The role of cross-finger flaps in the primary management of untidy flexor tendon injuries

The role of cross-finger flaps in the primary management of untidy flexor tendon injuries

IN THE THE ROLE OF CROSS-FINGER FLAPS PRIMARY MANAGEMENT OF UNTIDY FLEXOR TENDON INJURIES D. T. GAULT and A. A. QUABA From the Regional Plastic Sur...

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IN

THE THE

ROLE OF CROSS-FINGER FLAPS PRIMARY MANAGEMENT OF UNTIDY FLEXOR TENDON INJURIES D. T. GAULT and A. A. QUABA

From the Regional Plastic Surgery Unit, St. Andrew’s Hospital, Billericay, Essex

This is a report of five patients who sustained untidy division of flexor tendons in zones 1 and 2, associated with overlying soft tissue loss. Contrary to traditional teaching, the tendon injuries were repaired primarily, and the tissue loss was made good with a cross-finger flap. At final evaluation, three cases were assigned excellent grades and two cases fair grades by Kleinert criteria. This unexpectedly favourable outcome may be due to a quality of the inner surface of the cross-finger flap and/or to staggering of the skin and tendon suture lines. The primary repair of flexor tendon injuries has been shown to yield good results (Kleinert, 1967; Lister, 1977). However, critical selection of patients and exacting technique is important, particularly in zone 2 injuries. Unsatisfactory primary surgery may jeopardise subsequent reconstruction (Verdan, 1972) and where wounds are extensive and overlying tissue is missing, secondary tendon repair has been recommended for most cases (Kleinert, 1981). Staged repair of flexor tendons, however, has its own shortcomings. A small group of patients whose tendon injuries were associated with significant skin loss were treated by primary flexor tendon repair and immediate cover by a cross-finger flap. Their results are reported here. Patients and Methods Five patients, four men and one woman, presented with loss of skin and flexor sheath overlying divided digital flexor tendons (Table 1). Their average age was 27.6 years (range 18-56 years). Three patients injured their dominant hand and two their non-dominant hand. The injuries were treated by primary tendon repair and an immediate cross-finger flap. Split-skin grafts were applied to the dorsum of the donor finger. The flaps were divided after an interval of between 15 and 21 days (mean 18 days) and in each case early controlled mobilisation was possible.

Patients were recalled for a detailed assessment of hand function and their results graded according to the criteria of Kleinert (1973) and Buck-Gramcko (1976). The average interval to follow-up was 9.8 months. Case I. A 22 year-old printer sustained a deep electrical burn to the base of his right index finger while plugging in an electric lawn mower (Figure la). In addition to a full-thickness burn, he severed the flexor digitorum profundus and superficialis tendons of the digit and injured the volar plate of the proximal interphalangeal joint.

Three days after the injury the burn was excised, the tendons trimmed and repaired and the defect filled by a flap from the dorsum of his middle finger. His postoperative progress was uneventful except for the development of a flexion contracture at the proximal interphalangeal joint, which was improved by a dynamic extensor splint. His result was graded as “fair” by Kleinert and Buck-Gramcko criteria (Figure 1 b and c). Case 2. This 56 year-old man put his right hand into a wood-planing machine, removing skin from the flexor aspect of all four fingers. In addition, he sustained an untidy division of the profundus tendon at the level of the proximal interphalangeal joint of his middle finger, with loss of a large portion of the overlying flexor sheath.

TABLE 1 Details of patients

case

Age (years)

Se.Y

Finger

Flexor Tendons Divided

Zone

Olher Digits Injured

Follow-up (months)

1 2 3 4 5

22 56 21 18 21

M M F M M

Index Middle Index Middle Middle

Both FDP FDP FDP Both

2 2 2 1 2

NolIe Skin loss index, ring and little None Skin loss little and index Tendons and digital nerves divided in ring and little

19 9 5 11 5

Received for publication 6th October, 1986. D. T. Gault, F.R.C.S., Hospital for Sick Children,

62

Great Ormond

Street, London

WCI.

