- Email: [email protected]
Fillet flap from the ring finger dorsum for salvaging the little finger in electrically burned hand
Burns 28 (2002) 198–200
Case report
Fillet flap from the ring finger dorsum for salvaging the little finger in electrically burned hand Anton H. Schwabegger a,∗ , Hildegunde Piza b a
Department of Plastic and Reconstructive Surgery, Universitätsklinik für Plastische und Rekonstruktive Chirurgie Anichstrasse 35, A-6020 Innsbruck, Austria b Ludwig Boltzmann Institute for Quality Control in Plastic Surgery, Innsbruck, Austria Accepted 18 July 2001
1. Introduction Electrical burn injuries to small tissue units such as fingers may result in complete or partial necrosis of all components of the functional structures, including tendons, bones and joints and their nutrient vessels and nerves. Commonly, because of accountal grasping of the live conductor wires,
more than one finger is injured. Depending on the extent of destruction, the remaining vital parts of the fingers may be useful for reconstruction of other damaged structures of the hand. In the case presented, we aim to highlight the importance of thorough debridement in order to salvage important tissue for demanding reconstructive procedures to regain function in an electrically injured hand.
Fig. 1. (a and b) Following radical debridement of the ring finger, leaving a vascularised fillet flap, before transposition to the (not yet debrided) little finger. ∗ Corresponding author. Tel.: +43-512-504-2745; fax: +43-512-504-2735. E-mail address: [email protected] (A.H. Schwabegger).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 1 ) 0 0 0 9 3 - 6
A.H. Schwabegger, H. Piza / Burns 28 (2002) 198–200
2. Case report A 45-year-old male sustained an electrical burn injury of the ring and little finger of the left hand with deep and substantial necrosis of the palmar aspect of the fourth finger reaching into the proximal interphalangeal joint and revealing an extensive defect of the ulnar palmar neurovascular bundle. The defect at the little finger included the dorsal aspect reaching from the metacarpophalangeal joint to the
199
pulp, including the whole nail bed and, in part, the extensor tendon. After a thorough and radical debridement of all dead tissues (Fig. 1a and b), the decision was made to use the dorsal skin of the fourth finger, a composite flap with the extensor tendon as a fillet flap to cover the dorsum of the fifth finger. The intact radial palmar neurovascular bundle was included in the flap to guarantee vascularity and to provide it with sensation. As a modified fillet flap, it now served to
Fig. 2. (a–c) Functional result 15 months following the incident, almost full range of motion.
200
A.H. Schwabegger, H. Piza / Burns 28 (2002) 198–200
cover the large defect at the dorsum of the fifth finger, and the transposed extensor tendon replaced the damaged one. No extensor tendon suture was necessary, except reinsertion of the interossei tendons of the fifth finger to the transposed extensor tendon. A tendo-skeletal amputation of the remaining avascular fourth finger was performed through the metacarpophalangeal joint. The patient refused ray amputation in order to maintain full palm width necessary to his profession as an artisan. After verification of sufficient vascular supply, physiotherapy started at the third postoperative day. Three weeks later a remaining interdigital defect (2 cm × 2 cm) was covered with a small transposition flap and a skin graft. Intensive physiotherapy succeeded in regaining function and the patient returned to work with full sensibility of the reconstructed finger and normal nail growth. Seven months later Z-plasties and a dorsal rectangular flap were necessary to release a scar contraction at the proximal interphalangeal joint and at the web space, respectively. The patient rapidly regained almost full range of motion (extension deficit of 10◦ at the distal interphalangeal joint and lack of hyperextension at the metacarpophalangeal joint) and, 15 months after the incident, he is free of complaints with an aesthetically satisfactory result (Fig. 2a–c).
3. Discussion Burn injuries caused by electricity tend to result in deep layer destruction with partially vital skin. Thus, these
remaining vital structures [4] should always be saved as autologous tissue grafts for eventual further reconstructions. For example an avulsed “ring” finger can be regarded as a traumatically raised fillet flap and may be considered for reimplantation or other distinct defect coverage in complex hand injuries [1,2]. Pedicled fillet finger flaps are commonly used in reconstruction of palmar hand defects [1–4]. Commonly, as a result of the grip function of the thumb and index finger, burn injuries at the hand affect at least two fingers. However, in the case presented, the electrical circuit entered from the dorsum of the little finger and exited at the ring finger pulp, causing partial destruction. For cases like these, a “composite” reconstruction of one finger with viable parts from two fingers, offers a better result than amputating two fingers. In our opinion, it is justifiable to reconstruct even a severely damaged fifth finger, when another long finger is missing or lost, in order to reduce disability, to preserve and to maintain its aesthetic appearance and an almost full range of hand function. References [1] Idler RS, Mih AD. Soft tissue coverage of the hand with a free digital fillet flap. Microsurgery 1990;11:215–6. [2] Libermanis O, Krauklis G, Kapickis M, Krustins J, Tihonovs A. Use of the microvascular finger fillet flap. J Reconstr Microsurg 1999;15:577– 80. [3] Lister G. Skin flaps. In: Green DP, editor. Operative hand surgery I. 2nd ed. New York: Churchill-Livingstone, 1894. [4] Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg 1990;15A:148–54.
