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Le lambeau cubital
Abstract
The authors describe a flap with a pedicle derived from the dorsal branch of the unlar artery. The ulnar artery gives rise to the dorsal ulnar artery 2 to 5 cm before the pisiform. This artery passes under the flexor carpi ulnaris muscle, accompanied by the dorsal branch of the ulnar nerve. It supplies an area 10 to 20 cm long by 5 to 9 cm wide on the ulnar side of the forearm and it also supplies the skin lying over the last three metacarpals on the dorsum of the hand and the Vth abductor. This artery also sends a branch to flexor carpi ulnaris and to the pisiform. It is now possible to trace a large flap in the forearm without interrupting the arterial axis. Large defects of the dorsum of the hand, wrist, thenar and hypothenar eminences can be covered by this pedicle or island flap. This artery is remarkably constant. Five clinical cases are presented.
... The dorsal ulnar artery fasciocutaneous flap was first described by , perfused by the ascending branch of the dorsal ulnar artery, one of the major branches of the ulnar artery in the distal forearm. [1][2][3][4] The importance of this flap lies in the possibility of mobilization of tissue for reconstruction of the hand without losing a major vascular axis. The dorsal ulnar artery fasciocutaneous flap can be raised as a hinge (peninsular), or as a true island flap. ...
... Various flaps have been The dorsal ulnar artery fasciocutaneous flap was first described by Becker and Gilbert in 1988, as a local flap for covering small skin defects of hand. [1,2] The disadvantages Figures 1a and b), defect of palm with exposed repaired tendons [3] and for different indications in hand reconstruction. [3,5,[7][8][9][10] Similarly, Niranjan and Shibu in 1994 suggested that the dorsal ulnar artery flap should only be used for the ulnar side of the lower third of the forearm and the hand. ...
Soft tissue defects of hand with exposed tendons, joints, nerves and bone represent a challenge to plastic surgeons. Such defects necessitate early flap coverage to protect underlying vital structures, preserve hand functions and to allow for early rehabilitation. Becker and Gilbert described flap based on the dorsal branch of the ulnar artery for defects around the wrist. We evaluated the use of a dorsal ulnar artery island flap in patients with soft tissue defects of hand. Twelve patients of soft tissue defects of hand underwent dorsal ulnar artery island flap between August 2006 and May 2008. In 10 male and 2 female patients this flap was used to reconstruct defects of the palm, dorsum of hand and first web space. Ten flaps survived completely. Marginal necrosis occurred in two flaps. In one patient suturing was required after debridement and in other patient wound healed by secondary intention. The final outcome was satisfactory. Donor areas which were skin grafted, healed with acceptable cosmetic results. The dorsal ulnar artery island flap is convenient, reliable, and easy to manage and is a single-stage technique for reconstructing soft tissue defects of the palm, dorsum of hand and first web space. Donor site morbidity is minimal, either closed primarily or covered with split thickness skin graft.
... The (dorsal) ulnar artery perforator (Becker flap, UAP) flap [19,20] is based on the distal perforator of the ulnar artery located 3 to 6 cm proximal to the pisiform bone. The potential flap size is 12 × 4 cm and, similarly to the RAP flap, it is used for the reconstruction of wrist, ulnar side, and dorsum of the hand, up to the MCPJ. ...
Introduction: The choice of the most adequate surgical technique for upper limb defects remains challenging. The aim of this article is to discuss the main microsurgical (pedicled or free) reconstructive options for the post-oncological reconstruction of different anatomical areas of the upper extremity. Materials and methods: We reviewed different reconstructive methods reported in the literature needing microsurgical expertise and compared them to our clinical experience, in order to provide further guidance in the choice of different flaps for upper limb soft tissue reconstruction. Six clinical cases, one for each anatomical district, are presented as examples of possible solutions. Results: We report the options available in the literature for post-oncologic upper limb reconstruction, dividing them by anatomical area and type of flap: local flaps, regional flaps, free flaps, and distant pedicled flaps. Our examples of the reconstruction of each anatomical area of the upper limb include one reverse ulnar pedicled perforator flap, one free Antero-Lateral Thigh (ALT) flow-through flap, one perforator-based lateral arm flap, two myocutaneous latissimus dorsi pedicled flaps, and one parascapular perforator-plus flap. Conclusions: In oncological cases, it is important to consider reconstructive options that provide stable tissue and allow for the early healing of the donor and recipient site if the patient needs to undergo adjuvant radiotherapy or chemotherapy. A wider range of flap options is essential when choosing the proper technique according to the patient’s needs, surgeon’s preference, and logistical possibilities. Perforator flaps combine the advantages of other flaps, but they require microsurgical expertise. Free flap reconstruction remains the gold standard to obtain a better overall and cosmetic outcome in complex and wide defects, where no suitable local pedicled flap option exists. The pedicled latissimus dorsi flap should still be included among the reconstructive options for its strong vascularization, size, and arc of transposition.
... Relying on the results of this study, authors believe that when possible, the RAPF should be preferred to the classic radial forearm flap, along with other perforator flaps of the region. 28,29 This flap allows to cover tissue losses of big sizes and of numerous anatomical areas, achieving excellent esthetic results at the donor and receiving site, sparing main vessels. Nevertheless, in patients with cardiovascular issues, diabetics, or smokers, the classic radial forearm flap might be more appropriate to avoid complications. ...
