Further experience with the bipedicled neurovascular island flap in thumb reconstruction

A procedure is described for the transfer of sensibility to the thumb by means of an island flap. The donor site is the dorsoradial surface of the index finger. The flap is supplied by two neurovascular pedicles. The palmar one includes the digital artery of the index and the dorsal branch of the palmar digital nerve. The dorsal pedicle includes the dorsoradial artery and nerve of the index and one or two superficial veins. This procedure was used in 29 patients without early postoperative complications. The advantages of the method are the resurfacing of the prehensile surface of the thumb by a flap with good arterial and venous supply while preserving the innervation and the palmar skin of the donor finger.     

Revascularization of a finger with a thenar mini-free flap

A devascularized index finger with a soft tissue defect on its palmar side was managed by using a small free flap raised at the level of the metacarpophalangeal joint of the thumb. The radial digital artery was included in the flap and used to revascularize the index finger, and a palmar vein was used to drain the flap. This resulted in minimal donor side morbidity.     

Dual innervated index to thumb cross finger or island flap reconstruction

Partial volar amputations of the entire thumb pulp require soft tissue coverage that provides not only padding and protection for exposed bone and tendons, but also restoration of discriminative sensation. A modification of the radial sensory innervated cross finger flap from index to thumb is described, which includes separate reinnervation of the flap by repair of the dorsal sensory branch of the index radial digital nerve to the ulnar digital nerve of thumb. The anatomical basis for this flap is discussed and two example cases presented. Sensory reinnervation is rapid and does not require cortical reorientation.     

拇指撕脱离断伤再植术中两侧指固有神经的修复

目的介绍拇指撕脱离断伤再植术中修复拇指两侧指固有神经的方法。方法1999年8月-2009年4月,在12例拇指撕脱离断伤再植术中,采用食指桡侧指固有神经背侧支和桡神经浅支第2指蹼支移位的方法,修复拇指两侧指固有神经。结果12例拇指撕脱离断伤均再植成功,均获随访1～2年,平均16月。拇指两侧感觉均恢复良好,两点分辨觉小于10mm,平均约7mm,按照感觉功能评定标准为S4。结论拇指撕脱离断伤再植术中,应用食指桡侧指固有神经背侧支与桡神经浅支第2指蹼支移位,能恢复拇指指腹两侧良好感觉。     

Treatment of skin and median nerve defects with peroneal neurofasciocutaneous flap

A large neurofasciocutaneous flap that consisted of a peroneal flap and a segment of sural nerve was used in the simultaneous reconstruction of a large soft tissue and nerve defect caused by a crushing injury of the distal forearm. A 10 x 15 cm peroneal flap, including a 10 cm segment of sural nerve, was successfully transferred to an 8 x 12 cm skin defect, reconstructing a 5 cm defect of the median nerve. Two years after repair, the opponens pollicis muscle showed good contraction, although palmar abduction of the thumb remained poor. Static two-point discrimination was 20 mm on the pulp surface of both thumb and index finger and 15 mm on the middle finger.     

Apparent weakness of median and ulnar motors in radial nerve palsy

Muscle testing of a patient with radial nerve palsy can incorrectly suggest median and ulnar weakness because of a decreased ability to stabilize the thumb and wrist. Ten adult volunteers had radial nerve blocks and their strengths were quantitatively evaluated before and after blocking for grip, key pinch, isolated thumb adduction (adduction pinch), thumb palmar abduction, finger flexion, and flexor pollicis longus (FPL) function. Data were analyzed by paired t test (p less than 0.05). All composite motions that required stabilization of the wrist or thumb showed marked weakness after the radial nerve block (grip decreased 77%, key pinch decreased 33%, and thumb palmar abduction strength decreased 53%). The strength of adduction pinch, finger flexion, and FPL showed no significant decreases after the radial nerve block. Since adduction pinch and isolated FPL function can be easily tested clinically, they should be examined to prevent confusion with median and ulnar problems.     

Combined index finger pollicization with an anterolateral thigh flap for thumb reconstruction

A severe crush injury to the hand is devastating to patients. Under conditions in which the crush force is too great, the digits are not viable candidates for replantation. We present two cases in which the patients suffered from loss of the thumb ray at the first carpometacarpal joint and skin defect at the radial side. The tendons, radial nerve and metacarpal bone of the index finger were injured, and the second metacarpal head was retained. There was a comminuted fracture of the trapezium in both patients. The treatment protocols consisted of the index finger pollicization and the free anterolateral thigh flap transfer. The procedure was performed in a single operation. The new thumb is able to provide a stable post for pinch and grip after six months follow-up. Both patients were satisfied with the function and appearance of the reconstructed thumb.     

The dorsal flap of the first web

In the first web space region, there are communications between the dorsal arteries which arise from the dorsal branch of the radial artery and the digital arteries of the thumb and the index finger. These allow a distally based flap to be raised in the first dorsal intermetacarpal area. This flap has been used in 15 cases of soft-tissue loss from the thumb and index finger. The donor sites were closed primarily in all but two patients. There were no complications, and the results show that this flap is useful for soft-tissue defects on the tip and the palmar and dorsal surfaces of the thumb. Moreover, it may be used as a "cross-finger" flap.     

