Local neurovascular island flap Fingertip amputation,
with loss of the terminal
problem. Reconstruction
pulp and bone exposure presents a difficult
with use of a local neurovascular
island flap has been done in twenty-
one patients to restore sensibility and function with preservation two-point discrimination
values within two millimeters
of length. All patients achieved
of the normal contralateral
fingertip,
with adequate pad for pain-free pinch. We advocate this procedure for deep pulp loss over the distal phalanx.
It is reliable, single-staged,
and provides skin coverage closer to normal than
any regional flap technique. (J HAND SURG 1990;15A:798-802.)
F. W. Cook,
MD, Flint,
Mich., E. Jakab,
MD,
Toledo, Ohio, and M. A. Pollock,
BS,
Flint, Mich.
lf
mgertip injuries are exceedingly common, and palmar pad loss is particularly difficult to treat. With skin loss of less than 1 cm’, conservative treatment is recommended, and larger defects may require split-thickness or full-thickness skin grafting. However, once bone is exposed, to preserve length, flap reconstruction is required.‘, * When loss of the palmar pad in these injuries is too great for local flap reconstruction, regional flaps such as the cross-finger flap3, 4 or the thenar flap5 may be used, unless length is to be sacrificed. Digital length and the fingertip pad should be reconstructed when possible for adequate pinch, with the nail being retained for stability and pickup.6 To achieve these goals, we employ a local neurovascular island flap.
Materials and methods Twenty-one operations done at our institution before 1980 formed our study group. Nineteen of these op-
From the Department of Surgery, McLaren General Hospital, Flint. Mich.; and the Department of Orthopedic Surgery, Medical College of Ohio, Toledo, Ohio. Supported
by a grant from the Brownell
family
Received the first annual Sumner L. Koch award presented by the Chicago Hand Society, Baltimore, Maryland, September 1988. Received for publication 12, 1989.
Feb. 9, 1989; accepted in revised form Oct.
Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. Reprint requests: Frank W. Cook, Flint, MI 48503.
MD, 1071 N. Ballenger
3/l/17893
798
THE JOURNAL OF HAND SURGERY
Hwy..
erations were done to treat acute trauma involving palmar pad amputation with tissue loss greater than 1 cm’, with bone exposed. Varying degrees of nail bed involvement were found. Two operations were done as secondary reconstructive procedures in patients who had a previous injury resulting in pad loss. They had tender, deformed fingertips with painful pinch. The senior author has continued to employ this method of replacing major distal pad loss since 1980, but we include in this study only those cases that have a minimum 8-year follow-up.
Operative design (See Fig. 1, a through g,) The neurovascular island flap is outlined on the palmar surface of the distal phalanx or the distal portion of the middle phalanx, making the island 25% larger to account for the curvature of the pad. The distal extent coincides with the skin defect, when possible, and skin only is incised at the level of the neurovascular pedicle. The incision is continued midlaterally to the level of the web space (Fig. 1, b). It may be extended into the palm, but this was not found to be necessary in any of our cases. The flap is elevated in retrograde fashion, leaving sufficient subcutaneous tissue to enable subsequent coverage of the donor defect by full-thickness skin graft. After this, the neurovascular bundle is freed from Cleland’s ligament. Care is taken to leave sufficient fat around the neurovascular pedicle to ensure adequate venous drainage of the island. Length of the pedicle is gained by carrying the dissection to the web space (Fig. 1. c). With the finger in slight flexion, the flap is advanced into the pulp defect, leaving a small open area at the tip, and sutured in place with interrupted No. 6-O monofilament sutures (Fig. 1, 6). A full-thickness skin graft is harvested from the palmar wrist crease or the hypothenar
Vol. 15A, No. 5 September 1990
Local neurovascular islandjap
C.
799
d.
e.
