Treatment of avulsion injury of three fingers with a compound thoracodorsal artery perforator flap including serratus anterior fascia

Complete degloving injury of three digits not amenable to revascularization may leave poor cosmetic and functional results. We used a compound thoracodorsal artery perforator (TDAP) flap in a 34‐year‐old, right‐handed, male worker with traumatic degloving injury. The flap consisted of a thin nonbulky skin component isolated on two perforators in combination with serratus fascia, both pedicled on the thoracodorsal vessels. The mobility of the two flap components allowed the palmar and dorsal part of the fingers to be reconstructed without relying on multiple flaps or anastomoses. The skin component of the TDAP flap was transferred to the palmar defect, the serratus fascia flap to the dorsal part of the fingers and sutured loosely. Coverage of the serratus anterior fascia was done with split‐thickness skin graft. Both components of the flap survived completely. One month after the first operation, the surgical syndactyly between middle and ring finger was separated, one month later the syndactyly between the ring and little finger. Good coverage of the soft tissue defects with good function could be achieved. There were no donor‐site problems. Therefore, we consider the compound TDAP flap as a useful method that provides functional and cosmeticcoverage of severe avulsion injury of multiple digits. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

甲瓣加双“凸”状皮瓣组合移植修复全手皮肤脱套伤

目的探讨全手皮肤脱套伤的修复方法。方法采用甲瓣修复拇指创面,去除中、小指,双“凸”状皮瓣分别修复示指、桡掌背侧及环指、尺掌背侧皮肤缺损。结果临床治疗6例,取得了移植组织全部成活,手部恢复拿捏及对掌功能。结论甲瓣加双“凸”状皮瓣组合移植修复全手脱套伤是一种行之有效的治疗方法。     

不同形式的第二趾甲皮瓣移植修复不同程度的手指皮肤脱套伤

目的总结第二趾甲皮瓣的临床应用效果并探索手指皮肤脱套伤最合理的治疗方案。方法根据手指皮肤脱套伤的特点,将83例95指手指皮肤脱套伤分为二度。Ⅰ度脱套伤:2～5指皮肤脱套范围自指中节中段至指尖,采用单纯第二趾甲皮瓣修复,共59指。Ⅱ度脱套伤:2～5指皮肤脱套范围自指根部至指尖,采用带足背皮瓣的第二趾甲皮瓣修复,共36指。结果95块甲皮瓣全部存活。术后65指随访8个月～5年10个月,失访30指。按中华医学会手外科学会拇、手指再造功能评定试用标准评定,优62指、良3指。结论第二趾甲皮瓣是治疗手指皮肤脱套伤最合理的方法之一。对手指皮肤脱套伤的伤情进行分度,有利于治疗方案的选择。     

半环形邻指皮瓣的临床应用

目的 报道半环状邻指皮瓣修复手指皮肤缺损的方法与疗效。方法 应用半环状邻指皮瓣修复手指背侧、掌侧、指腹皮肤缺损及手指末节脱套伤28例。结果 术后25例皮瓣完全存活，3例皮瓣部分坏死。术后随访3-18个月，平均6个月，皮瓣的血运、质地均良好。结论 半环状邻指皮瓣是修复手指皮肤缺损，尤其是手指末端脱套伤的理想皮瓣。     

食指背侧翻转皮瓣和拇指掌侧前移皮瓣修复拇指末节脱套伤

目的 探讨一种治疗拇指开节脱套伤的有效术式。方法 对16例拇指末节脱套伤,选用拇指掌侧前移皮瓣,食指翻转皮瓣进行修复。结果 术后皮瓣全部成活,随访3－12个月,伤指修复后外形及屈伸功能均满意,感觉正常。结论 用拇指前移皮瓣和食拇翻转皮瓣修复拇指末节脱套伤,操作简易,皮瓣成活率高,修复后患指功能及外形均满意。     

