Double-toe transplantation following temporary insertion of a block of silicone for reconstruction of a traumatic metacarpal defect

Skeletal Fixation in a Mutilated Hand

Hand fracture fixation in mutilating injuries is characterized by multiple challenges due to possible skeletal disorganization and concomitant severe injury of soft tissue structures. The effects of skeletal disruption are best analyzed as divided into specific locales in the hand: radial, ulnar, proximal, and distal. Functional consequences of injuries in each of these regions are discussed. Although a variety of implants are now in vogue, K-wire fixation has stood the test of time and is especially useful in multiple fracture situations. Segmental bone loss is quite common in such injuries, which can be safely reconstructed in a staged manner.

Multiple-digit resurfacing using a thin latissimus dorsi perforator flap

Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces.