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Primary application of the one stage abdominal tubed pedicle
Primary Application o/ the One Stage Abdominal Tubed Pedicle--Charles S. Li, Stanley H. Nahigian, de Wayne G. Richey, Darre[ T. Shaw
P R I M A R Y APPLICATION OF THE ONE STAGE A B D O M I N A L T U B E D PEDICLE
C H A R L E S S. LI, S T A N L E Y H. N A H I G I A N , DE W A Y N E G. R I C H E Y and D A R R E L T. SHAW, Cleveland, Ohio Automobile accidents and industrial injuries from powerful machinery may cause severe avulsion injuries of the upper extremity, particularly of the forearm and the hand. Early skin cover is necessary to achieve the best functional recovery. If deep structures are to be repaired primarily or later reconstruction is contemplated, pedicle tissue may be required. If an avulsed skin flap of doubtful viability is re-sutured, necrosis may follow. The slow healing of the wound will result in less than satisfactory coverage of tendons, nerves and bone and in excess scar and contracture. The goal of treatment is to supply the best material for resurfacing the wound, as soon as possible, not only to salvage the limb but also to protect functional capacity. When it is considered that a pedicle is required, it may be used primarily. The advantage of the one stage abdominal tubed pedicle described by Shaw and Payne (1946) for war injuries is useful for primary cover of the wound with skin avulsion or for the replacement of badly contused non-viable skin flaps found in civilian practice. The following cases illustrate the usefulness of the procedure. Case 1
CASES
A fifty-one year old man was admitted to hospital on March 20, 1971 with history of having his right forearm caught and trapped between a moving belt and idler. There was avulsion of a skin flap to the depth of the extensor tendons and loss of a segment of the radial nerve. An emergency operation was carried out under a tourniquet to remove grease, dirt and dead tissue. The damaged dorsz_l skin flap showed doubtful viability and remained ischaemic after release of the tourniquet. A single stage abdominal tubed pedicle was applied to the defect. The pedicle was detached from the abdomen on April 5, 1971 and he was discharged from the hospital on April 8, 1971.
Fig. 1 Avulsion injury of right forearm from conveyor belt. Fig. 2 Single pedicle tube as an emergency procedure on dorsum of the forearm. Fig. 3 Abdominal pedicle divided fifteen days later. 184
The Hand--Vol. 4
No. 2
1972
Primary Application of the One Stage Abdominal Tubed Pedicle--Charles S. Li, Stanley H. Nahigian, de Wayne G. Richey, Darrel T. Shaw Case 2
A twenty-nine year old man was admitted to hospital on February 16, 1966 with a severe wound of the dorsum of the left,hand, with partial amputation and avulsion of skin of the thumb and multiple lacerations of the hand especially of the index finger and palm. This was a result of having his hand caught in a rubber mill. A single stage abdominal tubed pedicle was used to cover the defect following surgical debridement. Palmar and web skin was used for the volar surface of the thumb. The abdominal pedicle was divided on March 10, 1966 and he was discharged from the hospital on March 22, 1966. Since that time he has had two revisions because of redundant tissue. Multiple Z-plastics and defattening of the pedicle and release of scar contracture of the first web were carried out.