Introduction:
Radial forearm flap, first described in the early eighties in China, is a well-known and handy flap to cover soft tissue defects of the distal upper limb. It has, though, some inconveniences, such as the sacrifice of the radial artery and non-neglectable esthetic sequelae in the donor site. In the following years, a similar flap based on the perforators of the radial artery has been described as achieving similar results, allowing to spare a main vessel. The authors reviewed retrospectively the patients that underwent surgery with one of those two flaps in their center to compare outcomes.
Materials and methods:
Patients operated between January 2016 and January 2022 have been reviewed. Ten had a classic radial artery flap, and ten had a radial artery perforator flap. Twelve weeks after surgery, Vancouver Scar Scale was used to assess the results at the donor site and over the flap. Reintervention and failure rate within one year and patient satisfaction -using a visual analog scale ranging from 0 to ten-at 12 months were also assessed.
Results:
All classic radial artery flap group patients had "successful" surgery, and none needed secondary surgery. On the other side, three patients required a second surgery in the perforator flap group, and nine out of ten ended up with "successful" flaps. Mean Vancouver Scar Scale results regarding the flap are comparable, whereas those at the donor site are significantly better in the patients with the perforator flap. Patients' satisfaction results are similar in both groups.
Conclusion:
The radial artery perforator flap is an important flap to be held in mind by all surgeons approaching reconstruction of the elbow, the forearm, and the hand, and should be preferred, when possible, to the classic radial forearm flap.
... 2 Early reconstruction of such defects is required for optimal function and rehabilitation, and it remains a challenge for the plastic and reconstructive surgeon. 3 As the little finger is a border digit, it is commonly involved in hand trauma. Different causes contribute to defects on the little fingers, including industrial injuries, burns, and results of tumor excision. ...
There are different approaches for reconstruction of little finger and dorsal hand defects. The ulnar parametacarpal flap, first introduced by Backhach et al in 1995, is considered a good option for reconstructing such defects. In this study, we elevated this flap on one perforator and applied it as a propeller flap. We then discussed the reliability of this flap and which perforator (the proximal or the distal one) is more reliable.
Methods:
This study was carried out on 20 patients with different little finger and dorsal hand defects between June 2017 and March 2019. All defects were covered by perforator-based ulnar parametacarpal flaps. Ten flaps were based on the proximal perforator, whereas the other 10 were based on the distal perforator.
Results:
With a period of follow-up ranging from 6 months to 1 year, all flaps that were raised on the proximal perforator survived completely, whereas two of 10 flaps raised on the distal perforator showed venous congestion and also one flap showed partial necrosis of the distal one-third due to ischemia.
Conclusions:
The perforator based ulnar parametacarpal flap is a reliable option for reconstruction of little finger and dorsal hand defects. It is more reliable when it is raised on the proximal perforator rather than on the distal one.
... The reconstruction of medium to large defects of the dorsal aspect of the hand has always been difficult and challenging. The most common local surgical options to cover this kind of defect are the reverse radial forearm flap, the reverse ulnar forearm flap, the reverse posterior interosseous flap, and the dorsal ulnar artery fasciocutaneous flap described by Becker and Gilbert in 1988 [1,2]. The last two options have the significant advantage of not depriving the hand of one of its major vascular axis. ...
Cover of medium and large defects of the dorsum of the hand remains a substantial surgical challenge that often requires free
tissue transfer. We report the case of a 28-year-old male who presented with necrosis of most of the dorsum of his dominant
hand after an iatrogenic injury. A large Becker flap was raised to cover the entire defect. However, venous insufficiency
was noted intraoperatively. The flap was turbocharged by performing a venous anastomosis between the flap and the recipient
site, resulting in complete survival of the flap. The authors conclude that the turbocharged Becker flap can be a good alternative
for expeditiously covering large defects of the dorsum of the hand without having to resort to free tissue transfer.
KeywordsBecker flap–Dorsal ulnar artery flap–Fasciocutaneous flap–Turbocharged flap–Hand defects–Venous anastomosis
Nerve exploration with neurolysis, excision, and grafting as well as nerve wrapping and flap utilization is a surgical option available to the surgeon when surgical intervention of neuroma-in-continuity (NIC) is considered. These interventions follow a period of non-surgical management and watchful waiting for spontaneous resolution of pain and/or neurological recovery. In this chapter, the authors discuss the different modalities of surgical treatment options with their respective benefits, shortcoming, and controversies. Furthermore, two illustrative cases for decision-making in NIC surgery are presented, and finally, a decision-making algorithm for NIC surgical management is provided.
From a reconstructive viewpoint, injuries of the hand are particularly challenging. They are often associated with exposed tendons, bones, nerves and vessels, whereas little skin and soft tissue reserves are available for coverage. Functional and esthetic requirements necessitate a differentiated approach, depending on the location and extent of the defect. This article gives an overview of reconstruction techniques and flap surgery on the hand for various defect sizes and locations.
A vast array of tumors can occur on the skin. Recent data demonstrated that more than two million of new cases of skin cancer are diagnosed annually [1]. Areas of sun exposure are more prone to develop numerous nonmelanoma skin cancers. The skin of the upper extremity and the hand is not an exception. It is known that the hand represents 1–2% of the total body surface. However, skin cancers involving this area account for 10–15% of all cases of skin malignancies [2, 3]. Unfortunately, there is a poor documentation of their natural history [4–6]. An explanation could be that either heterogeneous groups of soft tissue and cutaneous hand tumors or only specific skin cancers (e.g., squamous cell carcinomas) have been considered in the published series [7–12]. It is important to notice that the skin of the hand disposes a unique structure and is highly specialized allowing mobility for complex motor skills along with fine sensibility and resistance to withstand tearing and wearing forces. In addition the subcutaneous tissue is thin covering and protecting functionally important deeper structures. Subsequently, any therapeutic attempt necessitates a special consideration in this area counterbalancing sometimes two contradictory issues: tumor eradication and preservation or function restoration.
