HAND INJURIES

BY Dr. SHADI NAASAN Senior resident in plastic surgery Hospital of Aleppo university Feb 2008

For an acutely injured hand, the purpose of treatment is to restore its function. It is necessary to prevent infection, salvage injured parts, and promote primary healing. Nerves and tendons may be repaired in the primary phase of care, but this is secondary in importance to thorough cleansing and debridement, correct stabilization of fractures and dislocations, and wound closure or coverage with skin grafts or skin flaps. Through patient history taking and careful physical examination the surgeon must personally appraise the injury to decide which primary procedures can be done safely and which secondary procedures may be necessary later

History
The history should provide accurately and concisely the following information:

(1) the exact time of injury (to determine the interval before treatment), (2) the first aid measures given and by whom and where, (3) the nature, amount, and time of receiving any medication, (4) the exact mechanism of injury (to determine the amount of crushing, contamination, and blood loss), (5) the nature, time, and amount of food and liquid taken by the patient (information necessary for selection of the anesthetic), (6) the patient's age, occupation, place of employment, handedness, and general health status. General, vague, nonspecific statements are best avoided.

First Aid
The patient's initial evaluation includes an assessment of other potentially serious or life-threatening injuries. Open hand wounds should be covered immediately with a sterile dressing to prevent further contamination. If the wound is severe and bleeding, the hand should be elevated with the patient lying supine; if bleeding is not controlled by elevation alone, manual or digital pressure must be applied to the wound through the dressing. Bleeding can be quickly controlled by removing an improperly applied tourniquet; rarely is a tourniquet necessary. However, at times, it may be helpful to elevate the arm and control bleeding with a pneumatic tourniquet or blood pressure cuff inflated to 100 to 150 mm Hg greater than the systolic pressure. The tourniquet should be deflated as soon as bleeding is controlled. Because of the potentially harmful effects of prolonged tourniquet use, those who apply tourniquets should be responsible for monitoring and removing them. Hemostats and ligatures should not be used to control bleeding in the emergency department because this may damage intact vessels and nerves, thereby interfering with later repair

First Examination
With the patient supine and as comfortable as possible, the wound is examined in two stages. The first examination is performed before surgery but under sterile conditions; masks should cover the faces of the examiner and, when possible, the patient. Sterile instruments and gloves are used. The purpose of this first examination is to estimate the size of the wound and determine the extent of skin loss and injury to the deep structures. Pain usually limits examination. Probing the depth of the wound rarely is helpful. The viability of the skin and any gross positional deformity are noted. The wound is then covered, and physical examination is attempted to determine which deep structures are functioning; each one of these structures must be considered damaged until proved otherwise. To lessen the chance of error, the assessment of each tissue should be orderly; attention is first directed to the circulation and skin and then to bones, tendons, and nerves. The classification advocated by Bchler and Hastings for assessing initial injuries includes (1) isolated injury (single hand structure) (2) combined injury (more than one important hand structure). Combined injuries are further subdivided into crush injuries, palmar combined injuries, dorsal combined injuries, and palmar and dorsal combined injuries. The condition of the skin is assessed constantly so that a timely choice can be made between primary closure by direct skin suture or by appropriate skin grafts or flaps. Roentgenograms of an injured hand are made routinely to reveal fractures, dislocations, or foreign bodies. If a patient's pain tolerance and general condition permit, stress views to assess ligament integrity and joint stability may be obtained. Careful assessments for severed tendons and nerves are made next. From this first examination the surgeon should obtain some idea about the extent of injury and what procedures will be necessary. A final decision is withheld until the second examination is done during surgery. The patient's general medical condition is evaluated. Antibiotics, sedation, blood transfusions, tetanus prophylaxis, and other measures are provided as indicated. Before sedatives or narcotics are given, the patient should be advised as to the extent of his injuries, the general plan of treatment, and the prognosis, especially with regard to any possible amputation. He also should be

ANESTHESIA
A regional block or general anesthetic may be selected, depending on the patient's age and general condition, the severity of the injury, other injuries, the interval since the last ingestion of food or drink, and whether a distant flap will be necessary TOURNIQUET A tourniquet is necessary while the wound is being cleansed and inspected and while the deep structures are being repaired. When the viability of an area of skin is questionable because of a crushing or avulsing injury, a tourniquet should be used as briefly as possible. For a large wound with fractures, elevation of the hand for 2 minutes is better than wrapping it with an elastic (Martin) bandage before inflation of the tourniquet. This prevents further crushing and displacement of fracture fragments

CLEANSING AND DRAPING OF HAND

After the patient or the part is anesthetized and the tourniquet is applied, the first aid dressing is removed and a sterile pad is placed over the major wound. The uninvolved skin surrounding the wound is shaved. The hand is held over a drain basin and scrubbed with antiseptic soap and water to above the elbow. The nails and nail beds are cleansed, and the nails are trimmed. Next, the wound is exposed and irrigated with normal saline solution .Usually antiseptics are not used in the wound because of potential tissue toxicity. The wound is irrigated with normal saline, either poured or through a pulsating lavage apparatus to provide a stream with enough force to loosen small foreign particles and to remove large hematomas. A gloved finger may be placed in the wound to loosen hematomas or to palpate the bones, but the depths of the wound should not be rubbed with a sponge or brush. Small bleeding vessels, which are sometimes more easily seen under water, are clamped with mosquito hemostats and cauterized. Small flaps and tags of devitalized fat and fascia seen floating in the solution may be removed at their bases. Nerve ends are not debrided. Ragged skin edges may be trimmed, but complete excision of the edges of the wound usually is not necessary in the hand. As the deeper parts of the wound are cleaned, they are carefully searched for foreign materials, especially if there is suspicion that they contain broken glass, wood, or pieces of glove or when the wound has been caused by a gunshot. Cleaning should not be hurried and often may take up half of the total operating time; it must be thorough to help prevent infection. Primary healing without infection is necessary to limit the scar and to allow additional early reconstruction, if needed. When the cleaning is complete, all instruments, gloves, and drapes used during this process are discarded, and the hand is redraped