Figs. 4 and 5 Degloving of dorsum of the left hand and thumb. Fig. 6 Release of scar contracture of the first web with Z-plasty. Fig. 7 Single pediele tube as an emergency procedure to dorsum of the hand and thumb. Case 3
A twenty-five year old man was admitted to hospital on January 11, 1959 following injury to his right forearm and hand which was caught in a roller of a coal conveyer. He was seen with a crushing wound of the right hand, wrist, and distal forearm with loss of all soft tissue down to the first, second and third metacarpals, and distal radius and ulna, including all the extensor tendons, and with partial loss of the metacarpals and carpal bones on the dorso-radial aspect. Surgical debridement, dressing, and splinting was performed on January 12, 1959 and again on January 20, 1959 under general anaesthesia because of ground in oil and coal. On January 28, 1.959 a single pedicle tube from the abdomen was applied to the defect of the hand, wrist and forearm. On March 2, 1959 the pedicle was detached from the abdomen and he was discharged from the hospital on March 12, 1959 with a splint to support the hand and wrist in extension. On October 12, 1959 tendon grafts from the left foot to the extensors of the thumb, index, middle and ring fingers were performed with a good functional result. The Hand--Vol. 4
No. 2
1972
I85
Primary Application of the One Stage Abdominal Tubed Pedicle--Charles S. Li, Stanley H. Nahigian, de Wayne G. Richey, Darrel T. Shaw
Figs. 8, 9, 10 Single pedicle tube following avulsion loss of soft tissue to the bone with subsequent extensor tendon grafts to fingers and thumb. DISCUSSION
The concept of a one stage abdominal tubed pedicle was developed for the treatment of war wounds of the upper extremity with extensive loss of soft tissue. The pedicle as advocated is based inferiorly to include the superficial circumflex iliac or superficial epigastric vessels. The abdominal wall allows almost unlimited size, shape and direction of application. This is in contrast to groin or thigh flaps which are limited in size and have less mobility. Large donor areas on the thorax and in the groin are less readily closed. The procedure with the direct abdominal flap offers speed, with cleanliness and mobility. Since primary closure of the wounds is usually accomplished without the necessity of using a skin graft to cover the donor area, the wound contamination is eliminated and secondary closure is not required. Delay is readily accomplished by clamps, rubber bands, or partial division. The application of skin and subcutaneous tissue has a noticeable effect in increasing mobility of joints, diminishing oedema and pain by improving the circulation of the whole part involved. If the flap is bulky it may be reduced by defattening or removal of fat in conjunction with a secondary reconstructive procedure. SUMMARY
The advantage offered by a single pedicle tube from the abdomen is that it allows primary treatment of acute avulsion or crush injuries of the hand and forearm. Wounds are closed early to protect the deep structures whether or not reconstructive surgery is contemplated. Unnecessary delay of wound healing or temporary skin grafting is avoided.
BIBLIOGRAPHY
SHAW, D. T. (1944) Open Abdominal Flaps for Repair of Surface Defects of the Upper Extremity. Surgical Clinics of North America 24: 293-308. SHAW, D. T. and PAYNE, R. L. (1946) Repair of Surface Defects of the Upper Extremity. Annals of Surgery 123: 705-730. SHAW, D. T. and PAYNE, R. L. (1946) One Stage Tubed Abdominal Flaps. Surgery, Gynecology, and Obstetrics, 83: 205-209. WEBSTER, J. P. (1937) Thoraco-epigastric Tubed Pedicles. Surgical Clinics ~ North America 17: 145-184. 186
The Hand~Vol. 4
No. 2
1972
P R I M A R Y APPLICATION OF THE ONE STAGE A B D O M I N A L T U B E D PEDICLE
C H A R L E S S. LI, S T A N L E Y H. N A H I G I A N , DE W A Y N E G. R I C H E Y and D A R R E L T. SHAW, Cleveland, Ohio Automobile accidents and industrial injuries from powerful machinery may cause severe avulsion injuries of the upper extremity, particularly of the forearm and the hand. Early skin cover is necessary to achieve the best functional recovery. If deep structures are to be repaired primarily or later reconstruction is contemplated, pedicle tissue may be required. If an avulsed skin flap of doubtful viability is re-sutured, necrosis may follow. The slow healing of the wound will result in less than satisfactory coverage of tendons, nerves and bone and in excess scar and contracture. The goal of treatment is to supply the best material for resurfacing the wound, as soon as possible, not only to salvage the limb but also to protect functional capacity. When it is considered that a pedicle is required, it may be used primarily. The advantage of the one stage abdominal tubed pedicle described by Shaw and Payne (1946) for war injuries is useful for primary cover of the wound with skin avulsion or for the replacement of badly contused non-viable skin flaps found in civilian practice. The following cases illustrate the usefulness of the procedure. Case 1
CASES
A fifty-one year old man was admitted to hospital on March 20, 1971 with history of having his right forearm caught and trapped between a moving belt and idler. There was avulsion of a skin flap to the depth of the extensor tendons and loss of a segment of the radial nerve. An emergency operation was carried out under a tourniquet to remove grease, dirt and dead tissue. The damaged dorsz_l skin flap showed doubtful viability and remained ischaemic after release of the tourniquet. A single stage abdominal tubed pedicle was applied to the defect. The pedicle was detached from the abdomen on April 5, 1971 and he was discharged from the hospital on April 8, 1971.