Objective
This study was designed to assess the effectiveness of an alternative technique using a perforator flap to manage secondary tendon exposure after a radial forearm free flap in head and neck oncologic surgery.
Study Design
Prospective cohort study.
Setting
Plastic Reconstructive Surgery Unit, Nice University Hospital, Pasteur 2 Hospital, France.
Subjects and Methods
Despite its numerous advantages, the radial forearm free flap is associated with significant donor site morbidity and the risk of secondary tendon exposure. Conventional skin grafts for secondary tendon exposure can lead to diminished wrist range of motion and grip strength, with residual pain and cold intolerance. Between 2012 and 2015, we prospectively studied 20 patients with secondary tendon exposure after a forearm radial free flap for head and neck reconstruction. Two techniques of secondary coverage were compared: a reference technique with a secondary full skin graft (10 patients) and a dorsoulnar artery perforator (DUAP) flap (10 patients).
Results
Maximum wrist extension (100%) was observed for the DUAP group compared with only 87% for the skin graft (SG) group ( P = .001). An improvement in grip strength (+14 kg) ( P = .028) and a decrease in pain or cold intolerance ( P = .002) were also observed in the DUAP group, in addition to a better aesthetic appearance.
Conclusion
The perforator flap procedure is an interesting tool in reconstructive surgery. The DUAP flap is a reliable, useful flap for secondary tendon exposure coverage after a radial forearm free flap.
Level of Evidence
III (case-control analytic studies of 1 center).
The most genuine interest in plastic surgery with all its subcategories is the correction or restoration of body form and function. For this, plastic surgery is based on a myriad of different techniques that are uniquely associated with this area of expertise but also originate from other medical specialties. Because plastic and reconstructive surgery is one of the most interdisciplinary medical specialties, it makes it necessary for the reconstructive surgeon to keep up to date with new techniques, but also to refine and critically appraise the currently available methods. The restoration of complex soft-tissue injuries combined with severe closed or open fractures resulting from severe trauma poses a significant clinical challenge. These injuries are often associated with significant clinical complications including wound infection, soft-tissue loss, compartment syndrome, non-union fractures, pain, stiffness, protracted course of treatment, joint contracture, osteomyelitis, chronic pain syndromes, and amputation of the respective extremity. A solid and cooperative team approach is indispensable to obtain initial tissue integrity as well as the respective organ function of the patient based on the complexity of the respective injury, complications which may arise, as well as the diversity of treatment options.
Poly-traumatized patients are prone to develop challenging complications related to exposure and insufficient soft tissue coverage of bone, muscle, joint, nerves and vasculature. Thus, soft tissue injury is a decisive factor in determining a prolonged inflammatory acute phase response, microbial infection or both a prolonged critical care and rehabilitation interval. Therefore, a focus both on surgical and non-surgical measures in these patients should be directed at minimizing secondary, thus avoidable damage to soft tissue in unison with early-intend reconstructive measures. Also, a deeper understanding of biological mechanisms of tissue inflammation and regeneration is likely to further improve outcomes in these patients. This chapter gives an overview over various advances and techniques in surgical wound management, tissue grafting and free vascularized tissue transfer in order to defer long-term functional and aesthetic sequels. In addition, a comprehensive approach to wound closure and soft tissue coverage is given.
In hand surgical practice, most of us will have an ongoing, although mercifully small, experience of patients who develop excessive peripheral nerve pain beyond that normally felt at, and immediately after, injury or surgery. This chapter describes the authors’ experience of treating those patients who develop significant nerve pain after injury and/or surgery by local conservative and surgical treatments. The authors believe most such patients can be treated by hand surgeons to achieve a cure of their pain without referral to pain clinics.
Neurogenic pain can develop after microsurgical repair of a median nerve injury or when the lesion is underestimated and therefore not treated at all. Nerve injury with neuromatous pain may be associated with tumefaction at the wrist, increased pain and tingling when tapped [1]. The aim of the treatment is to both minimize pain and preserve residual function of the median nerve.
Surgical procedures such as neurolysis do not always relieve the patients’ pain. Reconstruction with grafts is reserved only for cases with very poor sensory and motor recovery. Neurolysis should be performed carefully to avoid devascularization of the nerve and formation of a new scar around the nerve [2]. Particular attention has been given to the coverage and wrapping of a neuroma with different pedicle flaps as the pronator quadratus muscle flap [3], the Becker flap [4], the reverse island radial fascial flap with or without inclusion of the radial artery [2,5-7] and the local synovial flap [8]. With regards to free flaps, Wintsch [9] believes that a thin flap of gliding fascia is the ideal flap to cover a nerve, whereas Jones [10] advocates the use of a small hemi-latissimus dorsi muscle flap. The lateral arm flap [2,11,12] and the scapular flap [2,11] represent other options but the thickness of the subcutaneous tissue and the overlying skin often produce very prominent flaps [10]. Goitz and Steichen [13] reported the coverage of a scarred median nerve with a free omental flap.
The purpose of this study is to review the treatment of painful neuroma of the median nerve at the wrist treated with external neurolysis and coverage using the ulnar artery perforator adipofascial flap (UAPAF) or the radial artery perforator adipofascial flap (RAPAF).
