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Atlas of Finger Reconstruction: Techniques and Cases
9811996113, 9789811996115

Author / Uploaded
Jian Lin
Jianli Wang
Deqing Hu
Yongqing Xu
Tianhao Zhang

Table of contents :
Contents
Contributors
Part I: Introduction
1: The Development Situation of Finger Reconstruction
1.1 Historical Origin
1.2 Controversial Issues
1.2.1 Focus on Time for Operation
1.2.2 Hallux-to-Thumb Reconstruction, Nail Skin Flap of Great Toe Transplantation, or Second Toe Transplantation for Thumb Defects?
1.2.3 How to Reconstruct Fingers When Multiple Fingers Defect?
1.2.4 Whether to Reconstruct Sensory Nerves?
Further Reading
2: Anatomy of the Hand and Foot
2.1 Holistic View
2.1.1 Superficial Anatomy
Skin Anatomical Marks
Osseous Marks
Osseous Marks on the Hand
Osseous Marks of the Foot
Muscular (Tendon) Marks
Muscular (Tendon) Marks on the Hand
Muscular (Tendon) Marks on the Foot
2.1.2 Hand Positions
Resting Position of the Hand
Functional Position of the Hand
The Pinching Position of the Hand
The Holding Position of the Hand
2.1.3 Body Surface Reflection
Reflection of Hand Bones and Joints (Fig. 2.7)
Reflection of Vascular and Nerves (Figs. 2.8, 2.9, 2.10, 2.11, 2.12, 2.13, 2.14 and 2.15)
Limb Arteries
Limb Veins
Lymphatic Vessels of Limbs
Extrinsic Muscles of Hand and Foot
2.2 Applied Anatomy of the Hand
2.2.1 Dorsum of Hand
Superficial Structures
Dorsal Venous Rete of Hand
Superficial Lymph Vessels
Cutaneous Nerves
Deep Structures
Extensor Retinaculum
Dorsal Deep Facial of Hand
Ficial Space
Tendon of Extenson Digitorum
Dorsal Metacarpal Artery
2.2.2 Palm of Hand
Superficial Structures
Cutaneous Nerves
Palmaris Brevis
Deep Structures
Deep Fascia
Osteofascial Sheath
Fascial Spaces
Synovial Sheath of Palm
Intrinisic Muscles of Hand
Vasculars
Nerves
2.2.3 Fingers
Superficial Structrues
Skin
Nail
Subcutaneous Tissue
Flexor Digitorum
Morphological Structure Characteristics of Flexor Digitorum
Sheath Digitorum
Extensor Digitorum
Morphological Structure Characteristics of Extensor Digitorum
Partition of Extensor Digitorum
2.2.4 Bones of Hand
Carpal Bones
Metacarpal Bone
Phalanges of Finger
Joints and Ligaments of Hand
Radiocarpal Joint
Intercarpal Joint
Mediocarpal Joint
Intermetacarpal Joint
Metacarpophalangeal Joint
Interphalangeal Joint
2.3 Applied Anatomy of the Foot
2.3.1 Dorsum of the Foot
Superficial Structures
Deep Structures
2.3.2 Planta Pedis
Superficial Structures
Deep Structures
2.3.3 Toes
Superficial Structrues
Skin
Toe Nail
Subcutaneous Tissue
Veins of Toe
Nerves of Toe
Deep Structures
Tendons of Toe
Arteries of Toe
Bones of Foot
Tarsal Bone
Talus
Calcaneus
Navicular Bone
Cuboid Bone
Cuneiform Bones
Metatarsal Bones
Phalanges of Toe
Joints and Ligaments of Foot
Ankle (Talocrural)Joint
Intertarsal Joints
Subtalar (Talo-Calcaneal) Joint
Talocalcaneonavicular Joint
Calcaneocuboid Joint
Cuneonavicular Joint
Cuneocuboid Joint and Intercuneiform Joints
Tarsometatarsal Joint
Intermetatarsal Joints
Metatarsophalangeal Joints
Interphalangeal Joint of Foot
2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps
2.4.1 Perforator Flap with Dorsalis Pedis Artery
Applied Anatomy
Dissociation of the Flap
Key Points for Application
2.4.2 Perforator Flap with Dorsal Metatarsal Artery
Applied Anatomy
Dissociation of the Flap
Key Points for Application
2.4.3 Antemalleolar Flap
Applied Anatomy
Dissociation of the Flap
Key Points for Application
2.4.4 Medial Pedis Flap
Applied Anatomy
Medial Plantar Artery
Anterior Medial Malleolar Artery
Medial Tarsal Artery
Perforator of First Plantar Metatarsal Artery
Dissociation of the Flap
Key Points for Application
2.4.5 Lateral Pedis Flap
Applied Anatomy
Lateral Calcaneal Artery
Lateral Tarsal Artery
Anterior Lateral Malleolar Artery
Descending Perforator of Peroneal Artery
Perforator of Fifth Plantar Metatarsal Artery
Dissociation of the Flap
Key Points for Application
2.5 Cutaneous (Perforator) Flaps of Toe
2.5.1 Great Toe Flap
Applied Anatomy
Surgical Method
Key Points for Application
2.5.2 Second Toe Flap
Applied Anatomy
Surgical Method
Key Points for Application
2.5.3 Extensor Digitorum Brevis Flap
Applied Anatomy
Morphology of Extensor Digitorum Brevis
Blood Supply of Extensor Digitorum Brevis
Nerves of Extensor Digitorum Brevis
Surgical Methods
Keypoints for Application
2.5.4 Abductor Hallucis Flap
Applied Anatomy
Morphology of Abductor Hallucis
Blood Supply of Abductor Hallucis
Nerves of Abductor Hallucis
Surgical Methods
Keypoints for Application
2.5.5 Extensor Digitorum Myocutaneous Flap
Applied Anatomy
Morphology of Flexor Digitorum Brevis
Vassculars of Flexor Digitorum Brevis
Nerves of Flexor Digitorum Brevis
Surgical Methods
Keypoints for Application
2.5.6 Abductor Digiti Minimi Flap
Applied Anatomy
Morphology of Abductor Digiti Minimi
Vasculars of Aductor Digiti Minimi
Nerves of Abductor Digiti Minimi
Surgical Methods
Keypoints for Application
2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer
2.6.1 Thumb Reconstruction by Second Toe Transplantation
Arteries
Dorsalis Pedis Artery
First Dorsal Metatarsal Artery
First Plantar Metatarsal Artery
Dorsal and Plantar Digitorum Arteries
Veins
Nerves
Announcements
2.6.2 Finger Reconstruction by Second and Third Toe Transplantation
Arteries
Veins
Nerves
Announcements
2.6.3 Metacarpophalangeal Joints Reconstruction by Second and Third Metatarsophalangeal Joints Transplantation
Applied Anatomy
The Structure of Joints
Blood Supply of Joints
Nerves of Joints
Surgical Methods
Announcements
2.6.4 Metacarpophalangeal/Interphalangeal Joint Reconstruction by Proximal Interphalangeal Joint Transplantation of Second and Third Toe
Applied Anatomy
The Structure of Joints
Blood Supply of Joints
Nerves of Joints
Surgical Methods
Announcements
3: Preoperative Treatment for Finger Reconstruction
3.1 Design and Choice of Operation Plan
3.1.1 Systemic Assessment
3.1.2 Assessment of Finger Stump
Index of Thumb and Other Fingers Defect (Fig. 3.1)
Index of Thumb Defect
Index of Other Finger Defect
Assessment of Skin Condition of Finger Stump
Assessment of Nerve of Finger Stump
Assessment of Tendons
Assessment of Bone and Joint
3.1.3 Assessment of Vascular Condition of Donor and Recipient Site
Observation and Touch
Portable Color Doppler Ultrasonography (Fig. 3.2)
CT Angiography (CTA) (Fig. 3.3)
CE-MRA (Fig. 3.4)
3.1.4 Operation Design
3.1.5 Indications and Contraindications
Indications
Contraindications
3.1.6 Preoperative Preparation
Preparation of Surgical Team
Preparation of Patients
Preparation of Operation Room and Anesthesia
Further Reading
4: Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction
4.1 Commonly Used Microsurgical Instruments, Equipment, and Materials
4.1.1 Operating Microscope (Figs. 4.1 and 4.2)
History of Operating Microscope
Advantages of Operating Microscopes
Requirements for Operating Microscope
4.1.2 Operating Magnifying Glasses
4.1.3 Microsurgical Instruments (Figs. 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10 and 4.11)
4.1.4 Microsurgical Suture Materials
Further Reading
5: Common Medicines Used for Finger Reconstruction
5.1 Antibiotic Drugs
5.1.1 Penicillin
Adverse Reactions
Notices
5.1.2 Cephalosporins
Adverse Reactions
Notices
5.1.3 Macrolide Antibiotics
Adverse Reactions
Notices
5.1.4 Polypeptide Antibiotic
Adverse Reaction
Notices
5.1.5 Antifungal Drugs
Adverse Reactions
Notices
5.2 Anticoagulant Drugs
5.2.1 Low Molecular Dextran
Adverse Reactions
Notices
5.2.2 Heparin
Adverse Reaction
Notices
5.2.3 Aspirin
Adverse Reaction
Notices
5.3 Antispasmodic Drugs
5.3.1 Papaverine
Adverse Reactions
Notices
5.3.2 Tolazoline
Adverse Reactions and Notices
5.4 Other Drugs
5.4.1 Hibernation Drugs
Adverse Reaction
Notices
5.4.2 Analgesia Pump
Adverse Reactions
Notices
Further Reading
6: Selection of Anesthesia for Finger Reconstruction
6.1 Requirements for Anesthesia
6.1.1 No Pain at the Surgical Site
6.1.2 Adequate Limb Perfusion
6.1.3 Prevention of Vasospasm
6.1.4 Postoperative Analgesia
6.2 Methods of Anesthesia
6.2.1 General Anesthesia
6.2.2 Region Block Anesthesia
Subarachnoid Block Anesthesia
Epidural Block Anesthesia
Peripheral Nerve Block Anesthesia
Brachial Plexus Block
Sciatic Nerve Block Anesthesia
Femoral Nerve Block Anesthesia
Lateral Femoral Cutaneous Nerve Block Anesthesia
Obturator Nerve Block Anesthesia
Peri-Ankle Nerve Block Anesthesia
Peri-Elbow Nerve Block Anesthesia
Peri-Wrist Nerve Block Anesthesia
6.3 Selection of Anesthesia
7: Fundamental Skill for Finger Reconstruction
7.1 Micro-Suture Operation Training of Small Blood Vessels
7.1.1 Training Should Be Step by Step
7.1.2 Placement and Use of Microsurgery Instruments
7.1.3 Select Needle and Thread According to Vessel Diameter
7.1.4 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate
7.2 Skill and Key Points for Small Blood Vessel Suture
7.2.1 Clear Exposure of Blood Vessels
7.2.2 The Suture Must Be in the Normal Vascular Segment
7.2.3 The Size of Anastomosed Vessels Should Be Similar
7.2.4 The Tension of Blood Vessels Should Be Proper
7.2.5 The Operation Should Be Steady, Accurate, Light, and Skillful
7.2.6 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate
7.2.7 Proper Trim of Outer Membrane at Broken End and Flushing
7.2.8 Maintain the Vascular Bed Healthy and Flat
7.2.9 Stitching and Knotting Should Be Accurate and Proper
7.2.10 The Sequence of Stitches Should Be Proper
7.3 Suture Methods
7.3.1 End-to-End Anastomosis
Three Stay Sutures End-to-End Anastomosis (Fig. 7.1)
Two Stay Sutures End-to-End Anastomosis (Figs. 7.2 and 7.3)
Nonequidistant Two Stay Sutures End-to-End Anastomosis (Fig. 7.4)
Isometric Four Stay Sutures End-to-End Anatomosis of the Anterior Wall (Fig. 7.5)
Isometric Four Stay Sutures End-to-End Anatomosis of the Posterior Wall (Figs. 7.6 and 7.7)
Continuous Anastomosis (Figs. 7.8 and 7.9)
Side Wall Stayed Sutures Anastomosis
End-to-Side Anastomosis
Sleeve Insertion Anastomosis
Small Vessel Transplantation
Notices
References
Further Reading
8: Postoperative Management for Finger Reconstruction
8.1 Postoperative Treatment and Management
8.1.1 Postoperative Observation and Management (Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8 and 8.9)
Observation and Treatment of a Systemic Condition
Observation of Vital Signs
Observation of Blood Volume and Peripheral Circulation
Observation of the Amount of Liquid in and out
Observation of Uncomfortable Symptoms
Local Observation of Reconstructed Fingers
Changes of Color
Changes of Temperature
Changes of Skin Tension
Blood-Letting Test
Observation of Wound Bleeding
8.1.2 Drug Treatment
Prevention of Infection
Antipasmodic Therapy
Anticoagulation Therapy
Postoperative Analgesia
Neurotrophic Therapy
Blood Volume Augmentation Therapy
8.1.3 Judgment and Management of Vascular Crisis
Arterial Crisis
Arterial Spasm
Arterial Thrombosis
Venous Crisis
Treatments after Exploration
8.2 Cause Analysis and Prevention of Vascular Crisis
8.2.1 Cause Analysis
Prevention of Vascular Crisis
Further Reading
9: Functional Rehabilitation for Finger Reconstruction
9.1 Staging of Function Rehabilitation After Finger Reconstruction
9.2 Common Rehabilitation Methods
9.3 Rehabilitation Features of Finger Reconstruction
9.4 The Significance of Functional Rehabilitation
Further Reading
Part II: Different Types of Finger Reconstruction
10: Reconstruction of Thumb Defects
10.1 Reconstruction of Type I Defect of the Thumb
10.1.1 Indications
10.1.2 Surgical Design
10.1.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
10.1.4 Operation Characteristics
10.1.5 Announcements
10.1.6 Case Description
10.2 Reconstruction of Type II Defect of the Thumb
10.2.1 Indications
10.2.2 Surgical Design
10.2.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
10.2.4 Operation Characteristics
10.2.5 Announcements
10.2.6 Case Description
10.3 Reconstruction of Type III Defect of the Thumb
10.3.1 Indications
10.3.2 Surgical Design
10.3.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
10.3.4 Operation Characteristics
10.3.5 Announcements
10.3.6 Case Description
10.4 Reconstruction of Type IV Defect of the Thumb
10.4.1 Indications
10.4.2 Surgical Design
10.4.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
10.4.4 Operation Characteristics
10.4.5 Announcements
10.4.6 Case Description
10.5 Reconstruction of Type V Defect of the Thumb
10.5.1 Indications
10.5.2 Surgical Design
10.5.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
10.5.4 Operation Characteristics
10.5.5 Announcements
10.5.6 Case Description
10.6 Reconstruction of Type VI Defect of the Thumb
10.6.1 Indications
10.6.2 Surgical Design
10.6.3 Surgical Method
10.6.4 Postoperative Treatment
10.6.5 Operation Characteristics
10.6.6 Announcements
10.6.7 Case Description
11: Reconstruction of Single Finger Defects
11.1 Reconstruction of Type I Defect
11.1.1 Indications
11.1.2 Surgical Design
11.1.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
11.1.4 Operation Characteristics
11.1.5 Announcements
11.1.6 Case Description
11.2 Reconstruction of Type II Defect
11.2.1 Indications
11.2.2 Surgical Design
11.2.3 Surgical Method
11.2.4 Operation Characteristics
11.2.5 Announcements
11.2.6 Case Description
11.3 Reconstruction of Type III Defect
11.3.1 Indications
11.3.2 Surgical Design
11.3.3 Surgical Method
Preparaion for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
11.3.4 Operation Characteristics
11.3.5 Announcements
11.3.6 Case Description
11.4 Reconstruction of Type IV Defect
11.4.1 Indications
11.4.2 Surgical Design
11.4.3 Surgical Method
Preparaion for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
11.4.4 Operation Characteristics
11.4.5 Announcements
11.4.6 Case Description
11.5 Reconstruction of Type V Defect
11.5.1 Indications
11.5.2 Surgical Design
11.5.3 Surgical Method
Preparaion for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
11.5.4 Operation Characteristics
11.5.5 Announcements
11.5.6 Case Description
11.6 Reconstruction of Type VI Defect
11.6.1 Indications
11.6.2 Surgical Design
11.6.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
11.6.4 Operation Characteristics
11.6.5 Announcements
11.6.6 Case Description
12: Reconstruction of Multi-Finger Defects
12.1 Indications
12.2 Surgical Design
12.3 Surgical Method
12.3.1 Preparation for the Recipient Site
12.3.2 The Cutting of the Toe
12.3.3 Transplantation
12.3.4 Postoperative Treatment
12.4 Operation Characteristics
12.4.1 Announcements
12.4.2 Case Description
13: Reconstruction of Finger Joint Defects
13.1 Indications
13.2 Surgical Design
13.3 Surgical Method
13.3.1 Preparation for the Recipient Site
13.3.2 The Cutting of the Toe
13.3.3 Transplantation
13.3.4 Postoperative Treatment
13.4 Operation Characteristics
13.5 Announcements
13.6 Case Description
14: Reconstruction of Nail Defects
14.1 Reconstruction of Nail Defect by Split-Thickness Toenail Bed Transplantation
14.1.1 Indications
14.1.2 Surgical Design
14.1.3 Surgical Method
14.1.4 Postoperative Treatment
14.1.5 Operation Characteristics
14.1.6 Announcements
14.2 Reconstruction of Nail Defect by Superficial Dermal Fascia Composite Tissue Transplantation
14.2.1 Indications
14.2.2 Surgical Design
14.2.3 Surgical Method
14.2.4 Operation Characteristics
14.2.5 Announcements
14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation
14.3.1 Indications
14.3.2 Surgical Design
14.3.3 Surgical Method
Preparation for the Recipient Site
Preparation for the Donor Site
The Cutting of the Toe (Take the Toenail Flap of the Great Toe for Example)
Transplantation
Postoperative Treatment
14.3.4 Operation Characteristics
14.3.5 Announcements
14.3.6 Case Description
15: Reconstruction of Finger Pulp Defects
15.1 Reconstruction of Finger Pulp Defect by Local Thumb Flap
15.1.1 Indications
15.1.2 Surgical Design
15.1.3 Surgical Method
15.1.4 Operation Characteristics
15.1.5 Announcements
15.1.6 Case Description
15.2 Reconstruction of Finger Pulp Defect by Transposition of Local Finger Flap
15.2.1 Indications
15.2.2 Surgical Design
15.2.3 Surgical Method
15.2.4 Operation Characteristics
15.2.5 Announcements
15.2.6 Case Description
15.3 Reconstruction of Thumb Pulp Defect by Transposition of Dorsal Index Finger Flap
15.3.1 Indications
15.3.2 Surgical Design
15.3.3 Surgical Method
15.3.4 Operation Characteristics
15.3.5 Announcements
15.3.6 Case Description
15.4 Reconstruction of Finger Pulp Defect by Digital Artery Island Flap
15.4.1 Indications
15.4.2 Surgical Design
15.4.3 Surgical Method
Proper Digital Neurovascular Island Flap
15.5 Proper Digital Artery Island Flap Anastomosed with Dorsal Digital Nerve
15.5.1 Operation Characteristics
15.5.2 Announcements
15.5.3 Case Description
15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition
15.6.1 Surgical Design
15.6.2 Surgical Method
The Thumb Pulp Defect
The Finger Pulp Defect
15.6.3 Operation Characteristics
15.6.4 Announcements
15.6.5 Case Description
16: Reconstruction of Dorsal Digital Composite Tissue Defects
16.1 Indications
16.2 Surgical Design
16.3 Surgical Method
16.4 Operation Characteristics
16.5 Announcements
16.6 Case Description
17: Special Types of Finger Reconstruction
17.1 Aesthetic Reconstruction (Comprehensive Reconstruction)
17.1.1 Indications
17.1.2 Surgical Design
17.1.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
17.1.4 Operation Characteristics
17.1.5 Announcements
17.1.6 Case Description
17.2 Finger Reconstruction in Children
17.2.1 Indications
17.2.2 Surgical Design
17.2.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
17.2.4 Announcements
17.2.5 Case Description
17.3 Reconstruction of Congenital Deformity of Fingers
17.3.1 Indications
17.3.2 Surgical Design
17.3.3 Operation Characteristics
17.3.4 Announcements
17.3.5 Case Description
17.4 Reconstruction of Degloving Defects of Fingers
17.4.1 Indications
17.4.2 Surgical Design
17.4.3 Surgical Method
Preparation for the Recipient Site
The Cutting of the Toe
Transplantation
Postoperative Treatment
17.4.4 Operation Characteristics
17.4.5 Announcements
17.4.6 Case Description
17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger
17.5.1 Indications
17.5.2 Surgical Design
17.5.3 Surgical Method
17.5.4 Postoperative Treatment
17.5.5 Operation Characteristics
17.5.6 Announcements
17.5.7 Case Description
17.6 Temporary Heterotopic Replantation (Reconstruction) of Severed Fingers
17.6.1 Indications
17.6.2 Surgical Design
17.6.3 Surgical Method
17.6.4 Postoperative Treatment
17.6.5 Operation Characteristics
17.6.6 Announcements
17.6.7 Case Description
Further Reading