Fig. 1. Use of the flap: (a) Palmar pad loss with bone exposed. (b) Incision is made along the midlateral margin of the finger together with the island. (c) The island, slightly larger than the defect together with its neurovascular pedicle, is raised. (d) By slightly flexing the finger the pedicle is advanced to the defect and sutured in place. (e) and (f) The proximal defect is covered by a full-thickness skin graft. (crosshatched) (g) The tip may be covered with a crescent-shaped free full-thickness graft if necessary (crosshatched).
eminence to cover the donor site and the interval remaining between the distal portion of the island flap and nailbed (Fig. 1, e through g). The graft over the pedicle should be slightly larger than the defect. If the graft is too tight, the pedicle may be compressed causing congestion of the distal pedicle and possible loss of the island itself. The defect at the wrist or hypothenar eminence is closed primarily, a nonadherent dressing is applied, and the finger is immobilized in 15 to 30 degrees proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion, in an aluminum splint. Immobilization is continued for 1 week. After this, the splint is removed and range of motion exercises begun. The patients were all evaluated by the same examiner. The dimensions of the neurovascular flap were obtained and the area calculated. The distance of flap advancement was noted in each case. The patency of the neurovascular pedicle was assessed using the digital Allen test. Two-point discrimination testing was done using
the clinical guidelines of the American Society for Surgery of the Hand. The target fingertips were assessed for contour and residual deformity. Range-of-motion testing of the metacarpophalangeal (MP), PIP, and DIP joints was done. Patients were questioned with respect to residual pain and cold intolerance. Of the 21 patients having neurovascular island flap reconstruction, 18 were successfully contacted and fully evaluated. One patient had died in the intervening period, and two patients were lost to follow-up.
Results Follow-up ranged from 8 to 14 years, with a mean of 10.5 years. Age ranged from 7 to 72 years, with a mean of 38 years. All patients were right-handed. Four of the injuries involved the nondominant index finger, the remaining injuries were relatively evenly distributed among the other digits (Table I). Eleven of these patients had sustained a work-related injury. Of the 18 patients fully evaluated, the neurovascular pedicle was intact in
800
Cook.
Jalub.
and
The Journal ol HAND SURGERY
Pallock
Table 1. Patients reviewed Patient
Digit
L. I’. s. s. c. 1). E.
with loss of the terminal
problem. Reconstruction
pulp and bone exposure presents a difficult
with use of a local neurovascular
island flap has been done in twenty-
one patients to restore sensibility and function with preservation two-point discrimination
values within two millimeters
of length. All patients achieved
of the normal contralateral
fingertip,
with adequate pad for pain-free pinch. We advocate this procedure for deep pulp loss over the distal phalanx.
It is reliable, single-staged,
and provides skin coverage closer to normal than
any regional flap technique. (J HAND SURG 1990;15A:798-802.)
F. W. Cook,
MD, Flint,
Mich., E. Jakab,
MD,
Toledo, Ohio, and M. A. Pollock,
BS,
Flint, Mich.
lf
mgertip injuries are exceedingly common, and palmar pad loss is particularly difficult to treat. With skin loss of less than 1 cm’, conservative treatment is recommended, and larger defects may require split-thickness or full-thickness skin grafting. However, once bone is exposed, to preserve length, flap reconstruction is required.‘, * When loss of the palmar pad in these injuries is too great for local flap reconstruction, regional flaps such as the cross-finger flap3, 4 or the thenar flap5 may be used, unless length is to be sacrificed. Digital length and the fingertip pad should be reconstructed when possible for adequate pinch, with the nail being retained for stability and pickup.6 To achieve these goals, we employ a local neurovascular island flap.
Materials and methods Twenty-one operations done at our institution before 1980 formed our study group. Nineteen of these op-
From the Department of Surgery, McLaren General Hospital, Flint. Mich.; and the Department of Orthopedic Surgery, Medical College of Ohio, Toledo, Ohio. Supported
by a grant from the Brownell
family
Received the first annual Sumner L. Koch award presented by the Chicago Hand Society, Baltimore, Maryland, September 1988. Received for publication 12, 1989.
Feb. 9, 1989; accepted in revised form Oct.
Although none of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which one or more of the authors are associated. Reprint requests: Frank W. Cook, Flint, MI 48503.
