Hand CASE 49

CASE                               49                               

The patient is a 36-year-old otherwise healthy male who presents with a volar soft tissue defect overlying the distal phalanx of the index finger (Fig. 4–25). The patient reports that this is the result of a locally aggressive infection which required surgical debridement. The infection has been clinically eradicated with local wound care and a course of antibiotics. On examination, the patient has a 2 × 2 cm soft tissue defect of the volar distal phalanx of the index finger extending proximal to the DIP joint, with exposed flexor tendon sheath. The finger is stiff but is sensate and perfused.

 

 

 

Figure 4–25

 

Which of the following is NOT a reconstructive option for the patient?

1. Reverse radial forearm fascial flap with full thickness skin graft

2. Cross-finger flap from the dorsum of the ring finger

3. Free arterialized venous “flow through” flap from the volar forearm

4. Split thickness skin graft

5. Heterodigital island flap

 

Discussion

The correct answer is (D). There are many possible reconstructive solutions for this problem, including a cross-finger flap, arterialized venous flow through flap, heterodigital island flap, and reverse radial forearm flap with full thickness skin graft. A split thickness skin graft is not a good option for this patient given the exposed tendon and open wound that crosses the PIP joint. A split thickness skin graft undergoes significant secondary contracture and would likely result in progressive deformity with functional limitation at the PIP joint.

A cross-finger flap is performed from the dorsal aspect of the middle finger middle phalanx, with skin graft placement over the donor site. Seven days later, there is no appreciable take of the skin graft at the flap donor site and an open wound has resulted.

Which of the following reasons may have resulted in failure of skin graft take at the donor site?

1. Infection

2. Hematoma or seroma deep to the skin graft

3. Failure of adequate immobilization of the skin graft

4. Shear forces preventing continual adherence of the graft to the underlying tissue

5. All of the above

 

Discussion

The correct answer is (E). There are many reasons for failure of skin graft take, including infection, hematoma/seroma, shear forces on the graft, failure of adequate immobilization, and poor vascularity of the underlying tissue bed. These are best preempted prior to the operation to ensure the best chance for optimal graft take.

How long should one wait before confidently performing division of the cross-finger flap between the two fingers?

1. 2 to 3 days

2. 4 to 6 days

3. 7 to 9 days

4. 2 to 3 weeks

5. 5 to 6 weeks

 

Discussion

The correct answer is (D). Traditionally, pedicled flaps are divided approximately 3 weeks after creation to allow for development of sufficient neovascularization from the recipient bed. There is evidence that flap division can be performed earlier than

3 weeks but this depends on the anatomic area, the patient’s overall medical condition, and the defect size, among other factors. Pedicled flaps are often challenged with a tourniquet in the office prior to formal division to ensure that adequate vascularity has developed prior to division.

 

Objectives: Did you learn...?

 

 

Identfiy indications for split thickness skin graft? Describe reasons for failure of skin graft take?

 

Access timing of division for cross finger flaps?