改良第二掌背动脉皮瓣修复示中指中末节套脱伤

目的 探讨应用第二掌背动脉(second dorsal metacarpal artery,SDMA)逆行岛状皮瓣修复示、中指中末节皮肤套状撕脱伤的方法及疗效.方法 2004年5月至2010年1月,收治17例示指或中指中末节皮肤套状撕脱伤患者.采用SDMA岛状皮瓣进行修复,并缝合指背神经.皮瓣切取面积为2.5 cm×5.6 cm～5.0cm×6.5 cm,供区创面行游离植皮.结果 术后2例皮瓣远端出现张力性水泡,表皮结痂,经换药后愈合;其余皮瓣顺利存活.皮瓣及供区植皮切口均Ⅰ期愈合.术后17例获得4～27个月的随访,平均15.3个月.皮瓣质地柔软,外观饱满无臃肿.两点分辨觉为7～11 mm,平均8.6 mm.手功能按手指总主动活动度(total active movement,TAM)法评定:优8指,良7指,可2指;优良率为88.2%.结论 缝合指背神经的改良SDMA逆行岛状皮瓣,皮瓣切取面积足够覆盖示、中指中末节套状撕脱伤皮肤缺损创面,皮瓣血运可靠,手术安全,是一种较好的手术方法.

Abstract：

Objective To investigate the operative procedure and the clinical results of the modified reversed island flap based on the second dorsal metacarpal artery (SDMA) for repairing index or long finger degloving defects.Methods From May 2004 to January 2010, circumferential soft tissue defect in the middle and distal phalanx of the index or long fingers in 17 patients were repaired by the modified reversed island flaps based on SDMA.The dorsal digital nerve in the flap was coapted to the severed proper digital nerve.The area of the flaps ranged from 2.5 cm × 5.6 cm to 5.0 cm × 6.5 cm.The donor sites were closed by skin graft.Results Postoperatively blister and necrosis of the distal flap occurred in 2 cases which was cured by dressing change.All the other flaps survived uneventfully.Primary healing of the flaps and donor sites was achieved.All 17 patients were follow-up for 4 to 27 months with an average of 15.3 months.The flaps were pliable, full but not bulky.Two-point discrimination was 7 to 11 mm (mean 8.6 mm).Hand function as judged by the total active range of motion of the fingers was excellent in 8 fingers, good in 7 fingers and fair in 2 fingers.The satisfactory rate was 88.2%.Conclusion Modified SDMA reversed island flap transfer with dorsal digital nerve coaptation is an ideal procedure to repair index or long finger degloving injuries.The area of the harvested flap is large enough to cover the circumferential soft tissue defect in the middle and distal phalanx.The surgery is safe due to the reliable flap circulation.     

Cleft hands with six metacarpals

PURPOSE: The purpose of this study was to identify children with cleft hands whose radiographs showed metacarpal polydactyly with 6 metacarpals to support the hypothesis that cleft hand develops not as a result of a longitudinal failure of formation but through a process of central polydactyly and osseous syndactyly. METHODS: We screened the hand radiographs of all children with a transverse or longitudinal deficiency of the upper limb and identified 8 children with cleft hands containing 6 metacarpals. RESULTS: Six cleft hands had a missing middle finger and consisted of a thumb and index finger separated from the ring and small fingers by a V-shaped central cleft. Two children had a more severe form of cleft hand with absence of both the index and middle fingers but presence of 6 metacarpals. CONCLUSIONS: These 8 cleft hands containing 6 metacarpals showed progression of polydactyly of the middle finger and osseous syndactyly between the 2 middle finger metacarpals and the adjacent index and ring finger metacarpals. This contradicts a longitudinal failure of formation mechanism and supports the alternative hypothesis that cleft hand, polydactyly, and syndactyly develop through a similar teratogenic mechanism. The 2 cleft hands that had more severe suppression of the index and middle fingers yet had 6 metacarpal polydactyly provided confirmatory evidence that both typical cleft hands and the more severe manifestations of cleft hand with absence of multiple digits develop through a similar failure of induction mechanism.     