Citation preview

Atlas of Finger Reconstruction Techniques and Cases Jian Lin Jianli Wang Deqing Hu Yongqing Xu Tianhao Zhang

123

Atlas of Finger Reconstruction

Jian Lin • Jianli Wang • Deqing Hu Yongqing Xu • Tianhao Zhang

Atlas of Finger Reconstruction Techniques and Cases

Jian Lin Department of Center for Orthopaedic Repair and Reconstruction Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Xinhua Hospital Chongming Branch) Shanghai, China Deqing Hu Department of Orthopaedics The First Affiliated Hospital of Fujian Medical University Fuzhou, Fujian, China

Jianli Wang Department of Orthopaedic The 80th Group Army Hospital of PLA Weifang, Shandong, China Yongqing Xu Institute of Traumatology and Orthopedics Kunming, Yunnan, China

Tianhao Zhang Department of Center for Orthopaedic Repair and Reconstruction Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Xinhua Hospital Chongming Branch) Shanghai, China

ISBN 978-981-19-9611-5 ISBN 978-981-19-9612-2 (eBook) https://doi.org/10.1007/978-981-19-9612-2 © Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Contents

Part I Introduction 1 The Development Situation of Finger Reconstruction �� 3 1.1 Historical Origin �� 3 1.2 Controversial Issues�� 4 1.2.1 Focus on Time for Operation�� 4 1.2.2 Hallux-to-Thumb Reconstruction, Nail Skin Flap of Great Toe Transplantation, or Second Toe Transplantation for Thumb Defects?�� 4 1.2.3 How to Reconstruct Fingers When Multiple Fingers Defect?�� 4 1.2.4 Whether to Reconstruct Sensory Nerves?�� 5 Further Reading �� 5 2 Anatomy of the Hand and Foot�� 7 2.1 Holistic View�� 7 2.1.1 Superficial Anatomy�� 7 2.1.2 Hand Positions�� 10 2.1.3 Body Surface Reflection �� 11 2.2 Applied Anatomy of the Hand�� 18 2.2.1 Dorsum of Hand�� 18 2.2.2 Palm of Hand�� 22 2.2.3 Fingers�� 32 2.2.4 Bones of Hand�� 40 2.3 Applied Anatomy of the Foot �� 43 2.3.1 Dorsum of the Foot �� 43 2.3.2 Planta Pedis�� 46 2.3.3 Toes �� 49 2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps �� 55 2.4.1 Perforator Flap with Dorsalis Pedis Artery�� 55 2.4.2 Perforator Flap with Dorsal Metatarsal Artery �� 56 2.4.3 Antemalleolar Flap�� 58 2.4.4 Medial Pedis Flap �� 59 2.4.5 Lateral Pedis Flap �� 61 2.5 Cutaneous (Perforator) Flaps of Toe �� 63 2.5.1 Great Toe Flap�� 63 2.5.2 Second Toe Flap�� 65 2.5.3 Extensor Digitorum Brevis Flap �� 66 2.5.4 Abductor Hallucis Flap �� 67 2.5.5 Extensor Digitorum Myocutaneous Flap�� 69 2.5.6 Abductor Digiti Minimi Flap�� 70 2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer �� 72 2.6.1 Thumb Reconstruction by Second Toe Transplantation �� 72 2.6.2 Finger Reconstruction by Second and Third Toe Transplantation�� 76 v

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2.6.3 Metacarpophalangeal Joints Reconstruction by Second and Third Metatarsophalangeal Joints Transplantation�� 76 2.6.4 Metacarpophalangeal/Interphalangeal Joint Reconstruction by Proximal Interphalangeal Joint Transplantation of Second and Third Toe�� 79 3 Preoperative Treatment for Finger Reconstruction�� 81 3.1 Design and Choice of Operation Plan�� 81 3.1.1 Systemic Assessment�� 81 3.1.2 Assessment of Finger Stump�� 81 3.1.3 Assessment of Vascular Condition of Donor and Recipient Site�� 82 3.1.4 Operation Design�� 83 3.1.5 Indications and Contraindications�� 85 3.1.6 Preoperative Preparation �� 85 Further Reading �� 86 4 Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction�� 87 4.1 Commonly Used Microsurgical Instruments, Equipment, and Materials�� 87 4.1.1 Operating Microscope (Figs. 4.1 and 4.2)�� 87 4.1.2 Operating Magnifying Glasses �� 89 4.1.3 Microsurgical Instruments (Figs. 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10 and 4.11) �� 90 4.1.4 Microsurgical Suture Materials�� 91 Further Reading �� 93 5 Common Medicines Used for Finger Reconstruction�� 95 5.1 Antibiotic Drugs�� 95 5.1.1 Penicillin �� 95 5.1.2 Cephalosporins�� 96 5.1.3 Macrolide Antibiotics�� 96 5.1.4 Polypeptide Antibiotic�� 96 5.1.5 Antifungal Drugs�� 97 5.2 Anticoagulant Drugs �� 97 5.2.1 Low Molecular Dextran�� 97 5.2.2 Heparin�� 98 5.2.3 Aspirin�� 98 5.3 Antispasmodic Drugs�� 98 5.3.1 Papaverine�� 98 5.3.2 Tolazoline�� 98 5.4 Other Drugs�� 99 5.4.1 Hibernation Drugs�� 99 5.4.2 Analgesia Pump�� 99 Further Reading �� 99 6 Selection of Anesthesia for Finger Reconstruction �� 101 6.1 Requirements for Anesthesia�� 101 6.1.1 No Pain at the Surgical Site�� 101 6.1.2 Adequate Limb Perfusion �� 101 6.1.3 Prevention of Vasospasm�� 101 6.1.4 Postoperative Analgesia�� 101 6.2 Methods of Anesthesia�� 101 6.2.1 General Anesthesia�� 101 6.2.2 Region Block Anesthesia�� 102 6.3 Selection of Anesthesia �� 104

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7 Fundamental Skill for Finger Reconstruction�� 105 7.1 Micro-Suture Operation Training of Small Blood Vessels �� 105 7.1.1 Training Should Be Step by Step�� 105 7.1.2 Placement and Use of Microsurgery Instruments�� 105 7.1.3 Select Needle and Thread According to Vessel Diameter�� 106 7.1.4 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate�� 106 7.2 Skill and Key Points for Small Blood Vessel Suture�� 106 7.2.1 Clear Exposure of Blood Vessels�� 106 7.2.2 The Suture Must Be in the Normal Vascular Segment �� 106 7.2.3 The Size of Anastomosed Vessels Should Be Similar�� 106 7.2.4 The Tension of Blood Vessels Should Be Proper�� 106 7.2.5 The Operation Should Be Steady, Accurate, Light, and Skillful�� 107 7.2.6 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate�� 107 7.2.7 Proper Trim of Outer Membrane at Broken End and Flushing�� 107 7.2.8 Maintain the Vascular Bed Healthy and Flat�� 107 7.2.9 Stitching and Knotting Should Be Accurate and Proper�� 107 7.2.10 The Sequence of Stitches Should Be Proper�� 107 7.3 Suture Methods �� 107 7.3.1 End-to-End Anastomosis�� 107 References�� 110 8 Postoperative Management for Finger Reconstruction�� 111 8.1 Postoperative Treatment and Management �� 111 8.1.1 Postoperative Observation and Management (Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8 and 8.9)�� 111 8.1.2 Drug Treatment �� 114 8.1.3 Judgment and Management of Vascular Crisis �� 115 8.2 Cause Analysis and Prevention of Vascular Crisis�� 116 8.2.1 Cause Analysis�� 116 Further Reading �� 117 9 Functional Rehabilitation for Finger Reconstruction�� 119 9.1 Staging of Function Rehabilitation After Finger Reconstruction �� 119 9.2 Common Rehabilitation Methods �� 119 9.3 Rehabilitation Features of Finger Reconstruction�� 127 9.4 The Significance of Functional Rehabilitation �� 127 Further Reading �� 128 Part II Different Types of Finger Reconstruction 10 Reconstruction of Thumb Defects�� 133 10.1 Reconstruction of Type I Defect of the Thumb�� 133 10.1.1 Indications�� 133 10.1.2 Surgical Design�� 133 10.1.3 Surgical Method�� 134 10.1.4 Operation Characteristics�� 136 10.1.5 Announcements�� 136 10.1.6 Case Description �� 136 10.2 Reconstruction of Type II Defect of the Thumb �� 142 10.2.1 Indications�� 142 10.2.2 Surgical Design�� 142 10.2.3 Surgical Method�� 142

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10.2.4 Operation Characteristics�� 143 10.2.5 Announcements�� 143 10.2.6 Case Description �� 143 10.3 Reconstruction of Type III Defect of the Thumb�� 145 10.3.1 Indications�� 145 10.3.2 Surgical Design�� 146 10.3.3 Surgical Method�� 146 10.3.4 Operation Characteristics�� 146 10.3.5 Announcements�� 147 10.3.6 Case Description �� 147 10.4 Reconstruction of Type IV Defect of the Thumb�� 152 10.4.1 Indications�� 152 10.4.2 Surgical Design�� 153 10.4.3 Surgical Method�� 153 10.4.4 Operation Characteristics�� 155 10.4.5 Announcements�� 155 10.4.6 Case Description �� 156 10.5 Reconstruction of Type V Defect of the Thumb �� 162 10.5.1 Indications�� 162 10.5.2 Surgical Design�� 162 10.5.3 Surgical Method�� 162 10.5.4 Operation Characteristics�� 164 10.5.5 Announcements�� 164 10.5.6 Case Description �� 165 10.6 Reconstruction of Type VI Defect of the Thumb�� 171 10.6.1 Indications�� 171 10.6.2 Surgical Design�� 171 10.6.3 Surgical Method�� 171 10.6.4 Postoperative Treatment�� 172 10.6.5 Operation Characteristics�� 172 10.6.6 Announcements�� 172 10.6.7 Case Description �� 172 11 Reconstruction of Single Finger Defects�� 177 11.1 Reconstruction of Type I Defect �� 177 11.1.1 Indications�� 177 11.1.2 Surgical Design�� 177 11.1.3 Surgical Method�� 177 11.1.4 Operation Characteristics�� 178 11.1.5 Announcements�� 178 11.1.6 Case Description �� 178 11.2 Reconstruction of Type II Defect�� 181 11.2.1 Indications�� 181 11.2.2 Surgical Design�� 181 11.2.3 Surgical Method�� 182 11.2.4 Operation Characteristics�� 183 11.2.5 Announcements�� 184 11.2.6 Case Description �� 184 11.3 Reconstruction of Type III Defect�� 187 11.3.1 Indications�� 187 11.3.2 Surgical Design�� 187 11.3.3 Surgical Method�� 187 11.3.4 Operation Characteristics�� 187

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11.3.5 Announcements�� 187 11.3.6 Case Description �� 188 11.4 Reconstruction of Type IV Defect�� 191 11.4.1 Indications�� 191 11.4.2 Surgical Design�� 191 11.4.3 Surgical Method�� 191 11.4.4 Operation Characteristics�� 191 11.4.5 Announcements�� 191 11.4.6 Case Description �� 192 11.5 Reconstruction of Type V Defect�� 193 11.5.1 Indications�� 193 11.5.2 Surgical Design�� 194 11.5.3 Surgical Method�� 194 11.5.4 Operation Characteristics�� 194 11.5.5 Announcements�� 194 11.5.6 Case Description �� 194 11.6 Reconstruction of Type VI Defect�� 197 11.6.1 Indications�� 197 11.6.2 Surgical Design�� 197 11.6.3 Surgical Method�� 197 11.6.4 Operation Characteristics�� 197 11.6.5 Announcements�� 197 11.6.6 Case Description �� 197 12 Reconstruction of Multi-Finger Defects�� 199 12.1 Indications�� 199 12.2 Surgical Design �� 199 12.3 Surgical Method�� 199 12.3.1 Preparation for the Recipient Site �� 199 12.3.2 The Cutting of the Toe�� 200 12.3.3 Transplantation�� 200 12.3.4 Postoperative Treatment�� 200 12.4 Operation Characteristics�� 200 12.4.1 Announcements�� 200 12.4.2 Case Description �� 201 13 Reconstruction of Finger Joint Defects�� 205 13.1 Indications�� 205 13.2 Surgical Design �� 205 13.3 Surgical Method�� 205 13.3.1 Preparation for the Recipient Site �� 205 13.3.2 The Cutting of the Toe�� 206 13.3.3 Transplantation�� 206 13.3.4 Postoperative Treatment�� 206 13.4 Operation Characteristics�� 206 13.5 Announcements�� 206 13.6 Case Description �� 206 14 Reconstruction of Nail Defects�� 213 14.1 Reconstruction of Nail Defect by Split-Thickness Toenail Bed Transplantation�� 213 14.1.1 Indications�� 214 14.1.2 Surgical Design�� 214 14.1.3 Surgical Method�� 214

