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Microsurgical cross finger flap
Microsurgical Cross Finger Flap Gerard W. Sormann
M I C R O S U R G I C A L CROSS FINGER FLAP
GERARD W. SORMANN, Melbourne, Australia SUMMARY The c o m b i n a t i o n o f a cross f i n g e r f l a p a n d microsurgical technique was used in the repair o f an i n j u r e d hand.
A thirty eight year old leather worker injured his right dominant hand whilst working with a leather cutting machine. The machine worked like a press with a template cutting out predetermined patterns in the leather. The injury consisted o f amputation of the middle finger at the level of the middle of the middle phalanx, with the amputated part cut in two by the press. The ring finger had lost a middle segment consisting of the distal two thirds of the middle phalanx, together with the proximal one third of the distal phalanx. This left the distal two thirds of the tip of the finger with its pulp and nail intact, still attached to the proximal part of the finger by an ulnar skin bridge containing the undamaged neuro vascular bundle. (Fig. 1, Fig. 2). The tip of the ring finger had a normal circulation and noi'mal sensation. A decision not to discard the viable tip of the ring finger was made. Rather than leaving it attached to the ring finger, this distal segment was transferred to the middle finger. The amputated parts of the middle finger could not be reimplanted as they had been divided in two and were too small for this purpose. The ulnar digital artery of the ring finger and the digital nerve were divided at the proximal end of the skin bridge, leaving the venae comitantes intact (Fig. 3). The tip was attached to the stump of the middle finger, using microsurgical techniques to repair the digital artery and nerve from the tip of the ring finger to the corresponding vessel and nerve on the middle finger. The islan*d bridge containing the venae comitantes was sewn over the amputated tip of the ring finger and the reimplanted tip was fixed to the ring finger by means of a longitudinal Kirschner Wire (Fig. 4). Normal circulation was demonstrated in the transferred fingertip. By preserving the skin bridge, closure of the ring finger was performed without further shortening, and with the preserved venae comitantes in the bridge no venous anastomosis was required for venous drainage of the transferred fingertip (Fig. 5). Three weeks later, the skin bridge was divided, separating the two fingers, and early movements encouraged. The Kirschner Wire was removed at five weeks. Two months later, good hand function was demonstrated by the patient, with a well healed ring finger stump and well preserved tip on the middle finger with a full range of movement at the proximal interphalangeal joint of both the affected fingers. There was good sensation to light touch, and discrimination to pinprick on the transferred tip on the middle finger. The patient had returned to work and was coping well. Gerard W. Sormann M.B.B.S., F.R.A.C.S., Division of Plastic Surgery, Austin Hospital, Heidelberg, Victoria, Australia. 9 1982 British Societyfor Surgery of the Hand 0072-968X-82-00520279 $02.00 The Hand-- Volume 14
No. 3
1982
2 79
Microsurgical Cross Finger Flap Gerard W. Sormann
Fig. 1
Right hand with absent middle segment to ring finger and double amputation of middle finger.
Fig. 2
Digital artery and nerve divided. Tip transferred with re-anastomosis of vessel and suture of nerve.
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Microsurgical Cross Finger Flap Gerard W. Sormann
Fig. 3
Kirschner wire immobilisation.
Fig. 4
Maximum finger lengths preserved.
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No. 3
1982
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Microsurgical Cross Finger Flap Gerard W. Sormann
DISCUSSION
The classic cross finger flap is a standard technique in a hand surgeon's repertoire (Gurdin 1950, Tempest 1952). Whilst digital reimplantation following traumatic amputation (Komatsu and Tamai 1968) and digital transfers as toe to thumb (Cobbett 1970) are now feasible by microsurgical techniques, the unusual nature of the injury in this case has allowed both these principles to be combined. Preservation of the skin bridge to close the distal stump of the ring finger allowed full preservation of the remaining finger without stump trimming. This technique also allowed preservation of the venae comitantes of the digital vessel, obviating the need for a venous anastomosis during the transfer. The distal finger part of the ring finger was reimplanted to the middle finger, thus lengthening it and microsurgical arterial suture and nerve repair ensured vascularisation and return of pulp sensation. Reimplanting the distal part onto its own finger would have resulted in a marked lateral bulge of the skin bridge including the neurovascular bundle, which would have necessarily been severed when the bulge was trimmed at a later stage, thus risking necrosis of the tip and loss of sensation. CONCLUSION This case serves to illustrate the principles of tissue and finger length preservation in hand trauma and the combination of the classical cross finger flap technique has been enhanced by the use of a microsurgical transfer to achieve the best result . . . .
REFERENCES COBBETT, J. R. (1970) Free Pollicisation of the Great Toe. The Hand. 2: 57. GURDIN, M. and PANGMAN, W. J. (1950) The Repair of Surface Defects of Fingers by Transdigital Flaps. Plastic and Reconstructive Surgery. 5: 368-371. KOMATSU, S. and TAMAI, S. (1968) Successful Replantation of a Completely Cut-Off Thumb. Plastic and Reconstructive Surgery. 42: 374-377. TEMPEST, M. N. (1952) Cross Finger Flaps in the Treatment of Injuries to the Fingertip. Plastic and Reconstructive Surgery. 9: 205-222.