Second Examination
After a diligent effort has been made to convert the contaminated wound into a clean one in the operating room, the wound is reexamined. The tissues in the depths of the wound, including exposed bones, tendons, vessels, and nerves, are assessed in an orderly, anatomical manner to avoid error; the skin also is examined carefully. Only after an accurate assessment of the damage can correct decisions be made as to which structures can be repaired primarily. Bones and joints are inspected to assess bone loss, the extent of periosteal stripping, and fracture stability. This evaluation allows estimation of potential bone healing and the advisability of early joint motion after internal fixation of fractures. Conclusions drawn from the first examination may be wrong, so suspected tendon and nerve damage needs to be confirmed by direct inspection. Evaluating the skin damage is most important because primary wound closure depends on skin viability. Frequently some skin appears to be lost when actually it has only retracted; When skin is crushed or flaps of skin are avulsed, the possibility of necrosis must be seriously considered. Releasing the tourniquet may be necessary for accurate evaluation. A valuable sign that skin is viable is a prompt pink blush (about 6 seconds) after release of the tourniquet. The extent of bleeding from the skin edges, the color of the skin immediately after compression, and the amount of undermining of the skin edges must be observed. Necrosis, infection, and scarring can occur if flaps of doubtful viability are retained. The extent of skin loss from the injury itself and after surgical excision of nonviable flaps must be evaluated, and plans must be made for complete coverage. Passive finger motion often delivers severed tendons into the wound. Small hematomas seen within synovial sheaths may be indications of further tendon injury.

Considerations for Amputation

The only absolute indication for a primary amputation is an irreversible loss of blood supply to the part. More often, other factors must be considered in deciding whether amputation is advisable. The ultimate function of the part should be good enough to warrant the time and effort required of the patient if it is not amputated. One should be more hesitant in amputating a finger when other fingers are also injured; immediate amputation for the same injuries might be preferred if the other fingers were normal. An analysis of the five tissue areas (skin, tendon, nerve, bone, and joint) is sometimes helpful in making the decision to amputate. If three or more of these five areas require special procedures such as grafting of skin, suture of tendon or nerve, bony fixation, or closure of joint, then amputation should be strongly considered. In children, amputation rarely is indicated unless the part is nonviable and cannot be made viable by microvascular techniques; however, amputation of a single digit, except the thumb, may be indicated when both digital nerves and both flexor tendons are severed in persons over 50 years of age. Even if amputation is indicated, it may be wise to delay it if parts of the finger may be useful later in a reconstructive procedure. Skin from an otherwise useless digit can be employed as a graft. Skin and deeper soft structures can be useful as a filleted flap; if desired, the bone can be removed primarily and the remaining flap suitably fashioned during a secondary procedure. Skin well supported by one or more neurovascular bundles but not by bone can be saved and used as a neurovascular island flap Segments of nerves can be useful as autogenous grafts. A musculotendinous unit, especially a flexor digitorum sublimis or an extensor indicis proprius, can be saved for transfer to improve function in a surviving digit, for example, to improve adductor power of the thumb when the third metacarpal shaft has been destroyed or to improve abduction when the recurrent branch of the median is nonfunctional. Tendons of the flexor digitorum sublimis of the fifth finger, the extensor digiti quinti, and the extensor indicis proprius can be useful as free grafts. Bones can be used as peg grafts or for filling osseous defects. Under certain circumstances even joints can be useful. Every effort, of course, should be made to salvage the thumb

Order of Tissue Repair

Setting priorities for repair of injured structures is important After the wound is cleaned, the bony architecture must be reestablished immediately if possible or within a few days after the wound becomes clean; otherwise, the soft tissues will contract, making their repair difficult or impossible without grafting. Even though definitive closure may not be possible, the bony architecture should be reestablished. It is preferable to close the wound within the first 5 days. If the injury and wound conditions permit, tendons and nerves should be repaired at the time of primary or secondary skin closure. While awaiting repair, nerves will contract, especially in the fingers and palm. Therefore consideration should be given to tagging the nerve ends with a small suture to the soft tissues of the palm. If repairs of nerve and tendons are delayed, repair or reconstructions may be done later.

Arterial Injuries
Generally, the best treatment for major upper extremity arterial injury (subclavian, axillary, brachial) includes immediate diagnosis, emergent angiography, and surgical exploration and repair. The best management of injuries to the radial or ulnar arteries in the forearm and wrist is controversial. If the palmar arterial arches are complete, hand survival and function are possible if one or both arteries are transected. Problems with pain, cold intolerance, and weakness may occur later. Gelberman et al. found that unrepaired single artery injuries resulted in insignificant changes in hand circulation, but combined arterial and nerve injury resulted in disabling symptoms of pain and cold intolerance. It is helpful to remember that in about 20% of patients either the radial artery or ulnar artery does not have a connection with the superficial palmar arterial arch. Pulse volume measurements and digital oximetry are helpful in assessing adequacy of circulation to the hand and digits. Several options are available for treatment of radial and ulnar arterial injuries, alone or in combination. If an injury involves only one artery in a young person without nerve injury and with the intact artery providing adequate circulation, ligation remains a satisfactory option. In both younger and older patients with inadequate circulation through the intact artery, especially if a nerve injury is present, repair of the injured artery is preferable. If both arteries are transected, repair of both arteries should be performed, especially in older patients and in patients with concomitant nerve injury. Injuries to the palmar arterial arch and the digital arteries require exploration and repair if circulatory impairment threatens digital viability. Microvascular techniques usually are required for these injuries

