A DOUBLE

PULP FLAP FOLDS IN

TECHNIQUE SYNDACTYLY

L. LUNDKVIST

FOR CREATING RELEASE

NAIL-

and T. BARFRED

From the Sectionof Hand Surgery, Department of Orthopaedic Surgery, OdenseUniversity Hospital, Denmark

A method is described of creating nail-folds in the release of cases of complete syndactyly. A double pulp flap was used as a one-stage technique in 13 patients in whom webs were separated. All patients were reviewed after a minimum of one year. Fullness of pulp was achieved in all fingers. The nailfold was considered normal in 14 of 18 lingers covered with a broad flap and in 8 of 18 fingers covered with a narrow flap. In the remaining cases the nail-fold was small but never absent. No gap loss was encountered and there was no late nail deformity from scarring. Journal of Hand Surgery (British Volume, 1991) 16B: 32-34

In previous papers on syndactyly release, the creation of a web-space and the management of the adjacent sides of the fingers have received most attention. The problem of creating a proper nail, nail-fold and pulp has had less consideration. A common technique has been the resection of the central part of the common nail and nailbed, followed by skin-grafting. In some cases this has been accompanied by triangular resection of the pulp fat (Blauth, 1975; Flatt 1974). Boyes (1970) suggested that the skin should be reshaped around the nail edge by swinging a pointed flap from the side of the pulp around the angle of the nail. Unfortunately this description was not quite comprehensive. Thomson (1970) used a distant abdominal flap in a three-stage procedure. Marumo et al. (1976) recommended a thoracic flap, and Johansson (1982) described a thenar flap. These techniques of creating new nail-folds necessitated two-or three-staged procedures and incurred additional scarring. We have developed a one-stage technique of creating nail-folds with two flaps from the

Fig. 32

1 (a and b)

The incision

used for syndactyly

without

a nailfold

between

common pulp. We have used this technique since 1978 in all cases of complete syndactyly with absent nail-folds. Method (Fig. 1). A standard procedure was used with dorsal and volar triangular flaps to create the web space, followed by zig-zag incisions reaching the level of the D.I.P. joints. On the common distal phalanx, a longitudinal incision was used dorsally. A narrow flap was raised parallel to the distal nail-edge with its base in the middle of the common pulp. The side of this flap covered the denuded nail-edge (Fig. 2a). Proximal to the narrow flap, a broader flap was raised with its base on the other finger. It is important that this flap has a slope making the proximal side longer than the distal side: without this slope, the end of this flap will not fit properly along the denuded nail-edge. (Fig. 2b). The defect after raising the narrow flap can be sutured directly. The defect after the broad flap often needs a

the nails. THE

JOURNAL

OF HAND

SURGERY

A DOUBLE

Fig. 2

(a) Same patient as in Figure the broader flap.

1. The nailedge

PULP

of one finger

FLAP

IN

covered

SYNDACTYLY

RELEASE

with

the narrow

flap. (b) The nailedge

Fig.

3

of the other

finger

covered

with

rather

small

skin-graft. We have used full thickness skin-graft. Often it is necessary to resect a part of the nail and nail-bed, if the nail is either too broad or too curved. Patients

13 patients were treated in this way. All were reviewed between one and 10 years later (mean: 5.2 years). Two cases had Apert’s syndrome, and four cases had other deformities in the hand. One patient had three double pulp flap procedures, and three patients had two double pulp flaps, giving in all 18 web separations. Four patients had operations on both hands. Of nine patients having unilateral operations, two were operated on the right hand, and seven on the left. Seven patients were females, six patients males. In the same period 25 patients had treatment for more limited types of syndactyly. All the operations were performed by the senior author (T.B.) We prefer to VOL.

16B No.

1 FEBRUARY

1991

Same patient nailfolds.

as in Fig.

1. The final

result,

with

33

L. LUNDKVIST

AND

T. BARFRED

Fig. 4 The final result in another patient, with normal nailfold on both sides.

operate before the age of two years, but this was only possible in half of the cases.

Fig. 5 A bulb-like appearance of a small flap during healing.

Results All the operated fingers had a normal fullness of the pulp. The nail-fold was small, but never absent, in 10 of 18 fingers covered with a narrow flap, and 4 of 18 fingers covered with a broad flap (Fig. 3). In the other cases, the nail-fold was considered normal (Fig. 4). No flap loss was encountered, but in some cases the flap had been made too short to cover the most proximal part of the nail-edge properly. Two of these cases developed a nail-horn which later had to be removed. In another patient, the narrow flap contracted during the healing and developed a bulb-like appearance (Fig. 5). One third of the patients had a distorted nail or a deviated phalanx, but in no case did the condition deteriorate after operation. Discussion Buck-Gramcko (1988) has recently proposed a similar technique. He uses two pointed flaps, instead of one narrow and one broad flap, obtaining cover similar to that with our method, but has not yet published any results. With both techniques, it is possible to cover the raw bone when the syndactyly is combined with a bony bridge between the phalanges. Our method has proved reliable for covering the denuded nail-edge and creating a nailfold which is either normal or small but never absent. In

the period of follow-up, no nail distortion from scar tissue has been observed. The method does not correct deviation of phalanges or distortion of the nails existing at the time of separation of the fingers. It is not clear whether this is possible with the remote flap techniques. The drawbacks of the remote flap techniques are the two- or three-stage procedures, which mean additional hospitalization and extra strain on the child. References BLAUTH, W. (1979). Syndaktylie und Rezidiv. Fingersyndaktyljen und ihre Behandhmg. Zeitscrhift fiir OrthopHdie und ihre Grenzgebiete, 117: 523530. BOYES, J. H. Bunnell’s Surgery of the Hand, 5th edn. Philadelphia. J. B. Lippincott, 1970: 89-90. BUCK-GRAMCKO, D. Congenital malformations. In: Nigst, H., BuckGramcko, D., Millesi, H. and Lister, G. D. (Eds.). Hand Surgery, New York, Thieme, 1988: Vol. 1: 12.22-23. FLATT, A. E. The care of congenital hand anomalies. St. Louis, C. V. Mosby, 1977: 182-190. JOHANSSON,S. H. (1982). NagelwallbildungdurchThenarlappen bei komplettter Syndaktylie. Handchirurgie, 14: 199-203. MARUMO, E., KOJIMA, T., and SUZUKI, S. (1976). An operation for syndactyly, and its results. Plastic and Reconstructive Surgery, 58: 5: 561567. THOMSON, H. G. (1971). Isolated acrosyndactyly: avoiding post-operative contractwe. British Journal of Plastic Surgery, 24: 357-360.

Accepted: 21 November 1989

Lis Lundkvist, M.D., Department of Orthopaedic Surgery, Odense University Odense C, Denmark.

Hospital, 5000

0 1991 The British Society for Surgay of the Hand

THE

JOURNAL

OF HAND

SURGERY

A double pulp flap technique for creating nail-folds in syndactyly release.

A method is described of creating nail-folds in the release of cases of complete syndactyly. A double pulp flap was used as a one-stage technique in 1...
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