Resumen
El desarrollo de un neuroma es una temida complicación tras la cirugía de los nervios periféricos. El tratamiento es de gran complejidad, especialmente cuando afecta a los principales nervios a nivel de la muñeca. Presentamos un caso de neuroma en continuidad del nervio mediano tratado mediante neurolisis y cobertura mediante un colgajo sinovial.
Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.
Copyright © 2014 Elsevier Inc. All rights reserved.
This article deals with the classification, assessment, and management of painful nerves of the distal upper limb. The author's preferred surgical and rehabilitation techniques in managing these conditions are discussed in detail and include (1) relocation of end-neuromas to specific sites, (2) division and relocation of painful nerves in continuity (neuromas-in-continuity and scar-tethered nerves) involving small nerves to the same sites, and (3) fascial wrapping of painful nerves in continuity involving larger nerves such as the median and ulnar nerves. The results of these treatments are presented as justification for current use of these techniques.
Purpose
To review the outcomes of 8 patients with painful median nerve neuromas at the wrist treated with external neurolysis and covered with pedicled perforator adipofascial flaps.
Methods
Between 2004 and 2010, we treated 8 patients, who had a mean age of 37 years, and who had posttraumatic painful median nerve neuromas at the level of the wrist but with retained median nerve function . All of them reported neuropathic pain and had a positive Tinel's sign over the site of the presumed neuroma. The surgical procedure included external neurolysis and coverage with an ulnar artery perforator adipofascial flap (4 patients) or with a radial artery perforator adipofascial flap (4 patients). Patients were reviewed after a mean follow-up of 41 months (range, 18–84 mo). Preoperative and postoperative pain was measured with a visual analog scale.
Results
Pain improved from a preoperative mean value of 7.8 to a postoperative mean value of 3.6. There was complete resolution of pain in 5 patients, mild pain persisted in 2 patients, and 1 patient reported no improvement. No complications occurred at the donor site.
Conclusions
Vascularized soft tissue coverage of painful median nerve neuromas is an effective treatment. We do not believe that a free flap is of any particular advantage over a local pedicle flap which we suggest using to protect the median nerve.
Type of study/level of evidence
Therapeutic IV.
We recently reported a small study at the Federation of European Societies for Surgery of the hand, which was entitled 'What is secondary flexor tendon surgery'? This study concluded that 'secondary flexor tendon surgery' was a generic name encompassing a multitude of pathologies. Between 10% and 15% of cases exhibited pathology of the skin and subcutaneous fat and required flap reconstruction of these tissues. Skin replacement may be used prophylactically at primary surgery or become necessary at secondary surgery after release of scar contractures, to achieve cover of vital structures. The long-term problem of skin deficiency relating to flexor tendon function is one of loss of extension from longitudinal scar shortening of the integument, even if the flexor tendons are primarily concerned with bending the digits, not straightening them. This loss of extension can only be tolerated in a hand to a certain degree without significant loss of function. This paper is largely an analysis of the flaps available and suitable for different degrees of skin deficiency and at different places along the course of the flexor system. It attempts to dispel the idea that 'any flap will do' provided the flexors are adequately covered.
Surgical managment of soft tissue loss in the wrist consists of suitable coverage for the protection of vascular, nervous and tendinous structures. The fasciocutaneous cubital flap covers wrist defects, providing safe support over the nerves, tendons and vessels. Reported here is five cases of wrist defects by different etiology (extravasations, autolysis, trauma and neuritis). A fasciocutaneous cubital flap successfully covered the soft tissue loss in all cases. This flap is applied in an easy, one-stage procedure and it maintains the major arteries of the forearm.
Le tecniche di ricostruzione delle perdite di sostanza cutanee dell’arto superiore sono molto evolute nel corso dei tre ultimi decenni, beneficiando dell’apporto successivo delle nuove tecniche. Lo sviluppo della microchirurgia vascolare nel corso degli anni Settanta ha consentito l’utilizzazione dei lembi liberi. Questi ultimi, tra cui in particolare il lembo di latissimus dorsi, sono soprattutto impiegati nell’arto superiore nei casi di lesioni estese. I lembi sottocutanei peduncolati tra cui il lembo antibrachiale radiale che fu il primo a essere descritto agli inizi degli anni Ottanta, sono oggi i più utilizzati. Altre tecniche più classiche, come il lembo inguinale di Mc Gregor, conservano tuttavia delle indicazioni. L’arsenale dei mezzi terapeutici a disposizione dei chirurghi si è anche considerevolmente arricchito, rendendo il capitolato d’oneri di ricostruzione dell’arto superiore più «pesante». Quest’ultimo deve ormai rispondere non soltanto a un obbligo funzionale che autorizza una rieducazione precoce, ma anche a considerazioni estetiche. Nel quadro della traumatologia, l’affidabilità della copertura cutanea deve autorizzare il trattamento «tutto in un tempo» dell’insieme delle lesioni. A livello del braccio e della spalla, il lembo peduncolato di latissimus dorsi consente di trattare l’insieme delle lesioni. Le perdite di sostanza della regione del gomito sono più difficili da trattare e la scelta della tecnica è in funzione delle dimensioni della lesione e dell’esistenza dell’eventuale associazione di lesioni vascolari. Possiamo utilizzare un lembo muscolare peduncolato di brachioradiale, un lembo antibrachiale radiale o interosseo posteriore a peduncolo prossimale o, ancora, un lembo brachiale esterno. Il lembo peduncolato di latissimus dorsi consente da una parte di trattare la lesione cutanea e dall’altra di rianimare le flessione del gomito. Nei casi di una lesione vascolare associata con impossibilità di realizzare un lembo locale è possibile realizzare un ponte vascolare con un lembo peduncolato toracico o realizzare un lembo antibrachiale libero controlaterale-ponte. A livello dell’avambraccio, le perdite di sostanza estese o prossimali possono beneficiare di un lembo libero di latissimus dorsi. Al terzo distale dell’avambraccio la scelta tra lembo libero peduncolato distale e lembo interosseo posteriore o antibrachiale radiale a peduncolo distale è funzione delle esigenze estetiche o delle lesioni associate. A livello del polso bisogna aggiungere a queste ultime tecniche i lembi fasciocutanei quali il lembo dorsocubitale di Becker o lembo muscolare peduncolato di pronatore quadrato. Per ciascuna zona esistono più tecniche e la scelta non è sempre facile, perché deve integrare gli imperativi lesionali, funzionali e estetici alle abitudini del chirurgo così come alle possibilità tecniche e di rianimazione, in particolare nel quadro dell’urgenza.
