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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_801_Библиотеки_им_академика_М_И_Перельмана
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Fig. 15.1 Surgical design
15 Reconstruction ofFinger Pulp Defects
of the sheath of the exor digitorum tendon. It should be
noted that both proper digital arteries and nerve bundles
are contained within the ap. The dissociated length of
the ap to the nger root depends on the need of the
wound surface, but it is necessary to ensure that the aps
advancing forward have no tension. In general, to repair
distal segment injury, the ap should be dissociated to
the middle of the proximal segment of the nger, while
it should be dissociated to the root of the nger to repair
the nger pulp defect. After the ap is dissociated, the
tourniquet should be loosened to observe the blood ow
and stop the bleeding. Then the interphalangeal joint
should be put in exion position and the distal wound
should be sutured, followed by the lateral incisions on
both sides. When the proximal incision is not easy to
close, the base can be formed with the “Z” word
(Fig.15.1).
(e) Postoperative treatment: (a) Nursing should be
strengthened and the blood supply of the ap should be
closely observed; (b) Postoperative “three anti” and
other routine tissue transplantation therapy should be
carried out; (c) Heat preservation should be carried out;
(d) No smoking during the perioperative period.
15.1.4 Operation Characteristics
(a) The palmar nger ap advancement to reconstruct the
nger pulp defect could preserve the length of the nger.
In addition, the ap contains vascular and nerve bundles
and has a good feeling after the operation. The skin on
the palm of the nger is dense, and the postoperative
nger pulp is plump and wear resistant.
(b) The operation is simple and there is no need to dissociate
blood vessels which mean better safety.
(c) Due to the limitation of advancement, this ap is not
suitable for repairing the nger pulp defect which is over
2cm2.
(d) There is no signicant increase in the trauma of the
affected nger, only a prolonged incision on both sides.
15.1.5 Announcements
(a) The dissociation of the ap should be carried out on the
supercial surface of the tendon sheath of exor digitorum tendon, and the neurovascular bundles on both sides
should be included in the skin ap. If necessary, 3-0 silk
15.1 Reconstruction ofFinger Pulp Defect by Local ThumbFlap
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227
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Fig. 15.2 Reconstruction of the right thumb pulp defect by V–Y ap
advancement. (a) Preoperative dorsal condition of the nger defect. (b)
Preoperative palmar condition of the nger defect. (c) Preoperative
design. (d) Preoperative repair of the donor site. (e) Dissociation of the
ap. (f) Nail bed enlargement. (g) The palmar view of the reconstructed
nger 14 months after the operation. (h) Appearance comparison of
both hands 14 months after the operation. (i) Appearance comparison of
both hands 14 months after the operation
f
thread can be used to suture the wound edge of the skin
15.1.6 Case Description
ap for several stitches to avoid the separation and injury
to the neurovascular bundles.
(b) The width of the ap should be equal to the width of the
nger pulp defect.
(c) There should be no tension in the suture after the ap is
advanced. The interphalangeal joint should be in exion
position to avoid tension.
(d) The affected nger is xed in exion position of the
interphalangeal joint
(e) Function exercise should be strengthened after wound
healing to prevent exion deformity of nger.
Case 1 A 41-year-old male patient was admitted to hospital
for 1.5 h due to pain and bleeding of the right thumb caused
by punch injury. Physical examination: The nger pulp of
the right thumb was defective with exposed bone, and the
defect area was 2.0 × 1.6cm. After admission, routine preoperative preparation for reconstruction was given, and surgical
contraindications were excluded. After complete emergency
debridement, V-Y ap was designed on the palmar side of
the thumb which was cut according to the design line to
advance to reconstruct the nger pulp defect and repair the
228
15 Reconstruction ofFinger Pulp Defects
nail bed, and the donor site was sutured directly. The ap
area was 2.2 × 1.8cm. The operation was successful, after
the tourniquet relaxed, the reconstructed ngers were ruddy
with moderate tension, wrapped with the sterile cotton,
bulked, and stuffed with the broken cotton gauze around, and
he returned to the ward safely. Routine reconstruction treatment was given after the operation. Fourteen months’ regular
follow-up was conducted to guide functional exercise. The
appearance and function of the reconstructed nger were satisfactory (Fig.15.2).