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14.1.4 Postoperative Treatment�� 215 14.1.5 Operation Characteristics�� 215 14.1.6 Announcements�� 215 14.2 Reconstruction of Nail Defect by Superficial Dermal Fascia Composite Tissue Transplantation�� 215 14.2.1 Indications�� 216 14.2.2 Surgical Design�� 216 14.2.3 Surgical Method�� 216 14.2.4 Operation Characteristics�� 216 14.2.5 Announcements�� 216 14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation�� 217 14.3.1 Indications�� 217 14.3.2 Surgical Design�� 217 14.3.3 Surgical Method�� 218 14.3.4 Operation Characteristics�� 219 14.3.5 Announcements�� 219 14.3.6 Case Description �� 219 15 Reconstruction of Finger Pulp Defects�� 225 15.1 Reconstruction of Finger Pulp Defect by Local Thumb Flap�� 225 15.1.1 Indications�� 225 15.1.2 Surgical Design�� 225 15.1.3 Surgical Method�� 225 15.1.4 Operation Characteristics�� 226 15.1.5 Announcements�� 226 15.1.6 Case Description �� 227 15.2 Reconstruction of Finger Pulp Defect by Transposition of Local Finger Flap� 229 15.2.1 Indications�� 229 15.2.2 Surgical Design�� 229 15.2.3 Surgical Method�� 229 15.2.4 Operation Characteristics�� 229 15.2.5 Announcements�� 229 15.2.6 Case Description �� 230 15.3 Reconstruction of Thumb Pulp Defect by Transposition of Dorsal Index Finger Flap �� 232 15.3.1 Indications�� 232 15.3.2 Surgical Design�� 232 15.3.3 Surgical Method�� 232 15.3.4 Operation Characteristics�� 233 15.3.5 Announcements�� 233 15.3.6 Case Description �� 234 15.4 Reconstruction of Finger Pulp Defect by Digital Artery Island Flap �� 234 15.4.1 Indications�� 234 15.4.2 Surgical Design�� 234 15.4.3 Surgical Method�� 235 15.5 Proper Digital Artery Island Flap Anastomosed with Dorsal Digital Nerve�� 236 15.5.1 Operation Characteristics�� 236 15.5.2 Announcements�� 236 15.5.3 Case Description �� 237 15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition�� 238 15.6.1 Surgical Design�� 238 15.6.2 Surgical Method�� 238

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15.6.3 Operation Characteristics�� 240 15.6.4 Announcements�� 240 15.6.5 Case Description �� 240 16 Reconstruction of Dorsal Digital Composite Tissue Defects�� 245 16.1 Indications�� 245 16.2 Surgical Design �� 245 16.3 Surgical Method�� 245 16.4 Operation Characteristics�� 246 16.5 Announcements�� 246 16.6 Case Description �� 246 17 Special Types of Finger Reconstruction�� 249 17.1 Aesthetic Reconstruction (Comprehensive Reconstruction)�� 249 17.1.1 Indications�� 249 17.1.2 Surgical Design�� 249 17.1.3 Surgical Method�� 249 17.1.4 Operation Characteristics�� 250 17.1.5 Announcements�� 250 17.1.6 Case Description �� 250 17.2 Finger Reconstruction in Children�� 252 17.2.1 Indications�� 252 17.2.2 Surgical Design�� 252 17.2.3 Surgical Method�� 252 17.2.4 Announcements�� 254 17.2.5 Case Description �� 254 17.3 Reconstruction of Congenital Deformity of Fingers�� 257 17.3.1 Indications�� 257 17.3.2 Surgical Design�� 258 17.3.3 Operation Characteristics�� 258 17.3.4 Announcements�� 258 17.3.5 Case Description �� 258 17.4 Reconstruction of Degloving Defects of Fingers�� 262 17.4.1 Indications�� 262 17.4.2 Surgical Design�� 262 17.4.3 Surgical Method�� 262 17.4.4 Operation Characteristics�� 264 17.4.5 Announcements�� 264 17.4.6 Case Description �� 264 17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger�� 266 17.5.1 Indications�� 266 17.5.2 Surgical Design�� 266 17.5.3 Surgical Method�� 266 17.5.4 Postoperative Treatment�� 267 17.5.5 Operation Characteristics�� 267 17.5.6 Announcements�� 267 17.5.7 Case Description �� 267 17.6 Temporary Heterotopic Replantation (Reconstruction) of Severed Fingers�� 273 17.6.1 Indications�� 273 17.6.2 Surgical Design�� 273

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17.6.3 Surgical Method�� 273 17.6.4 Postoperative Treatment�� 273 17.6.5 Operation Characteristics�� 273 17.6.6 Announcements�� 274 17.6.7 Case Description �� 274 Further Reading �� 278

Contributors

Hui Liu Department of Hand Surgery, GuiZhou 3rd Provincial People’s Hospital, Guiyang, Guizhou Province, China Jun Li Department of Hand Surgery, Shanghai Haihua Hospital, Shanghai, China Li-Zhi Wu Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Linhai, China Mingwu Zhou Department of Microsurgery, The 988th Hospital of the Joint Logistics Support Force of the Chinese People’s Liberation Army, Zhengzhou, Henan Province, China He-Ping Zheng Laboratory of Basic Medicine, Dongfang Hospital (900th Hospital of the Joint Logistics Team), Fuzhou, China GuangJun Liu Department of Orthopaedic, Hospital of the 80th Group Army of the Chinese People’s Liberation Army, Weifang, China Zhi Jiang Wang Department of Center for Orthopaedic Repair and Reconstruction, Chongming Hospital Affiliated to Shanghai University of Medicine & Health Sciences (Xinhua Hospital Chongming Branch), Shanghai, China Xiang Wang Department of Hand Surgery, The People’s Liberation Army No. 906 Hospital, Ningbo, China

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Part I Introduction

1

The Development Situation of Finger Reconstruction

Abstract

The hand is the most valuable and versatile tool of human that is easily got hurt in life, learning, and work among which the most serious one is amputated finger. And if it is not replanted timely and effectively, it would cause lifelong injury to the patient, but such kind of situation is common in our clinic work. Even though finger replantation is timely and effective, the survival rate would not be 100%, then how to save the hand function that would be a difficult problem for microsurgeons. The good news is that the problem has been solved: finger reconstruction. Keywords

Finger reconstruction · Development situation

1.1 Historical Origin In the history of finger reconstruction, there are many key men and landmark operations that have had a decisive influence on later generations. Nicoladoni published a report in the journal Wiener klinische Wochenschrift in 1987 to introduce his experience on the method of pedicle flap from the thoracic area repairing the deployed thumb of three patients, and he suggested the method of thumb reconstruction with the second toe in the discussion part. But many doctors were reluctant to perform the operation since it should take a long time for immobilization in a forced position and sensory nerve regeneration of the flap would also be inadequate. Littler completed the first finger thumbization surgery and obtained satisfactory function in 1953, at the same time sacrificing the adjacent finger was inevitable. In 1960, Reid reconstructed the thumb with an expanded pedicle flap combined with bone transplantation. In 1964, McGregor’s method of a composite bone flap with a neurovascular bundle had overcome many shortcomings but immobilization and stage operation still remained. In 1965, Buncke transplanted the great toe to finger for three rhesus monkeys and

succeeded in two. But the author emphasized it would be no value if the transplanted toe had no sensory activity. In 1968, Cobbett reported a successful reconstruction of the left thumb defect in the base of the proximal phalanx with the left great toe free transplantation. In 1979, Buncke reported finger pulp reconstruction with great or second-toe pulp-free sensate flap. In 1980, Hamilton reported nail skin flap of great toe transplantation. In China the development of finger reconstruction with toe transplantation is divided into the following stages: from 1977 to 1995 is the popularization stage, from 1996 to 2006 is the stable stage and from 2006 to now is the innovation and improvement stage since 1996 the year the first thumb reconstruction with free second toe transplantation by Yang et al. According to statistics, there were 215 articles published in 4 medical journals, including 18 in Chinese Journal of Surgery, 87 in Chinese Journal of Hand Surgery, 67 in Chinese Journal of Microsurgery, and 43 in Journal of Practical Hand Surgery. Actually, more articles were published than above. There were also a number of related monographs published such as Hand Repair and Reconstruction, edited by Gu (1995), Replantation and Reconstruction of Finger, first edition edited by Cheng (1997), Repair and Reconstruction of Missing Limbs, edited by Gu (2005), and Replantation and Reconstruction of Finger, the second edition edited by Cheng et al. (2005). The article named “A report of 40 cases of thumb reconstructed with second toe free transplantation” was published in Chinese Journal of Surgery by Yang in 1977, the chapter named “Thumb and finger reconstructed by toe transplantation” written by Yang in Microsurgery was edited by Chen, Yang, Zhang et al. provided new method and experience for finger reconstruction with the second toe. Different methods were provided to solve the problem of vascular variation such as second blood supply system adopted by Gu et al. (1986) and the first plantar metatarsal artery adopted by Cheng (1986), In 1994, Cheng proposed the theory of arteriovenous anastomosis to rebuild blood circulation what was finger reconstruction revolution. Degree of thumb and finger defects reached an expert consensus at the meeting of a seminar on the degree of thumb and finger defects

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_1

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convened by Chinese Journal Orthopaedics in September 1999 in Wenzhou. As of April 2016, according to incomplete statistics from 23 hospitals in China: thumb and finger reconstruction with toe tissue transplantation reached 18,128 cases, 20,557 fingers, and 20,339 fingers survived, and the survival rate reached 98.9%. Actually, the real number should be more than above since there were more than 23 hospitals that had already carried out this operation. The number of hospitals that had reconstructed fingers over 400 cases reached 14, including the 89th Hospital of the Chinese People’s Liberation Army (PLA), the 401 Hospital of the PLA, Shanghai No. 6 People’s Hospital, Shanghai Huashan Hospital, etc. In recent years, some scholars have done a lot of exploration of the reconstruction methods, especially on aesthetic shaping, such as “aesthetic reconstruction” and “full-shaped reconstruction” that shift finger reconstruction mode from “moving” and “transplantation” to restoration of the appearance and function of the original finger. But whatever the method is chosen, the second toe-free transplantation is still the most widely used in the clinic. And with the development of microsurgery and the theory of “supermicrosurgery,” the reconstructed finger will get closer and closer to perfect.

1.2 Controversial Issues The only way for finger reconstruction to mature is continuously dialog with history and make progress in inheritance and criticism. Now we list some possible controversial issues at this stage as follows.

1.2.1 Focus on Time for Operation Emergency toe-to-hand transfer is for those without replanting conditions. And delayed or selective toe-to-hand transfer is for those with serious pollution or are not suitable for emergency and operated within 2 weeks, or operated within 3 days after primary closure or failed replantation. The time for operation should be decided with economic and therapeutic advantages and risks. The advantages of emergency reconstruction are including: shorten hospitalization and recovery time, easy to dissect neurovascular pedicles, retain the length of severed phalanx, and reduce adhesion of tendons. And the disadvantages are including: less satisfied with the results because of lack of pain time, more soft tissue of foot needed, and more disputes and conflicts happening because of less time and preparation before the operation. Current research suggests that the success rate for both emergency and selective operations is about 97%, and there is no statistical difference in infection rate and probe rate. There is 44% of patients undergoing emergency reconstruction would continue to do their original jobs meanwhile the number is

1 The Development Situation of Finger Reconstruction

26% in the selective group, the difference may not be significant because of the small sample size.

1.2.2 Hallux-to-Thumb Reconstruction, Nail Skin Flap of Great Toe Transplantation, or Second Toe Transplantation for Thumb Defects? How to choose a suitable method for thumb defects? According to balance function, appearance, or minimum damage of donor site? There is still no consensus. Hallux-to-thumb reconstruction and second-toe transplantation are the most reported in clinical literature. But compared with second toe transplantation, the function of hallux-to-thumb reconstruction would be much better, at the mean time, it is not acceptable to patients. Nail skin flap of the great toe connected with ilium transplantation makes the appearance better match the normal thumb and reduces side injury to the donor site. But the range of motion is limited, absorption of the ilium may occur, and the donor site should be covered with an adjacent digital flap. Aesthetic nail skin flap of great toe transplantation should remove bone and soft tissue at the medial side of the transplanted toe to make a more nature looking thumb but the cost is partial loss of interphalangeal range of motion. Reverse flaps make reconstructed thumb appearance more natural, retain epiphysis growth potential and reduce side injury, but on the other hand, it would be more complex, dangerous, take more time, and need higher technique than toe-tothumb transfer. A comparative study of 51 cases with thumb defect treated with hallux-to-thumb transfer, modified nail skin flap of great toe transplantation and aesthetic nail skin flap of great toe transplantation suggested that aesthetic nail skin flap of great toe transplantation was in inferior position in the interphalangeal range of motion and pinching force, and there were also problems in joint reduction and wound healing. The hallux-tothumb transfer should be first considered at the time of thumb defect combined with other finger injuries. There are also considerations of stump extension + “on top” hallux-to-thumb transfer when the defect reaches the level of the first metacarpal neck.

1.2.3 How to Reconstruct Fingers When Multiple Fingers Defect? The number and position of reconstructed fingers would directly affect the function recovery of hand, and the choice depends on residual hand function and patients’ needs. When two functional fingers are left on the radial side, there is no need for reconstruction, except for patients with special needs. It is suitable to reconstruct index and middle finger for those who need delicate operations. Those patients with contractures of the first web space are not suitable to reconstruct index finger. Staged-reconstruction is better for those with

Further Reading

impairment or loss of thenar muscle function. Reconstruction of multi-digits should consider the importance between static balance and dynamic balance and what is better to retain the great toe and another two toes (the fourth and fifth on the right, the second and fifth on the left).

1.2.4 Whether to Reconstruct Sensory Nerves? Some scholars suggested to reconstruct more than one sensory nerve to avoid theoretical degeneration and narrowing of joint space of denervated joints. But Dautel reported recently that there was no degeneration occurring in a 25-year follow-up patient. Toe-to-hand free transfer is an ideal method for finger reconstruction at this stage. On the other hand, the satisfactory effect depends on personalized therapy, prevention of surgical risk, and understanding of patients.

Further Reading Huemer GM. Carl Nicoladoni and the concept of toe-to-hand transfer at the turn of the nineteenth century. Plast Reconstr Surg. 2005;115(5):1432-3. Buncke HJ Jr, Buncke CM, Schutz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation,

5 utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19(4):332-7 Yang DY, Gu YD, Wu MM. Thumb reconstruction with free second toe transplantation in 40 cases. Zhonghua Wai Ke Za Zhi. 1977;15:13- 18 (in Chinese). Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51(4):677-9. Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps. Plast Reconstr Surg. 1979;63(5):607-12. Hamilton RB, Morrison WA. Microvascular segmental thumb reconstruction: a case report. Br J Plast Surg. 1980;33(1):64-7. Wang LY, Tian GL, Wang MY, et al. Analysis of the morphologic differences of the second toe and digits of the hand, and evaluation of potential surgical intervention to minimize the differences using computer-aided design technology. Plast Reconstr Surg. 2014;134(6):902e-12e. Sosin M, Lin CH, Steinberg J, et al. Functional donor site morbidity after vascularized toe transfer procedures. A review of the literature and biomechanical consideration for surgical site selection. Ann Plast Surg. 2016;76(6):735-42. Woo SH, Yoo MJ, Paeng JW. Recent advances in immediate toe-to- hand transfer. J Hand Surg.2016;21(3):292-299. Wei FC, Aldeek NF, Lin YT, et al. Metacarpal-like hand: Classification and treatment guidelines for microsurgical reconstruction with toe transplantation. Plast Reconstr Surg. 2018;141(1):128-135. Dautel G. Vascularized toe joint transfers to the hand for PIP or MCP reconstruction. Hand Surg Rehab.2018. https://doi.org/10.1016/j. hansur.2018.03.008 Chen ZW, Yang DY, Zhang TS, et al. Microsurgery, Shanghai, Shanghai Scientific & Technical Publishers, 1978. Cheng GL, Fang GR, Lin S, et al. Thumb and finger reconstruction by anastomosing the digital arteries of the toe transplant and finger. Chinese Journal of Surgery. 1994, 79-81.

2

Anatomy of the Hand and Foot

Abstract

The hand is not only the most valuable tool of labor but also an integral part of the human apparatus. Although finger defects will not endanger people’s life, they will bring inconvenience and physical and mental pain to patients. With the progress of the society and the improvement of people’s living quality, it is very important to repair and reconstruct finger defects. For a long time, people have tried a variety of surgical methods for finger reconstruction, but so far, the most acceptable and clinically effective surgical method is toe-to-hand reconstruction. So this section focuses on the anatomy of the hand and foot. Keywords

Anatomy · Hand and foot

2.1 Holistic View 2.1.1 Superficial Anatomy kin Anatomical Marks S Palmprint: Palmar facial skin has palmar proximal crease, palmar middle crease, and palmar distal crease (Fig. 2.1). (1) Palmar proximal crease: Located on the ulnar side of the thenar muscle, oblique downwards and outwards, the distal end is almost transverse, reaching the radial margin of the palm,

and corresponds to the second metacarpal head. Adapt to the separate movement of the thumb. (2) Palmar middle crease: The distal end overlaps with proximal transverse palmar crease, extends to the ulnar side of the palm, and ends at the lateral margin of the hypothenar muscle. Adapt to the separate movement of the index finger. (3) Palmar distal crease: Tranverse from 1.5 cm on the proximal side of the second finger web to the ulnar margin of the metacarpal, which is suitable for the third to the fifth metacarpal phalangeal joint line, and about 2 cm on the proximal side of the metacarpal finger crease. Adapt to the movement of the middle finger, ring finger, and little finger. Under normal situations, the distal finger pulp can touch palmar distal crease during flexion, which can be used as a simple clinical method to measure the degree of flexion of finger. Dorsal finger crease: The proximal and distal phalangeal joints of the dorsal side of the finger have several horizontal stripes and ring ridges to adapt to the dorsal extension of the interphalangeal joints. Finger (toe) web: The finger (toe) web is the skin fold formed between the distal end of the palm (planta pedis) and the root of the adjacent finger (toe), reaching the level of the middle part of the proximal phalangeal (toe) bone. First web space of hand is relatively large. Under normal conditions, if the thumb is fully extended, the Angle of the jaws will be greater than 90°. When scar contracture deformity occurs, the Angle will be reduced to different degrees, affecting the function of the thumb, so it must be repaired and reconstructed.