Considerations for Skin Closure

Primary skin closure is desirable and usually can be done in all sharply incised, clean wounds. The purpose of primary skin closure is to obtain early healing and to prevent infection, granulation tissue, edema, and excessive scar production. Misjudgment may lead to delayed healing as a result of hematoma, swelling, and infection, any of which may require reopening the wound for drainage or additional debridement. Certain wounds should never be closed primarily, for example, severely contaminated or crush wounds caused by farm machinery, human bites, tornado missiles, and augers. High-velocity missile wounds, other war wounds, and wounds contaminated with animal or human feces or fertilizer also should not be closed primarily. When in doubt, the wound should be left open after careful debridement using an anesthetic. Within about 24 to 48 hours the wound should be reinspected, and if it is sufficiently clean, it can be closed by direct suture or by skin graft. If possible, a wound should be closed within about 5 days of injury. Generally, a wound should not be left open to granulate and heal by secondary intention unless it cannot be made sufficiently clean to allow skin grafting or closure.

Methods and Indications for Skin Closure

DIRECT SUTURE Unless the wound is severely contaminated or crushed, consideration should be given to primary closure of every wound of the hand (except those mentioned previously) because healing by primary intention is the desired result. Most incised wounds can be closed by simple direct suture of the skin. Usually, the subcutaneous tissue is not sutured separately, but care should be taken to avoid inversion of the skin edges. Careful hemostasis is necessary. Closure is easier when all viable skin edges have been preserved during the initial cleansing. SKIN GRAFTS Wounds with distally attached flaps may have enough skin for primary closure but not enough venous drainage for the skin to survive. This deficient drainage causes engorgement and venous distention and finally thrombosis and necrosis; the color of the flap changes from a deep blue to purple and then to black. The retrograde flap often is the result of a crushing or tearing injury, and the very nature of this injury even further jeopardizes the survival of the flap. Such a flap on the dorsal surface of the hand or forearm is less likely to survive than one on the palm If doubt exists, the skin should be excised and replaced with a split graft If skin is lost and no deep structures (nerves, tendons, joints, or cortical bone) have been exposed, it should be replaced immediately with either a split-thickness graft or occasionally with a full-thickness one. SKIN FLAPS When a skin defect leaves deep structures exposed, a split-thickness or full-thickness skin graft is insufficient coverage for nerves, tendons, and cortical bone. These structures will not readily support a skin graft and require good nutrition to survive. A skin flap graft is necessary to provide subcutaneous tissue for coverage and for sufficient nutrition. This flap may be a local one but usually is obtained from a distance, either as a pedicle flap or a free tissue transfer

Fingertip injury
The fingertip is the most frequently injured part of the hand, and the middle finger is most vulnerable because it is the most distal and therefore the last to be withdrawn. Fingertip injuries are defined as those injuries occurring distal to the insertion of the flexor and extensor tendons. Although maintenance of length, preservation of the nail, and appearance are important, the primary goal of treatment is a painless fingertip with durable and sensate skin. Considerable hand dysfunction results when a painful fingertip causes the patient to exclude the digit from use. The specific wound characteristics determine which method of treatment is optimal for a given patient. It is important to know whether there has been loss of skin or pulp and the extent of such loss. The presence of exposed bone or injury to the nail bed or perionychial tissue must be determined. In the case of amputations, it is important to establish the level and angle of injury.

Anatomy
The fingertip is the end organ for touch and is supplied with special sensory receptors that enable the hand to relay the shape, temperature, and texture of an object. The skin covering the pulp of the finger is very durable and has a thick epidermis with deep papillary ridges. The glabrous skin of the fingertip is well-suited for pinch and grasp functions. Its volar surface consists of a fatty pulp covered by highly innervated skin. The skin of the fingertip is firmly anchored to the underlying terminal phalanx by multiple fibrous septa that traverse the fatty pulp

Classification
Allen has classified fingertip injuries based on the level of injury Type 1 injuries involve only the pulp Type 2 injuries involve the pulp and the nail bed Type 3 injuries include partial loss of the distal phalanx Type 4 injuries are proximal to the lunula This classification is useful to help generate a treatment plan. Additionally, tip amputations should be described in terms of the angle of injury : dorsal oblique, transverse, and volar oblique, as well as the presence of exposed bone

Treatment
Type 1 injuries may heal quite well by secondary intention. In contrast, Types 3 and 4 often require some type of flap coverage. Dorsal oblique and transverse injuries are more suited to local flaps. Volar oblique injuries often require a regional flap. Type 2 injuries require nail bed repair

Healing by Secondary Intention

The simplest treatment of fingertip injuries is to allow the wound to heal by secondary intention. It is reserved for small defects (8 to 10 mm2 ), with minimal bone exposure and minimal loss of tissue pulp. Local wound care should be performed 2 to 3 times daily with dressing changes. Healing is usually complete by 3 to 6 weeks depending on the size of the defect. In young children, this method provides good results even if larger areas of exposed bone.

Composite Grafts
If an amputated part has been recovered and it is clean and of adequate integrity, use the part for soft tissue coverage. If there is no exposed bone, de-fat the skin and suture it onto the defect. This piece will now function as a full-thickness skin graft. Minimize its thickness to enhance its chances of taking. Even if this skin necroses it will still serve as a biologic dressing.