defect area was 3.3 × 2.3cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete
emergency debridement, the thumb was reconstructed by
transposition of dorsal digital ap based on cutaneous
branch, and the donor site was covered by skin graft. The
ap area was 3.5 × 2.5cm. The operation was successful,
after the tourniquet relaxed, the reconstructed ngers were
ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze
around, and he returned to the ward safely. Routine reconCase 2 A 41-year-old male patient was admitted to hospital
for 1.5 h due to pain and bleeding of the left thumb caused
by punch injury. Physical examination: The nger pulp of
the right thumb was defective with exposed bone, and the
struction treatment was given after the operation. Twelve
months’ regular follow-up was conducted to guide func-
tional exercise. The appearance and function of the recon-
structed nger were satisfactory (Fig.15.3).
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Fig. 15.3 Reconstruction of the right thumb pulp defect by transposition of dorsal digital ap based on cutaneous branch. (a) Preoperative
palmar condition of the nger defect. (b) Preoperative dorsal condition
of the nger defect. (c) Preoperative design. (d) The palmar appearance
of the reconstructed nger after the operation. (e) The donor site cov-
ered by skin graft. (f) The appearance of the reconstructed nger pulp
12 months after the operation. (g) The appearance of the nail 12 months
after the operation. (h) Appearance comparison of both hands 14
months after the operation. (i) The function of the reconstructed nger
pulp 12 months after the operation
i
15.2 Reconstruction ofFinger Pulp Defect by Transposition ofLocal Finger Flap
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229
15.2 Reconstruction ofFinger Pulp Defect
by Transposition ofLocal Finger Flap
Finger pulp is the most sensitive part of hand touch, the
touch function of the hand completely depends on the nger pulp to complete. Therefore, the nger pulp defect
needs to be repaired with high quality as far as possible,
especially to restore the tactile function and good appearance. The development of microsurgery has also created
good technical conditions for the repair and reconstruction
of the nger pulp, so that surgeons can use this technology
to complete the reconstruction of the nger pulp defect
better.
The palmar nger ap is a skin ap containing bilateral
palmar proper arteries and nerve bundles, which can be dissociated and moved forward to repair and reconstruct the
nger pulp defect. Due to the dense skin structure on the
palm of the nger, the postoperative nger pulp is plump and
wear resistant, and the feeling is good.
15.2.1 Indications
(a) Simple nger pulp defect caused by trauma or nger pulp
ischemic necrosis, the range is not more than 1.5 cm; (b) The
defect in the distal segment of the nger.
15.2.2 Surgical Design
Longitudinal lines are drawn in the middle of both sides of
the affected nger, and the proper neurovascular bundles of
both sides should be included in the palmar ap.
15.2.3 Surgical Method
(a) The position of patients: In supine position, the affected
limb is abducted on the operating table.
(b) Anesthesia: Brachial plexus block, digital nerve block,
or exor tendon sheath anesthesia can be used.
(c) The design of the ap: A line should be drawn along the
middle line on both sides of the nger stump wound to
the root of the nger.