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b

Fig. 2.1 Superficial anatomy of hand. (a) Palmar view. (b) Dorsal view. (1) Palmar proximal crease. (2) Palmar middle crease. (3) Palmar distal crease. (4) Finger web. (5) First web space of hand

Finger (toe) nail: Located on dorsal end of finger (toe), what is a derived structure of the dorsal skin, formed by the thickening of the dermis (Fig. 2.2). The exposed part of the nail, called the nail body, is connected to the deep skin, and there is a white half moon-shaped region at the base of the nail, called lunule of nail. The proximal part of the nail, which is hidden under the skin, is called the nail root, which is the growing point of the nail and should be protected during the operation. The skin fold around the nail is called the nail fold. The cuticle of the nail root extends to the far side into a thin epidermal plica is called eponychium. The groove between the lateral margin of the nail and the plica is called nail sinus. The genuine leather under the nail is nail bed. The cuticle layer below the independent margin of the nail is particularly thick and extends under the nail, called hyponychium. Nails support the distal pith, give the fingers a beautiful appearance, and are a vulnerable part of the finger.

Osseous Marks Osseous Marks on the Hand Scaphoid tubercle: The scaphoid tubercle can be touched on the lateral side of the lateral wrist palmar crease, and the

scaphoid tubercle is on the distal side of the scaphoid tubercle, constituting the eminelntis carpi radialis. Pisiform bone: The pisiform bone can be reached on the medial side of the lateral wrist palmar crease. The slightly distal side of the pisiform bone is the hook bone, constituting the eminelntis carpi ulnaris. Metacarpals and phalanges: The metacarpals and phalanges on the back of the hand are subcutaneous and easily accessible, and the metacarpal head is obviously visible when the metacarpal phalangeal joint is bent. Osseous Marks of the Foot Medial malleolus, lateral malleolus: The medial malleolus, located in the medial side of the calf joint, which is the protrusion of the medial bone of the lower tibia, easily be observed and touched, and is an important osseous mark. The lateral malleolus is located lateral to the calf joint, which is tapered, elongated, narrow, and slightly smaller than the medial malleolus. The tip of the lateral malleolus is about 1 cm lower than that of the medial malleolus, and the position is backward. Talus and calcaneus: The talus lies among the tibia, fibula and calcaneus. When the foot is in the neutral position, the projection in front of the medial malleolus corresponds to

2.1 Holistic View Fig. 2.2 Shape of nails. (a) Thumbnail. (b) Big toenail. (1) Nail body. (2) Lunule of nail. (3) Nail fold. (4) Eponychium. (5) Nail sinus. (6) Hyponychium

9

a

the medial side of head and neck of talus. When the foot is in the plantar flexion position, the talus can slide forward significantly, showing that it can be touched before the calcaneal joint. The calcaneus lies behind and below the talus and calcaneal tuber can be clearly felt down the Achilles tendon at the bottom of calcaneus. In the lower part of the medial malleolus about a horizontal finger, if slightly pressed, sustentaculum tali can be touched, above which the talus neck is supported and tendon of flexor hallucis longus passes below. In the lower part of the lateral malleolus about a horizontal finger, processus trochlearis calcanei can be touched, behind which tendon of peroneous longus passes. Navicular tuberosity: It is a projection of the medial side of navicular facing inward and downward, located about 5 cm below the anterior part of the medial malleolus, and is the attachment point of tibialis posterior. The first metatarsal: The first metatarsal is thick and short, the base of which can be reached in front of medial cuneiform bone, and part of tibialis posterior is attached. From this point on the dorsal medial margin of foot we can touch the first metatarsal body till head. The fifth metatarsal tuberosity: It is the protruding part of the fifth metatarsal base and can be touched in the middle of the lateral margin of the foot.

b

Muscular (Tendon) Marks Muscular (Tendon) Marks on the Hand Thenar eminence and hypothenar eminence: The ventral eminence of the radial side of the palm formed mainly by thenar is called thenar eminence. When median nerve is injured, it can cause palsy and atrophy of thenar, resulting in thenar eminence flatness. The ventral eminence of the ulnar side of the palm formed mainly by hypothenar is called hypothenar eminence. When ulnar nerve is injured, it can cause paralysis and atrophy of hypothenar and interosseous muscle, the hypothenar eminence will be flat and the metacarpal space will be deepened. Center of palm: The triangular hollow in the middle of the palm is called center of palm, whose deep surface has larger blood vessels, nerves, flexor tendons, lumbricals, interossei, and so on. Tendon uplift: When the thumb extends, the extensor tendon can be felt from the back of the thumb to the bottom of the distal phalanx. When the other fingers extend, each extensor tendon can be seen clearly. When the thumb and index finger close to each other, the eminence formed by the dorsal muscle between the first bone can be seen in the space between the first metacarpal bone.

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Anatomical snuff-box: A depression at the dorsal end of the radius can be seen when the thumb abducts and extends, whose lateral boundary is tendon of extensor pollicis brevis and tendon of abductor pollicis longus, the medial boundary is tendon of extensor pollicis longus, and the fossa base is the scaphoid bone, trapezium bone and the base of the first metacarpal bone. Styloid process of radius is located in the fossa and the radial artery passes through to the first metacarpal bone space. Cephalic vein is one of the important contents in the shallow structure of snuff fossa, transecting tendon of extensor carpi radialis longus from inside to outside and then up. Muscular (Tendon) Marks on the Foot Tendon of tibialis anterior: From the medial side of the dorsum of the foot oblique forward and down, and ends at the medial side of medial cuneiform bone and the first metatarsal base. It can be touched clearly when the calcaneal joint is in dorsiflexion and inversion position. Tendon of extensor hallucis longus: It goes forward from the dorsum of the foot to the dorsum of the hallux. It can be clearly seen when the hallux is in dorsiflexion position. Tendon of extensor digitorum longus: When tendon of extensor digitorum longus reaches the lower part of the cruciate ligament, it is divided into five tendons, and the four medial tendons go to the dorsum of the second to the fifth toes respectively. The another one runs to the dorsum of the fifth metatarsal trochanter, called the third peroneal tendon. These tendons can be clearly seen or touched when the toes extend. Tendon of peroneus longus and peroneus brevis: Tendon of peroneus longus and peroneus brevis go forward and downwards through the posterior side of the lateral malleolus, tendon of peroneus brevis goes forward and downwards through the upper part of the calcaneal trochlear process, and tendon of peroneus longus goes forward and downwards through the posterior side of the calcaneal trochlear process. The two tendons can be touched when the calcaneal joint is in planta flextion and eversion position.

2.1.2 Hand Positions esting Position of the Hand R The resting position of the hand is the natural half-clenched position during sleep or general anesthesia (Fig. 2.3). Dorsal

2 Anatomy of the Hand and Foot

Fig. 2.3 Resting position of the hand

Fig. 2.4 Functional position of the hand

flexion of the wrist (10° to 15°) with slight ulnar inclination. The thumb is slightly abducted and the finger pulp touches the radial edge of the distal interphalangeal joint of the index finger. Metacarpal phalangeal joint and interphalangeal joint of the other fingers are in semi-flexion position, and the more to the ulnar side, the greater the flexion is. The index finger tilts slightly to the ulnar side and the little finger tilts slightly to the radial side. The flexor and extensor muscles in this position have a relative balance that would be disrupted when a hand is injured.

unctional Position of the Hand F The functional position of the hand is similar to the position that the hand holding a teacup. It is also the position that the hand can exert its maximum function (Fig. 2.4). Dorsal flexion of the wrist (about 30°) with slight ulnar inclination (about 10°), the thumb is abducted totally, and metacarpophalangeal joint and interphalangeal joint are slightly flexed. The other fingers are separated with different degrees of flexion, that is, metacarpal phalangeal joint flexion of 30° to 45°,

2.1 Holistic View

11

Fig. 2.5 The pinching position of the hand

Fig. 2.6 The holding position of the hand

proximal interphalangeal joint flexion of 60° to 80°, and distal interphalangeal joint flexion of 10° to 15°. When in the functional position, the hand can play its maximum function. So in the case of a hand fracture, the hand should generally be fixed in the functional position.

2.1.3 Body Surface Reflection

he Pinching Position of the Hand T The finger pulp of the thumb and the index finger (sometimes accompanied by the middle finger) are closely attached, to hold small objects (such as writing and pinching needles), called the pinching position (Fig. 2.5). In this position, the wrist is obviously dorsal flexed, the first metacarpal bone rotates and abducts, metacarpophalangeal and interphalangeal joints of the thumb are slightly flexed, the index finger is flexed also, and the tip of thumb and index finger touches each other like the arms of a pair of pliers. he Holding Position of the Hand T Holding is an important function of the hand, which can be divided into two forms: strong and precise. In strong form, wrist dorsiflexion, metacarpal phalangeal joints, and interphalangeal joints all flex at 90° and adduct, enabling the flexor longus of the finger to firmly press the object on the palm (Fig. 2.6). In precise form, wrist dorsiflexion or palmar flexion, fingers half fold, the thumb is opposite to the other fingers. In this position, the interosseous and lumbrical muscles of the hand enable the fingers to make various movements, which could quickly shift from one position to another. These two forms can also exist together.

eflection of Hand Bones and Joints (Fig. 2.7) R 1. Pisiform bone: The wrist distal crease just passes through the proximal end of pisiform bone. 2. Uncus of hamate bone: It is located about 1 cm away from the radial side of pisiform bone. 3. Scaphoid node: The medial side is covered by the flexor carpi radialis, and the distal side is overlapped by trapezium bone, which is not easy to be reached. It is obvious when the wrist is dorsal flexed. 4. Tubercle of trapezium bone: Next to the distal scaphoid node. 5. Radiocarpal joint: It is under wrist proximal crease. Styloid process of radius is about 1.2 cm lower than styloid process of ulna. 6. Metacarpophalangeal joints: The metacarpal phalangeal joint of the index finger is just opposite to a little distal side of the transverse part of thenar creaseon, the metacarpal phalangeal joints of the middle, ring, and little finger are just opposite to a little distal side of plamar distal crease, the metacarpal phalangeal joint of the thumb is just opposite to a little distal side of proximal finger crease. 7. Interphalangeal joint: Proximal interphalangeal joint is just opposite to middle finger crease, distal interphalangeal joint is just opposite to a little distal side of distal finger crease, to the thumb, interphalangeal joint is just opposite to distal finger crease.

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2 Anatomy of the Hand and Foot

Fig. 2.7 Reflection of hand bones and joints

eflection of Vascular and Nerves (Figs. 2.8, 2.9, R 2.10, 2.11, 2.12, 2.13, 2.14 and 2.15) 1. Ulnar nerve and ulnar artery: Ulnar nerve passes along the radial side of the pisiform bone, ulnar artery also resides on the radial side of the nerve. 2. Superficial palmar arch: An arc is drawn from the radial side of the pisiform bone and connected to the midpoint of the midline of the metacarpal line, which roughly represents the ulnar part of the superficial palmar arch. 3. Deep palmar arch: About 1 cm proximal to superficial palmar arch. 4. Recurrent branch of median nerve: The one-third of radial or ulnar part of the proximal thenar crease is the

course of this never that would be involved if this area is injured. 5. Deep branches of ulnar nerve: Between the distal margin of the pisiform bone and the proximal margin of hamate bone, walking along with deep palmar arch. 6. Digital arteries and nerves: Common palmar digital artery and common palmar digital nerve walk together, nerve resides deep surface. The artery bifurcated at 1.25 cm from the edge of finger web to form the proper palmar digital artery, and the nerve bifurcated a little more proximal than the artery. In the plane of the metacarpophalangeal joint, the proper arteries and nerves were arranged at the margins of each metacarpophalangeal surface, then the nerve runs palmar to the artery.

2.1 Holistic View

Limb Arteries Fig. 2.8 Upper limb arteries

Fig. 2.9 Upper limb arteries

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14

2 Anatomy of the Hand and Foot

Limb Veins Fig. 2.10 Upper limb veins

b

a

Fig. 2.11 Upper limb veins

a

b

2.1 Holistic View

15

Lymphatic Vessels of Limbs a

b

c

Fig. 2.12 Lymphatic vessels and lymph nodes of upper limb

a

Fig. 2.13 Lymphatic vessels and lymph nodes of lower limb

b

16

Extrinsic Muscles of Hand and Foot a

b

Fig. 2.14 Extrinsic muscles of hand. (a) Extensor digitorum. (b) Flexor digitorum

2 Anatomy of the Hand and Foot

2.1 Holistic View

17

a

b

c

d

Fig. 2.15 Extrinsic muscles of foot

18

2.2 Applied Anatomy of the Hand 2.2.1 Dorsum of Hand Superficial Structures The skin on the dorsum of hand is thinner, with hairs and sebaceous glands, full of elasticity, and easy to move due to loose combination with the superficial fascia. The skin will be tight when making a fist, and will not be too relaxed when straightening fingers, so trauma will easily lead to avulsion. Dorsal Venous Rete of Hand Superficial veins in the superficial fascia anastomosed with each other to form dorsal venous rete of hand (Fig. 2.16), which can be divided into five types (Fig. 2.17). Located on the superficial side of the cutaneous nerve, which receives the superficial layers of the fingers and palm and the veins from deep in the hand. There are many dorsal veins in the hand with large diameter. Most of the veins in the hand are collected and returned to the forearm. The radial and ulnar digital veins are distributed on both sides of the dorsal side of a

2 Anatomy of the Hand and Foot

each finger, and they are anastomosed to form the digital venous arch except collecting the small branches on the metacarpal surface of the finger. The radial and ulnar digital veins of the adjacent fingers converge at the metacarpal phalangeal joint to form the second to fourth dorsal metacarpal vein, and the metacarpal intercephalic vein enters into it at the confluence. The second dorsal metacarpal vein receives veins on the ulnar and radial sides of the index finger, and each dorsal metacarpal vein moves proximally along the metacarpal space to form a venous arch or network on the dorsum of hand. To the dorsum of wrist, the radial and ulnar ends of the arch or net continue to be the starting parts of cephalic vein and balsilic vein. The blood flow of hand mainly relies on the dorsal veins of hand, when in wrist replantation, which must be carefully anastomosed, in order to ensure the survival of the replanted hand. Superficial Lymph Vessels The lymphatic reflux of dorsum of hand is similar to that of the vein, which also forms a rich lymphatic network. The superficial lymphatic network at the distal end of the palm flows to b

Fig. 2.16 Dorsal venous rete of hand. (a) Object specimen. (b) Cast specimen. (1) Dorsal venous rete of hand. (2) Dorsal digital vein. (3) Cephalic vein. (4) Basilic vein

2.2 Applied Anatomy of the Hand

Fig. 2.17 The main types of dorsal veins of hand. (I) Ach type: The dorsal metacarpal vein forms a large venous arch in dors hand. (II) Ach type: The dorsal metacarpal vein forms a larger venous arch on the dorsal part of the wrist and sometimes forms a secondary or tertiary venous arch on the dorsum of hand; (III) Net type: The 2nd–4th dorsal metacar-

19

pal vein is large, merges to the proximal side gradually, forms a vein trunk; (IV) Net type: The 2nd–3rd dorsal metacarpal vein is large, forming a vein trunk; the other veins are small and reticulate; (V) Net type: The 3rd–4th dorsal metacarpal vein is large, forming a vein trunk; the other veins are small

the lymphatic network at dorsum of hand. Therefore, when the hand is infected, the dorsum of hand will be more swollen. Cutaneous Nerves Branch of cutaneous nerve (Fig. 2.18) (1) Superficial branch of radial nerve: Distributed on the dorsal radial half of hand and emitting five dorsal digital nerves distributed on the skin of the thumb, index finger, and the opposite edge of the middle finger; (2) Dorsal branch of ulnar nerve: Distributed on the dorsal ulnar half of hand and emitting five dorsal digital nerves distributed on the skin of the little, ring finger and the opposite edge of the middle finger; (3) Lateral antebrachial cutaneous nerve: Distributed on the dorsal radial side of the wrist; (4) Proper palmar digital nerve (median nerve): Distributed in the distal dorsal position of the radial three-and-a-half fingers. Distribution type of cutaneous nerve (Fig. 2.19) Type I: Superficial branch of radial nerve and dorsal branch of ulnar nerve are distributed in two and a half fingers on radial and ulnar side, respectively, accounting for 60.92%. Type II: The distribution is the same as before, and the two nerves are connected by anastomotic branches, accounting for 2.46%. Type III: The distribution of dorsal branch of ulnar nerve is larger than that of superficial branch of radial nerve, accounting for 3.28%. Type IV: The distribution of superficial branch of radial nerve is larger than that of dorsal branch of ulnar nerve, accounting for 28.69%. Type V: Superficial branch of radial nerve is distributed in whole dorsum of hand, and only a small dorsal branch of ulnar nerve is left or absent, accounting for 1.92%. Type VI: Lateral antebrachial cutaneous nerve replaces superficial branch of radial nerve and is distributed in dorsum of hand. Only a small superficial branch of radial nerve is left or absent, accounting for 2.73%.