指动脉双叶皮瓣修复拇指皮肤套状缺损

目的：探讨应用指动脉双叶皮瓣修复拇指套状缺损的可行性.方法：自2007年1月至2012年12月,对45例拇指套状缺损患者采用指动脉双叶皮瓣修复治疗.男39例,女6例;年龄19～46岁,平均32岁.平甲根平面的掌侧皮肤和甲床缺损18例,拇指末节皮肤套脱19例,整个拇指皮肤套脱8例.根据拇指皮肤缺损情况,分别于中指尺侧和环指桡侧设计皮瓣的2个叶,以中环间的指总动脉及其向中指及环指的2个指固有动脉为血管蒂,皮瓣携带指固有神经,将皮瓣转位后瓦合覆盖拇指外露指骨.皮瓣供区用全层皮片植皮,观察皮瓣的外观、质地、颜色和耐磨性,植皮区外观、颜色和凹陷,皮瓣的感觉,手指活动等.结果：所有患者皮瓣及植皮区组织全部成活,完成随访43例,平均随访25个月.失访2例,皮瓣色泽及质地与健侧拇指指腹相近,两点辨别觉平均（4.2±0.3） mm.植皮区,皮肤颜色略深于周围皮肤.结论：应用指动脉双叶皮瓣修复拇指套状缺损是风险小、成功率高、修复效果较理想的手术方式.     

第二趾套状切取加踇趾腓侧皮瓣组合移植治疗手指大部皮肤脱套伤

目的　探讨手指大部皮肤脱套伤的治疗方法及疗效。方法　对 12例 19指手指大部皮肤脱套伤患者 ,采用套状切取第二趾及趾腓侧皮瓣 ,修复伤指软组织的治疗方法。第二趾的皮肤及软组织套入包含浅筋膜、肌腱、指神经及骨架的伤指上 ,趾腓侧皮瓣嵌入第二趾软组织的腹侧以增大其周径。结果　 19指的皮瓣全部存活。术后随访半年 ,重建指的外形、感觉、运动功能恢复满意 ,血运稳定。X线片复查无骨质吸收。结论　第二趾套状切取加趾腓侧皮瓣组合重建术是治疗手指大部皮肤脱套伤的有效方法。     

带蒂尺动脉腕上皮支皮瓣修复对侧手指脱套伤

目的探讨采用上、下行联合的带蒂尺动脉腕上皮支皮瓣修复对侧手指脱套伤的疗效。方法 2005年8月-2009年8月,收治11例单指脱套伤患者。男8例,女3例;年龄19～55岁,平均26岁。机器绞伤9例,交通事故伤2例。损伤指别:拇指1例,示指7例,中指3例。皮肤撕脱范围均为自手指近节或中节以远完全撕脱,皮肤缺损范围5.0 cm×4.5 cm～8.0 cm×5.5 cm。合并指骨骨折2例,伸肌腱损伤3例,伸、屈肌腱损伤1例,指血管损伤9例,指神经损伤6例。患者受伤至手术时间为2～18 h,平均4.8 h。术中设计以肘窝内侧缘至腕部尺动脉搏动点(豌豆骨)的连线为皮瓣轴线,豌豆骨近端约4 cm处(尺动脉腕上皮支入点)为共同蒂部作远、近侧各一舌形皮瓣,下行皮瓣附于掌侧,上行皮瓣附于背侧,完全包绕脱套指缝合。皮瓣切取范围10 cm×3 cm～16 cm×3 cm。供区直接缝合。于皮瓣修复术后3周断蒂。结果术后3 d 1例皮瓣边缘出现少许浅黄色分泌物,皮瓣表面有湿疹,经换药2周后分泌物消失,皮疹逐渐消退;其余皮瓣均顺利成活,创面Ⅰ期愈合。供区切口均Ⅰ期愈合。术后3个月2例因皮瓣外观臃肿,行二期修整手术。术后患者均获随访,随访时间6～12个月,平均8个月。皮瓣质地优良,色泽正常,无破溃。术后6个月皮瓣两点辨别觉为12～20 mm;手指功能采用Jebsen手功能评定标准,获优8例,良2例,差1例。结论上、下行联合的带蒂尺动脉腕上皮支皮瓣血供可靠,切取容易,供区损伤小,修复术后手功能及外观佳,是修复手指脱套伤的较好方法之一。     