Flaps for Finger Coverage

The volar V-Y advancement flap also called the Atasoy or Kleinert flap, is most commonly used for the dorsal-oblique finger tip amputation with exposed bone. The inverted-triangle, V-shaped flap is elevated on the volar pad, and the distal advancement of the wound is closed in Y-fashion. With complete division of the fibrous septae and flap mobilization, 1 cm of advancement is routinely obtained

The bilateral triangular advancement flap, also called the Kutler flap, was classically used for the transverse, or volaroblique finger tip amputation with exposed bone. It is now rarely employed because (1) only about 3-4 mm advancement is obtained, (2) often it creates an insensate fingertip, and (3) it can create a sensitive sagittal scar at the finger tip.

The thenar flap is most often used to cover the index and long finger tip amputations. The donor site is found by placing the injured finger tip(s) over the thenar eminence, and an Hshaped incision is made to bury the stump in the thenar pad. The flap is separated after about 2 weeks.

BIPEDICLE DORSAL FLAPS A bipedicle dorsal flap is useful when a finger has been amputated proximal to its nail bed and when preserving all its remaining length is essential but attaching it to another finger is undesirable. When this flap can be made wide enough in relation to its length, one of its pedicles can be divided, leaving it attached only at one side

ADVANCEMENT PEDICLE FLAP FOR THUMB INJURIES Advancement flaps for fingertip injuries usually will survive if the volar flap incisions are not brought proximal to the proximal interphalangeal joint. In the thumb, however, the venous drainage is not as dependent on the volar flap, and thus this technique is safer and the flap can be longer Using tourniquet control and appropriate anesthesia, make a midlateral incision on each side of the thumb from the tip to the metacarpophalangeal joint. Elevate the flap that contains both neurovascular bundles without disturbing the flexor tendon sheath Flex both the joints to allow the flap to be advanced and carefully sutured over the defect with interrupted sutures. The joints should be maintained in flexion postoperatively for 3 weeks. This rather large flap is used only when a large area of thumb pulp is lost.

LOCAL NEUROVASCULAR ISLAND GRAFT A limited area of the touch pad can be resurfaced by a local neurovascular island graft. This graft provides satisfactory padding and normal sensibility to the most important working surface of the digit. Make a midlateral incision on each side of the finger (or thumb) beginning distally at the defect and extending proximally to the level of the proximal interphalangeal joint or thumb interphalangeal joint. On each side and beginning proximally, carefully dissect the neurovascular bundle distally to the level selected for the proximal margin of the graft Here make a transverse volar incision through the skin and subcutaneous tissues but carefully protect the neurovascular bundles Then if necessary, make another transverse incision at the margin of the defect, thus freeing a rectangular island of the skin and underlying fat to which is attached the two neurovascular bundles. Carefully draw this island distally and place it over the defect. Avoid placing too much tension on the bundles; should tension compromise the circulation in the graft, dissect the bundles more proximally or flex the distal interphalangeal joint, or both. Suture the graft in place with interrupted small nonabsorbable sutures. Now cover the defect created on the volar surface of the finger with a full-thickness graft. Place over the grafts wet cotton carefully shaped to fit the contour of the area to prevent pressure on the neurovascular bundles. Apply a compression dressing until suture removal at 10 to 14 days. AFTERTREATMENT. Begin digital motion therapy as soon as the wounds permit

COVERAGE OF SPECIFIC AREAS WITH FLAP

Skin defects on the palm or dorsum of the hand that expose vital structures can be covered with a local flap, a flap from an adjacent unsalvageable finger, a flap from the opposite forearm or upper arm, an axial pattern flap from the same forearm or hand, a flap from the abdomen, or a free flap, depending on the size of the defect and the presence and location of any associated injuries. Although cross-arm and cross-forearm flaps provide good skin, immobilizing both upper extremities is a disadvantage. In suitable situations, an arterialized axial flap from the same forearm allows comfortable positioning of the upper limb. An abdominal flap from the same side also permits comfortable positioning of the arm. To ensure survival of the random pattern flap (since it must be applied immediately), its base should be as wide as its length. The length-to-width ratio may exceed 3:1 with axial pattern flaps such as the groin pedicle flap. The donor area and the raw part of the flap that will not make contact with the defect should be covered with split-thickness skin grafts. A local rotation flap is unlikely to survive, however, if undermining of the skin is extensive, especially if the skin is already crushed or contused from the injury. A filleted injured finger makes an excellent pedicle graft when this technique is applicable In some situations, free tissue transfer by microvascular technique provides the best coverage

SKIN GRAFTS
When skin grafts are to be obtained, it is well to remember that "the thinner the graft, the better the take," and yet when the graft is expected to be permanent, "the thicker the graft, the better the function." A thick graft is better able to withstand friction and constant use than a thin one and will contract only about 10%; a thin graft may contract 50% to 75%. For the graft to survive, it must reestablish its nutrition before death of its entire thickness occurs; great care is therefore needed, both in operative technique and in aftercare, to ensure that it remains undisturbed and in direct contact with the recipient area during healing. This takes careful planning, especially in children. The graft will not survive if a hematoma separates it from the underlying vascular bed; rarely will it survive a gross infection. For primary coverage of acute wounds, skin grafts usually are of thin or medium thickness. They will not easily survive on bare cortical bone, bare tendon, or bare cartilage. Full-thickness skin grafts are used infrequently on the hand. However, such grafts or thick split grafts can be used for the palmar surface because it contains elastic tissue, and in growing children these contract less and tend to accommodate growth. Since the survival of a full-thickness graft is so uncertain, it is best used only in elective surgery for skin coverage in the palm; it should be used rarely in acute injuries, with the possible exception of the fingertips.