Fig. 2.18 Branch of cutaneous nerve. (1) Superficial branch of radial nerve. (2) Dorsal branch of ulnar nerve. (3) Cephalic vein. (4) Basilic vein. (5) Dorsal venous rete of hand

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2 Anatomy of the Hand and Foot

Fig. 2.20 Dorsal deep facial of hand. (1) Extensor retinaculum. (2) Digital extensor tendon. (3) Dorsal interosseous fascia. (4) Second dorsal metacarpal artery

Fig. 2.19 Distribution type of cutaneous nerve. (1) Superficial branch of radial nerve. (2) Dorsal branch of ulnar nerve. (3) Posterior antebrachial cutaneous nerve. (4) Lateral antebrachial cutaneous nerve

Deep Structures Extensor Retinaculum It is formed by the thickened deep fascia of forearm in the dorsum of wrist, also called as dorsal carpi ligament (Fig. 2.20). whose width is 2–3 cm, transverse and oblique, attached to the lateral margin of the lower radius and styloid process of radius on the radial side, bypassing the styloid process of ulna and its distal continued with and flexor retinaculum on the ulnar side, and attached to the pisiform bone and triquetral bone. Dorsal Deep Facial of Hand Doral deep fascia of hand can be divided into two layers: superficial and deep. The superficial layer is a continuation of the dorsal carpi ligament (extensor retinaculum), which binds to extensor tendon to form aponeurosis dorsalis manus, the second and fifth metacarpal bone are attached to one side, respectively. The deep layer covers the dorsal surface of the metacarpal bones from the second to the fifth and the interosseous dorsal muscles from the second to the fourth and is

called dorsal interosseous fascia. At the proximal end of the metacarpal, it is continued with the dorsal fascia of hand by a fibrous lattice, and the two layers of fascia at the distal end of finger web are bonded to each other. Ficial Space Since dorsal fascia of hand binds to each other at the proximal and distal end of the metacarpal bone, subcutaneous and subaponeurotic spaces are formed between superficial fascia, aponeurosis dorsalis manus, and dorsal interosseous fascia. The two spaces connect with each other, and when dorsum of hand is infected, the entire dorsum of hand will be swollen obviously. Tendon of Extenson Digitorum Tendon of extenson digitorum can be divided into radial group and ulnar group (Fig. 2.21). 1. Radial group: This group includes extensor pollicis longus and extensor pollicis brevis, which travel towards the thumb to form the radial and ulnar boundaries of anatomical snuffbox and meet at the metacarpophalangeal joint of the thumb, associated with thumb movement. 2. Ulnar group: This group includes tendon of extenson digitorum, extensor tendon of index finger, and extensor tendon of liittle finger, associated with the movement of second to fourth finger. Tendon of extenson digitorum has

2.2 Applied Anatomy of the Hand

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four thin and flat tendons, which go to the second to fifth finger, respectively. At the point close to the metacarpal head, the tendons are connected by 3 oblique tendon fiber bundles, which are called intertendinous connections. Intertendinous connections have the function of enhancing the stability of finger extension movement and limiting the individual movement of each finger, especially that of the middle, ring, and little finger is more obvious. When a certain extensor tendon is ruptured at the proximal side of the intertendinous connections, there is no obvious extensor dysfunction. Except for the middle finger and ring finger are one extensor tendon, the other fingers are two. Except for the two extensor tendons of the thumb, the extensor tendons of the index finger and the little finger were combined with the extensor tendons of the two fingers, and there was no obvious difference in the insertion point and formation structure. The skin and subcutaneous tissue of dorsum of hand are weak. The extensor tendon may be injured by cutting, twisting, squeezing, or tearing of dorsum of hand, and the incidence of wound pollution is more common than that of the palm.

Fig. 2.21 Tendon of extensor digitorum. (1) Extensor pollicis longus. (2) Extensor pollicis brevis. (3) Tendon of extensor digitorum. (4) Extensor tendon of index finger. (5) Extensor tendon of little finger. (6) Intertendinous connections. (7) Radial artery

a

b

Fig. 2.22 Origin, course, and distribution of dorsal metacarpal artery. (a) First dorsal metacarpal artery. (b) 2nd–4th dorsal metacarpal artery. (c) Anastomosis and branches at finger web. (1) First dorsal metacarpal

Dorsal Metacarpal Artery Located in the corresponding metacarpal space between tendon of extenson digitorum and the dorsal interosseous muscle, a total of 4 (Fig. 2.22). First dorsal metacarpal artery originates from dorsal part of radial artery through the first dorsal interosseous muscle and runs distal along the superficial surface of the muscle. The dorsal metacarpal artery (second to fourth) is

c

artery. (2) Second metacarpal artery. (3) Third dorsal metacarpal artery. (4) Forth dorsal metacarpal artery. (5) Dorsal digital artery. (6) Anastomotic branches. (7) Radial artery

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2 Anatomy of the Hand and Foot

formed by anastomosis of the proximal perforator of deep metacarpal arch and the traffic branch of the distal dorsal venous rete of wrist. It runs to the distal side of the superficial dorsal muscle between the corresponding bones and is divided into two small dorsal digital arteries at the head of the metacarpal bone. There are branches of anastomosis with common palmar digital artery in interwebbed space. Because of the superficial position of the dorsal metacarpal artery and it is constant, free flaps designed with it as the vascular pedicle is often used to repair the skin defect of the hand.

Palm of hand is a quadrilateral area between the wrist and fingers.

superficial fascia is relatively loose at thenar area, and the palmar part is very tight. There are many fibers passing through perpendicular to the palmar surface, connecting the superficial surface to skin, attaching the deep surface to palmar aponeurosis, and dividing the superficial fascia into numerous compartments, in which superficial blood vessels, lymphatics, and cutaneous nerves go through (Fig. 2.23). Since fiber bundle connects skin and palmar aponeurosis closely together, the mobility of the skin is so little, which is concomitant to hold tool, and facilitate labor. However, when there is inflammation in the superficial fascia, the pus is limited and difficult to spread in all directions. When the pus is cut open and discharged, the fiber bundle must be cut off to make drainage unblocked. The surgical incision of the palm should be parallel to the palmar crease to reduce scar contracture and ensure the function of the hand. The main structures in the superficial fascia include:

Superficial Structures The skin is thick and tough, lack of elasticity, without hair follicles and sebaceous glands but is rich in sweat glands. The

Cutaneous Nerves There are three main cutaneous nerves. (1) Palmar cutaneous branch of ulnar nerve: Descending along the anterior

2.2.2 Palm of Hand

a

b

Fig. 2.23 Superficial fascia and structure of palm. (a) Object specimen. (b) Cast specimen. (1) Palmar cutaneous branch of ulnar nerve. (2) Palmar cutaneous branch of median nerve. (3) Superficial branch of radial nerve. (4) Palmaris brevis

2.2 Applied Anatomy of the Hand

border of ulnar nerve to the palm, it penetrates into the deep fascia and distributes the skin of hypothenar; (2) Palmar cutaneous branch of the median nerve: At the margin of the flexor retinaculum, which diverts from the median nerve, penetrates the surface of the flexor retinaculum and distributes the skin of the middle of palm and thenar; (3) Superficial branch of radial nerve: after crossing extensor retinaculum, it is divided into four to five dorsal digital nerves, of which first dorsal digital nerve innervates the lateral skin of thenar. Palmaris Brevis It is a degenerate cutaneous muscle, located in the superficial fascia of the proximal part of hypothenar, which has a fixed effect on superficial fascia and can protect ulnar nerve and ulnar vessels. Deep Structures Deep Fascia

Deep fascia can be divided into superficial and deep layers. Superficial layer: It is a dense connective tissue membrane a

Fig. 2.24 Palmar aponeurosis and palmaris brevis. (a) Object specimen. (b) Schematic diagram. (1) Palmaris longus. (2) Palmar cutaneous branch of median nerve. (3) Superficial cutaneous branch of ulnar

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that covers the superficial surface of thenar muscle, hypothenar muscle, and flexor tendon of palm. Palmar aponeurosis is an aponeurotic structure composed of longitudinal fibers on the superficial side and transverse fibers on the deep side, located in the central part of palm, which covers the superficial surface of superficial palmar arch and the flexor digitorum superficialis, is thick and tough, slightly triangular that points to the proximal side. On the superficial side of flexor retinaculum, it is connected with palmaris longus, and the distal part is formed into four longitudinal fibers running at the distal phalanx of the second to fifth finger. It is connected with the fibrous sheath of each finger and the collateral ligament of metacarpophalangeal joints, and attachepalmar phalangeal joined to both sides of the base of phalanx (Fig. 2.24). At the head of the metacarpal bone, the transverse fibers in the deep layer of palmar aponeurosis and the four bundles of longitudinal fibers from the distal part of the aponeurosis form three fiber spaces, which are called web space, rich in fat, as well as blood vessels and nerves from palm to fingers, which are the communication channels of palm, dorsum of hand and fingers (Fig. 2.24). Dupuytren’s contracture may be b

nerve. (4) Palmar aponeurosis. (5) Longitudinal fasciculus. (6) Transverse fasciculus. (7) Superficial transverse metacarpal ligament. (8) Hypothenar. (9) Palmaris brevis. (10) Thenar

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caused by proliferative fibrous degeneration of palmar aponeurosis, which should be treated by cutting or resecting the aponeurosis. Infections of web spaces are more common in stab wounds, secondary infections (such as blisters and cracks), and spread of infection in palmar spaces. Since the palmar skin is thicker than the dorsal and the superficial fascia is dense, the redness and swelling on dorsum of hand will be more obvious when the web space is infected. Deep layer: covering the surface of metacarpal, palmar interossei and adductor pollicis, compared with superficial layer, it is weaker and is divided into palmar interosseous fascia and fascia of adductor pollicis. Palmar interosseous fascia covers the surface of palmar interosseous muscle and metacarpal bone and is located in the deep side of flexor digitorum profundus. Fascia of adductor pollicis arises from palmar interosseous fascia and extends on the radial side of third metacarpal bone and covers the surface of adductor pollicis. Osteofascial Sheath A fibrous septum arises from the lateral margin of palmar aponeurosis and is attached to the first metacarpal bone through thenar and flexor tendon of the index finger, which is called lateral intermuscular septum of palm. From the medial margin of palmar aponeurosis, a fibrous tissue septum, known as medial intermuscular septum of palm, extends deep between the hypothenar and flexor tendon of the little finger, and is attached to the fifth metacarpal bone. Thus palm forms the lateral, middle, and medial osteofascial sheath (Fig. 2.25).

Fig. 2.25 Osteofascial sheath of hand

2 Anatomy of the Hand and Foot

Fascial Spaces Located deep in palmar intermediate septum there is loose connective tissue, including lateral thenar space and midpalmar space. Palmar intermediate septum is a fibrous tissue septum connected between palmar aponeurosis and palmar interosseous fascia. After wrapping flexor tendon of the index finger and first lumbrical muscle, the palmar intermediate septum is attached to third metacarpal bone and divides palmar fascia space into midpalmar space and thenar space (Fig. 2.26). 1. Midpalmar space: Located in deep ulnar side of palmar intermediate septum. The anterior boundary starts from the radial side of is flexor tendon of third to fifth finger and second to fourth lumbricals; The posterior boundary is posterior part of palmar intermediate septum, the third and fourth metacarpal bones, interosseous muscle, and palmar interosseous fascia. The medial boundary is medial septum and the lateral boundary is palmar intermediate septum. Midpalmar space is communicated with the second to fourth web spaces along the second to fourth lumbricals canal and then leads to dorsum of hand. The proximal midpalmar space reaches the deep surface of the common tendinous sheath of flexor digitorum and communicated with posterior space of antebrachial flexor through carpal canal. So when this space is infected, it can spread through the above channels. 2. Thenar space: Located in deep radial side of palmar intermediate septum. The anterior boundary is the anterior part

2.2 Applied Anatomy of the Hand

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a

b

Fig. 2.26 Fascial spaces and tendinous sheath. (a) Projection; (b) axial section of fascial space: (1) palmar intermediate septum, (2) thenar space, (3) midpalmar space, (4) common tendinous sheath of flexor

digitorum, (5) tendinous sheath of flexor pollicis longus, (6) lumbricals canal, and (7) synovial sheath of finger

of palmar intermediate septum, flexor tendon of index finger, and first lumbricals. The posterior boundary is fascia of adductor pollicis. The lateral boundary is the lateral muscle septum. The medial boundary is posterior part of to the palmar septum to the palmar septum. The thenar space extends distal through first lumbricals canal dorsum of index finger, and the proximal end is a blind end.

zontal fingers above flexor retinaculum, and the distal end is at the same plane as the ulnar margin of thumb when abducted. The distal ulnar side is constantly communicated with synovial sheath of the little finger (accounting for 80%– 90%). In section view, the capsule penetrates into the middle of flexor digitorum superficialis and profundus, connects the ulnar margin, and separates the radial margin, like an E. The ulnar nerve walks on the superficial ulnar surface of the capsule, which should be avoided when the capsule is cut open. Tendinous sheath of flexor pollicis longus: Wrap the flexor pollicis longus, with the proximal end reaching the two horizontal fingers above flexor retinaculum, and the distal end communicating with the synovial sheath of the thumb constantly. Because the medial side is attached to the ulnar capsule, when one capsule is suppurated, it is easy to puncture the other. So the thumb and little finger can infect each other. Median nerve goes on the superficial surface between the radial and ulnar capsule, and its reverse branch goes on the anterior lateral side of the radial capsule, which should be avoided injury when the capsules are cut open.

Synovial Sheath of Palm The tendon is wrapped in the synovial sheath as it passes below the ligament or through the fibrous canal to reduce friction and facilitate tendon movement. There are common tendinous sheath of flexor digitorum (also known as ulnar synovial capsule) and tendinous sheath of flexor pollicis longus (also known as radial synovial capsule) on the palm surface (Fig. 2.27). Variations in the synovial capsule and flexor tendinous sheath are common (Fig. 2.28). Common tendinous sheath of flexor digitorum: Wrap flexor digitorum superficialis and profundus, most in the carpal canal. The proximal end of the capsule reaches two hori-

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2 Anatomy of the Hand and Foot

Fig. 2.28 Variations in the synovial capsule and flexor tendinous sheath

Fig. 2.27 Synovial sheath of palm. (1) Common tendinous sheath of flexor digitorum. (2) Tendinous sheath of flexor pollicis longus. (3) Synovial sheath of finger. (4) First lumbricals

Synovial sheath of finger: Wrap flexor tendons of each finger and attach to both sides of the phalanx and are covered by the fibrous sheath of the finger. The proximal end reaches the distal palmar crease or metacarpophalangeal joint, and the distal end ends at the base of distal phalanx of each finger. The vasculars and nerves of fingers go on both sides of palmar surface of synovial sheath, so incision of that should be carried out at both sides of phalanx. Intrinisic Muscles of Hand Intrinisic muscles of hand include the lateral group, the middle group, and the medial group (Fig. 2.29). The lateral group consists of adductor pollicis brevis, flexor pollicis brevis, opponens pollicis and adductor pollicis. The middle group consists of lumbricals, palmar interossei, and dorsal interossei. The medial group consists of abductor digiti minimi,

Fig. 2.29 Intrinsic muscles of hand. (1) Adductor pollicis brevis. (2) Flexor pollicis brevis. (3) Opponens pollicis. (4) Transverse head of adductor pollicis. (5) Abductor digiti minimi. (6) Flexor digiti minimi brevis. (7) Opponens digiti minimi. (8) Lumbricals. (9) Median nerve. (10) Ulnar nerve

27

2.2 Applied Anatomy of the Hand Table 2.1 Intrinisic muscles of hand Muscle groups The lateral group

Name Adductor pollicis brevis Flexor pollicis brevis

Opponens pollicis

Adductor pollicis

The middle group

First, second

Lumbricals

Third, fourth

First

The median group

Palmar interrossei

Start point Transverse carpal ligament, scaphoid nodules Superficial head: Transverse carpal ligament Deep head: Transverse carpal ligament, Trapezoid bone Transverse carpal ligament, Trapezium bone Oblique head: Capitate bone, transverse carpal ligament Transverse head: Anterior of third metacarpal Radial side of flexor digitorum profundus of index and middle finger Opposite side of flexor digitorum profundus of ring and little finger Ulnar side of second metacarpal

Insertion Sesamoid bone on lateral side of base of proximal phalanx of the thumb Sesamoid bone on both sides of proximal phalanx of the thumb

Function Abduce thumb

Innervation Median nerve (C6, 7)

Flex metacarpophalangeal joint of thumb

Median nerve (C6, 7) Ulnar nerve (C8)

Radial side of first metacarpal Oppose thumb

Median nerve (C6, 7)

Basement of proximal phalanx of the thumb

Ulnar nerve (C8)

Adduct and flex thumb

Aponeurosis dorsalis digiti of Flex metacarpophalangeal joints and Median proximal phalanx of second extense interphalangeal joints nerve (C6, 7) to fifth finger Ulnar nerve (C8)