En el tratamiento de la pérdida de sustancia cutánea de la mano se utilizan técnicas diversas, desde la cicatrización dirigida a los colgajos libres, pasando por los injertos cutáneos y por los colgajos locales, regionales y a distancia. Las técnicas que se presentan en este artículo han demostrado ser eficaces. Se plantearán sus indicaciones en función de la localización y de la extensión de la pérdida de sustancia que se va a tratar. La finalidad consiste en obtener una reconstrucción funcional y estética lo más precoz posible, que permita a la vez una movilización temprana y un buen resultado funcional. La elección del método más eficaz y más sencillo no excluye la sofisticación para alcanzar el objetivo fijado.
Die Kenntnis der regionenspezifischen Vaskularisation unter Normalbedingungen (Abb. 9.1 a–c, s. Plastische Chirurgie, Bd.
1, Kap. 17) und ihrer defektbedingten Beeinträchtigung beeinflusst die Auswahl des Therapieverfahrens entscheidend.
Il est nécessaire de connaître certaines bases anatomiques pour comprendre le support vasculaire et pouvoir réaliser les principaux
lambeaux pédiculés utiles á la couverture des pertes de substance cutanée de la main et des doigts. L’objectif n’est pas de
faire un exposé exhaustif, mais de souligner les points anatomiques permettant la réalisation de ces lambeaux.
Der primäre Wundverschluss an der Hand ist eine conditio sine qua non und bietet den besten Schutz für die Vitalität tiefer
Strukturen. Selbst wenn die endgültige Versorgung dieser Strukturen zu einem späteren Zeitpunkt vorgesehen ist oder wenn mehrere
Eingriffe erforderlich sind, ist eine gute Weichteildecke die Voraussetzung dafür.
Nerve compression syndrome of the upper limb is frequent in instrumentalist musicians who play instruments. These compressions are usually postural and can occur no matter what instrument is played. Almost all the nerves of the upper limb can be affected, but the frequency varies considerably according to the instrument. In our experience, the compressions most often seen are, in decreasing order, that of the median nerve at the carpal tunnel, that of the brachial plexus at the costoclavicular passage, and that of the cubital nerve at the elbow. Other possible sites for compression are much more rarely seen. In most cases, a conservative treatment is tried before surgery is performed.
Treatment of the post-surgical complications of carpal tunnel syndrome. Carpal tunnel surgery is the most frequently performed operative procedure in hand surgery centers. Surgical teatment for complications is more and more frequent. Among these complications we distiguish : complications after a lésion of a major anatomical stucture, complications secondary to flexor retinaculum section, incomplet release or recurrent syndrome, at least non specific complications. Nerve, vessel and tendon injuries must be treated without delay. Deffered surgery is more difficult and results are worse. In some cases of median nerve laceration an opponensplasty can be performed to improve hand fonction. Pillar pain is a frequent post-operative complication, about 30% of the cases. The cause of pillar pain remains elusive : alterations of the carpal arch, ligaments, muscles or nerves. Some complications can be considered as secondary effect of flexor retinaculum section : strenght’s decrease, trigger fingers, flexor tendons luxation and ulnar nerve compression at the Guyon tunnel. Persistence or recurrence of the clinical signs of carpal tunnel syndrome are the most frequent causes of surgical reexploration. Incomplete release of the flexor retinaculum and median nerve “neurodesis” are respectively in cause. The diagnostic must be confirmed, the surgical procedure consits in a complete retinacular section, neurolysis and in the majority of the cases an interposition vascularised flap.
Introduction – The posterior interosseous flap is used to cover skin defects in the hand, wrist, forearm and elbow. It is currently, commonly indicated for adults, but it may be used for child too.Materials and method – Twelve children underwent a posterior interosseus flap (13 flaps). Their ages ranged from 3 to 17,5 years with a mean of 6,5 years. There were seven boys and five girls. The flaps were used to treat different type of lesions: the most frequent etiology was burn injuries or sequels (nine patients), there were one extravasation of anticarcinogenic agent, one syndactyly and one arthrogryposis. The localizations of the skin loss were the first web space (six patients), the dorsal hand (five patients) and the elbow (two patients).Results – The average of the operation was eighty minutes. The survival of the flaps was excellent. Only one flap had a partial necrosis.Conclusion – Posterior interosseus flap may be used in coverage of children' s limb. The diameter of the vessels is not a difficulty in the flap dissection. As the adults, the viability of the flap is excellent and allows to cover most of the skin defect of the dorsal hand or elbow.
