Anatomic study of the dorsal arterial system of the hand

Thinking Out of the Box: Use of the Radial Artery Distally to the Snuffbox as Recipient Vessel

The use of the radial artery (RA) as a recipient vessel in the hand is mainly described in the snuffbox. However, we believe that employing the RA distally to the extensor pollicis longus (EPL) tendon may provide remarkable advantages.

Bipedicle strap flaps for reconstruction of longitudinal dorsal finger defects: a review of 42 cases

We report our experience with 42 bipedicle strap flaps in 42 fingers of 37 patients for the reconstruction of long longitudinal dorsal finger defects. Twelve cases were compound lesions with tendon lacerations. All flaps healed without infection, congestion or necrosis. At follow-up, mean total active interphalangeal joint mobility was 150° and 108° in patients without and with tendon lacerations, respectively. The median scores of the short version of the Disability of Arm, Shoulder and Hand questionnaire were 5 and 7, respectively. Patients were able to return to work or to their daily activities after a mean of 6 weeks. The patients were satisfied with the appearance in 34 of the 42 flaps. We conclude that the flap is a useful option for reconstructing dorsal digital lesions. It has a texture similar to the normal dorsal digital skin, and it is easy to perform without needing microsurgery.Level of evidence: IV.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

Use of a Reverse Metacarpal Bone Flap for the Treatment of Segmental Bone Defects of the Proximal Phalanges

PURPOSE

The purpose of this retrospective study was to report the results of reconstruction of segmental bone defects of the proximal phalanges using a reverse metacarpal vascularized bone flap harvested from the third metacarpal bone.

METHODS

From August 2012 to May 2017, 17 patients with segmental osteomyelitis or necrotic bone of the proximal phalanges were treated. There were 15 male and 3 female patients, with a mean age of 36 years (range, 19-65 years). The mean size of bone defects was 26 × 9 × 9 mm (range, 16 × 6 × 7 mm to 35 × 10 × 7 mm); and the mean size of bone flaps was 27 × 8 × 7 mm (range, 15 × 7 × 4 mm to 40 × 8 × 7 mm).

RESULTS

The mean follow-up period was 26 months. The mean motion arc of the metacarpophalangeal joints was 56° (range, 22°-90°). The mean pinch strength of the injured fingers was 3.1 kg (range, 2-3.6 kg), and the mean pinch strength of the normal contralateral side was 6.9 kg (range, 4.2- 8.5 kg).

CONCLUSIONS

The reverse metacarpal bone flap may promote osseous healing in reconstructing segmental defects of the proximal phalanges.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Use of the First Dorsal Metacarpal Artery-Based Fascial Flap for Reconstruction of Small Defects on the Dorsum of the Hands

PURPOSE

To describe the reconstruction of small defects on the dorsum of the hands using a first dorsal metacarpal artery-based fascial flap harvested through the borders of the defect.

METHODS

From January, 2015 to May, 2017, 29 patients (29 hands) with soft tissue defects on the dorsum of the hand were treated using a first dorsal metacarpal artery-based fascial flap. At final follow-up, we measured range of motion of the metacarpophalangeal joints and the first web span.

RESULTS

Average size of the defects was 2.7 × 2.5 cm. Average size of the flaps was 2.9 × 2.7 cm. Average length of the pedicle was 2.9 cm. All flaps survived. Range of motion of the second to fourth metacarpophalangeal joints reached 93% to 98% of the opposite hand. The span of the first web reached 98% of the opposite hand.

CONCLUSIONS

A first dorsal metacarpal artery-based fascial flap can be an alternative for reconstruction of small defects on the dorsum of the hands. Flap harvesting through the border of the defect avoided an additional scar at the donor site.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The reverse dorsal metacarpal artery flap in finger reconstruction: A reliable choice

Background:

The finger skin and soft-tissue defects are reconstructive challenges due to their nature and the intricate extensor apparatus and flexors it protects. The reverse dorsal metacarpal artery (RDMA) is a time-tested option for the reconstruction of the same.

Materials and Methods:

A total of 14 cases of RDMA flap for finger defects involving proximal to distal phalanx were performed. Thirteen of these patients were male and one patient female and the most common mode of injury was occupational in nature followed by road traffic accident. The overall appearance was assessed for the flap and the donor site. The associated injuries and the range of motion were noted.

Results:

All but one flap survived completely. One patient had partial distal flap loss, which was tackled with split-thickness skin grafting. The flap size varied from 3.5 cm × 1.5 cm to 9 cm × 2 cm with mean of 6.64 cm × 1.72 cm. The mean age of the patients was 33.4 years. All the patients had acceptable aesthesis. The donor site had no complications and healed with linear scar.

Conclusions:

RDMA flap is a reliable flap for finger defects reconstruction. The range of movement mainly depends on the associated injury rather than flap transfer alone and to prove this we require doing analysis of range of movement in patients with flap done alone or with associated injuries.