(d) Surgical steps: The operation is performed under the
control of a tourniquet. After debridement of the nger
stump, the skin is cut along the midline incision line on
both sides, and the skin is sharply separated from the
distal end to the proximal end on the supercial surface
of the sheath of the exor digitorum tendon. It should
be noted that both proper digital arteries and nerve bun-
dles are contained within the ap. The dissociated
length of the ap to the nger root depends on the need
of the wound surface, but it is necessary to ensure that
the aps advancing forward have no tension. In general,
to repair distal segment injury, the ap should be dissociated to the middle of the proximal segment of the
nger, while it should be dissociated to the root of the
nger to repair the nger pulp defect. After the ap is
dissociated, the tourniquet should be loosened to
observe the blood ow and stop the bleeding. Then the
interphalangeal joint should be put in exion position
and the distal wound should be sutured, followed by the
lateral incisions on both sides. When the proximal incision is not easy to close, the base can be formed with the
“Z” word
(e) Postoperative treatment: (a) Nursing should be
strengthened and the blood supply of the ap should be
closely observed; (b) Postoperative “three anti” and
other routine tissue transplantation therapy should be
carried out; (c) Heat preservation should be carried out;
(d) No smoking during the perioperative period.
15.2.4 Operation Characteristics
(a) The palmar nger ap advancement to reconstruct the
nger pulp defect could preserve the length of the nger.
In addition, the ap contains vascular and nerve bundles
and has a good feeling after the operation. The skin on
the palm of the nger is dense, and the postoperative
nger pulp is plump and wear resistant.
(b) The operation is simple and there is no need to dissociate
blood vessels which mean better safety.
(c) Due to the limitation of advancement, this ap is not
suitable for repairing the nger pulp defect which is over
2cm2.
(d) There is no signicant increase in the trauma of the
affected nger, only a prolonged incision on both sides.
15.2.5 Announcements
(a) The dissociation of the ap should be carried out on the
supercial surface of the tendon sheath of exor digitorum tendon, and the neurovascular bundles on both sides
should be included in the skin ap. If necessary, 3-0 silk
thread can be used to suture the wound edge of the skin
ap for several stitches to avoid the separation and injury
to the neurovascular bundles.
(b) The width of the ap should be equal to the width of the
nger pulp defect.
230
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15 Reconstruction ofFinger Pulp Defects
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Fig. 15.4 Reconstruction of the right index and middle ngers pulp
defect by transposition of proper digital ap based on dorsal branch. (a)
Preoperative palmar condition of the nger defect. (b) Preoperative
dorsal condition of the nger defect. (c) Preoperative design. (d)
Dissociation of the aps. (e) Transposition of the aps. (f) The palmar
view of the reconstructed nger after the operation. (g) The dorsal view
of the reconstructed nger after the operation. (h) The palmar view of
the reconstructed nger 2 months after the operation. (i) The dorsal
view of the reconstructed nger 2 months after the operation
f
(c) There should be no tension in the suture after the ap is
advanced. The interphalangeal joint should be in exion
position to avoid tension.
(d) The affected nger is xed in exion position of the
interphalangeal joint.
(e) Function exercise should be strengthened after wound
healing to prevent exion deformity of nger.
15.2.6 Case Description
Case 1 A 49-year-old male patient was admitted to hospital for 1.5 h due to pain and bleeding of the right index and
middle ngers caused by punch injury. Physical examina-
tion: Finger pulp defect of the right index and middle ngers with exposed bone, and the defect areas were 1.6 ×
2.0cm and 1.5 × 1.8cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete
emergency debridement, the ngers were reconstructed by
transposition of proper digital artery ap based on dorsal
branch in proximal segment of the same nger, and the
donor site was covered by skin graft. The ap areas were
1.8 × 2.2cm and 1.6 × 2.0cm. The operation was successful and routine reconstruction treatment was given after
the operation. Two months’ regular follow-up was conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory
(Fig.15.4).