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M I C R O S U R G I C A L CROSS FINGER FLAP
GERARD W. SORMANN, Melbourne, Australia SUMMARY The c o m b i n a t i o n o f a cross f i n g e r f l a p a n d microsurgical technique was used in the repair o f an i n j u r e d hand.
A thirty eight year old leather worker injured his right dominant hand whilst working with a leather cutting machine. The machine worked like a press with a template cutting out predetermined patterns in the leather. The injury consisted o f amputation of the middle finger at the level of the middle of the middle phalanx, with the amputated part cut in two by the press. The ring finger had lost a middle segment consisting of the distal two thirds of the middle phalanx, together with the proximal one third of the distal phalanx. This left the distal two thirds of the tip of the finger with its pulp and nail intact, still attached to the proximal part of the finger by an ulnar skin bridge containing the undamaged neuro vascular bundle. (Fig. 1, Fig. 2). The tip of the ring finger had a normal circulation and noi'mal sensation. A decision not to discard the viable tip of the ring finger was made. Rather than leaving it attached to the ring finger, this distal segment was transferred to the middle finger. The amputated parts of the middle finger could not be reimplanted as they had been divided in two and were too small for this purpose. The ulnar digital artery of the ring finger and the digital nerve were divided at the proximal end of the skin bridge, leaving the venae comitantes intact (Fig. 3). The tip was attached to the stump of the middle finger, using microsurgical techniques to repair the digital artery and nerve from the tip of the ring finger to the corresponding vessel and nerve on the middle finger. The islan*d bridge containing the venae comitantes was sewn over the amputated tip of the ring finger and the reimplanted tip was fixed to the ring finger by means of a longitudinal Kirschner Wire (Fig. 4). Normal circulation was demonstrated in the transferred fingertip. By preserving the skin bridge, closure of the ring finger was performed without further shortening, and with the preserved venae comitantes in the bridge no venous anastomosis was required for venous drainage of the transferred fingertip (Fig. 5). Three weeks later, the skin bridge was divided, separating the two fingers, and early movements encouraged. The Kirschner Wire was removed at five weeks. Two months later, good hand function was demonstrated by the patient, with a well healed ring finger stump and well preserved tip on the middle finger with a full range of movement at the proximal interphalangeal joint of both the affected fingers. There was good sensation to light touch, and discrimination to pinprick on the transferred tip on the middle finger. The patient had returned to work and was coping well. Gerard W. Sormann M.B.B.S., F.R.A.C.S., Division of Plastic Surgery, Austin Hospital, Heidelberg, Victoria, Australia. 9 1982 British Societyfor Surgery of the Hand 0072-968X-82-00520279 $02.00 The Hand-- Volume 14
No. 3
1982
2 79
Microsurgical Cross Finger Flap Gerard W. Sormann
Fig. 1
Right hand with absent middle segment to ring finger and double amputation of middle finger.
Fig. 2
Digital artery and nerve divided. Tip transferred with re-anastomosis of vessel and suture of nerve.
280
The Hand-- Volume 14
No. 2
1982
Microsurgical Cross Finger Flap Gerard W. Sormann
Fig. 3
Kirschner wire immobilisation.
Fig. 4
Maximum finger lengths preserved.
The Hand-- Volume 14
No. 3
1982
281
Microsurgical Cross Finger Flap Gerard W. Sormann
DISCUSSION
The classic cross finger flap is a standard technique in a hand surgeon's repertoire (Gurdin 1950, Tempest 1952). Whilst digital reimplantation following traumatic amputation (Komatsu and Tamai 1968) and digital transfers as toe to thumb (Cobbett 1970) are now feasible by microsurgical techniques, the unusual nature of the injury in this case has allowed both these principles to be combined. Preservation of the skin bridge to close the distal stump of the ring finger allowed full preservation of the remaining finger without stump trimming. This technique also allowed preservation of the venae comitantes of the digital vessel, obviating the need for a venous anastomosis during the transfer. The distal finger part of the ring finger was reimplanted to the middle finger, thus lengthening it and microsurgical arterial suture and nerve repair ensured vascularisation and return of pulp sensation. Reimplanting the distal part onto its own finger would have resulted in a marked lateral bulge of the skin bridge including the neurovascular bundle, which would have necessarily been severed when the bulge was trimmed at a later stage, thus risking necrosis of the tip and loss of sensation. CONCLUSION This case serves to illustrate the principles of tissue and finger length preservation in hand trauma and the combination of the classical cross finger flap technique has been enhanced by the use of a microsurgical transfer to achieve the best result . . . .
REFERENCES COBBETT, J. R. (1970) Free Pollicisation of the Great Toe. The Hand. 2: 57. GURDIN, M. and PANGMAN, W. J. (1950) The Repair of Surface Defects of Fingers by Transdigital Flaps. Plastic and Reconstructive Surgery. 5: 368-371. KOMATSU, S. and TAMAI, S. (1968) Successful Replantation of a Completely Cut-Off Thumb. Plastic and Reconstructive Surgery. 42: 374-377. TEMPEST, M. N. (1952) Cross Finger Flaps in the Treatment of Injuries to the Fingertip. Plastic and Reconstructive Surgery. 9: 205-222.
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The H a n d - - Volume l 4
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1982