Cleft hand

Definition, incidence, genetics, and etiology of typical cleft hand are discussed in this paper. Cleft hand, central polydactyly, and osseous syndactyly were induced experimentally when the same teratogenic factors acted on the embryos at the same developmental stage. Typical cleft hand, central polydactyly, and syndactyly should be classified together as manifestations of the same entity, that is, failure of induction of finger rays. Typical cleft hand may be further subdivided into five types on the basis of the number of defective finger rays. Treatment of the typical cleft hand involves cosmetic and functional considerations. Reduction of the wide interdigital space is performed primarily for cosmetic reasons, while separation of syndactyly between thumb and index finger and correction of deviation of the thumb is performed for functional improvement. A zigzag incision with a small triangular flap is recommended for reduction of the interdigital space. If metacarpal remnants or cross bones prevent drawing the metacarpals together, they should be removed. The deep transverse metacarpal ligament should be reconstructed by ligamentous flap made out of the flexor tendon sheaths of the index and ring fingers to prevent later spreading of the fingers. A dorsal-based rotation flap fashioned from the skin of the cleft is recommended for the treatment of cleft hand with partial syndactyly of the thumb and index finger. Deviation of the thumb is often caused by a delta phalanx by a trapezoidal-shaped extra phalanx. Deviation of the thumb is corrected by removing the delta phalanx or osteotomy of the trapezoidal phalanx. When the cleft is closed at approximately 1 year of age, spontaneous correction of the flexion deformity of the ring finger is sometimes observed.     

中环指岛状皮瓣、示指背侧岛状皮瓣转移修复拇指损伤

目的 评价中环指岛状皮瓣和（或）示指背侧岛状皮瓣转移修复拇指损伤的疗效。方法 １９８９年７月￣１９９８年１１月共８例拇指损伤应用中环指岛状皮瓣和（或）示指背侧岛状瓣修复。其中示指侧同状皮瓣转移修复拇指损伤２例,中指尺侧岛状皮瓣加示指背侧岛状岛状皮瓣转移修复拇指脱套伤１例,中环指双岛状皮瓣转移修复拇指撕脱离断伤１例。中指尺侧岛状皮拇指损伤４例。随访７个月－９年１１个月,平均５年１个月,主要观察皮     

弃指游离指甲瓣移植在指端缺损修复中的临床应用

目的探讨弃指指甲瓣在指端缺损修复中的应用效果。方法对32例43指（示指15指,中指13指,环指9指,小指6指）指端缺损采用指根神经阻滞麻醉,残端短缩清创,保留骨膜完整,将弃指的指甲瓣游离移植于指端,并采用弹性加压方法缝合加压。结果2例失访,30例（39指）得到随访,时间6～32个月,1指因感染失败而行皮瓣转移覆盖创面,余移植的指甲瓣全部成活。采用吕桂欣等方法进行疗效评定：优24例32指,占82%;良3例4指,占10%;差3例3指,占8%。结论采用弃指游离指甲瓣移植修复指端缺损操作简单,疗效满意。     

第2趾甲皮瓣及足背皮瓣修复全指脱套伤

目的探讨第2趾甲皮瓣及足背皮瓣修复全指皮肤脱套伤的临床效果。方法对23例26指（食、中指）全指皮肤脱套伤,采用第2趾甲皮瓣及足背皮瓣进行修复,皮瓣切取面积最大11．5cm×12．0cm,最小8．0cm×10．0cm。结果术后皮瓣全部成活,随访10-24个月,平均12．4个月,伤指外形及屈伸功能均满意,两点辨别觉为5-8mm。结论采用第2趾甲皮瓣及足背皮瓣修复全指皮肤脱套伤,可最大限度地恢复伤指的外形和功能。     

手先天性并指畸形的治疗

目的 介绍手先天性并指畸形的治疗。方法 42例先天性并指畸形患者中，2指并指36例，多指并指6例；软组织并指30例，远节指骨骨性并指12例。均采用并指间背侧矩形皮瓣形成指蹼，指间掌背侧锯齿状皮瓣进行分指。皮瓣移位后指部外露创面用游离植皮覆盖，指端骨外露者用局部皮瓣覆盖。结果 3例的游离植皮部分坏死，创面经换药后愈合；39例的创面均I期愈合。术后1年12例失访，30例的指蹼坡度良好，指尖部软组织饱满，手术指的外展良好。12例术毕因指间关节侧弯，术后用支架纠正畸形，效果满意。结论 并指畸形的治疗关键是指蹼的形成，指间关节侧弯术后使用支架纠正为一良好的方法。     

