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A two stage cross arm flap for severe multiple degloving injury of the hand
A Two Stage Cross Arm Flap for Severe Multiple Degloving Injury of the Hand A vner Karev and Bernard Hirshowitz
A TWO STAGE CROSS A R M FLAP FOR SEVERE MULTIPLE D E G L O V I N G INJURY OF THE H A N D A V N E R K A R E V and B E R N A R D H I R S H O W I T Z , Haifa, Israel SUMMARY The resurfacing of three severely degloved fingers, by a two stage cross arm flap operation, to maintain length and function is described. CASE REPORT A twenty-year-old carpenter sustained a severe injury to three fingers of his nondominant left hand, which was caught in a mangle two hours before admission. On examination, there was degloving of the index finger from the proximal interphalangeal joint crease distally; degloving of the middle finger from the metacarpophalangeal joint and amputation of the distal phalanx, and, in the ring finger, degloving from the mid level of the middle phalanx, as well as an amputation of the distal phalanx. (Fig. 1). The little finger had a longitudinal laceration on its volar aspect with no sensory loss, and both flexor tendons were intact. There were no fractures in the remaining phalanges. OPERATIVE TECHNIQUE Under general anaesthesia a thorough debridement was done leaving fairly clean exposed tissues. The anterodateral aspect of the opposite arm was chosen as the site for a cross-arm flap. Three separate incisions were made at different levels corresponding to that of the degloved fingers, giving access to the sub-cutaneous tissues of the arm. Three pockets were extended laterally in the following plane of cleavage: Epidermis and dermis superficial to the plane and the rest of the sub-cutaneous fatty tissue deep to it. By inserting the three fingers in the three pockets, a full thickness flap covered the dorsum of the fingers, which were now retained in a protective environment (Fig. 2). The crossed arms were immobilised for three weeks.
Fig. 1. Palmarview of multiple deglovedfingers, Avner Karev. M.D., Department of Plastic Surgery and The Hand Unit, Rambam Medical Center - Aba Khoushy School of Medicine, Haifa, Israel. 276
The Hand--Vol. 10
No. 3
1978
A Two Stage Cross Arm Flap for Severe Multiple Degloving Injury o f the Hand A vner Karev and Bernard Hirshowitz
Fig. 2. The degloved fingers inserted in the subcutaneous pockets.
Fig. 3. Result in Extension.
The setting-in of the cross arm flap (second stage) was done by the following technique: The three pockets were incised around each finger, leaving the flaps attached to the dorsum of the fingers. Surplus skin resulting from incising of the pockets was used to resurface the sides and tips of the reconstructed fingers. On the volar aspect, the plane of cleavage was between the subcutaneous fat and the fascia, (the Crane principle). In this way the formerly degloved volar aspect of the fingers was now covered by a thin layer of subcutaneous fat, on which full-thickness skin grafts taken from the inguinal region, were applied. The Hand--Vol. 10
No. 3
1978
277
A Two Stage Cross Arm Flap for Severe Multiple Degloving Injury of the Hand A vner Karev and Bernard Hirshowitz
Fig. 4. Result in Flexion
POST OPERATIVE COURSE
Healing was uneventful and there was a full take of the grafts. The patient started active physical therapy to regain motion in the small joints - eighteen days after the second stage. Good skin coverage enabled the patient to resume his activities and go back to his work after three months (Figs. 3 and 4). DISCUSSION
The technique could be modified by creating the same pockets on the medial aspect of the arm. In this manner, the flaps of epidermis and dermis would cover the volar aspect of the fingers whereas the subcutaneous fat would be on the dorsum. This two stage method is easy and practical. It saves length and function of the degloved fingers and is relatively convenient for the patient as far as posture is concerned. Additional reconstructive procedures may include a sensory neurovascular island flap to give sensation to the tip of the index finger. REFERENCES EMMETT, A. J. J. (1974). Finger Resurfacing By The Multiple Subcutaneous Pedicle Or Louvre Flaps. British Journal of Plastic Surgery. 27: 370-374. BARRON, J. N. and EMMETT, A. J. J. (1965). Subcutaneous Pedicle Flaps. British Journal of Plastic Surgery. 18: 51-78. COLSON, P., HOUOT, R., GANGOLPHE, M., de MOURGES, A., LAURENT, J., BIRON, G. and JANVIER, H. Utilisation Des Lambeaux Degraisses En Chirurgie Reparatrice De La Mains. AnnaUs de Chirurgie Plastique (Paris (1967). 12:298-310.