MD, 1071 N. Ballenger
3/l/17893
798
THE JOURNAL OF HAND SURGERY
Hwy..
erations were done to treat acute trauma involving palmar pad amputation with tissue loss greater than 1 cm’, with bone exposed. Varying degrees of nail bed involvement were found. Two operations were done as secondary reconstructive procedures in patients who had a previous injury resulting in pad loss. They had tender, deformed fingertips with painful pinch. The senior author has continued to employ this method of replacing major distal pad loss since 1980, but we include in this study only those cases that have a minimum 8-year follow-up.
Operative design (See Fig. 1, a through g,) The neurovascular island flap is outlined on the palmar surface of the distal phalanx or the distal portion of the middle phalanx, making the island 25% larger to account for the curvature of the pad. The distal extent coincides with the skin defect, when possible, and skin only is incised at the level of the neurovascular pedicle. The incision is continued midlaterally to the level of the web space (Fig. 1, b). It may be extended into the palm, but this was not found to be necessary in any of our cases. The flap is elevated in retrograde fashion, leaving sufficient subcutaneous tissue to enable subsequent coverage of the donor defect by full-thickness skin graft. After this, the neurovascular bundle is freed from Cleland’s ligament. Care is taken to leave sufficient fat around the neurovascular pedicle to ensure adequate venous drainage of the island. Length of the pedicle is gained by carrying the dissection to the web space (Fig. 1. c). With the finger in slight flexion, the flap is advanced into the pulp defect, leaving a small open area at the tip, and sutured in place with interrupted No. 6-O monofilament sutures (Fig. 1, 6). A full-thickness skin graft is harvested from the palmar wrist crease or the hypothenar
Vol. 15A, No. 5 September 1990
Local neurovascular islandjap
C.
799
d.
e.
Fig. 1. Use of the flap: (a) Palmar pad loss with bone exposed. (b) Incision is made along the midlateral margin of the finger together with the island. (c) The island, slightly larger than the defect together with its neurovascular pedicle, is raised. (d) By slightly flexing the finger the pedicle is advanced to the defect and sutured in place. (e) and (f) The proximal defect is covered by a full-thickness skin graft. (crosshatched) (g) The tip may be covered with a crescent-shaped free full-thickness graft if necessary (crosshatched).
eminence to cover the donor site and the interval remaining between the distal portion of the island flap and nailbed (Fig. 1, e through g). The graft over the pedicle should be slightly larger than the defect. If the graft is too tight, the pedicle may be compressed causing congestion of the distal pedicle and possible loss of the island itself. The defect at the wrist or hypothenar eminence is closed primarily, a nonadherent dressing is applied, and the finger is immobilized in 15 to 30 degrees proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion, in an aluminum splint. Immobilization is continued for 1 week. After this, the splint is removed and range of motion exercises begun. The patients were all evaluated by the same examiner. The dimensions of the neurovascular flap were obtained and the area calculated. The distance of flap advancement was noted in each case. The patency of the neurovascular pedicle was assessed using the digital Allen test. Two-point discrimination testing was done using
the clinical guidelines of the American Society for Surgery of the Hand. The target fingertips were assessed for contour and residual deformity. Range-of-motion testing of the metacarpophalangeal (MP), PIP, and DIP joints was done. Patients were questioned with respect to residual pain and cold intolerance. Of the 21 patients having neurovascular island flap reconstruction, 18 were successfully contacted and fully evaluated. One patient had died in the intervening period, and two patients were lost to follow-up.
Results Follow-up ranged from 8 to 14 years, with a mean of 10.5 years. Age ranged from 7 to 72 years, with a mean of 38 years. All patients were right-handed. Four of the injuries involved the nondominant index finger, the remaining injuries were relatively evenly distributed among the other digits (Table I). Eleven of these patients had sustained a work-related injury. Of the 18 patients fully evaluated, the neurovascular pedicle was intact in
800
Cook.
Jalub.
and
The Journal ol HAND SURGERY
Pallock
Table 1. Patients reviewed Patient
Digit
L. I’. s. s. c. 1). E.