Hautdefekte von oberflächlichen Erosionen bis hin zu komplexen Verlusten des Integuments sind ein ernst zu nehmendes Problem in allen medizinischen Bereichen, v. a. aber den operativen Disziplinen. Die Rekonstruktion solcher Defekte verlangt eine individuelle, dem Patienten angepasste Therapie. Vielfach sind ausgefeilte plastisch-rekonstruktive Maßnahmen notwendig, um beste funktionelle und kosmetische Ergebnisse zu erzielen. Der vorliegende Beitrag stellt die aktuellen Therapiekonzepte der plastisch-chirurgischen Wiederherstellung des Integuments dar und beschreibt ?Algorithmen zur Entscheidungsfindung bei der Vielfalt zur Verfügung stehender Möglichkeiten zur Defektdeckung.
La vascularisation du bord médial de l’avant-bras par le rameau dorsal de l’artère ulnaire a été étudiée par C. Becker et
A. Gilbert (1). Ils ont décrit en tère 1988 un lambeau cutanéo-adipeux basé sur cette artère avec une vascularisation antérograde
(fig. 1). L’avantage de ce lambeau par rapport aux lambeaux tion de l’artère radiale et de l’artère ulnaire est sa simplicité
technique de prélève- prélèvement sans interruption d’un axe principal de la main. Le site donneur, situé ment sur le bord
médial de l’avant bras, est relativement facile á cacher. Son inconvénient principal est la brièveté de son pédicule qui ne
lui permet que d’at- vénient d’atteindre le poignet et les têtes des métacarpiens. Nous avons proposé en 1994 teindre une
modification originale de ce lambeau sous forme d’îlot á flux rétrograde augmentant considérablement son arc de rotation (2).
Peripheral nerve surgery performed under unfavorable conditions results in increased scar formation and suboptimal clinical outcomes. Providing the operated nerve with a protective barrier, reduces fibrosis and adhesion formation and may lead to improved outcomes. The ideal coverage material should prevent scar and adhesion formation, and maintain nerve gliding during motion. Nerve protection using autologous tissues has shown good results, but shortcomings include donor site morbidity and limited availability. Various types of methods and materials have been used to protect nerves. There are both advantages and disadvantages associated with the various materials and techniques. In this report we summarize currently used protective materials applied for nerve coverage under various surgical conditions. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.
The dorsoradial flap is a recently described cutaneous flap, which is harvested from the distal forearm and indicated for covering dorsal soft tissue defects of the hand and thumb. Vascularization of the flap is assured by a cutaneous branch of the radial artery, which arises at the level of the first intermetacarpal space and supplies the skin of the distal quarter of the forearm dorsum. This area corresponds to the skin island of the dorsoradial flap. We report our clinical experience on seven patients where this flap was used for covering post-traumatic defects of the thumb. Dimensions of the defect varied from 18 to 28 cm(2). The donor site was skin grafted. All flaps survived and provided satisfactory coverage of the defect. Based on a secondary vascular axis, the flap has a large skin paddle and a wide rotation arc that allows soft tissue reconstruction of the dorsal and radiopalmar areas of the thumb.
Background:
The objective of this study was to provide anatomical information for the repair of small tissue defects in the hands and forearms with ulnar artery pedicle cutaneous branches-chain perforator flaps.
Methods:
Twelve ulnar artery pedicle cutaneous branches-chain perforator flaps taken from human cadavers were studied using three methods: latex perfusion for microanatomy analysis, denture material and vinyl chloride mixed packing for cast analysis, and polyvinyl alcohol and bismuth oxide perfusion for molybdenum target x-ray arteriography. Statistical analysis was performed on cutaneous perforators with a diameter of 0.2 mm or greater. Cluster analysis was conducted to determine the overall distribution of perforators.
Results:
There are two main clusters of perforators at a relative distance of 22.34 percent and 58.73 percent along the pisiform bone to the medial epicondyle. Two thick cutaneous perforators extend through the flexor digitorum superficialis and the flexor carpi ulnaris muscle gap, which are located 4.57 ± 0.59 cm proximal to the pisiform bone and 7.73 ± 1.14 cm distal to the medial epicondyle, with diameters of 0.63 ± 0.09 and 0.75 ± 0.15 mm and pedicle lengths of 1.49 ± 0.34 and 1.46 ± 0.54 cm. At the two main clusters of perforator-intensive sites, vessel chains formed by adjacent perforators were parallel to the flexor digitorum superficialis and the flexor carpi ulnaris muscle gap.
Conclusion:
This study demonstrated that the ulnar artery has two main clusters of perforators in the proximal one-third and distal one-fourth of the forearm, which can be used for ulnar artery pedicle cutaneous branches-chain perforator flaps to repair hand and forearm parenchymal defects.
Background: Management of soft tissue defects of the hand is one of the most challenging issues in hand surgery. Methods: The current use of local flaps from the hand and forearm, the operative techniques, indications for their use, and their advantages and disadvantages are reviewed. Microsurgical techniques and temporary pedicled flaps from other regions of the body are excluded because they are discussed in another contribution to this special issue on hand surgery. Results: Defects may be sequelae of trauma, burns or tumour resection. Their treatment may require not only surgical techniques such as simple skin grafting or local transposition flaps but also microsurgical procedures. The armamentarium for the treating hand surgeon consists of local techniques at the hand and forearm and free microsurgical techniques or temporary pedicled tissue transfer from other regions of the body. In the past few years, new flaps have been explored with a more careful evaluation of donor sites; also, newly developed techniques such as the perforator flap has come into the focus of interest. New flap techniques have to prove their advantages over established techniques with their well-known possibilities and risks before becoming routine procedures. Conclusions: The advantages and disadvantages of each technique regarding difficulty of harvest, reliability of anatomy, donor-site defect and other issues have to be carefully weighed one against the other when choosing the best technique suitable for each patient.