278
The Hand--Vol. 10
No. 3
1978
A TWO STAGE CROSS A R M FLAP FOR SEVERE MULTIPLE D E G L O V I N G INJURY OF THE H A N D A V N E R K A R E V and B E R N A R D H I R S H O W I T Z , Haifa, Israel SUMMARY The resurfacing of three severely degloved fingers, by a two stage cross arm flap operation, to maintain length and function is described. CASE REPORT A twenty-year-old carpenter sustained a severe injury to three fingers of his nondominant left hand, which was caught in a mangle two hours before admission. On examination, there was degloving of the index finger from the proximal interphalangeal joint crease distally; degloving of the middle finger from the metacarpophalangeal joint and amputation of the distal phalanx, and, in the ring finger, degloving from the mid level of the middle phalanx, as well as an amputation of the distal phalanx. (Fig. 1). The little finger had a longitudinal laceration on its volar aspect with no sensory loss, and both flexor tendons were intact. There were no fractures in the remaining phalanges. OPERATIVE TECHNIQUE Under general anaesthesia a thorough debridement was done leaving fairly clean exposed tissues. The anterodateral aspect of the opposite arm was chosen as the site for a cross-arm flap. Three separate incisions were made at different levels corresponding to that of the degloved fingers, giving access to the sub-cutaneous tissues of the arm. Three pockets were extended laterally in the following plane of cleavage: Epidermis and dermis superficial to the plane and the rest of the sub-cutaneous fatty tissue deep to it. By inserting the three fingers in the three pockets, a full thickness flap covered the dorsum of the fingers, which were now retained in a protective environment (Fig. 2). The crossed arms were immobilised for three weeks.
Fig. 1. Palmarview of multiple deglovedfingers, Avner Karev. M.D., Department of Plastic Surgery and The Hand Unit, Rambam Medical Center - Aba Khoushy School of Medicine, Haifa, Israel. 276
The Hand--Vol. 10
No. 3
1978
A Two Stage Cross Arm Flap for Severe Multiple Degloving Injury o f the Hand A vner Karev and Bernard Hirshowitz
Fig. 2. The degloved fingers inserted in the subcutaneous pockets.
Fig. 3. Result in Extension.
The setting-in of the cross arm flap (second stage) was done by the following technique: The three pockets were incised around each finger, leaving the flaps attached to the dorsum of the fingers. Surplus skin resulting from incising of the pockets was used to resurface the sides and tips of the reconstructed fingers. On the volar aspect, the plane of cleavage was between the subcutaneous fat and the fascia, (the Crane principle). In this way the formerly degloved volar aspect of the fingers was now covered by a thin layer of subcutaneous fat, on which full-thickness skin grafts taken from the inguinal region, were applied. The Hand--Vol. 10
No. 3
1978
277
A Two Stage Cross Arm Flap for Severe Multiple Degloving Injury of the Hand A vner Karev and Bernard Hirshowitz
Fig. 4. Result in Flexion
POST OPERATIVE COURSE
Healing was uneventful and there was a full take of the grafts. The patient started active physical therapy to regain motion in the small joints - eighteen days after the second stage. Good skin coverage enabled the patient to resume his activities and go back to his work after three months (Figs. 3 and 4). DISCUSSION
The technique could be modified by creating the same pockets on the medial aspect of the arm. In this manner, the flaps of epidermis and dermis would cover the volar aspect of the fingers whereas the subcutaneous fat would be on the dorsum. This two stage method is easy and practical. It saves length and function of the degloved fingers and is relatively convenient for the patient as far as posture is concerned. Additional reconstructive procedures may include a sensory neurovascular island flap to give sensation to the tip of the index finger. REFERENCES EMMETT, A. J. J. (1974). Finger Resurfacing By The Multiple Subcutaneous Pedicle Or Louvre Flaps. British Journal of Plastic Surgery. 27: 370-374. BARRON, J. N. and EMMETT, A. J. J. (1965). Subcutaneous Pedicle Flaps. British Journal of Plastic Surgery. 18: 51-78. COLSON, P., HOUOT, R., GANGOLPHE, M., de MOURGES, A., LAURENT, J., BIRON, G. and JANVIER, H. Utilisation Des Lambeaux Degraisses En Chirurgie Reparatrice De La Mains. AnnaUs de Chirurgie Plastique (Paris (1967). 12:298-310.
278
The Hand--Vol. 10
No. 3
1978