15.2 Reconstruction ofFinger Pulp Defect by Transposition ofLocal Finger Flap
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231
a
d
g
b
e
h
c
f
i
Fig. 15.5 Reconstruction of the left ring and little ngers pulp defect
by transposition of proper digital ap based on dorsal branch. (a)
Preoperative palmar condition of the nger defect. (b) Preoperative
dorsal condition of the nger defect. (c) Preoperative design. (d)
Dissociation of the aps. (e) Transposition of the aps. (f) The palmar
Case 2 A 23-year-old male patient was admitted to hospital due to pain and bleeding of the left ring and little
fingers caused by punch injury. Physical examination:
Finger pulp defect of the left ring and little fingers with
exposed bone, and the defect areas were 1.8 × 1.2cm and
1.6 × 1.3cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency
debridement, the fingers were reconstructed by transpo-
view of the reconstructed nger after the operation. (g) The dorsal view
of the reconstructed nger after the operation. (h) The palmar view of
the reconstructed nger 2 months after the operation. (i) The dorsal
view of the reconstructed nger 2 months after the operation
sition of proper digital artery flap based on dorsal branch
in proximal segment of the same finger, and the donor
site was covered by skin graft. The flap areas were 2.0 ×
1.6cm and 1.6 × 1.2 cm. The operation was successful,
and routine reconstruction treatment was given after the
operation. Two months’ regular follow- up was conducted
to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory
(Fig.15.5).
232
15.3 Reconstruction ofThumb Pulp Defect
by Transposition ofDorsal Index
Finger Flap
The dorsal index nger ap is located on the dorsal side of
the proximal segment of the index nger with the rst dorsal
metacarpal artery and dorsal digital vein as the blood supply
and two dorsal digital nerves issued by the supercial branch
of the radial nerve. The ap can form an island ap with a
neurovascular pedicle or an axial ap for local transposition.
In 1979 index nger dorsal ap was rst applied by Foucher
for thumb pulp defect reconstruction, due to the variation of
axis vessels, clinical application was limited, with the development of microanatomical study and deeper understanding
of the effect of deep fascial vessels on the blood supply of
fascial ap, at the same time the dorsal island ap of index
nger with fan-shaped fascia, and vascular nerve pedicle was
designed, which increased clinical application.
15.3.1 Indications
15 Reconstruction ofFinger Pulp Defects
(a) Thumb pulp defect caused by acute trauma accompanied
by bone, joint, tendon, nerve, and other deep tissue
exposed;
(b) To reconstruct the sensation of the thumb pulp.
15.3.2 Surgical Design
The vascular and nerve pedicle of the dorsal proximal index
nger ap runs on the dorsal side of the rst metacarpal
space. The blood supply in this area is mainly the branches
of the dorsal radial artery of the index nger and the proper
digital artery, and the sensory nerve is the terminal branch of
the supercial branch of the radial nerve (Fig.15.6).
A line is drawn from the midpoint of snuff box to the
junction point of the dorsal radial side of the second metacarpophalangeal joint, from proximal to distal 2.5cm along this
line, which is the starting point of the dorsal radial artery of
the index nger, and also the passing point of the vein and
nerve of the skin ap, which can be regarded as the key point
of the ap. The distal line of the key point is the dorsal radial
artery of the index nger, which is also the surface projection
of the axial vessels of the ap. The width of the ap on the
dorsum of the nger is 2–3 cm, and the width of the ap on
the dorsum of the hand is based on the vascular projection as
the central axis, 1.5cm to the ulnar side and 2.5cm to the
radial side. The distal end of the ap should not be more than
the proximal interphalangeal joint, and the proximal end is
bound by the key point.
Fig. 15.6 The blood supply and sensory nerves
15.3.3 Surgical Method
(a) The position of patients: In the supine position, the
affected limb is abducted 80° and placed on the small
operating table.
(b) Anesthesia: Brachial plexus block is used.
(c) The design of the ap: The ap should be designed
according to the size of the wound in the recipient site.
The cutting range reached the proximal interphalangeal
joint of the index nger, and the two sides should not
exceed the midline of the lateral nger, and the proxi-
mal end can extend upward as needed. The area of skin
ap can be cut: island ap 3 × 6mm and axial ap 9 ×
10cm.