SPLIT-THICKNESS SKIN GRAFTS

Frequently only a small or postage stamp graft is needed, and it can be obtained within the same operative field from the forearm; however, taking a graft from this area can be undesirable in children and women because it leaves a slight scar. The hypothenar area of the palm can be used to obtain satisfactory split-thickness skin grafts, especially for skin loss on the fingertips. More suitable donor areas for these and larger grafts are the anterior and lateral aspects of the thigh and the medial aspect of the arm just inferior to the axilla. In some older women skin is available inferior to a pendulous breast without leaving a readily visible scar

FREE FULL-THICKNESS GRAFTS

When a full-thickness graft is used, the recipient area must be free of infection and hemostasis must be complete. Preferred donor areas include the groin or the medial aspect of the arm, where the skin is thin and where the defect created by removing the graft may be closed by undermining and suturing the skin edges Sometimes an associated injury makes a detached piece of skin and underlying fat available; in this instance the skin can be stabilized on a dermatome drum and a full-thickness graft excised from the fat.

LOCAL FLAPS
Local flaps may be designated as advancement, rotation, translation, and transposition types. Use of an advancement flap involves mobilizing a small flap of skin to cover an adjacent defect without using a skin graft for the donor defect. These are used to cover fingertip amputations. Rotation flaps are raised on a curved radius with undermining of the flap and closed under modest tension without a skin-grafted donor defect Translation flaps usually are rectangular and are used to close an adjacent defect. The flap is moved around a pedicle base and is closed without tension. Translation flaps require a skin graft for the donor site Transposition flaps usually are moved across an adjacent area of normal skin to close an adjacent defect without tension. Skin grafting at the donor site is necessary The advantages of a local flap over one from a distant part are that the involved hand is not tied to the distant donor and that in many instances finger motions may continue. If the defect is too large to be covered with a local flap, an axial arterialized pedicle flap from the forearm, a distant flap from the abdomen, or a free tissue transfer is indicated. .

Local Flaps in Fingers

In the fingers they are either random pedicle flaps, receiving their circulation through the base of a skin pedicle, or they can be designed with circulation through the proper digital artery or one of its branches Local flaps used in the fingers usually are of the simple transposition type. This type covers vital structures but leaves a defect that must in turn be covered with a split-thickness graft). A common error in designing a local flap is to make it too short; it must be remembered that the fixed point of pivot from which the advancement is made is at that border of the base that is opposite the defect. If the corresponding border of the flap is not long enough, tension occurs when the flap is sutured in its new bed. Skin to be used for a local flap should not be damaged, since necrosis may occur. Developing a local skin flap requires undermining and minimal tension on the flap

Local Flaps from Dorsum of Hand

Local flaps used over the dorsum of the hand may be of any of those types previously listed. Hallock reported that the inclusion of the fascia in a random fasciocutaneous flap is helpful in this area. According to reports by Foucher, Foucher and Braun, and Sherif, various vascularized flaps can be developed on the basis of the first dorsal metacarpal artery In addition, the abductor digiti quinti and the palmaris brevis may be mobilized as pedicled muscle flaps to cover adjacent areas. A variety of local flaps can be used in the hand and fingers. They include local rotation flaps from the dorsum of the hand to fill defects in the web spaces ,cross finger flaps , thenar flaps, and other transposition flaps, such as the flag flap.

CROSS-FINGER FLAPS
Cross-finger flaps are useful for covering a defect of the skin and other soft tissues on the volar surface of the finger when tendons and neurovascular structures are exposed and a small amount of subcutaneous fat is needed. They also are useful for some amputations of the thumb These grafts are best avoided in patients over 50 years of age, in hands with arthritic changes or a tendency to finger stiffness for some other reason, or if local infection is present. TECHNIQUE Excise the edges of the defect so that it is rectangular, with its longer sides parallel to the long axis of the finger but not crossing skin creases. Then measure its dimensions. Place the injured finger against the donor finger and determine where to locate the base of the proposed flap. Cut the flap from the donor finger through the skin and subcutaneous tissues, leaving its base attached to the side adjacent to the recipient finger). Make the flap 4 to 6 mm wider than the defect and long enough both to cover the defect (allowing for normal skin contraction) and to provide a bridge between the fingers. If necessary, the flap may be raised from one midlateral line of the donor finger to the other, but be careful to avoid incising the volar surface of the donor finger. When raising the flap, make the incisions through the subcutaneous tissue but not through the peritenon of the extensor expansion. If possible, avoid using skin distal to the distal interphalangeal joint so as not to injure the nail bed. The skin over the dorsal surface of the proximal interphalangeal joint also should be avoided unless needed for width. If necessary, the base of the flap may be freed further by cutting the oblique fibers of the deep tissue that attaches the skin to the extensor tendon and periosteum along the side of the finger. Handle the flap with small hooks to prevent crushing and necrosis. Release the tourniquet and obtain absolute hemostasis; reinflate the tourniquet. Cut a thick split graft (0.018 inch) from the forearm or thigh and suture it to the donor area and to the undersurface of the bridge. Now apply the flap to the recipient area and suture it in place with the finest suture (5-0 or 6-0 nylon); the entire recipient area should be in contact with the flap. Leave the sutures long at the edges of the free split graft and fashion a stent dressing. Take care to avoid excessive tension on sutures transverse to the long axis of the finger to avoid vascular compromise. Cover the suture line with nonadhering gauze, place moist cotton pledgets about the graft, and apply gauze wrapping. To ensure immobility of the recipient finger, an oblique Kirschner wire through the interphalangeal joint sometimes can be used. A volar splint of plaster or fiberglass also can be used if additional support is needed. AFTERTREATMENT. The flap may be detached after 12 to 14 days. The skin margins of the recipient finger should be trimmed so that the junction of the normal skin with thegraft is at a midlateral position on the finger. Motion of both fingers can be started the day after the flap is detached.