Color Doppler ultrasound assessment for identifying perforator arteries of the second dorsal metacarpal flap

PURPOSE

The second dorsal metacarpal (SDMC) perforator flap has been widely used for the soft tissue reconstruction of the hand. However, it is difficult to identify the depth and branches of the perforators of the second dorsal metacarpal artery (SDMA) using only handheld acoustic Doppler flowmetry (HADF), which is the most common method. The purpose of this study was to compare the results of examination by color Doppler ultrasonography (CDU) with those of HADF and to evaluate the efficacy of CDU for detection of the perforators to be used in the design of the SDMC flap.

METHODS

Twenty-two healthy volunteers (42 hands) were examined using both CDU and HADF. All locations identified as the perforators of the SDMA by the two examinations were mapped respectively.

RESULTS

The total perforator arteries detected with CDU in all hands were 111 branches, 49 branches of which could not be identified with HADF. The average number of perforators of the SDMA per hand found with CDU was 2.8 branches, while that for HADF was only 1.8 branches. The detection rates of the cutaneous perforators of the SDMA by CDU were 100% in the proximal one-third of the second metacarpal and 95% in the distal one-fourth of the second metacarpal.

CONCLUSION

This study demonstrated the superiority of CDU compared with HADF for detection of the perforators of the SDMA. The CDU examination could easily identify the locations of the cutaneous perforators and help in the useful assessment of vascularity for the SDMC flap.

Thumb Reconstruction Using Foucher's Flap

BACKGROUND

Extensive pulp defects of the thumb, with the exposure of tendon or bone, are challenging reconstructive problems. Surgical treatment includes the use of local, regional, and free flaps.

AIM

This paper is focused in Foucher's neuro vascular flap. First DMCA or Foucher's pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.

MATERIAL AND METHODS

The first dorsal metacarpal artery (FDMCA) arises from the radial artery in the first intermetacarpal space, just distal to the tendon of the extensor pollicis longus. Pulp area of the thumb is the area where Foucher's flap is more utilizable. This technique has other applications such as first web reconstruction, thumb lengthening, and following resection of tumors on the dorsum of the hand.

RESULTS

We have in study 7 cases with work related trauma in two years period of time, between 2012 and 2014. We had only one partial flap survival and all the other flaps survived entirely. We have also taken in consideration subjective satisfaction with a range score from 4 to 10, cold intolerance, flap area and donor site sensibility with a range score from low to medium to normal.

CONCLUSION

Careful pedicle discovery, secured elevation, pedicle strangulation prevention are very important for flap survival.

Interpretation of upper extremity arteriography: vascular anatomy and pathology [corrected]

Understanding the utility and interpretation of upper extremity angiography is critical for the hand surgeon treating vaso-occlusive diseases of the hand. Although invasive and requiring the use of contrast dye, it remains the gold standard for imaging of the vascular system of the upper extremity. Angiography may detect numerous variants of the upper limb arterial system which may contribute to surgical pathology. Extensive vascular collateralization helps to maintain perfusion to the hand and facilitates reconstruction of the upper extremity. It is paramount to remember that angiography is a dynamic study and should represent a "flexible roadmap" for surgical reconstruction.

Vascularization of the dorsal base of the second metacarpal bone: an anatomical study using C-arm cone beam computed tomography

BACKGROUND

Vascularized bone grafts of the hand are a promising option for treatment of hand abnormalities. Therefore, the purpose of this study was to analyze the arterial anatomy of the dorsal aspect of the second metacarpal base to further investigate this possible donor site for bone grafts.

METHODS

The authors examined 16 fresh frozen cadaveric hands by using a C-arm cone beam computed tomography scanner and depicted the three-dimensional course of the second dorsal metacarpal artery and measured the diameter, length, and arc of rotation of this nutritive vessel. In addition, the authors dissected six of the hands under a dissecting microscope and, after selective injection of gelatin dye solution, the authors analyzed the vessel entrances into the bones histologically.

RESULTS

In all examined hands, the second dorsal metacarpal artery was a nutritive vessel to the dorsal base of the second metacarpal. The average diameter was 1.3±0.4 mm and the average length of the vascular pedicle was approximately 3.3±0.3 cm. In 14 of 16 cases, the arc of rotation was sufficient to reach the lunate without difficulty. Histologic analysis showed an intrinsic blood supply in the donor region with a vessel diameter of approximately 58 μm. A clinical case with application in Kienböck disease is presented.

CONCLUSION

Pedicled vascularized bone grafts from this area are suitable for clinical application to treat Kienböck disease if standard donor sites are unavailable.