Case report
Fillet flap from the ring finger dorsum for salvaging the little finger in electrically burned hand Anton H. Schwabegger a,∗ , Hildegunde Piza b a
Department of Plastic and Reconstructive Surgery, Universitätsklinik für Plastische und Rekonstruktive Chirurgie Anichstrasse 35, A-6020 Innsbruck, Austria b Ludwig Boltzmann Institute for Quality Control in Plastic Surgery, Innsbruck, Austria Accepted 18 July 2001
1. Introduction Electrical burn injuries to small tissue units such as fingers may result in complete or partial necrosis of all components of the functional structures, including tendons, bones and joints and their nutrient vessels and nerves. Commonly, because of accountal grasping of the live conductor wires,
more than one finger is injured. Depending on the extent of destruction, the remaining vital parts of the fingers may be useful for reconstruction of other damaged structures of the hand. In the case presented, we aim to highlight the importance of thorough debridement in order to salvage important tissue for demanding reconstructive procedures to regain function in an electrically injured hand.
Fig. 1. (a and b) Following radical debridement of the ring finger, leaving a vascularised fillet flap, before transposition to the (not yet debrided) little finger. ∗ Corresponding author. Tel.: +43-512-504-2745; fax: +43-512-504-2735. E-mail address: [email protected] (A.H. Schwabegger).
0305-4179/02/$22.00 © 2002 Elsevier Science Ltd and ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 0 1 ) 0 0 0 9 3 - 6
A.H. Schwabegger, H. Piza / Burns 28 (2002) 198–200
2. Case report A 45-year-old male sustained an electrical burn injury of the ring and little finger of the left hand with deep and substantial necrosis of the palmar aspect of the fourth finger reaching into the proximal interphalangeal joint and revealing an extensive defect of the ulnar palmar neurovascular bundle. The defect at the little finger included the dorsal aspect reaching from the metacarpophalangeal joint to the
199
pulp, including the whole nail bed and, in part, the extensor tendon. After a thorough and radical debridement of all dead tissues (Fig. 1a and b), the decision was made to use the dorsal skin of the fourth finger, a composite flap with the extensor tendon as a fillet flap to cover the dorsum of the fifth finger. The intact radial palmar neurovascular bundle was included in the flap to guarantee vascularity and to provide it with sensation. As a modified fillet flap, it now served to
Fig. 2. (a–c) Functional result 15 months following the incident, almost full range of motion.
200
A.H. Schwabegger, H. Piza / Burns 28 (2002) 198–200
cover the large defect at the dorsum of the fifth finger, and the transposed extensor tendon replaced the damaged one. No extensor tendon suture was necessary, except reinsertion of the interossei tendons of the fifth finger to the transposed extensor tendon. A tendo-skeletal amputation of the remaining avascular fourth finger was performed through the metacarpophalangeal joint. The patient refused ray amputation in order to maintain full palm width necessary to his profession as an artisan. After verification of sufficient vascular supply, physiotherapy started at the third postoperative day. Three weeks later a remaining interdigital defect (2 cm × 2 cm) was covered with a small transposition flap and a skin graft. Intensive physiotherapy succeeded in regaining function and the patient returned to work with full sensibility of the reconstructed finger and normal nail growth. Seven months later Z-plasties and a dorsal rectangular flap were necessary to release a scar contraction at the proximal interphalangeal joint and at the web space, respectively. The patient rapidly regained almost full range of motion (extension deficit of 10◦ at the distal interphalangeal joint and lack of hyperextension at the metacarpophalangeal joint) and, 15 months after the incident, he is free of complaints with an aesthetically satisfactory result (Fig. 2a–c).
3. Discussion Burn injuries caused by electricity tend to result in deep layer destruction with partially vital skin. Thus, these
remaining vital structures [4] should always be saved as autologous tissue grafts for eventual further reconstructions. For example an avulsed “ring” finger can be regarded as a traumatically raised fillet flap and may be considered for reimplantation or other distinct defect coverage in complex hand injuries [1,2]. Pedicled fillet finger flaps are commonly used in reconstruction of palmar hand defects [1–4]. Commonly, as a result of the grip function of the thumb and index finger, burn injuries at the hand affect at least two fingers. However, in the case presented, the electrical circuit entered from the dorsum of the little finger and exited at the ring finger pulp, causing partial destruction. For cases like these, a “composite” reconstruction of one finger with viable parts from two fingers, offers a better result than amputating two fingers. In our opinion, it is justifiable to reconstruct even a severely damaged fifth finger, when another long finger is missing or lost, in order to reduce disability, to preserve and to maintain its aesthetic appearance and an almost full range of hand function. References [1] Idler RS, Mih AD. Soft tissue coverage of the hand with a free digital fillet flap. Microsurgery 1990;11:215–6. [2] Libermanis O, Krauklis G, Kapickis M, Krustins J, Tihonovs A. Use of the microvascular finger fillet flap. J Reconstr Microsurg 1999;15:577– 80. [3] Lister G. Skin flaps. In: Green DP, editor. Operative hand surgery I. 2nd ed. New York: Churchill-Livingstone, 1894. [4] Strauch B, de Moura W. Arterial system of the fingers. J Hand Surg 1990;15A:148–54.