This technique can be altered so that the base of the flap is proximal rather than lateral; such a flap is useful for covering a defect near the tip of an adjacent finger or thumb Rotation of the flap is necessary, and care should be taken to prevent strangulation at the base and necrosis. Rotated flaps that are based proximally can be used to cover defects on the same finger

FOREARM FLAPS FOR HAND COVERAGE

Two arterialized pedicle flaps from the forearm the radial forearm flap and the posterior interosseous flap have been found useful for covering defects in the hand. Each has a consistently reliable arterial supply. However, variations in forearm vascular anatomy, especially in the posterior interosseous artery, may preclude use of these flaps.

Radial Forearm Flap

According to descriptions by Foucher et al. and Yang et al., the radial artery supplies blood to the distal, palmar, and lateral forearm skin (an area approximately 16 8 cm). The flap territory is supplied through a branch of the radial artery arising about 7 cm from the radial styloid .The radial forearm flap, which is innervated by branches of the musculocutaneous nerve, is thin and can be used as an osteocutaneous flap with a portion of the radius, a fasciocutaneous flap on the pedicle, or as a free tissue transfer. As a pedicle flap, it can be mobilized to cover many parts of the hand). Some surgeons find the donor defect and the sacrifice of the radial artery objectionable. If the flap is used as a fascial flap, the skin can be closed with minimal scarring and the flap can be covered with a skin graft.. A preoperative Allen test is required to assess the adequacy of ulnar arteria l flow. If the status of the ulnar artery cannot be determined, arteriography should give a definitive picture of hand circulation. TECHNIQUE (Foucher et al.) After preparation of the wound to be covered, if it is suitable to receive the flap, proceed with flap design. Design a flap centered over the radial artery. The largest flaps obtained by Foucher et al. were 16 cm long 9 cm wide. Expose the radial artery at the proximal and distal borders of the flap. Ligate the radial artery proximal to the flap. At the proximal border of the flap, identify, dissect, and preserve the musculocutaneous nerve. Incise the anterior (medial) border, extending beyond the forearm midline if needed. Progressively raise the medial two thirds of the flap (medial to the radial artery), leaving the perimysium intact. Ensure that the radial artery and veins are taken as a single block from the radial groove. Upon reaching the distal end of the pedicle, dissect the lateral border of the flap laterally and medially. Leave the cephalic vein and the superficial radial nerve intact. Dissect from proximal to distal to mobilize the flap; avoid damage to the venae comitantes. If necessary, lengthen the pedicle by dissecting to the angle between the first and second metacarpals. Delicately dissect the vessels from the abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus, opening the retinacular sheaths to allow passage of the flap beneath the tendons. Obtain hemostasis with bipolar electrocoagulation of the numerous small vessels. Upon completion, a pedicle of about 8 cm is obtained, which allows rotation to many parts of the hand. Proceed with other requirements of the specific injury. AFTERTREATMENT. Flap circulation should be monitored for at least 24 hours. If flap viability is uncertain, the flap should be monitored until it is safe to allow the patient to return home. Sutures that appear too tight are removed. Causes of vasospasm (smoking, cold drinks, an excessively cold environment, emotional upsets) should be avoided. Skin sutures are removed in about 10 to 14 days, and rehabilitation appropriate for the specific injury is begun

Posterior Interosseous Flap

The posterior interosseous artery, usually a branch of the common interosseous artery, supplies a skin flap territory on the dorsal surface of the forearm. In the distal forearm the posterior interosseous artery joins the anterior interosseous artery at the distal part of the interosseous space. Over its course the posterior artery gives four to six cutaneous branches, passing through the septum between the extensor digiti minimi and extensor carpi ulnaris muscles, supplying an area of skin in about the middle third of the dorsum of the forearm. Flap islands from 1.5 4 cm to 9 11 cm were obtained by Bchler and Frey. Using the "retrograde flap, an arc of rotation up to 19 cm centered over the distal radioulnar joint allowed coverage of sites as far distal as the dorsum of the proximal interphalangeal joint. Anatomical variation may preclude development of the flap as planned. According to these authors, preoperative evaluation should include consideration of injury at the wrist, location of the defect on the distal finger, the need for sensation, the presence of peripheral arterial disease, and the presence of injury on the volar forearm with damage to the anterior interosseous artery..

Technique

On the dorsal (posterior) surface of the forearm, draw a line between the lateral epicondyle and the distal radioulnar joint along the course of the posterior interosseous artery . Design a flap that is centered on this line and preserve the cutaneous branches. Mark point A 2 cm proximal to the ulnar styloid that represents the distal anastomoses between the anterior and posterior interosseous arteries and the rotation point of the flap pedicle. From point A measure to the most distal point to be covered on the hand, point B. Transfer this length back proximally along the longitudinal line to a new point, C. Measure the length of the cutaneous defect to be covered and transfer that length along the line X-X1 from the proximal point distally to a new point. Distance CD is the flap length, and distance A-B is the length of the vascular pedicle. The width of the flap is determined by measuring the width of the defect to be covered and transferring that shape along the X-X1 line between points C and D. Begin the skin incision at the distal point of anastomosis between the interosseous arteries. Incise only the skin proximally along the radial (lateral) side of the flap; do not include the fascia in the flap. Dissect the flap mediallytoward line X-X1, observing the cutaneous branches, dissecting and protecting them. Open the fascia longitudinally over the extensor digiti minimi and the extensor carpiulnaris muscles. Use gentle blunt dissect between these two muscles to expose the posterior interosseous artery with its venae comitantes. Preserve the posterior interosses nerve. Electrocauterize the muscular branches of the artery. Section the posterior interosseouartery proximally near its origin near the distal edge of the supinator muscle. Open the ulnar (medial) side of the flap with a skin incision along the ulnar border of the flap. Gently elevate the flap distally to the distal anastomosis with the anterior interosseous artery. Gently dissect the vascular pedicle as far distally as possible to gain more length. Arrange the flap to appropriately cover the recipient wound. Proceed with the other requirements of the specific injury. If the donor skin defect does not exceed 3 to 4 cm in width, close it primarily; otherwise, cover it with skin graft.