(d) Dissociation of the ap: In the case of the island ap,
the forearm is not exorcised and the operation is per-
formed under the control of an inatable tourniquet. The
dorsal metacarpal vein on the dorsal side of the second
metacarpal is used as a mark to make an S-shaped inci-
sion, which is about 3–4cm. To dissociate the rst dor-
sal metacarpal artery and vein and supercial branches
of radial nerve with some perivascular soft tissue and the
interosseus membrane of the rst dorsal interosseous
muscle on the supercial surface of the rst dorsal inter-
osseous muscle. The vessel pedicle should be as long as
possible to ensure no tension after the transposition of
the ap. After the vascular pedicle is exposed, the skin
15.3 Reconstruction ofThumb Pulp Defect by Transposition ofDorsal Index Finger Flap
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Fig. 15.7 Full-thickness skin graft. (a) Design of the ap. (b) Dissociation of the ap. (c) Transplantation of the ap
233
should be cut along the designed line, and the ap is
lifted retrograde on the supercial surface of the extensor digitorum tendon. The tourniquet should be relaxed
for hemostasis and the blood supply of the ap should be
observed. Then the ap should be transferred to the
recipient site. Attention should be paid to avoid torsion
and local compression of the vessel pedicle, and a rubber
sheet should be put subcutaneously for drainage. Fullthickness skin graft is performed on the donor site and
packed for compression (Fig.15.7).
(f) Postoperative treatment: (a) Nursing should be
strengthened, and the blood supply of the ap should be
closely observed; (b) Postoperative “three anti” and
other routine tissue transplantation therapy should be
carried out; (c) Heat preservation should be carried out;
(d) No smoking during the perioperative period.
15.3.4 Operation Characteristics
(a) The dorsal index nger ap of the proximal segment is
adjacent to the thumb, so the skin color and texture are
similar to that of the thumb, and the length is appropriate,
so it is an ideal donor site for reconstruction of the thumb
pulp defect.
(b) The vascular pedicle of the ap is long which is exible
to be transferred.
(c) Without suturing blood vessels, the operation is simple,
the effect is stable, safe, and reliable.
(d) The size of the ap is small, and only a linear scar can be
left in the donor site.
15.3.5 Announcements
(a) Because the rst dorsal metacarpal artery is relatively
thin and does not form a bundle with the dorsal metacar-
pal vein and radial nerve branch, it is appropriate to dis-
sociate with the peripheral tissues together to form a
neurovascular bundle, rather than disassociate the rst
dorsal metacarpal artery alone.
(b) In the process of dissociation, the action should be gen-
tle to avoid pulling vascular pedicle and affect blood
supply.
(c) When the vascular pedicle rotated and transferred, it
should not be compressed, and the suture of surrounding
cutaneous margin should not be too tight.
(d) Postoperative bandaging must be loose to prevent post-
operative swelling which would affect blood supply.
(e) If the ap area is larger, it can be extended proximally.
(f) Postoperative environment of patients should pay atten-
tion to heat preservation, keep quiet, strictly smoke-free
environment, patients absolutely lie in bed for a week
(g) The blood supply of reconstructed nger pulp should be
observed closely after the operation.
(h) Postoperative dressing change should be gentle, and
attention should be paid to the use of warm disinfectant
for disinfection and clean scab.
234
15 Reconstruction ofFinger Pulp Defects
a
b
d e
Fig. 15.8 Reconstruction of the left thumb pulp defect by transposition of the dorsal index nger ap. (a) Preoperative palmar condition of
the thumb defect. (b) Preoperative design. (c) Dissociation of the ap.
c
(d) The appearance of the reconstructed nger after the operation. (e)
The ap survived 10 days after the operation
15.3.6 Case Description
Case 1 A 31-year-old male patient was admitted to hospital
for 1.5 h due to pain and bleeding of the left thumb caused by
punch injury. Physical examination: Finger pulp defect of
the left thumb with exposed bone, and the defect area was
3.3 × 2.3cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement,
the thumb pulp was reconstructed by transposition of the
dorsal index nger ap, and the donor site was covered by
skin graft. The ap area was 3.5 × 2.5cm. The operation was
successful, routine reconstruction treatment was given after
the operation. Twelve months’ regular follow-up was conducted to guide functional exercise. The appearance and
function of the reconstructed nger were satisfactory
(Fig.15.8).
