指根侧部逆行岛状皮瓣的临床应用

目的寻求对手指末节软组织缺损修复的可靠新方法.方法1999年8月～1999年11月,采用缝接指背皮神经带指背浅静脉的指动脉指根侧部逆行岛状皮瓣修复指端及指腹软组织缺损10例14指.结果10例14指皮瓣全部成活,皮瓣最大面积3.0cm×2.5cm,最小2.0cm×1.5cm.皮瓣感觉恢复佳,外形良好,无一例发生静脉危象.结论缝接指背皮神经带指静脉的指动脉逆行岛状皮瓣切取方便、损伤小、静脉危象发生率低,提高了皮瓣的成活质量,值得推荐推广.     

A modified reversed digital island flap incorporating the proper digital nerve

A standard reversed digital artery flap is based on the digital artery and vena comitantes alone, leaving the proper digital nerve intact. In the authors' opinion, in situations in which the fingertip pulp is lost completely, it is unnecessary to leave the nerve in situ. Using their technique, the proper digital nerve is included in the pedicle. The pedicle is raised as a monobloc of fatty tissue containing the small veins important for drainage. The proper digital nerve in the flap is sutured to the stump of the opposite proper digital nerve. They found this flap to be very reliable, and quite easy and quick to raise. A patient is presented and discussed in detail.     

Injuries to the digital extensors

The tendency to regard lesions of the flexor tendons of the hand as difficult to repair and those of the extensor tendons as simple to treat is completely arbitrary. Extensor tendons have the advantage of running an almost entirely extrasynovial course, which facilitates the repair. On the other hand, they are thin, superficial structures, and when damaged they tend rapidly to become adherent to the underlying bones and joints. The excursion of the extensor tendons of the hand is considerably less than that of the flexors; thus, a loss of length is more difficult to compensate for. In our experience, management of lesions of the extensor apparatus has given rise to many difficulties. However, failures or partial failures are usually of less consequence than with the flexors.     

Blood supply of the digital sheath

One hundred upper extremities from fresh human cadavers aged 20 to 80 years were injected with coloured latex or Indian ink and gelatin. Under the dissecting microscope two main and one occasional source of vascularization of the digital sheath were identified. Originating from the digitopalmar arches, from the proper palmar digital arteries and occasionally from the arcus palmaris superficialis, a complex arterial system supplies the various parts of the digital sheath. The best vascularized area is the floor of the sheath, while the pulleys and the palmar surface of the sheath are less well vascularized. These data may be of interest to those involved in reconstruction of the tendons of the digital flexor muscles.     

指掌侧固有动脉逆行岛状皮瓣修复指端缺损

目的探讨指掌侧固有动脉逆行岛状皮瓣修复指端缺损的临床效果.方法2002～2004年应用指掌侧固有动脉逆行岛状皮瓣修复8例指端缺损.结果8例皮瓣均存活,术后经12～24个月随访,外形满意,效果良好.结论指掌侧固有动脉逆行岛状皮瓣是修复指端缺损的一种可行方法.     

Aggressive digital papillary adenocarcinoma of the hand

This paper reports the case of a 26-year-old Caucasian male with an aggressive digital papillary adenocarcinoma of his right index finger. Aggressive digital papillary adenocarcinoma is a rare tumour arising from sweat glands which occurs characteristically on the hands, fingers and toes. It has a high rate of local recurrence and can metastasise, occasionally resulting in mortality.     

Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery

The dorsal digital and metacarpal island flaps have been described for use in a variety of clinical situations. On the basis of the authors' previous angiographic studies, these two skin flaps were planned on the dorsum of the proximal phalanx or intermetacarpal space based on the vascular anastomoses between the proximal dorsal cutaneous branches of the palmar digital artery and the dorsal digital branches of the dorsal metacarpal artery at the level of the proximal phalanx. The authors present a series of 13 patients using these flaps. To reconstruct the injured finger pulp, the reverse dorsal digital flap was used in 5 patients, and the reverse dorsal metacarpal flap was used in 8 patients. Most of the 13 patients sustained a work-related injury. Associated injuries of bone, joint, or tendon occurred in most patients. In all patients, the skin defect was located distal to the proximal interphalangeal joint. The skin paddle was taken from the dorsal aspect of the middle and ring fingers or the first, second, third, and fourth metacarpal area. All flaps survived completely. Two patients who had the dorsal branch of the sensitive radial nerve anastomosed to the digital nerve recovered 6-mm two-point discrimination in the reverse dorsal digital flap. The results of this anatomic study and the authors' clinical experience confirm the reliability of the dorsal digital and metacarpal island flaps.     