Crosses ulnar side of the index finger and terminates in aponeurosis dorsalis digiti of the finger Second, Radial side of fourth Crosses radial side of the third and fifth metacarpal fourth to fifth finger and terminates in aponeurosis dorsalis digiti of the fingers First, Dorsal Opposite side of first Crosses radial side of the second interrossei to fifth metacarpal second to third finger and terminates in aponeurosis dorsalis digiti of the fingers Third, Crosses ulnarl side of the fourth third to fourth finger and terminates in aponeurosis dorsalis digiti of the fingers Abductor digiti minimi Pisiform bone, Ulnar side basement of pisohamate ligaments proximal phalanx of little finger Flexor digiti minimi Hamate bone, brevis transverst carpl ligament Opponens digiti Ulnar side of fifth metacarpal minimi

flexor digiti minimi brevis, and opponens digiti minimi. The starting point, function, and innervation of each muscle (Table 2.1). Vasculars The blood supply of hand mainly comes directly from the branches of radial and ulnar arteries, which anastomosis with each other into superficial palmar arch and deep palmar arch. The anterior and posterior interosseous arteries of the fore-

Adduct second, fourth, fifth fingers, Ulnar nerve flex metacarpophalangeal joints, and (C8) extense interphalangeal joints

Abduct second, fourth fingers, flex metacarpophalangeal joints and extense interphalangeal joints

Flex and abduct little finger

Ulnar nerve (C8)

Flex joints of little finger Oppose little finger

arm are involved in the formation of dorsal carpal arterial rete. Some individuals have developed median artery which distributes in proximal part of palmar or participates in the formation of superficial palmar arch. Superficial palmar arch: On the deep surface of palmar aponeurosis and palmaris brevis, and on the superficial surface of the flexor digiti minimi brevis, common palmar digital nerve, flexor digitorum, and lumbricals, the convex side of the arc points to finger side. The projection line of the

28

a

2 Anatomy of the Hand and Foot

b

Fig. 2.30 Position, composition, and branches of superficial palmar arch. (a) Object specimen. (b) Cast specimen. (1) Terminal branch of ulnar artery. (2) Superficial palmar branch of radial artery. (3) Superficial

palmar arc. (4) Common palmar digital arteries. (5) Ulnar palmar artery of quinary finger. (6) Common palmar digital nerve. (7) Lumbricals. (8) Proper palmar digital artery

body surface is roughly in the curve from the middle point of middle palmar crease to the radial side of pisiform bone. Superficial palmar arch is formed by anastomosis of the terminal branch of ulnar artery and superficial palmar branch of radial artery (Fig. 2.30). The outer diameter of middle part of superficial palmar arch is 2.2 mm. The superficial palmar arch can be divided into four types according to the source of the artery anastomosis with the terminal branch of ulnar artery: ulnar artery type (51.72%) is composed of the terminal branch of ulnar artery, while radial artery is not involved. Radial ulnar artery type (37.31%) is composed of the terminal branch of ulnar artery and the superficial branch of radial artery. Median ulnar

artery type (4.51%) is composed of the terminal branch of ulnar artery and median artery. Median radial artery type (0.96%) is composed of the terminal branch of ulnar artery and the superficial branch of radial artery and median artery (Fig. 2.31). The convex side of superficial palmar arch often gives off three common palmar digital arteries and ulnar palmar artery of quinary finger, and the concave side sends out several small reverse branches to the wrist to participate in the formation of palmar carpal rete. The superficial palmar arch and its branches are accompanied by eponymous veins. Common palmar digital arteries: The occurrence rate is almost 100%, and the initial outer diameter of each artery is

2.2 Applied Anatomy of the Hand

a

29

b

c

Fig. 2.31 Types of superficial palmar arc. (a) Ulnar artery type, (b) radial ulnar artery type, (c) median ulnar artery type. (Note: Median radial artery remains 1.0%)

1.2–1.5 mm. Common palmar digital arteries are accompanied by common palmar digital nerve, descend along the corresponding lumbrical surface of second to fourth metacarpal space, receive palmar metacarpal arteries and the perforating branch of dorsal metacarpal arteries near the metacarpophalangeal joint, and send out two proper palmar digital arteries at 1.2 cm from web edge. Ulnar palmar artery of quinary finger: It originates from ulnar margin of the convex side of superficial palmar arch, descends along the surface of thenar and distributes in the ulnar side of little finger. Deep palmar arc: It is located among flexor digitorum superficialis, flexor digitorum profundus, lumbricals, superficial head the flexor pollicis brevis, and the flexor digiti minimi brevis and interosseous muscle, transverse from the basement of first metacarpal space to the basement of fifth metacarpal space. The surface projection of the arch corresponds to the line from the proximal end of first metacarpal space to hamate bone. Deep palmar arch and its branches are accompanied by eponymous veins. Deep palmar arch is mainly composed of terminal branch of radial artery, outer diameter of middle part of which is

2.0 mm. The arc can be divided into two types according to whether the terminal branch of radial artery anastomoses with other arteries (Fig. 2.32). (1) Complete type: (accounts for 95%), the arch formed by the anastomosis of terminal branch of radial artery with ulnar palmar branch or other branches accounts for 55%, that formed by the anastomosis of terminal branch of the radial artery with the upper or lower palmar branch of ulnar palmar artery accounts for 30%, and that formed by the anastomosis of common palmar artery or ulnar palmar artery of the third finger accounts for 10%. (2) Incomplete type:(accounts for 5%), the terminal branch of radial artery runs inwards and does not anastomose with other branches. In fact, the terminal branch of radial artery has extensive anastomosis with other peripheral branches, which just are small. The terminal branch may become a perforating branch passing through the fourth metacarpal space to form the fourth dorsal metacarpal artery, or it may terminate at the fourth metacarpal space. The convex side of the deep arch gives off three palmar arteries, the concave side of the arc sends out two to four reverse branches to participate in the formation of palmar carpal rete, and the dorsal side of the arc sends out 3 penetrating branches to dorsum of hand.

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2 Anatomy of the Hand and Foot

a

b

Fig. 2.32 Position, composition, and branches of deep palmar arch. (a) Object specimen. (b) Cast specimen. (1) Deep palmar arc. (2) Superficial palmar arc. (3) Superficial palmar branch of radial artery. (4) Terminal branch of radial artery. (5) Deep palmar branch of ulnar

artery. (6) Terminal branch of ulnar branch. (7) Principal artery of thumb. (8) Common palmar digital arteries. (9) Proper palmar digital artery. (10) Ulnar palmar artery of quinary finger

Nerves Ulnar nerve, median nerve, and their branches are distributed on palm of hand (Fig. 2.33). Ulnar nerve: The main trunk passes on the superficial side of the flexor retinaculum, descending between radial side of pisiform bone and ulnar artery, and then on deep side of palmaris brevis to palm, which is divided into superficial and deep branches at laeral and lower part of pisiform bone. (1) Superficial branch of ulnar nerve: It runs medial to ulnar artery, gives off a branch to palmaris brevis, and divides into proper palmar digital nerve and common palmar digital nerve on deep surface of this muscle. Proper palmar digital nerve is distributed to ulnar margin of palmar surface of the little finger. Common palmar digital nerve is divided into two proper palmar digital nerves at web space which are distributed to the skin at opposite edge of the little finger and the ring finger (Fig. 2.34). (2) Deep branch of ulnar nerve: It runs with deep palmar branch of ulnar artery, passes through the beginning of hypothenar, accompanies by deep palmar arch, and branches to hypothenar, all interosseous muscles, lumbricals of the third and fourth finger, and adductor pollicis. The deep branch between pisiform bone and hamate

bone is superficial and easy to be injured, which presents as “clawed hand” after injury due to paralysis of adductor pollicis, interosseous muscles, and abductor digiti minimi. Median nerve: It enters palm through carpal canal and goes on deep side of superficial palmar arch (slightly to radial side) and superficial flexor tendon. It usually divides into two branches immediately after carpal canal. (1) Lateral branch: This branch is relatively smaller, which first produces a reverse branch and then divides into three proper palmar digital nerves, which are distributed on both sides of the thumb and radial palmar skin of the index finger respectively (Fig. 2.34). Reverse branch arises at the lower margin of flexor retinaculum and runs proximally around medial margin of flexor pollicis. The branches supply flexor pollicis, extensor pollicis, and opponens pollicis. The surface projection of median nerve is the midpoint of medial margin of thenar, which is equivalent to about 2.5 cm below carpal canal. So incision should not be made here in order to avoid the loss of thumb function caused by nerve injury. (2) Medial branch: This branch is relatively larger and immediately divides into two common palmar digital nerves. Accompanying the eponymous blood vessels to finger web,

2.2 Applied Anatomy of the Hand

a

Fig. 2.33 Ulnar nerve, median nerve, and the branches. (a) Median nerve ulnar nerve and the branches. (b) Course, branches of deep branch of ulnar nerve. (1) Ulnar nerve. (2) Pisiform bone. (3) Ulnar artery. (4) Superficial branch of ulnar nerve. (5) Deep branch of ulnar nerve. (6) Common palmar digital nerve. (7) Proper palmar digital

a

Fig. 2.34 Innervation of hand skin. (a) Anterior view. (b) Dorsal view

31

b

nerve. (8) Deep branch of ulnar artery. (9) Deep palmar arc. (10) Lateral branch. (11) Medial branch. (12) Reverse branch. (13) Abductor digiti minimi. (14) Flexor digiti minimi brevis. (15) Opponens digiti minimi. (16) Lumbricals. (17) Adductor pollicis (transverse head). (18) Adductor pollicis (oblique head). (19) Interosseous muscle

b

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2 Anatomy of the Hand and Foot

sending out two proper palmar digital nerves distributed on the skin of the opposite border of the second to the fourth finger on the proximal side of the artery branch. Median nerve also gives off muscle branches to supply the first and second lumbricals.

Nail A derived structure of dorsal skin consisting of multiple layers of tightly connected keratinized epithelial cells. It can protect the fingertip and support the function of the finger. It not only gives the finger beauty but also is vulnerable site to be injured.

2.2.3 Fingers

Subcutaneous Tissue The subcutaneous fat in palm of fingers is thick and accumulates into a ball, with fiber bundles in, connecting the skin to phalangeal periosteum and tendinous sheath (Fig. 2.35). When is infected, it often spreads to the deep layer. Finger dorsal subcutaneous fat is thin and loose, with a greater glide. Finger artery: Theoretically, each finger is supplied by two palmar and two dorsal digital arteries. Actually, the obvious trunk that can be seen by the naked eye is palmaral digital arteries, doral digital arteries are generally underdeveloped (except for the thumb) and is only a few scattered small branches. Dorsal digital artery: It is variety. The dorsal digital arteries of the index, middle, and ring fingers are derived from the corresponding dorsal metacarpal arteries (Fig. 2.36). Dorsal digital artery is mostly distributed to the proximal half of proximal phalangeal or to dorsal side of the proximal interphalangeal joint, but rarely to the distal phalangeal. The radial dorsal digital artery of thumb with an external diameter of about 0.5 mm, comes from the branch of the nasal cavity of radial artery. The ulnar dorsal digital artery originates

Fingers are connected with the palm by metacarpophalangeal joints, and the movement is very flexible. The thumb is thick and short, with only two phalanx bones, but it has the largest range of motion and can perform 50% of the hand function.

Superficial Structrues Skin The palmar skin of the fingers is thicker, rich in sweat glands and fingerprints, but without hair and sebaceous glands, so it is not easy to cause pain and swelling. In finger pulp, nerve endings are very rich, especially sensitive to touch to distinguish the shape and texture of objects. In the site of finger and palm crease, because there is no subcutaneous tissue, so the skin is directly connected with tendinous sheath, and when the wound is infected, often leads to tenosynovitis. Dorsal skin of finger is thinner, subcutaneous fat is less, and activity is bigger than palmar. The blood supply to the skin of fingers is rich and should be kept as much as possible in case of trauma or burns.

a

b

c

Fig. 2.35 Structures of finger. (a) Sagittal view (specimen). (b) Schematic diagram. (c) Cross-section of phalangette. (1) Phalangette. (2) Fat

2.2 Applied Anatomy of the Hand

33

Fig. 2.36 Origin of dorsal digital arteries. (1) Dorsal digital arteries. (2) Second metacarpal artery. (3) Anastomotic branch. (4) Proper palmar digital arteries

a

b

Fig. 2.37 The course, branch, and distribution of finger arteries. (a) Palmar view of middle finger. (b) Lateral view of middle finger. (c) Dorsal view of middle finger. (1) Proper digital arteries. (2) Dorsal

from first dorsal metacarpal artery with an external diameter of about 0.8 mm. The radial dorsal digital artery of little finger originates from fourth dorsal metacarpal artery, while the ulnar side originates from a branch of dorsal carpal artery, with an external diameter of 0.3–0.4 mm. Proper palmar digital arteries: The common palmar digital artery is divided into two proper palmar digital arteries in the metacarpal head plane. The latter runs distal along both sides of flexor digitorum tendon sheath and travels with the proper digital nerve in a narrow vascular and nerve bundle of osseous cutaneous ligament. Proper palmar digital artery is located on lateral and dorsal side of proper palmar digital nerve and its outer diameter is smaller than the nerve. According to this anatomical relationship, the arteries and nerves can be found successfully in finger replantation. Proper palmar digital artery sends out branches to c

metacarpal arteries. (3) Dorsal perforator branch. (4) Proper digital nerve. (5) Anastomotic branch

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a

2 Anatomy of the Hand and Foot

b

Fig. 2.38 Fingertip vascular network. (a) Palmar view. (b) Dorsal view. (1) Proper palmar digital artery. (2) Palmar digital arc. (3) Distal phalanx. (4) Proximal palmar arc. (5) Distal palmar arc. (6) Dorsal branch of middle phalanx. (7) Proximal dorsal arc. (8) Nail arterial network. (9) Distal dorsal arc Fig. 2.39 The course, branches, and distribution of thumb artery. (a) Palmar view of thumb. (b) Dorsal view of thumb. (1) Radial proper palmar artery of thumb. (2) Ulnar proper palmar artery of thumb. (3) Dorsal artery of thumb. (4) Radial dorsal cutaneous nerve of thumb. (5) Abductor pollicis longus. (6) Extensor pollicis longus. (7) Extensor pollicis brevis. (8) Abductor pollicis longus. (9) Dorsal perforator

a

palmar side and anastomosis to corresponding branches on opposite side to form the digital palmar arch and sends out several perforating arteries and articular branches to dorsum, distributed in dorsum, and interphalangeal joints of fingers (Fig. 2.37). In the distal phalanx, the main trunk of proper palmar digital artery gradually moved to medial side and anastomosed with the contralateral artery, forming fingertip vascular network. At the midpoint between nail bed and distal interphalangeal joint, a transverse anastomotic branch with a diameter of about 0.5 mm is produced at a constant rate, which anastomosis coincides with the contralateral homonymous branch to form distal dorsal digital arch (Fig. 2.38), that gives off five main branches distal on superficial of flexor digitorum. One on each side, with an outer diameter of 0.1–0.2 mm. There are three in the middle, representing the terminal branch of finger pulp, and the outer diameter is 0.2– 0.3 mm. The five main trunks intersect each other, and any of them can be anastomosed. There are ulnar and radial proper palmar digital arteries on the palm of thumb. The former is thicker with an initial outer diameter of 1.8 mm, which is mainly separated from the main artery of thumb, which is then released through the ulnar side of flexor pollicis longus, across between adductor pollicis insertion and the ulnar sesamoid bone to distal thumb. The latter is thinner, with an initial outer diameter of 1.1 mm, and originates from the main artery of thumb (85%) and superficial palmar branch of radial artery (15%), which arises after passing through deep surface of flexor pollicis b

2.2 Applied Anatomy of the Hand Fig. 2.40 Digital veins. (a) Cast specimen. (b) Object specimen

35

a

longus to the radial side, bypass the deep head free margin of flexor pollicis brevis, across between adductor pollicis longus and the radial sesamoid bone to distal thumb. The ulnar and radial proper palmar digital arteries give off branches in the distal direction of thumb palm, the lateral skin, soft tissue, etc. Meanwhile, the two arteries communicate with each other by means of a constant digital, metacarpal arch and pulp arc (Fig. 2.39). Digital veins The veins of fingers are divided into superficial and deep. Superficial palmar digital veins are close to skin, which is thin and arises from the ventral network of fingers. Three or four larger veins are anastomosed to the proximal side and anastomosed to network along the way, and branches by both sides to the dorsal, the adjacent superficial veins at web merge into venules and merge into dorsal digital veins (Fig. 2.40). Superficial dorsal digital vein is the main route of venous blood reflux, which has a certain pattern of movement between the subcutaneous and extensor digitorum. On both sides of the fingernail, one to two venules were synthesized from methyl to distal phalanx dorsal venules, with an external diameter of 0.5–0.6 mm and a net confluence towards the

b

proximal end. These converging venules form several veins with an external diameter of 0.8–1.0 mm on the dorsal side of the proximal interphalangeal joint, which tend to be concentrated in the dorsal part of the proximal phalangeal finger and form a network, and then form one to three layers of venous arch (Fig. 2.41). At the base of fingers, the venous arc adjacent to each other converge to form dorsal metacarpal vein or intercephalic vein. The distribution of superficial dorsal digital vein is as follows: (1) Focus on the clock face at 10–2 o’clock. (2) Off-center phenomenon: Taking the middle line of middle finger as the center line, the superficial dorsal vein of thumb and index finger is more to the radial side, and the diameter is also thick; the superficial dorsal vein of ring and little finger is more to the ulnar side. The phenomenon is most obvious in index and little finger. Deep digital vein is generally accompanied by proper palmar digital artery and dorsal digital artery, but diameter of the vein accompanied is smaller and the position is not constant. There are valves in digital veins. Dorsal veins of hand have a pair of venous valves spaced about 2 cm apart. The valve is opened from the distal end to the proximal end and from the palmar side to the dorsal end to ensure that venous

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2 Anatomy of the Hand and Foot

Fig. 2.41 The distribution type of superficial digital vein. (a) The distribution type of superficial digital vein in the dorsal digital aspect. (b) The distribution type of superficial digital vein in the distal volar digital

aspect. (c) The distribution type of superficial digital vein in the distal lateral digital aspect. (d) The distribution of superficial digital vein in the lateral digital aspect

blood flows from the distal end to the proximal end and from the palmar side to the dorsal end.

ficial flexor tendon and deep flexor tendon, which run in the tendinous sheath of each finger. At the proximal phalanx, flexor digitorum superficialis is located on the palmar side of flexor digitorum profundus, runs around flexor digitorum profundus, and then divides into two distal segments, attached to both sides of middle phalanx, between which a tendon hiatus is formed, allowing flexor digitorum profundus to pass through (Fig. 2.42a). Flexor digitorum profundus comes out of the hole of the tendon and ends at the bottom of

Flexor Digitorum Morphological Structure Characteristics of Flexor Digitorum Flexor digitorum include superficialis and profundus. Thumb has only one flexor tendon, and the other fingers have super-

2.2 Applied Anatomy of the Hand

a

37

b

Fig. 2.42 The shape of flexor digitorum of fingertip. (a) Object specimen. (b) Schematic diagram. (1) Flexor digitorum superficialis. (2) Flexor digitorum profundus. (3) Interossei. (4) Lumbricals. (5) Vincula

tendinum. (6) Mesotendon. (7) Extensor digitorum. (8) Aponeurosis dorsalis digiti

the phalanx. Flexor digitorum superficialis mainly bends proximal interphalangeal joint, metacarpophalangeal joint and carpal joint, and flexor digitorum profundus bends distal interphalangeal joint, also makes finger and wrist completely flexor.

