘要】目的 探讨第1掌背动脉皮瓣联合大鱼际皮瓣修复拇指末节皮肤套脱伤的疗效。方法 2009年1月至2014年7月,我院对19例拇指末节皮肤套脱伤患者,创面缺损面积在20mm×50mm～30mm×60mm之间,拇指末节皮肤套脱合并甲床缺如13例,皮肤套脱伴甲床残留6例,均采用第1掌背动脉皮瓣联合大鱼际皮瓣进行修复,并观察术后19例拇指功能外形感觉等指标。 结果 本组12例皮瓣术后完全存活;5例术后2～4天皮瓣表面出现水疱,颜色暗红、发紫,间断拆除蒂部旋转点缝线后,皮瓣血运逐渐好转,最终存活良好;2例第1掌背动脉皮瓣尖端皮缘坏死,换药后痂下愈合,无骨外露,所有供区切口均1期愈合。经过3个月随访,手指皮瓣外形良好,指腹皮瓣感觉可,两点辨别觉6～9mm,指背皮瓣无感觉恢复;按照手指总主动活动度(TAM)法评定,优17指,良2指,优良率为100％,按照Michigan手外科问卷评定患者对拇指术后外观的满意度评定,非常满意15例,满意4例. 结论 该术式疗效满意,是治疗拇指末节皮肤套脱伤可行性的一种方法。     

拇指背侧皮神经营养血管皮瓣修复拇指远端缺损

目的:介绍拇指背侧皮神经营养血管皮瓣修复拇指远端缺损的方法及临床疗效。方法:2011年2月~2014年2月,共接收21例拇指远端缺损患者,采用拇指背侧皮神经营养血管皮瓣逆转修复,全厚皮片植皮皮瓣供区。结果:术后21例皮瓣、皮片全部存活。随访6~18个月,拇指外形良好,皮瓣两点辨别觉为8~12mm。结论:采用拇指背侧皮神经营养血管皮瓣修复拇指远端缺损,手术简易,设计灵活,成功率高,不必寻找指定动脉,不损伤供区主干血管,血管蒂长,切取面积大,皮瓣内带有皮神经,术中可与缺损区的神经断端吻合,利于恢复保护性感觉,是修复拇指软组织缺损的理想方法。     

Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap

In the management of a debilitated burned hand due to contractures, thumb reconstruction constitutes the most crucial part for a beneficial functional outcome. Among the limited local flap alternatives for the thumb, the first dorsal metacarpal artery flap, harvested from the dorsal aspect of the index finger can provide elastic, durable and sensate coverage for soft tissue defects after contracture release. In a 3-year period, neurovascular island first dorsal metacarpal artery flap was used in 14 patients suffering thumb deformities. The time elapsed after the underlying injury until reconstruction ranged from 5 months to 17 years. Follow-up revealed that all deformities were successfully treated with satisfactory functional recovery and cosmetic results. Donor site morbidity was minimal with an acceptable scar on the dorsum of the index finger and adequate tendon gliding without producing extension deficit. Our experience with management of deformities involving the thumb and/or adjacent thenar area revealed that the first dorsal metacarpal artery flap is a reliable local neurovascular island flap option, offering acceptable functional and cosmetic outcomes in respect to sensation, elasticity, durability and skin-match.     

第一掌骨背侧间隙皮瓣修复拇指腹缺损

拇指受伤率高，对于拇指远侧指关节、示指近侧段的皮肤软组织缺损，修复方法较多，作者2001年2月-2003年1月应用第一掌骨间隙背侧皮瓣修复手指面，取得满意效果，报告如下。     

The first dorsal metacarpal flap in first web space and thumb reconstruction

Small local flaps for reconstruction of contractures or defects on the hand are useful. The first dorsal metacarpal flap from the dorsal surface of the proximal index is a convenient local flap in hand surgery. The flap may include the dorsal vein and, most importantly, the cutaneous branch of radial nerve. Although there may be some variations of the vascular pedicle, the flap is reliable using careful dissection. In a series of 15 patients, reconstruction with this flap was successful except for 1 patient with marginal necrosis. The first dorsal metacarpal flap is a reliable and convenient local flap in reconstruction of defects or contracture on the thumb and first web space.     

Foucher first dorsal metacarpal artery flap versus littler heterodigital neurovascular flap in resurfacing thumb pulp loss defects

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.     