An alternative approach in the treatment of Dupuytren's contracture skin defects: first dorsal metacarpal artery island flap

Skin defects are often present following surgery for Dupuytren's contracture. The first dorsal metacarpal artery island flap (FDMA) has been used by others for soft tissue reconstruction about the radial and dorsal aspect of the hand, thumb and fingers. We have used it successfully to fill the skin defects often seen following palmar fasciectomy for Dupuytren's contracture. The thin nature of the flap makes it suitable for this application. The FDMA arises from the radial artery just before the radial artery enters the first dorsal interosseous muscle and divides into three branches: 1 to the thumb, 1 to the index finger (radiodorsal branch) and a muscular branch. It is the radiodorsal branch that supplies the skin over the index finger. The island flap based on this artery includes the dorsal terminal branches of the radial nerve and venae comitantes. The flap is formed to include the fascia of the first dorsal interosseous muscle to avoid injury to a possible deep artery and to yield sufficient fat to promote venous drainage. The flap is passed subcutaneously through the first web space and sutured in place to cover the skin defect in the palm. A full thickness skin graft is used to cover the defect over the proximal phalanx of the index finger.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

Innervated boomerang flap for finger pulp reconstruction

The boomerang flap originates from the dorsolateral aspect of the proximal phalanx of an adjacent digit and is supplied by the retrograde blood flow through the vascular arcades between the dorsal and palmar digital arteries. To provide sensation of the boomerang flap for finger pulp reconstruction, the dorsal sensory branch of the proper digital nerve and the superficial sensory branch of the corresponding radial or ulnar nerve are included within the skin flap. After transfer of the flap to the injured site, epineural neurorrhaphies are done between the digital nerves of the pulp and the sensory branches of the flap. We used this sensory flap in five patients, with more than 1 year follow-up, and all patients achieved measurable two-points discrimination. The boomerang flap not only preserves the proper palmar digital artery but also provides an extended and innervated skin paddle. It seems to be an alternative choice for one-stage reconstruction of major pulp defect.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.

Abstract：

Objective To explore a new method for repair of concurrent skin and nerve defect at palm and carpal on ulnar side. Methods From April 2000 to August 2009, five cases with concurrent skin and nerve defect at palm and carpal on ulnar side were reconstructed with free medial plantar flaps.Palmar nervous proprii defect at ulnar side of little finger was repaired by the first toe tibia nervous proprii in one case. The superficial branch of radial nerve was applied to repair the defect of ulnar nerve, as well as its deep or superficial branch in two cases. The superficial branch of radial nerve was also used to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, Little finger ulnar palmar nervous proprii in one case. The dorsal branch of ulnar nerve was applied to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, little finger ulnar palmar nervous proprii in one case. The vascular bundle of medial plantar flap was anastomozised with ulnar vascular bundle. The wounds at donor sites were covered with free skin grafts which were obtained from upper leg. Results All the flaps and skin grafts were survived completely. The five patients were followed up for six months to four years with no muscular atrophy or claw hand deformity. The esthetic result was satisfied. The Sensory of flaps and fingers recovered to S3 to S3+. The two-point discrimination distance on flaps was range from 7 mm to 10 mm. The postoperative comprehensive evaluation was excellent in the cases whose superficial and deep branches of ulnar nerve were repaired.Conclusions Free medial plantar flap is an effective method to repair concurrent skin and nerve defect at palm and carpal on the ulnar side.     

Reverse-flow island flap from the thenar area of the hand

A reverse-flow island flap from the thenar eminence of the hand was applied in six patients to treat palmar skin defects, and amputation injuries of the thumb. There was one female and five males, and the patients' ages at the time of surgery averaged 48 years. A 3 x 2 to 5 x 3.5-cm fasciocutaneous flap from the radial aspect of the thenar eminence, located over the abductor pollicis brevis muscle, was designed and transferred in a retrograde fashion, to cover skin and soft-tissue defects of the thumb. The flap was based on the superficial palmar branch of the radial artery and, in three patients, was made sensate by the palmar branch of the superficial radial nerve. Follow-up periods averaged 61 months. The postoperative course was uneventful, and all the flaps survived without significant complications. The donor site was primarily closed in five patients, and one patient required flap coverage. A reverse island flap from the thenar area is easily elevated, contains durable fasciocutaneous structures, and has good color and texture, matching to the finger pulp. This flap offers a good alternative for reconstruction of palmar skin and soft-tissue defects of the thumb in selected patients.     

