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A 45-year-old carpenter sustained a table saw injury to his right hand while at work earlier today. Evaluation in the Emergency Department reveals the defect depicted in Figure A. An island volar advancement flap was selected for wound closure. This method of thumb reconstruction is best indicated for which of the following sized defects?
less than 1 cm
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The clinical vignette is consistent with an oblique amputation of the distal phalanx of a thumb with a defect measuring >2.5 cm. Island volar advancement flaps are a safe and effective procedure for single-stage closure of considerably large thumb defects measuring up to 3.5 cm in length.
The operative technique chosen for reconstruction of distal volar thumb defects depends largely on the size of the defect. Island volar advancement flaps used for defects up to 3.5 cm are pure island flaps in which all of the proximal attachments, with the exception of the neurovascular bundles, are divided to provide maximal advancement. Mobility up to 4 cm can be achieved with elevation of the entire volar skin of the thumb from the underlying tendon sheath providing a considerable advantage in thumb reconstruction. The island volar advancement flap is useful for coverage of the entire distal phalanx from the IP joint crease to the nail bed.
Foucher et al. reviewed long-term clinical results of 13 neurovascular palmar advancement flaps for thumb tip coverage. Specifically, they reported on Moberg and O’Brien flaps. The Moberg flap is a pedicled advancement flap proximally-based on an intact skin pedicle of the thumb including both neurovascular bundles. The O’Brien flap is a modification of the Moberg technique which advances a volar flap based on a subcutaneous pedicle including both neurovascular bundles by incising the proximal skin and skin grafting the donor site. The study found that both flaps preserved near-normal pulp sensibility, MP and IP joint motion, and grasp and pinch strength. They suggested that Moberg and O’Brien flaps remain the first choice for coverage of 1-2 cm thumb pulp defects.
Baumeister et al. reported on the functional outcomes of 25 patients that underwent thumb pulp reconstructions utilizing Moberg volar advancement flaps. They found that 72% of patients had no or only minor subjective complaints, 74% had normal sensitivity, DASH scores showed only minor impairments, no flaps resulted in decreased grip strength, and only minor restrictions were identified in active IP joint motion. All defects with a length less than or equal to 2 cm were successfully reconstructed, whereas, patients presenting with defects >2 cm developed complications.
Mutaf et al. reviewed outcomes of 12 patients that underwent thumb reconstruction utilizing an island volar advancement flap for traumatic distal thumb injuries measuring 3 to 3.5 cm in length. Their results showed that none of the flaps failed, no patients had limited mobility or scar contractures, near-normal sensation was achieved, excellent recovery of pinch strength occurred, and maximal preservation of thumb length was possible in all patients.
Figure A and Illustrations A through C represent a case example presented by Mutaf et al. Figure A depicts an oblique amputation of the distal phalanx of a right thumb. Illustration A reveals elevation of an island volar advancement flap on both sides of the digital neurovascular bundles in the same thumb. Illustration B reveals flap advancement and Illustration C reveals a postoperative image of the same thumb 4 months after surgery.
Answers 1 & 2: Small or superficial defects may be amenable to conservative treatment or local flaps depending on the location of the defect.
Answers 3 & 4: The Moberg flap with modifications to lengthen distal advancement as necessary is considered a standard option for medium-sized defects of the thumb pulp less than or equal to 2 cm.
Foucher G, Delaere O, Citron N, Molderez A.
Br J Plast Surg. 1999 Jan;52(1):64-8. PMID: 10343593 (Link to Abstract)
Baumeister S, Menke H, Wittemann M, Germann G
J Hand Surg Am. 2002 Jan;27(1):105-14. PMID: 11810623 (Link to Abstract)
Baumeister, JHS 2002
Mutaf M, Temel M, Günal E, Isik D
Ann Plast Surg. 2012 Feb;68(2):153-7. PMID: 21629080 (Link to Abstract)
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Average 1.0 of 71 Ratings
A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and follow-up within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Answer 1: Emergent replantation is not indicated in distal fingertip amputations.
Answer 2: Revision amputation through the DIP joint could be considered for Zone III injuries
Answer 3: Moberg advancement flaps are considered for volar thumb soft tissue loss.
Answer 4: Z-plasty is considered for soft tissue loss in the webspaces.
Quell M, Neubauer T, Wagner M.
