Article
Choosing the Flap in Complex Injuries of the Hand
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Authors
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Alexandru Valentin Georgescu
- University of Medicine Iuliu Hatieganu Cluj Napoca, Clinical Hospital of Recovery, Cluj Napoca, Romania
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Ileana Ileana Matei
- University of Medicine Iuliu Hatieganu Cluj Napoca, Clinical Hospital of Recovery, Cluj Napoca, Romania
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Irina Irina Capota
- University of Medicine Iuliu Hatieganu Cluj Napoca, Clinical Hospital of Recovery, Cluj Napoca, Romania
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Octavian Olariu
- Clinical Hospital of Recovery, Cluj Napoca, Romania
| Published: | February 6, 2020 |
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Outline
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Objectives/Interrogation: Coverage of complex tissue loss in the hand after severe traumas by crushing or avulsion is very challenging. These defects involve generally all the anatomical structures. The difficulties in repairing such a compromise hand are primarily related to the necessity to obtain an as good as possible functionality. The key of obtaining a good functional rehabilitation is to perform, whenever is possible, both the reconstruction and coverage as an all-in-one procedure.
Methods: We take into account the cases with very complex injuries involving all the structures of the hand. In 70% of our cases we used local or regional perforator flaps, and in 30% of cases free flaps.
In case of need to cover soft tissue defects over repaired fractures, vessels, nerves and tendon lesions, we prefer to use-whenever is possible-local or regional perforator flaps; if the skin defect is to big, a free flap is preferred.
For composite skin and bone defects we use generally composite flaps including bone.
For amputations or devascularized segments with skin defects, a free flow-through flap is used.
For amputations of different segments, and especially of the thumb accompanied by skin defects, we cover the defect with a free flow-through-flap which is used in mean time to revascularize one or more toe transfers.
Results and Conclusions: All the hands treated by this protocol survived. The failure rate of the flaps was comparable with the one in the literature. By using local/regional perforator flaps we experienced no complete necrosis, but only a transitory venous congestion (20%) followed by a superficial necrosis in 5% of cases. We lost 2 free flaps out of 45 (4.4%). We obtained a satisfactory functional rehabilitation of the reconstructed hand in 10% of cases, a good one in 40% of cases, and a very good one in the remaining 50%.
In complex injuries of the hand the modality of reconstruction is up to the team experience. The use of local/regional perforator flaps has a very good indication in small and medium skin defects, and only in the purpose of coverage. The use of free flaps remain the gold standard in solving big composite defects. The emergency all-in-one reconstruction and the beginning of kinetotherapy as soon as possible after surgery are the key stone of a good functional recovery.