THE JOURNAL OF HAND SURGERY

CROSS-FINGER FLAPS IN FLEXOR TENDON INJURIES

The tendon was trimmed and repaired and the skin defect filled with a cross-finger flap. Split-skin grafts were applied to the other fingers. A compression garment to minimise scarring and a dynamic extensor splint to prevent flexion contractures were fitted. Final evaluation of the finger showed the result to be “fair” by Kleinert’s criteria and “good” according to BuckGramcko’s criteria. Case 3. This 21 year-old lady slipped on ice, removing skin and tendon sheath from the flexor aspect of her right index finger. The profundus tendon and the radial digital nerve were divided at a level just distal to the proximal interphalangeal joint. The tendon and nerve were repaired and the defect filled by a cross-finger flap. Her result was graded as “excellent” by both Kleinert and Buck-Gramcko criteria.

Fig. 1

(a). Deep electrical burn to the base of the index finger. Postoperative range of flexion (b) and extension (c). A fair grade was assigned to the result by Kleinert’s criteria.

VOL. 13-B No. 1 FEBRUARY

1988

Fig. 2

(a and b). This patient achieved a full range of flexion and extension following a zone 1 injury with tissue loss requiring a cross-finger flap. (Case 4). 63

D. T. GAULT

Case 4. This 18 year-old window cleaner cut his left hand while working, removing skin from the flexor aspect of the middle and index fingers. The profundus tendon to the middle finger was divided at the level of the distal interphalangeal joint (zone 1) and a segment of flexor sheath was missing. The tendon was repaired and the defect filled by a cross-finger flap. A split-thickness skin graft was applied to the flexor surface of the index finger. His post-operative progress was uneventful and his result, when evaluated at eleven months by both Buck-Gramcko and Kleinert criteria, was “excellent” (Figure 2). Case 5. This 21 year-old roofer cut his left little, ring and middle fingers on the unravelled spiral metal casing of a public telephone cable. In the middle finger, he divided both flexor tendons, the ulnar digital nerve and artery, and the volar plate of the proximal interphalangeal joint with loss of the skin and tendon sheath overlying the middle phalanx. He had similar injuries to his ring and little fingers but without skin loss.

wounds. This staggering of the skin and tendon suture lines helps to combat the problem of mass healing of all divided structures, referred to by Peacock as the “one wound: one scar concept” (Peacock, 1970). A second explanation is that the loose areolar tissue seen on the inner surface of the cross-finger flap provides a good gliding bed (Souquet and Souquet, 1986) and to some extent replaces the lost tendon sheath. Certainly, at operation, this tissue has a slippery feel and appearance. The interposition of a layer of loose connective tissue has been used to provide a gliding surface in difficult hand reconstructions: fascial layers of the scalp and the loose connective tissue beneath latissimus dorsi have both been used in this context (Wintsch, 1986; Upton, 1986). Loose connective tissue is also found on the undersurface of a cross-finger flap. Histological examination of this tissue shows it to be composed of a rich plexus of blood vessels embedded in fat and loose areolar tissue

All tendons and nerves were repaired. A cross-finger flap was used to fill the defect on the flexor surface of the middle finger and, at assessment after five months, the finger had “excellent” function (Kleinert and BuckGramcko criteria). Results The results of primary tendon repair and cross-finger flap cover in these five severely injured fingers are summarised in Table 2. All patients returned to their original occupation within five to twelve weeks of the injury. TABLE 2 Results at follow-up Heinert Case

I 2 3 4 5

grading

Fair Fair Excellent Excellent Excellent

Buck-Cramcko grading

Fair Good Excellent Exaeknt Excellent

TAM’

as %

normal

61 73 88 100 90

of

side

Time before to work

returning (weeks)

7 12 5 8 12

* TAM = Total active mcmmenf

Discussion Satisfactory results have been obtained by primary repair in these five patients despite untidy injuries associated with overlying soft-tissue loss. There are several possible explanations for these favourable results. The introduction of well-vascularised tissue to replace a lost block of skin, subcutaneous tissue and tendon sheath to a certain extent enables the tendon repair to heal independently of the overlying skin 64