Vincula tendinum is synovial plica located in the sheath of flexor digitorum, which can be divided into short vincula tendinum and long vincula tendinum according to their morphology. Each flexor digitorum has two types of vincula tendinum (Fig. 2.42b).Short vincula tendinum: There are

38

a

2 Anatomy of the Hand and Foot

b

c

Fig. 2.43 Flexor digitorum and tendinous sheath. (a) Object specimen. (b) Schematic diagram. (c) Cross section. (1) Synovial sheath of flexor digitorum. (2) Fibrous sheath. (3) Visceral layer of synovial sheath. (4)

Parietal layer of synovial sheath. (5) Mesotendon. (6) Phalanges. (7) Proper palmar digital vasculars and nerves

two triangles, located at the proximal end of superficial and deep flexor tendon, with the proximal edge free, the dorsal side attached to the midsagittal position palmar side of phalangeals, and the palmar side attached to the dorsal side of tendons. The blood supply comes from the branches of the palmar arterial arch and the small periosteum vessels at the stopping point, and the vessels anastomose with each other to form a vascular network. Long vincula tendinum: It is a long thin cable structure, and its shape, position, and number are not as constant as the short ones. Long vincula tendinum of flexor digitorum profundus is mostly directly or indirectly from short vincula tendinum of flexor digitorum superficialis which is issued near the insertion point and penetrates the center of flexor digitorum superficialis to flexor digitorum profundus.

Partition of flexor digitorum: Clinically, the therapeutic principles and functional prognosis of tendon injuries in different parts are also very different. Therefore, it is of clinical significance to divide the flexor digitorum by its location. The flexor digitorum is usually divided into five regions (Fig. 2.44). End of tendon (I or TI region): This region is from distal phalanx tendon to the middle of middle phalanx (the thumb is the middle of proximal phalanx), and proximal phalanx length is about 1.5 cm. There is only one flexor digitorum profundus or flexor pollicis, which is partially enclosed in tendinous sheath. There is a constant short vincula tendinum at the proximal phalanx and a good blood supply. The movement of tendon is small, and the early repair effect will be better. Sheath region (II region or T II region): Also known as “no man’s land.” This region is from the middle of middle phalanx to distal palmar crease. There are two flexor tendons in this region which are located in flexor tendinous sheath, and the blood supply is poor. Therefore, the surgical treatment of tendon injury in this region is difficult and ineffective. The thumb “T II region”, although only one flexor pollicis, is relatively simple, but on both sides of metacarpo-

Sheath Digitorum Sheath digitorum is the sheath tube surrounding flexor digitorum superficialis or flexor digitorum profundus, which is composed of synovial sheath and fibrous sheath of tendons (Fig. 2.43).

2.2 Applied Anatomy of the Hand

39

Fig. 2.44 Partition of flexor digitorum Fig. 2.45 The morphology of aponeurosis dorsalis digiti

phalangeal joint from two pieces of sesamoid clamping, from the narrow channel, in pathological situation, adhesion cannot be avoided. Palm region (III region or T III region): This region extends from distal palmar crease to distal margin of flexor retinaculum. In this segment, the flexor tendons of thumb and little finger are encapsulated by separate radial and ulnar synovial sacs. The flexor tendon of the middle three fingers is located in the space of loose connective tissue, surrounded by parathyroid tissue, with lumbrical muscle rising from flexor digitorum profundus. Carpal region (IV region): Located in a carpal tunnel which is a narrow passage. The nine flexor tendons in this region are crowded with median nerve, which is the site of nerve entrapment syndrome. Forearm region (V region): This region is above flexor retinaculum. In this region, there are more loose connective tissues, easy-to-perform tendon repair, and less postoperative adhesion, which has little influence on the sliding function of tendons.

Extensor Digitorum Morphological Structure Characteristics of Extensor Digitorum Extensor digitorum crosses the metacarpal head and the dorsum of proximal phalanx and expands to form aponeurosis dosalis digiti, also known as the tendon hood (Fig. 2.45). Aponeurosis dosalis digiti is divided into three longitudinal bands to the far side, and the middle band is forward. Some fibers from the two bands are added, ending at the base of middle phalanx and joint capsule. On either side of proximal phalanx two lateral bands are added from interosseous and lumbrical tendons running from the palm to the dorsum. The two lateral bands merge in the dorsal part of middle phalanx and then end at the dorsal part of distal phalanx and joint capsule. The main function of aponeurosis dosalis digiti is to stabilize the metacarpophalangeal joint and the interphalangeal joint and to provide the structural basis for internal muscles of hand. If extensor digitorum is ruptured and the joints

40

will be flexed. The proximal phalanx joint could not be straightened when the middle band is broken, and when the two lateral bands are ruptured, the distal phalangeal joint could not be extended. Partition of Extensor Digitorum According to The Verdan method, the extensor digitorum is divided into eight regions (Fig. 2.46). From far to near is: distal interphalangeal joint region (E I), middle phalanx region (E II), proximial interphalangeal joint region (EIII), proximial phalanx region (EIV), metacarpophalangeal joint region (EV), metacarpal region (EVI), carpal reigion (EVII), with forearm region (EVII). Thumb is divided into four regions, which are interphalangeal joint region (TEI), proximial interphalangeal joint region (TEII), metacarpophalangeal joint region (TEIII), and

Fig. 2.46 Partition of extensor digitorum

2 Anatomy of the Hand and Foot

metacarpal region (TEIV). Among them, the odd region corresponds to the joint, and the even region corresponds to the finger shaft. Extensor tendon injuries at different sites, bone and joint dysfunction, deformity, and treatment measures are not the same. Therefore, it is of clinical significance to subdivide extensor digitorum.

2.2.4 Bones of Hand Bones of hand are divided into carpal bones, metacarpal bones, and phalanges (Fig. 2.47).

Carpal Bones At the wrist, there are eight pieces, arranged in two rows. The proximal carpal bones are scaphoid bone, lunate bone, triquetral bone, and pisiform bone from outside to inside. The distal carpal bones are trapzium bone, trapezoid bone, capitate bone and hamate bone. All carpal bones are short bones, which are covered with a layer of dense outside, and cancellous inside. Generally cube, there are six sides, palm and dorsum are attached with ligament, appear rough, and the other four are connected to each other in a joint. Except that the palmar surface of lunate is wider and the dorsal surface is narrower, the others are opposite. Metacarpal Bone There are five metacarpal bones which are tubular bones, each with a base, shaft, and head. The base is an enlarged end, and the proximal side is related to the distal carpal bone, forming capometacarpal joint, but the articular surface is not consistent. The first, third, and fifth metacarpal bones are only connected to one carpal bone respectively; the second metacarpal bone is connected to trapezium and trapezoid bones and capitate bone; the fourth metacarpal bone is connected to capitate bone and hamate bone; therefore, capitate bone has articular surfaces that are connected to second to fourth metacarpal bones. The base of first metacarpal is sella-like and forms capometacarpal joint of thumb with trapezium bone. The two sides of metacarpal base are connected with the adjacent metacarpal base to form intermetacarpal joint, except for first metacarpal bone. The transverse section of shaft is triangular. Anterior margin of second, fourth, and fifth metacarpals are attached with palmar interossei. Anterior margin of third metacarpal is attached to transverse head of adductor pollicis. The adjacent margin of five metacarpal bodies is attached to dorsal interossei. The shaft of metacarpal is relatively thin and can easily cause fracture. Because of the strong strength of

2.2 Applied Anatomy of the Hand

a

41

b

Fig. 2.47 Bones of hand. (a) Palmar side. (b) Dorsal side. (1) Scaphoid bone. (2) Lunate bone. (3) Triquetral bone. (4) Pisiform bone. (5) Trapezium bone. (6) Trapezoid bone. (7) Capitate bone. (8) Hamate bone. (9) First metacarpal. (10) Second metacarpal. (11) Third metacar-

pal. (12) Fourth metacarpal. (13) Fifth metacarpal. (14) Base of metacarpal. (15) Shaft of metacarpal. (16) Head of metacarpal. (17) Proximal phalanx. (18) Middle phalanx. (19) Distal phalanx. (20) Base of phalanx. (21) Shaft of phalanx. (22) Head of phalanx

flexor muscle, the fracture piece often forms an angle to dorsal side. The head is round and its spherical articular surface is connected with the base of proximal phalanx to form metacarpophalangeal joint. Most of the joint surface is located on palmar side, while a small part is located in dorsal side. The convexity in the front and rear direction of the joint is greater than that in the transverse direction. When metacarpophalangeal joint flexed, proximal phalanx base sides forward, and metacarpal head is exposed and palpable on the body surface.

Phalanges of Finger Total of 14 pieces, except two thumb sections, the other for three sections, which are named proximal phalanx, middle phalanx, and distal phalanx. Each phalanx divides into three parts, namely base, shaft, and head. Base is broad with depressed ovoid articular surface; shaft is thin, with a flat and depressed palm, as a part of bone fibrous tube, abaxial surface is convex, which is covered by aponeurosis dorsalis digiti. Head is narrow, in the shape of a pulley, and there are two small condyles on the articular surface.

42

a

2 Anatomy of the Hand and Foot

b

Fig. 2.48 Joints and ligaments of hand. (a) Palmar side. (b) Dorsal side

J oints and Ligaments of Hand Joints of hand include radiocarpal, intercarpal, mediocarpal, capometacarpal, intermetacarpal, metacarpophalangeal, and interphalangeal joints (Fig. 2.48). Radiocarpal Joint It is a biaxial elliptic joint consisting of the radial wrist surface, lower surface of articular disc, and upper surface of scaphoid, lunate, and triquetral bones. The capsule is thin and loose which is enhanced by the around volar carpal ligament, dorsal carpal ligament, carpal radial collateral ligament, and carpal ulnar collateral ligament. Thin layers of cartilage cover the articular surface and articular head. The joint space is broad. The radiocarpal joint is a unified functional whole during movement. Intercarpal Joint The proximal intercarpal joint is composed of scaphoid, lunate and triquetral bones and belongs to fretter plane joint which is enhanced by intercarpal volar ligament, intercarpal dorsal ligament, and intercarpal interosseous ligament. In addition, pisiform bone joint is formed with pisiform bone and triquetral bone, with an independent joint capsule and joint cavity, and is enhanced by pisiform palm ligament and pisiform lunate ligament. The distal intercarpal joint is composed of trapezium, trapezoid, capitate bone, and hamate bones and belongs to fretter plane joint which is also enhanced by intercarpal volar ligament, intercarpal dorsal ligament, and intercarpal interosseous ligament. Mediocarpal Joint This joint is a deformed plane joint between two rows of carpal bones, which is actually an elliptical joint. The articular surface is curved in the shape of ~. The trapezium and

trapezoid bones on the outer side form concave surface to connect with scaphoid bone, while the medial cephaloid bone and humate bone form convex surface to connect with scaphoid bone, lunate bone, and triquetral bone. The joint cavity is very large, and the left and right sides are completely connected. It can also be communicated with the proximal and distal carpal interarticular cavities. The capsule is enhanced by carpal radiate ligaments and dorsal intercarpal ligaments. Intermetacarpal Joint There are three intermetacarpal joints, which are located at the bottom of the second to fifth metacarpal bones. They are fretter plane joints that are related to the capsule respectively. The joint cavity is communicated with the carpal metacarpal joint. The joint capsule is enhanced by metacarpal, dorsal and interosseous ligaments of metacarpal. Metacarpophalangeal Joint It is a ball and socket joint composed of the metacarpal head and the proximal phalanx bottom can do flexion and extension, retraction and rotation, but the thumb metacarpophalangeal joint is flexion joint, and can only do flexion and extension movement. The volar ligaments around the capsule are also called palmar plate and collateral ligaments. The second to fifth metacarpal heads are connected by deep transverse ligament. Interphalangeal Joint Interphalanx joint is composed of proximal phalanx bones and middle phalanx bones and distal phalanx bones, a total of nine, belonging to axial trochlear joint. The capsule is loose and thin, and the capsule is surrounded by enhanced volar ligaments (i.e., palmar plate), collateral ligaments, and collateral ligaments.

2.3 Applied Anatomy of the Foot

2.3 Applied Anatomy of the Foot 2.3.1 Dorsum of the Foot Superficial Structures The dorsum of foot is similar to that of hand, thinner and more mobile, with loose superficial fascia and lack of fat. Therefore, the superficial veins, tendons, and other structures in the deep surface of the skin are clearly visible. When edema occurs, the subcutaneous tissue of dorsal foot is swollen, especially in front of and around the medial malleolus. Superficial veins: The abundant superficial veins in the superficial fascia form dorsal venous arch of foot, whose

a

Fig. 2.49 Dorsal superficial structures of foot. (a) Superficial veins. (b) Cutaneous nerves. (1) Arcus venosus dorsalis pedis. (2) Great saphenous vein. (3) Small saphenous vein. (4) Dorsal digital vein of toe. (5) Medial cutaneous nerve of foot. (6) Medial dorsal cutaneous nerve

43

inner and outer ends back along the two sides of the foot dorsal edge to the ankle on both sides, gradually proceed upward to great saphenous vein and small saphenous vein (Fig. 2.49a). Great saphenous vein passes in front of the medial malleolus in the premalleolus region and is accompanied by saphenous nerve. Superficial lymph vessels: Lymph vessels are also similar to veins, forming a rich network of lymphatic vessels. The superficial lymphatic network of distal palm of foot flows into dorsal lymphatic network at the webs. Cutaneous nerves: There are four cutaneous nerves in dorsal area of foot (Fig. 2.49b): (1) Saphenous nerve (terminal branch of femoral nerve) distributes in medial dorsal

b

of foot. (7) Middle dorsal cutaneous nerve of foot. (8) Lateral dorsal cutaneous nerve of foot. (9) Deep peroneal nerve. (10) Dorsalis pedis artery. (11) First dorsal metatarsal artery

44

a

2 Anatomy of the Hand and Foot

b

c

Fig. 2.50 Dorsal deep structures of foot. (a) Superior layer of dorsal foot; (b) Deep layer of dorsal foot; (c) Schematic of dorsal deep structures. (1) Superior extensor retinaculum. (2) Inferior extensor retinaculum. (3) Extensor longus tendon of great toe. (4) Extensor digitorum

longus tendon. (5) Third peroneus muscle. (6) Dorsal artery of foot. (7) Extensor brevis tendon of great toe. (8) Deep peroneal nerve. (9) First dorsal metatarsal artery. (10) Extensor digitorum brevis. (11) Tendinous sheath

margin of foot; (2) Medial dorsal cutaneous nerve of foot and middle dorsal cutaneous nerve of foot (the terminal branch of superficial peroneal nerve) distribute in the medial dorsal and middle part of foot; (3) Lateral dorsal cutaneous nerve (the terminal branch of sural nerve) distributes in lateral dorsopart of foot; (4) The terminal branch of deep peroneal nerve penetrates the fascia to the skin at the web between first and second toe and distributes in the skin at the opposite edge.