The first dorsal metacarpal artery neurovascular island flap

A first dorsal metacarpal artery island flap from the index finger was used in 20 cases for reconstruction of defects in the hand. In six cases it was used as a neurovascular flap for sensory resurfacing of the thumb and in five cases for release of a contracted first web. One flap underwent necrosis and there was a complication in one donor site.     

The first dorsal metacarpal artery neurovascular osteocutaneous flap--a new method of distal thumb reconstruction]

Basing on the earlier experience with neurovascular flap from the dorsal part of the index when reconstructing soft tissues of thumb and thenar, first of the authors elaborated a method of harvesting this flap together with a dorsal aponeurosis and bone fragment of the proximal phalanx. Blood flow comes from the periosteum of the proximal phalanx. Many small vessels penetrate into it from the dorsal soft tissues thus piercing central part of the dorsal aponeurosis in many points. The flap was used in 25 year old male who had secondary reconstruction of the mutilating thumb pulp when the nail and nail matrix were preserved and in 27 year old male after amputation and replantation of nearly completely damaged distal part of the thumb. In this case bone healing was not obtained in spite of the arthrodesis and extensive impairment of digital nerves did not allow to carry out a primary nerve suture. A bone fragment in the flap was used to perform secondary arthrodesis and well innervated soft tissues of the flap improved sensation of the thumb distal part. The functional and cosmetic results were good. During thirteen and eleven years follow up the patients did not show any complications both in the donor and recipient sites.     

改良第一掌背动脉岛状皮瓣修复拇指软组织缺损的疗效观察

目的 探讨改良第一掌背动脉岛状皮瓣修复拇指远端软组织缺损的成活优良率和感觉重建的疗效.方法 2004年3月至2007年10月,应用第一掌背动脉(the first dorsal metacarpal artery,FDMCA)皮瓣修复拇指近(末)节掌侧软组织缺损65例,获得完整随访资料者49例.男37例,女12例;年龄18～65岁,平均32岁.分别采用改良(31例)及常规筋膜蒂切取法(18例)治疗.改良方法与传统方法不同之处在于蒂部除包含FDMCA及该血管周围1 mm的肌袖外,还携带第一背侧骨间肌两肌腹间沟内的组织及宽1.5～2.0 cm的深筋膜及骨间肌肌膜为蒂.并将筋膜蒂中的神经束切断与拇指掌侧指神经残端以8-0线吻合.对两组皮瓣出现远端坏死、血管危象的频率及感觉恢复的差异进行统计学分析.结果 术后随访20个月～3年,平均2年.49块皮瓣中46块完全成活.用常规方法切取的皮瓣18例中5例术后出现血管危象,最终3块皮瓣远端部分坏死.31例改良FDMCA皮瓣成活良好,感觉恢复满意,且定位于拇指;18例神经转位皮瓣均有不同程度的混合感觉(33%)或异位感觉(62%),仅1例皮瓣感觉完全定位于拇指.结论 改良筋膜蒂切取法的FDMCA皮瓣成活优良率明显提高.将皮瓣内携带的桡神经浅支与受区拇指掌侧指神经吻合可使皮瓣感觉定位于拇指,但尚不能证明其对皮瓣两点分辨觉及实体感觉恢复有明显影响.     

第一掌骨背逆行筋膜皮瓣修复拇指皮肤缺损

目的介绍一种修复拇指皮肤缺损的新型逆行筋膜皮瓣。方法取１０只新鲜尸体手，从桡动脉灌注红色乳胶，对第一掌骨背及拇指指背软组织的血管进行显微解剖，根据其血管分布设计成第一掌骨背逆行筋膜皮瓣。自甲根部桡侧缘至第一掌骨同侧背侧缘的连线为轴心线，其蒂部宜设在拇指指间关节近侧１ｃｍ以近的轴心线上。结果第一掌骨背及拇指指背软组织的血供主要由拇指两条指掌侧固有动脉向指背侧发出的分支，在指背筋膜内与两侧指背动脉及桡神经浅支伴行血管（桡、尺侧各２条）形成的血管网提供。１９９６年２月～１９９７年９月，临床应用该皮瓣修复拇指皮肤缺损６例，皮瓣全部成活。结论第一掌骨背及拇指指背软组织血供丰富，可形成第一掌骨背逆行筋膜皮瓣。该皮瓣设计合理、血供可靠、操作简便，适用于修复拇指，尤其是拇指桡侧皮肤的缺损