Fig.. 3

Cross-section of dorsal digital tissue showing the layer of loose areolar tissue (A) adjacent to the extensor tendon which forms the undersurface of a cross-finger flap. (Masson Trichrome; X18). THE JOURNAL OF HAND SURGERY

CROSS-FINGER FLAPS IN FLEXOR TENDON INJURIES

(Figure 3). We had wondered whether cells from the outer layers of the extensor paratenon could also be present. However, Alcian Blue staining has not shown an excess of glycoprotein (mucoid tissue), said by Peacock to be present in cells of the paratenon. Another important aspect of this replacement tissue is its vascularity. Rayner (1976) has commented that oxygen availability may well prove crucial in influencing the line of cellular development in connective tissue; hypoxia of cells involved in the repair process can lead to increased fibrosis. Lastly, the flap joins the injured finger to an uninjured donor finger, and this may encourage movement in the early post-operative period which is so vital if optimal gliding is to be preserved beneath the replacement tendon sheath. It is difficult to draw firm conclusions from a small series but these results in difficult cases (60% excellent, 40% fair), which compare favourably with a recent evaluation of our zone 1 and 2 tendon injuries without soft tissue loss (42% excellent, 13% good, 26% fair and 19% poor), encouraged us to report this line of management

VOL. 13-B No. I FEBRUARY 1988

Acknowledgments We wouldlike to thank Dr. S. G.

Subbuswamy MD., FRCPath., Dr. A. AlNafussi MRCPath., D.Phil., and the technical staff of the Histopathology Department of St. Andrew’s Hospital for their help.

References BUCK-GRAMCKO, D., DIETRICH, F. E. and GGGGE, S. (1976). Bewertungskriterien bei Nachuntersuchungen van Beugesehnenwiederherstellungen. Handchirurgie, 8: 2: 65-69. KLEINERT, H. E., KUTZ, J. E., ASHBELL, T. S. and MARTINEZ, M. (1%7). Primary Repair of Lacerated Flexor Tendons in No Man’s Laud. The Journal of Bone and Joint Surgery, 49A: 3: 577. KLEINERT, H. E., KUTZ, J. E., ATASOY, E. and STORMO, A. (1973). Primary Repair of Flexor Tendons. Orthopaedic Clinics of North America, 4 : 4: 865-876. KLEINERT, H. E., SCHEPEL, S. andGILL, T. (1981). Flexor Tendon Injuries. Surgical Clinics of North America, 61: 267-286. LISTER, G. D., KLEINERT, H. E., KUTZ, J. E. and ATASOY, E. (1977). Primary Flexor Tendon Repair Followed by Immediate Controlled Mobilisation. The Journal of Hand Surgery, 2: 6: 441-451. PEACOCK, E. E. and VAN WINKLE, W. Surgery and Biology of Wound Rep&. Philadelphia, London, Toronto. W. B. Saunders Company, 1970. RAYNER, C. R. W. (1976). The Origin and Nature of Pseudo-Synovium Appearing Around Implanted Silastic Rods. An Experimental Study. The Hand, 8: 2: 101-109. SOUQUET, R. and SOUQUET, J. R. (1986). The Actual Indications of Cross finger Flaps in Finger Injuries. Annales de Chirurgie de la Main, 5: 1: 43-53. UPTON, J., ROGERS, C., DURHAM-SMITH, G. and SWARTZ, W. M. (1986). Clinical Applications of Free Temporoparietal Flaps in Hand Reconstruction. The Journal of Hand Surgery, 1lA: 4: 475-483. VERDAN, C. E. (1972). Half a Century of Flexor Tendon Surgery, Current Status and Changing Philosophies. The Journal of Bone and Joint Surgery, 54A: 3: 472-491. WINTSCH, K. and HELALY, P. (1986). Free Flap of Gliding Tissue. Journal of Reconstructive Microsurgery, 2: 143-150.

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