Handchir Mikrochir Plast Chir. 1998 Jan;30(1):24-9. PMID: 9541835 (Link to Abstract)
Tupper J, Miller G.
J Hand Surg Br. 1985 Jun;10(2):183-4. PMID: 4031598 (Link to Abstract)
Tupper, JHANDS 1985
Average 4.0 of 16 Ratings
Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect.
Answer 1: Fingertip amputations with minimal soft tissue loss and no exposed bone can be allowed to heal through secondary intention.
Answer 2: The posterior interosseous fasciocutaneous flap is an excellent option for lacerations to the first web space.
Answer 4: This large soft tissue defect on the dorsum of the hand may be treated with a groin flap.
Answer 5: Fingertip amputations with exposed bone are best treated with local advancement flaps such as a VY advancement flap.
J Hand Surg Am. 1994 Jan;19(1):26-31. PMID: 8169365 (Link to Abstract)
Sherif, JHS 1994
J Hand Surg Am. 1994 Jan;19(1):32-8. PMID: 8169366 (Link to Abstract)
Average 3.0 of 12 Ratings
Which of the following hand injuries is most appropriately treated with a volar advancement (Moberg) flap closure?
Figure D shows a volar thumb defect which can be best covered with a Moberg advancement volar flap (if < 2 cm). FDMA (1st dorsal metacarpal artery) and neurovascular island flaps are typically used to cover larger soft tissue defects of volar aspect of the thumb. FDMA (1st dorsal metacarpal artery) flaps can also be used for dorsal thumb wounds as shown in Figure B. The cross-finger flap is a useful heterodigital flap for digital wounds with primarily volar tissue loss (Figure A). Additionally, several articles have advocated secondary intention healing even if bone is exposed as discussed in the 2009 OITE question #48. The thenar flap is useful for volar defects of the index and middle fingers (Figure C). Figure E represents a ring avulsion injury and it is treated with vessel repair if there is inadequate circulation and the bone, tendon, and nerve components are intact. Amputation of the digit is chosen if there is inadequate circulation concomitant with bone, tendon, or nerve injury.
The referenced articles by Martin and Hynes are review articles discussing the treatment options available for digit injuries. Illustration A shows the planned incisions for a moberg advancement flap on a volar thumb defect and Illustration B shows the completed Moberg.
Martin C, González del Pino J.
Clin Orthop Relat Res. 1998 Aug;(353):63-73. PMID: 9728160 (Link to Abstract)
Martin, CORR 1998
Hand Clin. 1997 May;13(2):207-16. PMID: 9136035 (Link to Abstract)
Hynes, HANDC 1997
Average 4.0 of 20 Ratings
A 6-year-old boy sustained a finger tip amputation shown in Figure A after grabbing a broken glass out of the dishwasher. Your plan was to perform a bedside irrigation and debridement of the finger after digital anesthetic block and apply antibiotic ointment with a sterile dressing. Upon exploration of the wound you notice that distal phalanx is exposed. Your plan should change to include which of the following treatments?
Homodigital island flap
Volar flap advancement
V-Y advancement flap
No change from your initial plan of ointment and dressing
In young children with a fingertip amputation, ointment and dressing changes is the most appropriate treatment even if bone is exposed.
When deciding on a treatment, consideration of a "reconstruction ladder" is helpful in determining the least invasive procedure to obtain the optimal outcome. The ladder includes primary closure, healing by secondary intention, split-thickness skin grafts, full-thickness skin grafts, random pattern local flaps, axial pattern local flaps, island pattern local flaps, distant random pattern flaps, distant axial pattern flaps, and free tissue transfer.
Lamon et al reviewed 25 patients, with an average age of 30 years old, with fingertip injuries treated with dressings and warm soaks started 2 days after injury and noted no healing complications. Only one patient in this cohort had bone exposed.
Soderberg et al performed a Level 3 study of 36 operative and 34 conservatively treated fingertip amputations with bone exposure and found no benefit to surgery.
Farrell et al conducted a Level 4 review of 21 fingertip amputations with 6 having exposed bone and concluded that they healed with excellent results in regards to contour, sensation, and finger length.
Illustration A shows a homodigital island flap. Illustration B shows a thenar flap. Illustration C shows a volar flap advancement. Illustration D shows a volar V-Y flap advancement.
