Dorsal Adipofascial Turnover Flap for Dorsal Defects of Finger Injury

Sabah Hassan Naji
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Keywords : Dorsal Adipofascial Turnover Flap, Dorsal Defects, Finger Injury
Medical Journal of Babylon  8:1 , 2014 doi:1812-156X-8-1
Published :2011

Abstract

Deep dorsal defects of fingers are common problems which often seen in emergency units, and there are several methods of treatments for reconstruction. In our prospective study composed of seven patients with dorsal defects of fingers in different sites at Al-Wasiti hospital in which reconstruction were performed by the use of dorsal adipofascial turnover flaps. By this technique we use this flap from the dorsal aspect of the finger which is raised from the base of the base of the proximal phalanx to cover the full thickness defect as a one stage procedure. Our results were good the flaps survived completely, the mean follow up was 6 months. This technique proved to be simple, did not require the use of distant flap or a flap from adjacent digits, ready availability & it s Single and simple procedure with no significant donor site morbidity. Our results and complications were comparable with other studies which were carried for reconstruction of deep dorsal defects of the fingers.

Introduction

Deep dorsal defects of the fingers represent the most common hand injuries seen in emergency room [1]. These injuries may occur after thermal or traumatic accidents which may result in full thickness tissue loss with exposure of bone, joint or tendon and this type of injury should be covered by flap, and it required great surgical experience because inadequate management cause time loss from work, persistent pain and functional loss .There are many flaps which can be used for reconstruction of dorsal defects of fingers for example cross finger flaps , flag flap and distant flaps from the abdomen or chest wall [2,7] ,in our technique we used local adipofascial flap from the dorsal surface of the same injured digit, this flap depends on its vascularity on the arterial anastomosis between the branches of the dorsal digital arteries which are branches of the dorsal metacarpal artery and the dorsal branches of the palmer digital arteries, and as we know there are a dorsal venous and arterial network which lie in the subcutaneous plane between the dermis and the paratenon of the extensor tendons, and based on anatomical study which had been done by MR.jefferson Braga at 2003 he confirmed the presence of two constant dorsal branches originating from the proper palmer digital artery over the proximal and middle phalanges. Our aim of study is to represent a simple and reliable method for reconstruction of the deep dorsal defects of finger injuries with the use of dorsal adipofascial turnover flap which provides functional criteria which are Stable and durable skin coverage, Minimal site morbidity and rapid healing with early return to work.

Materials and methods

In our prospective study we evaluated a total
number of seven patients with dorsal defects
of seven fingers of different causes in ALWasiti
teaching hospital treated by using
adipofascial turnover flaps, from November
2008 to March 2010. Patient s details are
provided in the following table, the cause
was mostly due to direct trauma in five
patients, one patient had chemical injury and
one patient had electrical injury. Four males
and three females, the age ranged from2-35
years old. All the defects were deep down to
the bone and joints. The adipofascial flap
was used to cover these defects. All patients
were operated by using general anesthesia &
under pneumatic tourniquet control, the skin
graft was taken from the inner aspect of the
thigh. The mean follow up was about 6
months


Results

Our prospective study evaluated Seven patients (4 males and 3 female), with age ranged from2-35 years old with dorsal defects of the seven fingers at different sites were treated by using dorsal adipofascial turn over flap which provided us successful results in all of the patients. All flaps and grafts survived with good viability after of six months of follow up and the sensation is similar to any area that has received partial thickness skin graft.. No significant complications occurred as no infection or flap necrosis, and in four patients were the joints were exposed the mobility of the joints after coverage with this flap regained the same ranged of mobility as before the operation.

Discussions

Full thickness dorsal defects of the digits with exposure of the bone, tendon, or joint represent one of the difficult problems which need early coverage to preserve the exposed tissue to prevent complications and early return to work. There are many flaps were described for reconstruction of such defects as cross finger flap, flag flap, local transposition or rotation flaps, and distant flaps as abdominal, chest, or groin , these flaps has many disadvantages namely long period of immobilization with joint stiffness especially in old age patients, they usually need two stage technique and significant donor site scar. Comparing the adipofascial flap with the other mentioned flaps it proved to be simpler, more reliable as it is accomplished by single procedure with no significant donor site morbidity or distant scars. Our results were comparable to several works present in the literatures as a study done in 2005 by MR.A.Karacalar in which he used the adipofascial turnover flap to resurface finger defect in seven cases, the flaps survived completely except one which had a 20% loss. MR. Jefferson Braga-Silva in which proved that this flap is reliable with rich 2004 used adipofascial flaps on forty patients and based his work on sound anatomical study of vascular supply of the flap blood supply and his result is highly successful. Other study done by D.Nicole Deal at 2009, he presented 13 patients with complex hand wounds of different types of injuries treated by adipofascial flap as random flap based on the same anatomical principle of blood supply and have100% success. Dr.Muhittin Ulker 1n 2000 have used this flap to cover deep dorsal tissue loss of fingers in nine patients ands he added one step to re innervate the flap by epineurIal anastomosis between the dorsal digital branch and volar digital nerves with the aid of loupe magnification and he claimed that it becomes full sensory flap in comparison to the sensation of our flaps in which it developed as any sensation in skin graft. So it appears from all these works that there is a consensus in the grade, merits of this procedure as being simple, one stage, no distant or other site morbidity and provides good coverage and preservation of exposed tendon, joint,or tendon and resulting in preservation of the mobility of the joint with high successful rate in almost all the cases and it proved to be a good option for reconstruction of deep dorsal defect in the fingers and hands in our patients.

Conclusions

Dorsal adipofascial turnover flap provides reliable covering for composite tissue defects at the dorsal surface of the fingers with exposed bone, tendon or joint. It provides good functional results by single procedure without the presence of distant donor site morbidity with no added complications.

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