急诊修复拇指指腹缺损三种方法的研究

目的 报道采用不同方法急诊修复拇指指腹缺损的疗效。方法 采用示指背侧岛状皮瓣，拇指桡侧指动脉逆行岛状皮瓣转位有趾腹皮瓣游离移植三种方法，为21例线指指腹缺损进行急诊修复。结果 20例以瓣成活，1例失败。术后随访半年－2年，平均10个月。所有皮瓣血运，弹性，质地均良好。指腹二点分辨觉：示指背侧岛状皮瓣平均为92.mm，拇指桡侧动脉逆行岛状皮瓣平均为8mm，趾腹皮瓣平均为5.6mm。结论 急诊修复拇指指腹缺损首选趾腹皮瓣，其次为拇指桡侧指动脉逆行岛状皮瓣或示指背侧岛状皮瓣。     

The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects

PURPOSE: Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. METHODS: From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. RESULTS: All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. CONCLUSIONS: The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Treatment of thumb soft-tissue defects using a bipedicle island flap of the index finger: anatomical basis and clinical application

Purpose

Reconstruction of the thumb with exposure of bone and tendon is challenging. We designed a bipedicle island flap from the dorsum of the index finger to repair thumb defects. One pedicle includes the radial proper palmar digital artery (PDA) of the index finger, another pedicle includes the first dorsal metacarpal artery (FDMA). The aim of the study was to investigate the anatomical basis and clinical application of this flap.

Methods

Eleven fresh cadaver hands were dissected, the FDMA and the radial proper PDA were exposed. Their origin, distribution and diameter in different locations, especially in the dorsum of the proximal phalanx of the index finger, were examined. Ten patients (11 hands) underwent thumb reconstruction using this flap. During follow-up, the flap survival and hand function were evaluated.

Results

The origin of the FDMA in three cadaver hands was abnormal. The FDMA was mainly distributed in the proximal area of the dorsum of the proximal phalanx. The radial proper PDA of the index finger formed one constant dorsal branch, mainly distributing in the middle and distal area of the dorsum of the proximal phalanx. All flaps survived. At follow-up, the span of the first web and the range of motion of the thumbs and index fingers reached more than 94 % of the contralateral finger. All patients were satisfied with the hand function according to the Michigan Hand Outcomes Questionnaire (MHQ).

Conclusions

The bipedicle island flap has two arterial systems to provide sufficient blood supply. This technique provides another option for thumb reconstruction when a large supercharged FDMA island flap needs to be designed, or when there is an additional injury to the radial side of the dorsum of the hand or if there are anatomical variations of the FDMA, or if damage to the FDMA occurs during surgery.     

正中神经掌皮支营养血管远端蒂肌皮复合瓣解剖学研究及临床应用

目的 探讨正中神经掌皮支营养血管肌皮瓣转移术修复拇指组织缺损的解剖学依据及临床效果.方法 对30侧成人尸体手标本进行解剖,系统观测正中神经掌皮支营养血管链的组成、分支、分布及其同大鱼际肌相互交通吻合的情况.2007年2月以来,临床应用正中神经掌皮支营养血管远端蒂肌皮瓣转移术修复拇指组织缺损17例.结果 桡动脉掌浅支恒定地向拇短展肌和拇短屈肌发出3～5支肌皮穿支,节段性参与正中神经掌皮支营养血管链,肌皮穿支平均外径为[(0.3±0.1)mm,x±s,下同],均有1条静脉伴行.17例术后肌皮瓣全部存活,拇指外观及功能满意,11例患者在术后1周皮瓣两点分辨觉为(6.1～8.2)mm.结论 正中神经掌皮支营养血管链同拇短展肌和拇短屈肌肌皮穿支恒定吻合,该肌皮瓣是修复拇指组织缺损的良好供区.     

手与前臂皮神经伴行血管逆行岛状皮瓣的临床应用

目的：报道手、前臂皮神经伴行血管逆行岛状皮瓣的临床应用结果。方法：用桡神经拇指背尺侧支及前臂外侧皮神经前支伴行血管为蒂设计逆行岛状皮瓣，蒂部携带浅静脉及皮下组织，修复拇指缺损时皮神经与指神经缝合。结果：手部６例、前臂部２例皮瓣全部成活，伤指恢复良好感觉。结论：这两种皮瓣血供充分，不牺牲主干血管，前者可修复拇指指腹及指端缺损，后者可修复腕、掌背侧中、小面积皮肤缺损。     

手桡侧毁损伤分型初步探讨

目的 探讨手桡侧毁损伤分型及一期修复的方法与临床效果.方法 回顾性研究总结129例手桡侧毁损伤患者,将手桡侧毁损伤分为五型:Ⅰ型:拇指毁损(54例);Ⅱ型:拇指毁损并虎口皮肤缺损(33例);Ⅲ型:拇指毁损、虎口皮肤缺损并示指毁损(10例);Ⅳ型:拇指毁损、虎口皮肤缺损、示指毁损并中指毁损(29例);Ⅴ型:拇指毁损、虎口皮肤缺损、示指毁损、中指毁损并手掌桡侧毁损(3例).根据分型的不同,分别采用游离足趾移植或残存手指异位再植方法再造拇指,以股前外侧、足背或上臂外侧皮瓣等修复手桡侧创面.结果 术后129例移植组织存活128例,成活率为99.2%.随访时间为1～4年,手功能恢复按中华医学会手外科学会上肢部分功能评定试用标准评价:优46例,良61例,可19例,差3例,优良率为82.9%.结论 对手桡侧毁损伤,根据其分型不同,分别选用不同术式行一期修复与功能重建,效果良好.