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Lateral arm flap

Indications In both free antegrade and pedicled reverse designs, the lateral arm flap is useful for coverage and resurfacing of forearm, elbow, and dorsal hand wounds. It is thin, has fascia to provide a tendon gliding surface, and has a consistent vascular pedicle that does not require intramuscular perforator dissection. The donor site can often be closed primarily. The free antegrade lateral arm flap is based…

Groin flaps

Introduction The pedicled groin flap is an axial vascular flap based on the superficial circumflex iliac artery (SCIA). As an axial flap, it can be designed to cover a larger length-width ratio than what is possible with random abdominal flaps. It predominantly serves as a distant pedicled flap and is seldom raised as a free flap because of the short vascular pedicle. It is a workhorse…

Pedicled forearm flaps

Introduction Three pedicled forearm flaps, including the reverse radial forearm flap, ulnar artery perforator flap (Becker flap), and posterior interosseous artery (PIA) flap, are commonly used for coverage of hand defects ( Table 90.1 ). TABLE 90.1 Pedicled Forearm Flaps for Coverage of Hand Defects Reverse Radial Artery Flap Ulnar Artery Perforator Flap Reverse PIA Flap Source vessel Radial artery Ulnar artery perforator (dorsal ulnar artery…

Dorsal metacarpal artery flap and dorsal metacarpal artery perforator flap

Introduction The dorsal metacarpal artery (DMA) flap is a vascularized skin flap from the dorsum of the hand. It can be based on the second, third, or fourth DMA and its cutaneous perforators. The flap also can be based on the cutaneous perforators alone, in which case it is termed a dorsal metacarpal artery perforator flap. The DMA flap can be designed as an advancement, transposition,…

Flap coverage of thumb defects

Introduction The thumb is an essential part of the hand and plays a key role in power and precision grip, together with the fingers. The major goals of thumb reconstruction vary from patient to patient, but may include maintenance of stability, sensation, length, mobility, and appearance. Exposed structures (tendon, bone, vessels, fat), concomitant injuries to the hand, and defect size dictate the choice of reconstruction. This…

Flap coverage of fingertip injuries

The fingertip refers to the part of the finger that is distal to the insertion of the flexor and extensor tendons. Local flaps of the hand, including the palmar V-Y advancement flap, cross-finger flap, and thenar flap, are often used to cover the soft tissue defect of the fingertip to preserve the nail and distal interphalangeal (DIP) joint. V-Y advancement flap Indications The V-Y flap is…

Local tissue rearrangement for treatment of scar contractures

Introduction As with reconstruction elsewhere on the body, surgeons must keep in mind the “reconstructive ladder” when repairing hand defects. Consider treatment options that range from “simple to complex” and from “local to distant.” Local flaps are composed of skin and subcutaneous tissue that is adjacent to the recipient site and has an independent blood supply. These flaps are preferred ( Fig. 86.1 ) because the…

Management of mangled extremities

Indications for reconstruction The word mangled derives from a French word meaning “cut to pieces,” or a Latin word for to “cut or lop off.” Mangled extremities are typically defined as the result of a traumatic injury that harms three or more structures. Crush, avulsion, and blast injuries are common causes of mangled upper extremities. It is often preferable to save a hand with rudimentary function…

Release of de Quervain tenosynovitis

Indications Surgery is indicated for cases that do not respond to conservative therapy. Conservative therapy includes one to two steroid injections (usually performed with or without ultrasound guidance), nonsteroidal anti-inflammatory medications, splinting, and avoiding activities that cause symptoms. If it is suspected that a separate subsheath or septum is present for the extensor pollicis brevis (EPB) tendon (see the EPB entrapment test later in this chapter),…

Release of trigger finger

Primary trigger finger is commonly seen in healthy middle-aged women with a frequency two times that of men. Commonly affected sites are the thumb and middle and ring fingers. Secondary trigger finger is often seen in patients with diabetes, rheumatoid arthritis (RA), chronic kidney disease, and other metabolic or autoimmune diseases. These patients may be less responsive to nonoperative treatment compared with patients with primary trigger…

Acute repair of extensor tendon injuries: Zones I to VII

Indications Extensor tendon injuries are relatively common. The mechanism of finger extension is more complicated than that of flexion. It is achieved through the synergistic action of both extrinsic and intrinsic muscles with contribution from several passive ligamentous structures. Extensor tendons over the fingers are thinner, flatter, and lie closer to bony structures than flexor tendons ( Fig. 82.1 ). Surgical treatment is considered for most…

Tenolysis of flexor tendons

Overview Flexor tendon tenolysis is a difficult procedure, in which it is frequently more challenging to obtain a good outcome than primary tendon repair, and should not be taken lightly without ensuring patient cooperation. Patient selection plays an important role in successful tenolysis. If both flexor and extensor tenolysis and joint releases are needed, the procedures should be performed in two stages. The first stage begins…

A2 flexor tendon pulley reconstruction with free tendon graft

Overview Although flexor tendon pulley reconstruction is not common, several surgical techniques have been described, including grafting to pulley remnants, Lister’s single loop of extensor retinaculum, Widstrom’s loop-and-a-half technique, and the triple loop technique. Some surgeons prefer to use the triple loop technique because of the superior biomechanical result compared with the other reconstruction techniques, but using the pulley remnants is also acceptable ( Fig. 80.1A–B…