Lesser digital arthrodesis

Arthrodesis at the proximal interphalangeal joint is a surgical procedure useful when dealing with semireducible or nonreducible contractures of the lesser digits. When arthrodesis of the proximal interphalangeal joint is performed, there is conversion of the retrograde dorsal buckling force of the long extensor tendon to a plantargrade straightening force of the flexor tendon. This occurs as a result of the rigid strut created at the arthrodesis site. If metatarsal equinus is present, arthrodesis can help reduce this deformity and eliminate plantar pressure contributing to submetatarsal tyloma. An arthroplasty procedure does not resist deforming forces and is more useful in correcting painful deformities where flexibility is desired postoperatively. It is therefore important, even in "simple" digital surgery, to understand the etiology of the pathology and identify and structure the goals of the surgery. The end-to-end arthrodesis offers the advantage of being easy to perform, relatively free of complication, and able to maintain the length of the digit. A fixation device, such as a Kirschner wire or monofilament wire, may be needed to maintain the correction. Its inherent complications have been described. It can be relatively unstable. The peg in hole arthrodesis offers the advantage of better stability which does not necessarily require internal fixation. There is also rapid bone healing due to the side-to-side configuration of the arthrodesis site. The procedure is more complicated and time consuming to perform than an end-to-end procedure. There is more shortening in the peg in hole. Taking these factors into account, the surgeon should choose the procedure which best meets the preoperative criteria and expected postoperative results.     

Infantile digital fibromatosis

The authors report a case series on four patients with infantile digital fibromatosis located on pedal digits. Surgical excision was performed in all cases, with no evidence of recurrence. It is a rare form of juvenile fibromatosis, which presents on the fingers and toes of infants and children. Conservative treatment is recommended by authors owing to the benign nature of the lesion and its tendency to regress, and reports of recurrence after surgical intervention. We believe that surgical excision of lesions in this condition, however, remains an appropriate recommendation for the management of this rare entity.     

Experimental restoration of the digital synovial sheath

The digital synovial sheath constitutes an important component of the delicate mechanism of flexor tendon nutrition and gliding function, In the present study the true nature of the inner cell layers of secondary healed defects in the tendon sheath as well as of free tendon sheath autografts were studied. Leghorn chickens were used as experimental animals and the gradual development of the pseudosheath as well as the healing of sheath autografts were studied both macroscopically and histologically including transmission electron miscroscopy. Synovial regeneration by extension from intact parts of the sheath was never observed and the pseudosheath formed around silastic rods consisted of granulation tissue with fibroblasts and macrophages. The free tendon sheath autografts demonstrated a normal process of healing at the edges of the defect. Synovial regeneration appeared to be that of metaplasia and proliferation of fibroblasts and macrophages. This phenomenon was demonstrable both in the secondary healed defects and more convincingly in the sheath autografts. Further, the silastic rod was found to induce foreign body reaction in the healing synovium. It is concluded that grafting of autologous tendon sheath tissue seems to be a promising method for restoration of defects in the digital tendon sheath.     

Infantile digital fibromatosis

Infantile digital fibromas are rare benign neoplasms that occur principally in children and are usually confined to the digits. These lesions are similar in appearance to several benign and malignant lesions, and biopsy is often required to confirm the diagnosis. The tumor is composed of myofibroblasts, which contain pathognomonic intracellular inclusion bodies. There is a strong tendency for recurrence after excision. We present a 2-year-old who developed extensive involvement of all 4 extremities after syndactyly release. This case is unusual in that the lesions occurred postsurgically and were substantially more extensive than those previously described.     

Transthecal digital block at the proximal phalanx

This study assessed the efficacy of a modified transthecal digital block. Three-hundred-and-sixty consecutive digits were anaesthetised with this technique for the treatment of fractures, infections and foreign bodies. Complete palmar and dorsal anaesthesia was achieved in 357 of the 360 digits (99%), including 52 of 53 thumbs (98%). The technique was extremely easy to perform and no complications occurred.     

Transpositional digital replantation

When a functionally important digit is injured as part of a multiple digit injury, transpositional digital replantation is worth considering to preserve greater hand function and to avoid or minimize the necessity for secondary reconstructive procedures. We present two such cases with transpositional digital replantation. The indications for this technique are: 1) multiple digit injury, 2) severe crush injury, 3) the possibility of preserving more and better joints in some fingers, and 4) injury distal to Tamai's zone V (11). The benefits of this procedure are that function can be better with the more completely preserved digits replanted into the most useful positions and of similar lengths. Difficulties are encountered when there are large discrepancies in size of surviving digits, and problems with soft-tissue coverage, tendon repair, a 'step' at the fracture site after bone fixation, and with vessel anastomosis. Use of this procedure can result in preservation of hand function and fewer secondary reconstructive procedures.     

The spectrum of the oro-facial digital syndrome

The Oro-facial Digital Syndromes are well recognised, but confusion exists over their characteristics and nomenclature, especially as two new types have recently been described. Since there is no single feature that distinguishes one type from another, the authors recommend that classification be restricted to those sub-divisions with a known inheritance pattern, i.e., Types I and II. This enables accurate genetic counselling to be offered whilst accepting the variable clinical presentation. The literature is reviewed and seven new cases are presented.     

Suturing of digital lacerations: digital block or local infiltration?

A prospective trial was carried out to assess the relative efficiency of digital block and local infiltration as methods of anaesthesia when suturing lacerations of the digits. A standard technique and questionnaire were applied to a consecutive group of 62 patients attending the Accident Department of the Bristol Royal Infirmary. Digital block was found to be a more effective technique than local infiltration for anaesthetising digital lacerations.