ABDOMINAL FLAPS
In addition to the flaps previously discussed, the size of the defect and the thickness of the flap required may make it necessary to use a remote pedicle flap from the abdominal region. Traditionally, flaps from the abdomen have been used as tubed pedicle flaps or as direct flaps. The tubed pedicle technique requires the formation of a bipedicle tube and 6 weeks of maturation followed by detachment of one end of the tube to be applied to the hand, followed by another 3 to 6 weeks before the flap is completely detached and "inset" into the defect. The direct abdominal flaps typically are limited in their length-to-width ratio because of the random circulation. It rarely is safe to use such a flap with a length-to-width ratio that varies significantly from 1:1. A better understanding of the skin circulation has led to the development and use of flapsaxial pattern flapsthat have a defined arteriovenous supply. Axial pattern flaps allow a safe length-to-width ratio of at least 3:1, the possibility of covering either the dorsal or palmar surface, and a sufficiently long pedicle to allow arm and hand movement . Because such flaps usually do not require a delay in detachment of one end, they are useful for coverage of acute hand injuries.

Random Pattern Abdominal Pedicle Flaps

A random pattern abdominal flap to be applied to the hand should have its base either distal, toward the superficial epigastric vessels, usually on the same side as the affected hand, or proximal, above the umbilicus toward the thoracoepigastric vessels, usually on the opposite side. The flaps above the umbilicus should not be used in a patient with a "barrel chest" with chronic lung disease. Abdominal flaps obtained from areas above the umbilicus usually avoid the fat "storage areas." If the flap is obtained from the infraumbilical area, the recipient grafted area usually increases in bulk, since the infraumbilical area skin adds fat. TECHNIQUE On sterile paper make a pattern of the defect and outline it on the abdomen; then outline the flap, making it sufficiently larger than the pattern to allow for normal skin contraction and for the pedicle "bridge" between the abdomen and the defect. As a rule the flap should be rectangular to avoid a circular outline when the flap is attached to the hand. Avoid making the flap too thick. If possible, follow the principles of appropriate hand incision to avoid tension lines and excessive scarring. Using sharp dissection, raise the skin flap of the desired size and thickness. Maintain hemostasis and handle the fat carefully to avoid necrosis. Close the donor site defect by widely undermining the skin margins and suture them together, or apply a split-thickness skin graft, or both. With a split skin graft, cover that part of the raw, exposed undersurface of the flap pedicle that will not cover the hand defect. Slightly undermine the edges of the defect on the hand and apply the flap over the entire defect. Suture the edges of the flap to those of the defect and suture the free edge of the split graft to that edge of the defect nearest to the base of the pedicle, thus covering all raw surfaces. Place strips of nonadhering gauze (Xeroform or Adaptic) over the suture line and a dry dressing on the flap; be careful to prevent kinking, tension, and rotation at its base. Using flannel cloth reinforced with either plaster or wide adhesive tape, apply a bandage around the trunk and shoulder supporting the hand. The flap should be easily accessible for inspection through the dressing.

Groin Pedicle Flap

Advantages of the groin flap include (1) its location in an area sparse in hair, (2) minimal donor site morbidity, (3) multiple arteriovenous supply, (4) potential for incorporating bone with the overlying skin flap even when used as a pedicle flap, (5) potentially large size. Disadvantages include (1) problems with color matching, (2) possibility of damage to vessels from previous inguinal surgery, (3) thickness of the flap in obese patients The groin pedicle flap usually receives its arterial supply from the superficial circumflex iliac branch of the femoral artery. Its venous drainage is through the superficial inferior epigastric and superficial circumflex iliac veins.

Technique
Position the patient supine or turned slightly away from the affected side with sandbags or bolsters beneath the scapula and pelvis on the side of the flap to allow free access to the flank if a large flap is required. To help determine the central axis of the flap, identify and locate the course of the superficial circumflex iliac artery using a Doppler probe, usually about 2.5 cm distal and parallel to the inguinal ligament. After skin preparation and draping, use a suitable material such as sterile paper or plastic sheeting to outline the recipient defect with allowances for skin contraction. Place the pattern in the inguinal region, parallel with the inguinal ligament, along the course of the superficial circumflex iliac artery Although somewhat unusual, a groin flap as large as 20 30 cm has been elevated in some situations. The usual dimensions fall within a width of about 10 cm and a length extending about 5 cm posterolateral to the anterosuperior iliac spine. Landmarks to remember and refer to include the (1) pubic tubercle, (2) anterosuperior iliac spine, (3) inguinal ligament, and (4) pulsation of the femoral artery.