双侧带足趾趾蹼的足背皮瓣组合移植治疗全手皮肤套状撕脱伤

目的;介绍用组织瓣组合移植治疗全手皮肤套状撕脱伤的方法。方法：采用双侧带足趾、趾蹼的足背皮瓣组合移植修复6例全手皮肤套状撕脱伤,并再造拇指和中、环指、足背皮瓣修复手掌及手背部的皮肤缺损,趾蹼皮瓣重建虎口。结果：6例所有的组织瓣全部成活。术后随访1－3年,所有伤手外形尚好,虎口开大如健侧,拇、中环指能对指,对捏;指腹二点分辨觉为6－9mm。结论：带双侧足背和趾蹼皮瓣的足趾游离移植是治疗全手皮肤套状撕脱伤的良好方法。     

以第一、二掌背动脉为蒂的岛状皮瓣修复拇指套脱伤

目的介绍应用以第一、二掌背动脉为蒂的岛状皮瓣修复拇指套脱伤的临床疗效。方法选择9例拇指套脱伤而指血管神经束、甲根、甲床完好或可修复的患者，采用以第一、二掌背动脉为蒂的手背桡侧岛状皮瓣转移修复拇指。结果术后9例皮瓣及供区植皮全部存活。术后7例获得6个月-4年的随访，2例失访。修复后的拇指及指甲外形、供区皮肤外形均较满意，指甲生长正常，拇指对指功能正常。皮瓣两点分辨觉为6．9mm，平均8mm。结论对拇指套脱伤指血管神经束存在，甲根、甲床尚好或可以修复的患者，采用以第一、二掌背动脉为蒂的手背桡侧岛状皮瓣修复是一种疗效较好的手术选择。     

双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤

目的 探讨应用组合组织移植修复全手皮肤套脱伤的方法.方法 对3例全手皮肤套脱伤患者,分别采用一侧足部以胫前动脉为蒂的带踝前皮瓣、足背皮瓣、足内侧皮瓣和足外侧皮瓣的拇甲皮瓣再造拇指,修复桡侧手掌手背及虎口区皮肤缺损;另一侧足部带以上相同皮瓣的第二趾甲皮瓣再造示指(或中指),修复尺侧手掌及手背皮肤缺损.结果 术后3例,除一再造示指坏死外,其余组织瓣全部存活.术后随访3～12个月,修复后手部外形和捏、握、抓等功能基本恢复.皮瓣及再造拇、示指(或中指)感觉恢复至S2～S4.结论 双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤是一种有效的治疗方法.     

真皮下血管网皮瓣修复手指脱套伤30例

目的探讨真皮下血管网皮瓣修复手部脱套伤皮肤缺损的疗效。方法根据手部脱套伤的皮肤缺损面积、形状设计髂腹股沟真皮下血管网皮瓣或腹壁随意真皮下血管网皮瓣修复30例（34指）。切取皮瓣为6cm×2cm～17cm×8cm。供区直接缝合26例（26指）,中厚皮片修复4例（8指）。术后7～10d血运无障碍再训练3d后断蒂。结果34指皮瓣全部成活,供区创面均一期愈合。30例均获随访,时间6～12个月,手部外形、功能满意。两点辨别觉〉10mm。结论应用真皮下血管网皮瓣修复手指脱套伤具有操作简便、安全性高、实用性强等优点,适合在基层医院开展。     

改良掌背动脉逆行岛状皮瓣修复手指中末节软组织缺损

目的探讨改良掌背动脉逆行岛状皮瓣修复手指软组织缺损的效果。方法采用改良带掌背动脉逆行岛状皮瓣修复手指软组织缺损12例,其中食指7例,中指3例,环指2例。皮瓣蒂部不经皮下隧道穿过,而由刃厚皮片包裹后置于皮肤之外。结果皮瓣全部存活,随访6～12月,外形及屈伸功能恢复满意。结论与传统掌背动脉皮瓣比较,改良掌背动脉皮瓣可减少蒂部压迫,操作简单,效果满意,是修复手指软组织缺损的较好方法。