Although never exceeding a few square centimeters, finger pulp defects are reconstructive challenges due to their special requirements and lack of neighboring tissue reserve. Local flaps are the common choice in the management of this injury. However, the development of microsurgery and clinical practice have greatly boosted the application of different free flaps for finger pulp reconstruction with excellent results, especially when local flaps are unsuitable or impossible for the coverage of large pulp defects. These flaps are all located in the same operation field and can be performed under one tourniquet; therefore, they are more convenient with better patients' compliance in clinical setting. Nonetheless, there is still no consensus about which type of these flaps should be preferred among various finger pulp reconstructive options. In this article, we attempt to review articles describing finger pulp reconstruction using free flaps from the upper extremity from the literature. We summarize the clinical applications of these free flaps and detail their advantages and drawbacks, respectively. The algorithm of flap selection for finger pulp reconstruction based on our experience and literature review is also discussed.
The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2–6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 × 5.5 cm to 23 × 7 cm (average 15 × 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.
Some patients develop excessive peripheral nerve pain beyond that normally experienced after injury or surgery. Managing this pain can be a difficult and frustrating experience for both the surgeon and patient concerned. We present a system for the classification, assessment and treatment of painful neuromas of the upper limb.
The objective of the two-staged flexor tendon method is to improve the predictability of final results in difficult problems dealing with tendon reconstruction. This article reviews the evolution and benefits of this procedure. It also considers the use of the technique to help deal with problems requiring pulley and skin reconstruction simultaneously with re-constituting the flexor tendon system.
To introduce our experiences of using the flap based on the distal cutaneous branch of the ulnar artery.
Twenty-four patients sought surgical treatment for soft tissue defects of the hand at our medical institution between January 2003 and December 2008. Fifteen cases had soft tissue defect on the palmar aspect of the hand, and nine cases had soft tissue defects on the dorsal aspect of the hand. The flap based on the distal cutaneous branch of the ulnar artery was performed in all these patients. The size of the flaps ranged from 5 cm to 12 cm in length and from 4 cm to 8 cm in width.
Two flaps developed partial necrosis (25-35% of their area). In the other cases, both the donor and recipient sites healed successfully. No patient complained of cold intolerance of the hand or any altered sensation in the forearm. The range of motion of the wrist and hand joints was within normal limits in most cases, with 14 cases with excellent, 8 cases with good, 2 cases with fair, and 0 case with poor results according to the total active motion (TAM) criteria. None of the patients had limitations in activities of daily living.
Because the flap does not compromise the dominant hand arteries and provides a reliable blood supply, it is a good choice for soft tissue reconstruction of defects in the dorsal and palmar aspects of the hand.
Reverse radial forearm flap has been proven reliable and effective for hand reconstruction. Here we report our experience with the use of reverse forearm flap that does not contain the radial or ulnar artery for reconstruction of hand defects in 65 cases with soft tissue defects of the hand.
Sixty-five patients who sought surgical treatment for soft tissue defects of the hand at our hospital between January 2003 and December 2008 were included in the study. 39 cases had soft tissue defect on the dorsal aspect of the hand and 26 cases on the palmar aspect of the hand. 65 flaps were performed with the posterior interosseous artery flap in 26 cases, island flap supplied by the distal cutaneous branch of the ulnar artery in 23 cases, and the flap based on distally perforator of the radial artery in sixteen cases with the size of the flaps ranging from 5 to 12 cm in length and from 4 to 8 cm in width.
The distal cutaneous branch of the ulnar artery flap showed partial necrosis (25-35% of their area) in two cases. Both the donor and the recipient sites healed successfully in other cases. At 8.4 months of follow up, all patients had insensitivity in recipient sites. No patient complained of cold intolerance, pain, numbness and so on in the forearm and hand. According to the TAM criteria (the total active motion of the finger joint) and DASH (Disability of the Arm, Shoulder, and Hand) score showed that postoperative functions were excellent and symptoms were minor, with no significant differences among the groups (P > 0.05).
Our results indicated that the reverse forearm flap preserving the radial and ulnar artery is a reliable and effective method to cover skin defects of the hand.
This prospective study reports treatment by neurolysis then wrapping the nerves in vascularized forearm fascia and, when necessary, adjunctive procedures of twelve median and two ulnar nerves in continuity in the distal forearm with neurogenic pain. Preoperatively, all 14 patients had severe pain in at least one of the five modalities of pain analysed. There was complete resolution of all modalities of pain in eight of 14 patients following neurolysis and fascial nerve wrap surgery and two more patients had only mild pain in one or two modalities. After the addition of wrist pinning or arthrodesis alone or in conjunction with selective division of flexor tendons in four patients, there was complete resolution of all modalities of pain in nine of 14 patients. A further three patients had mild pain in three or less modalities and only one patient continued to have severe pain in one modality.
Because of the thin skin envelope of the hand, especially at the dorsum, flaps are frequently required for defect reconstruction in the hand. The pedicled radial forearm flap is a time proven procedure that offers reliable coverage in this area without the need of advanced microsurgical expertise. Despite several alternatives and an increasing acceptance of free tissue transfers, the pedicled radial forearm flap can still be the procedure of choice under special circumstances. Variations of the original technique address the two main disadvantages, the conspicuous donor site and the sacrifice of the radial artery. Indications, anatomy, surgical technique, and limitations of this classic workhorse flap are presented.
