gms | German Medical Science

Objectives/Interrogation: The dorsum of the hand is a specialized region with thin and fragile skin characterized by poor subcutaneous tissue. The dorsal aspect of the hand is frequently prone to different types of injuries that result in exposed tendon and bone. The treatment of cutaneous defects may be achieved with local pedicle flaps, distant pedicle flaps, or free flaps. The purpose of this study is to review the patients with dorsal soft tissue defects treated with different pedicle flap or free tissue transfer and to determine the best flap for dorsal hand coverage in terms of aesthetic appearance and donor site morbidity and to define an algorithm of treatment of this type of injury.

Methods: A retrospective study of all flaps used for dorsal hand coverage was done. Between 1990-2016, 67 patients (mean age, 37 years; range 16 to 79 years) were treated for large soft tissue defects located on the dorsum of the hand.

22 patients with composite tissue loss of tendon and skin on the dorsum of the hand were treated employing a completely vascularized single-stage reconstruction (the cutaneo tendinous dorsalis pedis and the radial tendinous island flap were used). In 4 cases ALTF and Gracilis Flap were employed in conjunction with tendon grafts.

The management of pure cutaneous defects (41 cases) includes different type of pedicle fascial cutaneous flaps (radial forearm flap with different modifications, posterior interosseous flap and groin flap), or using a free tissue transfer (LAF, ALTF).

Results and Conclusions: All flaps survived completely. Tendon-cutaneous flap required tenolysis in two cases. Fasciocutaneous flap required debulking procedures in 7 cases. Fascio-cutaneous flaps had the highest need for skin grafting at the donor site.

The approach to the patient with a dorsal hand injury requires the surgeon to be aware of a variety of treatment options. Techniques that most closely replace that which has been injured are the most successfully. Flap selection must be individualized to the specific patient and defect. Cutaneous and fascial flap showed good functional and aesthetic results, donor site was better in fascial flaps. The replacement of combined loss of skin and tendons in only one stage gives the best opportunity for functional recovery, and can allows patients a relatively rapid return to a productive life. The dorsalis pedis flap and radial forearm flap are less often used now because of the donor site morbidity. The ALTF represents a good choice in case of extensive defect.