15.4 Reconstruction ofFinger Pulp Defect
by Digital Artery Island Flap
Lateral digital ap is on the side of the nger, which contains
proper digital artery and nerve. The ring nger neurovascular
island ap for sensation reconstruction of nger tip of the
thumb the index nger in 1956 by Littler. But as a result of
sensory dysfunction in donor site, which makes its clinical
application is limited. In recent years, with the development
of microsurgery, the lateral digital ap pedicled with the
proper digital artery is used, also known as the digital artery
ap without the digital nerve which can keep the sensory
function of the donor nger after the ap is removed, so the
ap can be selected from the side of any nger adjacent to
the wound surface, with exible design and convenient transposition. If the ap contains the dorsal branch of the proper
palmar digital nerve, it also has a good sensory function. In
addition, ngertip or nger pulp defect can be reconstructed
by reverse lateral digital ap.
15.4.1 Indications
(a) Small ngertip or nger pulp defect; (b) The patient has
a desire for limb salvage, with good general condition and
without systemic organic disease; (c) The patient who needs
to reconstruct sensory function after thumb reconstruction.
15.4.2 Surgical Design
Incision design in the recipient site: (a) If the patient is
open wound, the rst-stage emergency reconstruction should
15.4 Reconstruction ofFinger Pulp Defect by Digital Artery Island Flap
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be performed to complete debridement of the thumb and nger pulp defect, and the irregular and redundant skin should
be temporarily retained; (b) If it is a selective operation, the
necrotic tissue is completely removed in the whole layer
around, and the periphery is properly dissociated.
Incision design in the donor site: On the side of the
injured nger, an island ap is designed along the central
axis according to the size of the wound, and the direction of
the digital artery and dorsal branch of digital nerve should be
marked. The rotation point of the ap is generally designed
at the midpoint of the middle phalanx, and the furthest is not
more than the metacarpal vascular arch of the distal segment
of the injured nger.
15.4.3 Surgical Method
Proper Digital Neurovascular IslandFlap
(a) The position of patients: Supine position, the affected
hand is abducted 80°and placed on the small operating
table.
(b) Anesthesia: Brachial plexus block or high epidural
anesthesia can be used.
(c) The design of the ap: This ap is mostly used to
reconstruct the sensory function of the thumb, and the
donor site is mostly on the ulnar side of the middle and
ring ngers. The ap is designed on the ulnar side of the
middle nger or ring nger according to the needs of the
sensory area wound of the thumb. The range of the ap
is within the midline of the dorsum of the nger, and the
distal side is not more than half of the distal segment,
including the proper palmar digital artery and nerve on
one side. The ap should be designed slightly larger than
the recipient site.
(d) Surgical steps: The operation is performed under an
inatable tourniquet without expulsion of blood. First, a
serrated incision was made in the palm of the hand to
expose and dissociate the common digital artery and
common digital nerve as the neurovascular pedicle.
After the neurovascular bundle enters the ap, the skin
should be cut along the design line of the ap, which is
dissociated from the palmar side to the dorsal side on
the supercial surface of the exor and extensor tendons. After the ap is removed, the distal part of the
proper digital artery and nerve should be cut off and
ligated, and the proper digital artery supplying the adjacent nger should be ligated at the bifurcation of the
common digital artery. If the movement range of the
nerve is not enough, the common digital nerve can be
split proximally. At this time, the ap pedicled with
artery and nerve is formed and can be transferred to the
recipient site through the subcutaneous tunnel. The
donor site is covered full-thickness free skin graft that
can be packed and xed under pressure (Figs.15.9 and
15.10)
235
Fig. 15.9 Design of proper digital neurovascular island ap
Fig. 15.10 Dissociation of proper digital neurovascular island ap
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