Lamon RP, Cicero JJ, Frascone RJ, Hass WF.
Ann Emerg Med. 1983 Jun;12(6):358-60. PMID: 6859631 (Link to Abstract)
Söderberg T, Nyström A, Hallmans G, Hultén J.
Scand J Plast Reconstr Surg. 1983;17(2):147-52. PMID: 6361983 (Link to Abstract)
Farrell RG, Disher WA, Nesland RS, Palmatier TH, Truhler TD.
JACEP. 1977 Jun;6(6):243-6. PMID: 864887 (Link to Abstract)
Average 3.0 of 30 Ratings
You are taking care of an adult patient with significant scar contracture in her first web space after a thermal burn. Which of the following techniques will allow you to lengthen her scar approximately 75%?
Two-flap Z-plasty with 60 degree limbs
Two flap Z-plasty with 25 degree limbs
Island pedical flap
Split-thickness skin graft
One of the most commonly used techniques for lengthening scar contracture in hand surgery is the Z-plasty. When the two 60 degree triangular flaps are transposed and closed, the original direction of the scar is rotated and the scar length is increased by approximately 75% Because of its history the 60 degree Z-plasty is the technique to which other methods of contracture lengthening are compared.
Hove et al describe the technique, various applications, and different types of Z-plasty used today. Neither the cross-finger flap nor island pedical flap are useful for this amount of scar release. Two flap Z-plasty with 25 degree limbs does not offer enough lengthening. Split-thicknes skin grafts are not useful for either lengthening or the volar aspect of the hand due to the significant contracture they experience.
Illustration A and B depict the Z-plasty technique.
Hove CR, Williams EF 3rd, Rodgers BJ.
Facial Plast Surg. 2001 Nov;17(4):289-94. PMID: 11735063 (Link to Abstract)
Average 4.0 of 25 Ratings
A 28-year-old factory worker has his ring finger caught in the machinery at work. A photograph of the injury is shown in Figure A. Which of the following procedures will best supply coverage of the wound?
Amputation through the proximal interphalangeal joint
Shortening of the distal phalanx, nail bed removal, and V-Y flap
The clinical presentation is consistent with a transverse fingertip amputation. Shortening of the distal phalanx, nail bed removal, and dorsal V-Y flap would be the most appropriate treatment.
The V-Y flap is useful for extending dorsal skin to cover a transverse or dorsally angulated fingertip injury. They are typically used for finger tip amputations which have more dorsal soft tissue loss than palmar loss. Nail bed removal is important to prevent a subsequent hook nail deformity.
Fassler reviews the proper management of fingertip injuries including the different flap coverage outlines discussed above. If there is no exposed bone, healing by secondary intention is acceptable. If bone is exposed in the wound but there is enough nail bed remaining to support a nail plate, then a local advancement flap is a good option. If local flap coverage is not feasible due to the extent of the soft tissue injury, a regional flap (cross-finger or thenar) is necessary. If the wound is proximal to the nail bed, then shortening and primary closure is most reasonable.
Figure A shows a transverse fingertip amputation. Illustration A shows the different zones of fingertip amputations: Zone I is distal to the phalanx; Zone II is distal to the lunula; Zone III is proximal to the lunula. Illustration B shows the basic steps of a V-Y flap.
There is too much exposed bone remaining to simply cover with sterile dressings.
Answer 1: An amputation would not be indicated.
Answer 3: Cross-finger flaps are useful for fingertip injuries with volar tissue loss only.
Answer 4: A groin flap would not be indicated in this clinical situation.
Answer 5: Thenar flaps are reserved for index and middle fingertip injuries and carry a risk of postoperative flexion contractures.
J Am Acad Orthop Surg. 1996 Jan;4(1):84-92. PMID: 10795040 (Link to Abstract)
Fassler, JAAOS 1996
Average 3.0 of 28 Ratings
A 29-year-old intravenous drug user undergoes irrigation and debridement of a ring finger abscess. After adequate eradication of the infection, he is left with the skin defect shown in Figure A. What is the most appropriate treatment at this time?
Local woundcare and healing by secondary intention
Based on the location of the lesion, a cross-finger flap would be most appropriate.
Cross finger flaps are indicated in patients > 30 years of age when the lesion is a volar oblique finger tip lacerations or a volar proximal finger lesions. The advantage is it leads to less stiffness.