Le but de l’étude était d’évaluer le lambeau de fléchisseur superficiel des doigts dans le traitement des névromes en continuité du nerf médian au poignet. Nous avons revu six patients opérés de septembre 2000 à mars 2007. Ils présentaient tous des douleurs handicapantes que ce traitement a permis de réduire considérablement. Quatre patients sont très satisfaits. C’est un lambeau de proximité, de réalisation simple et sans séquelles du prélèvement. Nous le comparons aux différentes solutions décrites dans la littérature pour ce type de pathologie.
Local flap reconstruction is often required for soft tissue defects of the hand. The optimal reconstruction method should provide thin, supple, well-vascularized tissue with minimal donor-site morbidity. Short operating time and a sizable pedicle for microsurgical anastomosis are helpful. In this study, outcomes of hand defects after reconstruction with a reverse dorsoulnar flap were retrospectively analyzed.
Between 2001 and 2008, 36 patients were evaluated (28 men, 8 women). Twenty-seven pedicle flaps and 9 free flaps were used. Nineteen patients had flexion contractures in their palms and fingers after burn injuries, 14 patients had traumatic soft tissue loss, and 3 patients had defects after tumor exicision. In 26 cases the defects were on the palm site, and in 10 cases the defects were on the dorsum of the hand. Mean follow-up was 12 months.
The success rate was 100%, with satisfactory cosmetic results. Functional recovery of the hands showed good results as well as acceptable donor healing without complication.
The dorsoulnar flap as either pedicle or free flap provides good and reliable skin cover for substantial soft tissue defects on the palm, dorsum of the hand, and the fingers.
Despite its high incidence and its reputation for simplicity and efficacy, carpal tunnel release does not invariably produce good results and dissatisfied patients are not infrequently encountered. Unsatisfactory results are due to inaccurate diagnosis and, all too frequently, iatrogenic surgical complications. Surgical technique plays an important role in the achievement of good quality results. Various technical points are controversial and are here discussed: the incision, the division of the retinaculum, neurolysis, repair of the transverse carpal ligament and postoperative management. Our views on the management of recurrence, postoperative sequelae and complications are outlined.
Eight patients with skin coverage of the hand by the distally based posterior interosseous island flap (DBPIIF) are presented. The first web was reconstructed in 6 and the volar and dorsal aspect of the hand in 2 patients. Primary closure of the donor sites has always been possible. An echo Doppler examination is indicated to verify the presence and size of the vessel and the direction of its flow. The dissection of the vascular pedicle, however, is frequently quite complex and time consuming. To better appreciate the cosmetic aspect of the DBPIIF and its donor site, a random study has been undertaken to compare this flap with the radial forearm and the groin flap and their corresponding donor sites. Females have more often preferred the groin flap, whereas doctors preferred the DBPIIF. Reliability, a good aesthetic result at the donor site, and the preservation of the main vessels of the hand are the specific merits of the DBPIIF.
The posterior interosseous flap has been used for resurfacing in 23 cases of hand injury in the past 5 years. There was complete necrosis in two cases, partial necrosis in three and temporary post-operative nerve palsy in one.
1.The groin flap, a single pedicled flap similar in principle to the delto-pectoral flap but exploiting the superficial circumflex iliac arterio-venous system, is described.2.Its role in resurfacing the hand and forearm and as a substitute for the standard tube pedicle is described and its advantages in these and other roles is discussed.
We present our experimental and clinical experiences with the free neurovascular forearm flap. The flap is based on the radial artery, one of the great veins of the forearm (cephalic, basilic, or interconnecting vein), and one or two cutaneous forearm nerves (ulnar, median, or lateral). Because of the standard anatomy, the large caliber of blood vessels, the good sensory supply, the quality and quantity of the forearm skin, and the thin layer of subcutaneous fat, the free forearm flap is a technically easy and safe flap for reconstruction of soft-tissue defects, especially those in the head and neck and those areas of the extremities where sensitive skin is desired.
The Chinese forearm flap based on the radial artery is extremely versatile. It can be used as an island-skin flap, a free flap or as a compound forearm flap including vascularised nerve, bone or tendons. This paper describes and discusses some of these applications and is based on a series of 17 patients who presented with problems of reconstruction in the hand.
The authors examined 41 dried pisiform specimens; it was found that the vascular apertures were situated on the lateral aspect, in the proximal half of the ridge occupied by the ulnar artery, on the medial aspect and at the distal tip of the bone. An average number of 6.9 foramina were encountered, their mean diameter attained 40/100 mm. In 34 injected specimens the nutrient vessels of the pisiforme were traced from the ulnar artery and its carpal dorsal and deep volar branches; all the tiny bony twigs anastomosed with one another and contributed to an arterial circle running around the pisiforme. The carpal dorsal artery which provides at least 2 descending branches toward the proximal tip of the bone, can be called the main pedicle; when its superficial branches are ligated, the pedicle is long enough (3 cm) to make the replacement of the lunate by the pisiform attached to the flexor carpi ulnaris quite safe in Kienböck's disease, without any risk of osteonecrosis.
An overview of flaps for hand and forearm reconstruction must include random pattern, axial pattern, myocutaneous, and free flaps. Each has its place, and selection should follow careful evaluation of all factors, with each measured against the alternatives. The single-stage operation is an attractive aspect of free transfers by microvascular anastomosis, and the potentials of these techniques are surely in their infancy. As understanding and surgical techniques improve, the reconstructive needs of the upper extremity are being progressively better met.