The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation

PURPOSE

The treatment of comminuted fractures of the proximal interphalangeal joint is highly challenging due to the complexities of joint bio-mechanics and stability. The hemi-hamate osteochondral auto-graft has been popularised in this role, able to replace articular loss and restore joint stability. Recent evaluation of their long-term follow-up however has shown the early development of osteoarthritis and potential early cartilage loss, which may be due to the non-vascularised nature of the graft. We offer a new technique that maintains vascularisation of the transferred hamate fragment, and investigate the anatomical vascular basis for the technique.

METHODS

Dissection and angiographic studies of ten cadaveric specimens were undertaken, exploring the vascular anatomy of the dorsal hamate. A clinical case of hemi-hamate osteochondral free flap is presented, including preoperative, intraoperative and postoperative investigation of the relevant vasculature.

RESULTS

Cadaveric studies demonstrated dorsal vascular supply to the hamate from the central of three dorsal carpal arches. The arch was supplied by the dorsal branch of the ulnar artery. Multiple supracapsular veins are present for use in flap venous drainage. This vascular pattern was found to be constant. A clinical case of hemi-hamate osteochondral free flap harvest demonstrated the same vascular anatomy intraoperatively. The digital artery was used as a recipient for microvascular anastomosis. Postoperative computed tomographic angiography and nuclear bone scan confirmed flap perfusion.

CONCLUSIONS

The hemi-hamate osteochondral flap has a reliable anatomical vascular basis, and is clinically feasible as a technique for early vascularisation of the osteochondral fragment to sustain the transferred articular cartilage.

Temporary arterial stenting in a full-house spaghetti wrist injury in a remote rural setting: benefit for hand perfusion or risk of increased morbidity?

We report a case of temporary arterial plastic tube stenting of the ulnar and radial artery in a complete spaghetti wrist injury in a remote rural setting. Exploration in a specialist centre 18 h postinjury revealed that the tubes were clotted off with adjacent thrombi but hand perfusion was maintained. Intimal damage required vein grafting of both arteries 24 h postinjury. Hand perfusion was not compromised at follow-up. This case highlights that arterial hand perfusion can be maintained without the ulnar and radial artery. Arterial manipulation and tube insertion outside a specialist centre bears the risk of increased morbidity and potential microembolism and must therefore not be attempted.

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.

Unipedicled laterodigital transposition flap for covering dorsal longitudinal skin defects in multi-digit injuries

A variety of flaps have been described to treat longitudinal soft tissue defects located on the dorsal aspect of the fingers. We report 13 dorsal soft tissue defects in four patients in which unipedicle laterodigital transposition flaps were used for reconstruction. This flap is especially useful for the reconstruction of long and narrow defects located on the dorsal region of the fingers in multi-digit injuries.

Treatment of symptomatic distal interphalangeal joint arthritis with percutaneous arthrodesis: a novel technique in select patients

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques.

Distally based venous flap: a new technique for the correction of syndactyly without skin graft in adult patients

Skin grafts and local flaps are conventional methods for repairing simple syndactyly. Skin grafts usually leave unsightly appearance and contracture formation. In this study, unipedicled distally based venous flap were raised from third or fourth metacarpal area of the hand for syndactyly treatment. The distally based venous flap was to provide skin coverage to one side of the finger, in order to avoid complications arising from using skin graft. Nine patients' syndactylies (5 simple incomplete and 4 simple complete syndactyly) were treated using this method. The mean follow-up period of the flaps was 14 months, ranging from 12 to 16 months. Mild edema and venous congestion occurred in all flaps. Superficial necrosis involving two flaps did not affect flap survival. All flaps survived completely. In this article, we have described a new surgical technique for the correction of syndactyly in a single surgical procedure that utilizes a distally based venous flap to provide skin coverage without skin graft.

Measurement of the flexing force of the fingers by a dynamic splint with a dynamometer

PURPOSE AND METHODS

In order to determine forces acting upon an articular joint during hand rehabilitation, a dynamic splint was built and connected to a dynamometer (capable of measuring forces in the range 0 - 600 gf). Through trigonometric calculation, the authors measured the flexing force in the proximal interphalangeal joint of the middle finger at 30 degrees, 45 degrees, 60 degrees, and 90 degrees of flexion. Measurements were obtained in a population of 40 voluntary adults, 20 females and 20 males, This flexing force was correlated with age, sex, and anthropometric measures.

RESULTS

Force in the flexing tendon is maximal at the start of flexion, and decreases as the angle of joint flexion increases. A relationship was observed between finger length and the magnitude of the force exerted on the tendon: the longer the finger, the greater the force exherted upon the tendon. Force is greater at all the measured angles, (except 30 degrees) in males and in individuals of higher stature, and bigger arm span.

CONCLUSIONS

The flexing force can be effectively measured at all flexing angles, that it correlates with a number of different anthropometric parameters, and that such data are likely to open the way for future studies.