Incise the skin along the outline of the pattern, tapering the margins of the flap to a narrower pedicle of skin overlying the vessels that lie about 2.5 cm distal to the inguinal ligament near the medial border of the sartorius. Incise the skin and subcutaneous tissue down to the deep fascia and continue to elevate the flap in this plane. While dissecting along the superior margin of the flap, identify, ligate, or cauterize and divide the superficial epigastric vessels to ensure that the superficial circumflex iliac vessels are kept within the flap. Approach the lateral border of the sartorius with care because these vessels penetrate the sartorius fascia near this point. At the lateral margin of the sartorius, incise the fascia and carefully elevate it to the medial border. At the medial border of the sartorius the superficial circumflex iliac artery usually has a deep branch. Dissection of the flap medial to the medial border of the sartorius requires division of this branch and might place the trunk of the artery at risk. Usually a sufficient skin flap can be elevated without extending the dissection medial to the sartorius. Dissect and handle the flap gently, maintaining hemostasis throughout the procedure. When elevation of the flap is complete, determine the best hand and forearm position for attachment of the flap. Determine also the amount of the flap required to cover the hand defect and manage the intervening pedicle bridge of skin either by forming a tube in the pedicle or by applying a split skin graft to the raw, exposed area on the pedicle. If forming a tube causes excessive pressure on the pedicle vessels, a split skin graft provides safer coverage of this exposed tissue. While preparing the recipient area on the hand or forearm, cover the raw deep surface of the flap with moist gauze to prevent drying. Usually groin flaps will have a pale appearance after elevation. If there is any doubt regarding the axial arterial integrity after flap elevation, it may be necessary to replace the flap in its donor area, allowing a delay of 10 to 14 days. After the recipient area has been prepared, elevate the skin at the margin of the defect to allow easier insetting of the flap. After elevation of small to medium-sized flaps, close the donor site by mobilizing the skin margins, flexing the hip, and closing the subcutaneous and skin layers. Close the donor site before attaching the flap to the hand defect. Securely attach the flap skin to the skin margins of the recipient hand defect with a nonstrangulating suture technique. Apply a nonadherent gauze (such as Adaptic or Xeroform) to the suture lines and pad the axilla with absorbent padding to avoid maceration of the axillary skin. With the help of assistants, elevate the patient's torso using a board or similar device to support the back while the shoulder, arm, and forearm are included in a circumferential flannel wrapping, incorporating the torso and affected extremity. Secure the cloth wrap by wrapping over it with adhesive tape. Create a small window in the bandage to allow inspection of the flap. Take care at all times while moving or assisting the patient not to pull the arm away from the body.

Hypogastric (Superficial Epigastric) Flap

Its arteriovenous pedicle consists of the superficial epigastric artery and vein The axis of the flap usually is oriented in a superolateral direction, with the base near the inguinal ligament centered at about the midpoint of the ligament. Flaps measuring up to 18 cm long 7 cm wide have been used. Its advantages and disadvantages are similar to those described for the groin pedicle flap. Usually a bone graft cannot be incorporated into the skin flap. During preoperative planning it is important to examine the abdomen on the affected side for the presence of previous surgical or traumatic scars that might have damaged the arterial supply.

TECHNIQUE
Position the patient and elevate the affected side with a sandbag as needed. After skin preparation and draping, use a suitable material such as sterile paper to outline the recipient defect, making allowances for skin contraction. Place the pattern over the distribution of the superficial epigastric artery, arranging the base of the flap along the inguinal ligament. Arrange the axis of the flap so that it extends superiorly and slightly laterally from the inguinal ligament and is centered at about the midpoint of the ligament. Take care to avoid exceeding a length-to-width ratio of more than 3:1. Make the skin incisions along the skin markings of the pattern outline, with two parallel incisions extending superiorly and tapering toward the superiormost extreme of the flap. The distal extent of the dissection should not extend inferior to the inguinal ligament. Extend the skin incision through the subcutaneous tissue so that the plane of dissection is at the level of the Scarpa fascia. Elevate the flap inferiorly to the level of the inguinal ligament and then cover the deep subcutaneous tissues with moistened gauze. Prepare the recipient site on the hand and mobilize and elevate the skin at the margins of the defect on the hand to allow ease of attachment of the flap to the hand. Close or skin graft the donor site before attaching the flap to the hand defect. After the elevation of small to medium-sized flaps, the donor site usually can be closed by mobilizing the skin margins and closing the subcutaneous and skin layers. Attach the flap skin to the skin margins of the recipient hand defect with a nonstrangulating suture technique. Apply a nonadherent gauze (such as Adaptic or Xeroform) to the suture lines. With the help of an assistant, lift the patient's torso and support it with a board or similar device while the shoulder, arm, and forearm are incorporated in a circumferential flannel wrap about the torso and affected extremity. Wrap over the cloth wrap with wide adhesive tape to secure the dressing. Arrange the bandage so that the flap can be inspected. Take care while moving the patient so that the flap is not disrupted by pulling on the arm.

FILLETED GRAFTS
A filleted graft is a flap of tissue fashioned from a nearby part, usually a finger, from which the bone has been removed but in which one or more neurovascular bundles have been retained. In the hand such a flap is indicated only when deep tissues such as tendons, nerves, and joints are exposed and when a nearby damaged finger is to be sacrificed because it is not salvageable; it is never used at the expense of a salvageable, useful part. A filleted graft is especially convenient when other injuries more proximal in the same extremity would interfere with positioning the hand to receive a flap from a distant part. The advantages of this graft are that (1) it can be applied in a one-stage procedure at the time of injury and is obtained from within the same surgical field as the injured part; (2) its survival is almost ensured because one or more of its neurovascular bundles are preserved (3) its skin is similar to that which is to be replaced; (4) it is not attached to a distant part, and consequently after surgery the hand may be splinted in the position of function and elevated; (5) it provides an adequate thumb web when the index finger is the donor.

TECHNIQUE
Because the main vessels course anterolaterally through the digit, it is easier to fashion a flap with its base anterior and cover a defect on the dorsum of the hand than vice versa. Make a midline dorsal incision along the full length of the finger and skirt it around the nail distally. Deepen the dissection to the extensor tendon. Then remove this tendon, the underlying bone, and the flexor tendons and their sheath, but preserve the fat in which the neurovascular bundles are located; take great care to avoid damaging these bundles. Spread the flap thus created and place it on the donor area. If it is too wide, trim its edges, or if it is too long, excise its end; in the latter instance ligate the digital vessels and resect the digital nerves far enough proximally to prevent their being caught in the scar. Suture the flap in place so that it lies flat; avoid strangulating its base and trim only slightly any dog-ears that may be produced at the margins of the base so as to preserve the blood supply of the flap.