Martin et al review the treatment options available for digit injuries. They report treatment of fingertip injuries is a continuous focus of controversy among hand and orthopaedic surgeons. Different treatment options have been described, depending on the affected segment and finger, type of lesion, gender and age of the patient, location, size, and depth of the defect.
Fassler et al reviews the proper management of fingertip injuries discussing variables such as the severity of soft tissue loss and whether bone is exposed.
Answer 1: Secondary intention healing of this wound is inappropriate due to size and exposed tendon.
Answer 2: V-Y advancement flaps are for dorsal injuries.
Answer 3: Thenar flaps are good for getting more bulk for distal fingertip injuries.
Answer 4: A Moberg flap is performed on the thumb. A cross-finger flap is a full-thickness flap useful for volar soft tissue loss distal to PIP.
Average 3.0 of 23 Ratings
Which of the following complications is most likely to occur following the procedure on the middle finger of a right hand shown in Figure A?
Cosmetic mismatch of the skin
Median nerve motor branch injury
Recipient site sensitivity
Flexion contracture at the recipient proximal interphalangeal joint
The image shows a thenar flap. The digit is flexed at the PIPJ and extended at the DIPJ during the period prior to flap division, leading to PIPJ stiffness and flexion contracture.
Thenar flaps can be used for coverage of digital tip injuries where there is exposed bone or extensive pulp loss. Advantages include more subcutaneous fat than a cross finger flap, good color and texture match, and primary closure of the donor site. Other disadvantages include limited flap size and donor site tenderness. Contraindications include RA, Dupuytren’s contracture and advanced age with degenerative disease as these predispose to joint stiffness.
Fassler et al. reviewed fingertip injuries. The thenar flap can be used for any finger, although the small finger can be difficult to position comfortably. The flap can be as wide as 2 cm and should be 1.5 times as wide as the
defect so as to restore the normal rounded contour to the tip. To decrease the amount of PIPJ flexion required, the MCPJ and DIPJ should be flexed as much as possible.
Figure A demonstrates a thenar flap of the middle finger of the right hand. Illustration A shows a preoperative image with surgical planning marks on the right hand.
Answer 1: The flap is attached by a pedicle prior to flap division. After division, there is generally good flap take because of adequate neovascularization of the flap.
Answer 2: Thenar skin is a good cosmetic match for digital pulp skin (both volar skin).
Answer 3: Injury to the recurrent motor branch of the median nerve is distinctly uncommon with this flap.
Answer 4: Donor site sensitivity (not recipient site) is a known complication of this flap.
Average 3.0 of 16 Ratings
A 25-year-old left hand dominant musician sustains an injury to the left thumb shown in Figure A. He is unable to extend the interphalangeal joint and has less than 2 second capillary refill at the thumb. What is the most appropriate method to achieve soft tissue coverage after extensor tendon repair or transfer?
Moberg advancement flap
Vacuum-assisted wound closure
First dorsal metacarpal artery (Kite) flap
The clinical scenario is consistent with a dorsal thumb avulsion with missing extensor tendon and exposed bone necessitating soft tissue coverage. The first dorsal metacarpal artery (Kite) flap is the most appropriate flap for defects of the dorsal aspect of the thumb.
Fassler et al in a Level 5 review state that the first dorsal metacarpal artery (Kite) flap is appropriate for defects of the dorsal aspect of thumb. The flap is performed in one stage with the skin over the dorsum of the proximal index finger elevated with incisions on all four sides. An incision is extended proximally over the dorsum of the first web space, and a pedicle containing the first dorsal metacarpal artery, the subcutaneous veins, and branches of the dorsal sensory branch of the radial nerve is isolated. The skin island with the attached pedicle is transferred to the thumb defect and sutured in place.
Illustration A shows the technical steps of the first dorsal metacarpal artery (Kite) flap. Illustration B shows the final functional results of the first dorsal metacarpal artery (Kite) flap are shown in Illustration B.
Answer 1: Moberg advancement flaps are indicated for volar thumb defects.
Answer 2 & 3: Wet to dry dressings or vaccuum-assisted wound closure would be inappropriate in this situation.
Answer 5: V-Y advancement flaps are most appropriate for transverse or dorsal oblique fingertip amputations.
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