Fig. 1 Avulsion injury of right forearm from conveyor belt. Fig. 2 Single pedicle tube as an emergency procedure on dorsum of the forearm. Fig. 3 Abdominal pedicle divided fifteen days later. 184
The Hand--Vol. 4
No. 2
1972
Primary Application of the One Stage Abdominal Tubed Pedicle--Charles S. Li, Stanley H. Nahigian, de Wayne G. Richey, Darrel T. Shaw Case 2
A twenty-nine year old man was admitted to hospital on February 16, 1966 with a severe wound of the dorsum of the left,hand, with partial amputation and avulsion of skin of the thumb and multiple lacerations of the hand especially of the index finger and palm. This was a result of having his hand caught in a rubber mill. A single stage abdominal tubed pedicle was used to cover the defect following surgical debridement. Palmar and web skin was used for the volar surface of the thumb. The abdominal pedicle was divided on March 10, 1966 and he was discharged from the hospital on March 22, 1966. Since that time he has had two revisions because of redundant tissue. Multiple Z-plastics and defattening of the pedicle and release of scar contracture of the first web were carried out.
Figs. 4 and 5 Degloving of dorsum of the left hand and thumb. Fig. 6 Release of scar contracture of the first web with Z-plasty. Fig. 7 Single pediele tube as an emergency procedure to dorsum of the hand and thumb. Case 3
A twenty-five year old man was admitted to hospital on January 11, 1959 following injury to his right forearm and hand which was caught in a roller of a coal conveyer. He was seen with a crushing wound of the right hand, wrist, and distal forearm with loss of all soft tissue down to the first, second and third metacarpals, and distal radius and ulna, including all the extensor tendons, and with partial loss of the metacarpals and carpal bones on the dorso-radial aspect. Surgical debridement, dressing, and splinting was performed on January 12, 1959 and again on January 20, 1959 under general anaesthesia because of ground in oil and coal. On January 28, 1.959 a single pedicle tube from the abdomen was applied to the defect of the hand, wrist and forearm. On March 2, 1959 the pedicle was detached from the abdomen and he was discharged from the hospital on March 12, 1959 with a splint to support the hand and wrist in extension. On October 12, 1959 tendon grafts from the left foot to the extensors of the thumb, index, middle and ring fingers were performed with a good functional result. The Hand--Vol. 4
No. 2
1972
I85
Primary Application of the One Stage Abdominal Tubed Pedicle--Charles S. Li, Stanley H. Nahigian, de Wayne G. Richey, Darrel T. Shaw
Figs. 8, 9, 10 Single pedicle tube following avulsion loss of soft tissue to the bone with subsequent extensor tendon grafts to fingers and thumb. DISCUSSION
The concept of a one stage abdominal tubed pedicle was developed for the treatment of war wounds of the upper extremity with extensive loss of soft tissue. The pedicle as advocated is based inferiorly to include the superficial circumflex iliac or superficial epigastric vessels. The abdominal wall allows almost unlimited size, shape and direction of application. This is in contrast to groin or thigh flaps which are limited in size and have less mobility. Large donor areas on the thorax and in the groin are less readily closed. The procedure with the direct abdominal flap offers speed, with cleanliness and mobility. Since primary closure of the wounds is usually accomplished without the necessity of using a skin graft to cover the donor area, the wound contamination is eliminated and secondary closure is not required. Delay is readily accomplished by clamps, rubber bands, or partial division. The application of skin and subcutaneous tissue has a noticeable effect in increasing mobility of joints, diminishing oedema and pain by improving the circulation of the whole part involved. If the flap is bulky it may be reduced by defattening or removal of fat in conjunction with a secondary reconstructive procedure. SUMMARY
The advantage offered by a single pedicle tube from the abdomen is that it allows primary treatment of acute avulsion or crush injuries of the hand and forearm. Wounds are closed early to protect the deep structures whether or not reconstructive surgery is contemplated. Unnecessary delay of wound healing or temporary skin grafting is avoided.
BIBLIOGRAPHY
SHAW, D. T. (1944) Open Abdominal Flaps for Repair of Surface Defects of the Upper Extremity. Surgical Clinics of North America 24: 293-308. SHAW, D. T. and PAYNE, R. L. (1946) Repair of Surface Defects of the Upper Extremity. Annals of Surgery 123: 705-730. SHAW, D. T. and PAYNE, R. L. (1946) One Stage Tubed Abdominal Flaps. Surgery, Gynecology, and Obstetrics, 83: 205-209. WEBSTER, J. P. (1937) Thoraco-epigastric Tubed Pedicles. Surgical Clinics ~ North America 17: 145-184. 186
The Hand~Vol. 4
No. 2
1972