the medial one; extensor longus tendon of great toe, extensor digitorum longus tendon, and third peroneus muscle passing through the lateral one (Fig. 2.50); (2) inferior extensor retinaculum (also called cruciate ligament): distal to superior extensor retinaculum, located at the junction of anterior ankle region and dorsum of foot, also formed by local thickening of deep fascia. The lateral end is attached to the lateral surface of calcaneus. The medial end is divided into upper and lower bands attached to the medial malleolus and first cuneiform bone respectively. Inferior extensor retinaculum gives off fibrous septum to deep bone surface and forms three osteofibrous canals: medial, middle, and lateral. Tibialis anterior in medial canal, extensor longus tendon of great toe, dorsal vessels of foot and deep peroneal nerve in middle canal, extensor digitorum longus tendon, and third peroneus muscle in lateral canal. Dorsal facial and facial spaces of foot: Dorsal fascia of foot can be divided into superficial and deep layers. The superficial layer is the continuation of inferior extensor retinaculum, which is attached to periosteum of medial and lat-

Deep Structures Extensor retinaculum Continuation from deep fascia of the lower leg, local thickening in the anterior malleolus region, formed two extensor retinaculums, which are: (1) superior extensor retinaculum (also called ligamentum transversum cruris): It is a wide band located at the junction of lower end of the calf and ankle, between the lower end of tibia and fibula, formed by thickening of the transverse fibers of deep fascia in front of the lower leg. There are two spaces in deep surface, tibialis anterior, anterior tibial vessels, and deep peroneal nerve passing through

45

2.3 Applied Anatomy of the Foot

a

b

Fig. 2.51 Dorsal muscles and tendons of foot. (a) Dorsal external tendons of foot. (b) Dorsal intrinsic muscles of foot. (1) Extensor brevis of great toe. (2) Extensor digitorum brevis. (3) Dorsal vein of foot. (4)

Extensor longus of great toe. (5) Extensor digitorum longus. (6) Third peroneus muscle. (7) Tibialis anterior. (8) Tibialis posterior. (9) Dorsal metatarsal artery

eral edges of foot. The deep layer is also known as dorsal interosseous fascia, which is attached to the surface of interosseous dorsal muscle and periosteum of metatarsal bones. The dorsal fascia space between the superficial and deep layers accommodates extensor digitorum longus tendon and tendinous sheath, extensor digitorum brevis and its tendinous sheath, dorsal artery and its branches, associated veins, and deep peroneal nerve. Dorsal muscles of foot: They are extensor brevis of great toe and extensor digitorum brevis (Fig. 2.51, Table 2.2).

Table 2.2 Dorsal muscles of foot Name Extensor brevis of great toe Extensor digitorum brevis

Origin Anterior upper and lateral sides of calcaneus Anterior upper and lateral sides of calcaneus

Insertion The base of the proximal phalange of great toe The base of the proximal phalanges of second to fourth digits

Function Extend great toe

Extend second to fourth toes

Innervation Deep peroneal nerve (L4–S2)

46

2 Anatomy of the Hand and Foot

a

b

c

d

Fig. 2.52 Lateral dorsal vessels of foot. (1) Dorsal artery of foot. (2) Lateral supramalleolar artery. (3) Lateral tarsal artery. (4) Second lateral tarsal artery. (5) Arcuate artery. (6) Dorsal perforator of plantar arc. (7) Dorsal metatarsal artery

Dorsal artery of foot: It is the main source of blood supply for toes and continues to anterior tibial artery at the lower margin of superior extensor retinaculum. Usually, it goes down the lateral side of extensor longus tendon of great toe and reaches the first metatarsal space through the deep surface of MU extensor brevis of great toe, which is divided into two terminal branches: deep plantar branch and first dorsal metatarsal artery. The former reaches the plantar and anastomoses with lateral plantar artery to form plantar arch. The latter is distributed on dorsal part of great toe and medial part of dorsal part of second toe. Branches of dorsal artery of foot include lateral tarsal artery, medial tarsal artery, arcuate artery, and cutaneous perforator (Fig. 2.52). Deep peroneal nerve: In dorsal area of foot most line at the inside of dorsal artery of foot, gives off muscle branches that dominate dorsal muscles of foot. The terminal branch becomes a cutaneous branch, divided into two dorsal digital nerves of toe that distribute to the skin on dorsal side of the opposite edge of first and second toe after coming through the first metatarsal space. Once the deep peroneal nerve is injuried, the muscle cannot extend ankle joint and toes.

2.3.2 Planta Pedis Superficial Structures The skin is thick, dense, and tough, with small mobility, especially in the following parts, such as the heel, first and fifth metatarsal bones that are weight support points, which is easy to form callose due to friction thickening. Dense fibrous bundles in superficial fascia connect the skin to deep plantar fascia closely, and there is a lot of fat between the bundles, forming fibrous fat pads, which can play the role of seismic buffer. In addition, the plantar skin is hairless, but the sweat glands are rich and sensitive. Deep Structures Deep structures are mainly plantar fascia, plantar nerves, and blood vessels. The deep fascia is divided into two layers: The plantar aponeurosis is formed by the superficial layer covering the plantar muscle surface, which is thin on both sides and thick in the middle, just like palmar aponeurosis. The deep layer covers the plantar side of interosseous muscle, also known as plantar interosseous fascia (Fig. 2.53).

2.3 Applied Anatomy of the Foot

a

47

b

c

d

Fig. 2.53 Structures of plantar pedis. (a) Morphology of aponeurosis plantaris. (b) Plantar nerve, arteries, and veins at the superficial layer. (c) Plantar nerve, arteries, and veins at the middle layer. (d) Plantar nerve, arteries, and veins at the deep layer. (1) Middle bund (plantar aponeurosis). (2) Lateral bund (plantar aponeurosis). (3) Medial bund (plantar aponeurosis). (4) Abductor pollicis of toe. (5) Abductor digitorum minimi. (6) Proper nerve at the base of first toe. (7) Transverse bund. (8) Common nerves, arteries, and veins at the base of toes. (9)

Superficial branch (lateral plantar nerve). (10) Flexor pollicis brevis of toe. (11) Flexor digitorum minimi. (12) Flexor digitorum brevis. (13) Lumbricals. (14) Plantar metatarsal artery. (15) Quadratus plantae. (16) Lateral plantar artery. (17) Medial plantar artery. (18) Flexor digitorum longus. (19) Oblique head (adductor pollicis of toe). (20) Transverse head (adductor pollicis of toe). (21) Plantar interosseous fascia. (22) Proper nerve, arteries, and veins at the base of toes. (23) Flexor digitorum brevis

Plantar aponeurosis: It is a long triangle with narrow posterior end, attached to the medial part of the anterior margin of calcaneal tubercle, and its front end is fan-shaped into 5 bands to the tendon sheath of each toe. It gives off two muscular spaces, ending at first and fifth metatarsals respectively, which divide the plantar pedis into three osteofascial sheaths: medial, middle and lateral. (1) Medial osteofascial sheath: It is medial to first metatarsal bone, accommodating abductor pollicis of toe, flexor pollicis brevis of toe, flexor pollicis longus of toe, and its blood vessels and nerves; (2) middle osteofascial sheath: It is located between the lateral side of first metatarsal and the medial side of fifth metatarsal, accommodating flexor digitorum brevis, quadratus plantar, adductor pollicis of toe, flexor digitorum longus, lumbricals, lateral plantar nerve and branches, plantar artery arch and branches, etc. (3) Lateral osteofascial sheath: Lateral to fifth metatarsal bone, accommodating abductor digitorum minimi, flexor digitorum brevis minimi, as well as its blood vessels and nerves.

These muscles in fascia sheath and tendons from calf posterior muscle group are arranged in four layers on plantar to maintain arch of foot. Abductor pollicis of toe, flexor digitorum brevis, and abductor digitorum minimi are in the first layer. Quadratus plantae, lumbricals, flexor digitorum longus and flexor pollicis longus of toe are in the second layer. Flexor pollicis brevis of toe, adductor pollicis of toe, flexor digitorum brevis minimi are in the third layer. Three plantar interossei and four dorsal interossei are in the fourth layer (Table 2.3). Blood vessels and nerves of plantar pedis Posterior tibial artery and tibial nerve are divided into medial and lateral plantar arteries and medial and lateral plantar nerves respectively when they cross malleolar canal. Medial plantar artery is the smaller of the two terminal branches, which runs along plantar pedis with the eponymous vein and nerve, moves forward along the medial margin and distributes in adjacent tissues, and its end is anastomosed with first to third plantar arteries digital. Lateral plantar artery is larger, accompanied by the eponym vein and nerve oblique forward, pen-

2 Anatomy of the Hand and Foot

48 Table 2.3 Plantar muscles Muscle groups The median group

The middle group

The lateral group

Name Origin Abductor pollicis Medial process of calcaneal of toe tuberosity, Tuberositas ossis navicularis FLexor pollicis Plantar surface of medial brevis of toe cuneiform bone and tibialis posterior Adductor pollicis Oblique head: Long plantar of toe ligament, tendon sheath of peroneus longus: Second to fourth metatarsal base Transverse head: Third to fifth metatarsophalangeal joint capsule Quadratus plantae Under calcaneal and long plantar ligament Flexor digitorum Medial process of calcaneal brevis tuberosity and plantar aponeurosis Lumbricals Flexor digitorum longus

Plantar interossei

Medial surface of third to fifth metatarsal bones

Drosal interossei

Opposite sides of metatarsal bones

Abductor The bottom of calcaneal digitorum minimi tuberosity Flexor digitorum Fifth metatarsal base brevis minimi

Insertion The plantar and medial surfaces of proximal phalange base of great toe Medial side of the plantar surface of proximal phalange base of great toe The plantar surface of proximal phalange base of great toe

Function Abduce great toe, Maintain plantar arch of foot

Innervation Medial plantar nerve (L4, 5)

Flex great toe

Adduct and flex great toe

Lateral plantar nerve (S1–2)

Flexor digitorum longus

Flex second to fifth toes

Middle phalange bases of second to fifth toes

Flex second to fifth toes

Medial plantar nerve (S4–5)

Aponeurosis dorsalis digitorum

Flex second to fifth metatarsophalangeal joints, extense interphalangeal joints Adduct third to fifth toes

Medial and lateral plantar nerves (L4–S2) Lateral plantar nerve (S1–2)

Proximal phalange bases of third to fifth toes, aponeurosis dorsalis digitorum Abduce second to fourth toes Proximal phalange bases of second to fourth toes, aponeurosis dorsalis digitorum Proximal phalange base of Flex and adduct little toe little toe Flex little toe

a

b

Fig. 2.54 Blood vessels of plantar pedis. (a) Composition and branches of plantar arc of foot. (b) Anastomosis of plantar artery and dorsal artery of foot. (1) Medial plantar artery. (2) Lateral plantar artery. (3)

Plantar deep arc. (4) Plantar arc of foot. (5) Plantar artery digital. (6) First plantar artery digital. (7) Toe base proper artery. (8) Perforator. (9) Lateral tarsal artery. (10) Dorsal artery of foot

etrating the deep surface of flexor digitorum brevis to the lateral plantar margin, branches distributed in adjacent tissues. The terminal branch curves inwards to the first metatarsal space and anastomose with the deep plantar branch of dorsal artery of foot to form plantar arch of foot, from which plantar arch gives off four plantar arteries distributed in each toe. Medial plantar nerve runs with the eponymous artery,

and the muscular branches supply the muscles of medial plantar group and first and second lumbricals. Cutaneous branches supply the skin on medial half of plantar pedis and medial three-and-a-half toes. Lateral plantar nerve runs with the eponymous artery, and muscular branches supply the lateral group muscles, the skin on lateral half of plantar pedis, and lateral one-and-a-half toes (Fig. 2.54).

2.3 Applied Anatomy of the Foot

49

a

b

Fig. 2.55 The structures of a toenail. (a) Sagittal plane. (b) Horizontal plane. (1) Nail body. (2) Nail root. (3) Free edge. (4) Nail bed. (5) Nail stroma. (6) Distal phalange of toe. (7) Eponychium. (8) Nail fold. (9) Hyponychium. (10) Nail sinus

a

b

c

d

e

Fig. 2.56 Plantar hierarchical structure of great toe. (a) Cutaneous plantar venous network. (b) Superficial transverse metacarpal ligament and plantar nerve and vessels. (c) Plantar tendons, nerve, and vessels of great toe. (d) Transverse head and oblique head of adductor hallux. (e) Plantar interosseous muscles. (1) Interphalangeal veins. (2) Cutaneous plantar venous arch. (3) Cutaneous plantar venous network. (4) Plantar proper nerve, arteries, and veins. (5) Plantar cutaneous venous arch. (6)

Deep branch of medial plantar artery. (7) Common plantar nerve. (8) Flexor digitorum longus tendon. (9) Flexor digitorum brevis tendon. (10) Lumbrical muscles. (11) Flexor hallucis longus tendon. (12) Hallux abductor. (13) Transverse head of hallux adductor. (14) Oblique head of hallux adductor. (15) Plantar artery. (16) Flexor digitorum brevis. (17) Flexor hallucis longus tendon. (18) Plantar interosseous muscles

2.3.3 Toes

phalangeal periosteum and tendinous sheath. Toe dorsal subcutaneous fat is thin and loose, with a greater glide.

Superficial Structrues Skin The plantar skin of toes is thicker, rich in sweat glands and toe prints, but without hair and sebaceous glands, so it is not easy to cause pain and swelling. In toe pulp, nerve endings are very rich, especially sensitive to touch to distinguish the shape and texture of objects. Dorsal skin of toe is thinner, subcutaneous fat is less, and activity is bigger than plantar. The blood supply to the skin of toes is rich. Toe Nail It is similar to nail (Fig. 2.55). Subcutaneous Tissue The subcutaneous fat in plantar of toes is thick and accumulates into a ball, with fiber bundles in, connecting the skin to

Veins of Toe Each toe has two dorsal digital veins of toe, which originate from nail bed vein plexus, run backward along, and connect to form dorsal metatarsal vein at toe web. There are three to four shorter ones, and then they flow into dorsal venous arch of foot (Fig. 2.56). Nerves of Toe Dorsal medial cutaneous nerve of foot originates from superficial peroneal nerve and distributes the skin of the medial margin of foot and great toe. Medial dorsal cutaneous nerve of foot originates from superficial peroneal nerve and distributes the skin of dorsal foot and second toe web. Deep peroneal nerve divides into two terminal branches in front of the ankle. The medial branch travels along the first

50

2 Anatomy of the Hand and Foot

a

b

Fig. 2.57 Blood vessels of toe. (a) Dorsal blood vessels of toe (the flap turned from tibia to fibular). (b) Plantar blood vessels of toe. (1) Dorsal artery of foot. (2) First dorsal metatarsal artery. (3) Dorsal artery of great

toe. (4) Plantar deep arc. (5) First plantar metatarsal artery. (6) Common plantar digitorum artery. (7) Tibia common plantar digitorum artery of great toe. (8) Fibular common plantar digitorum artery of great toe

metatarsal space and gives off dorsal lateral nerve of great toe and dorsal lateral nerve of second toe, which innervate the skin adjacent to great toe and second toe, as well as the first dorsal interossei, intertarsal joint and metatarsophalangeal joint.

toe. Extensor pollicis brevis of toe and extensor digitorum brevis run laterally to the deep surface of extensor longus, and fuse with extensor longus to form dorsal aponeurosis of toe on the dorsal side of proximal phalanx. First dorsal interossei originate from the opposite plane of first and second metatarsal bodies, passing through deep transverse ligament that reaches the medial side of the base of proximal phalanges of second toe and dorsal aponeurosis of toe.

Deep Structures Tendons of Toe Dorsal aponeurosis of toe or extensor device is similar to that of finger, located on dorsum of toe. Dorsal aponeurosis of toe is less functionally important than aponeurosis dorsalis digiti and unlike hand, lacks sagittal band, tendinous cap, and support band system. Extensor pollicis longus of great toe passes along the dorsal side of first metatarsal bone and terminates at aponeurosis of great toe. Extensor longus of toe goes forward along dorsum of foot and terminates at aponeurosis of second to fifth

Arteries of Toe Each toe is supplied by four arteries: tibial and fibular dorsal digitorum arteries, and tibial and fibular plantar digitorum arteries (Fig. 2.57). They are the continuation of dorsal metatarsal artery and plantar metatarsal artery, respectively, and become terminal branches. First dorsal metatarsal artery: It originates from dorsal artery of foot before that penetrates plantar pedis, and moves forward along the surface of first dorsal interossei, and

2.3 Applied Anatomy of the Foot

51

divides into three dorsal arteries of toe at the proximal phalangeal bone. The medial one is distributed on the medial margin of great toe through the deep surface of extensor pollicis longus of great toe, while the lateral two are distributed on the adjacent sides of first and second toes. The distal end of first dorsal metatarsal artery can be connected to fibular common plantar digitorum artery of great toe (49%), to the bifurcation of tibial common plantar digitorum artery of second toe, and fibular common plantar digitorum artery of great toe (23%), or the blood supply of the great toe is mainly supplied by the branch of first dorsal metatarsal artery (38%). Therefore, in second toe transfer, Fig. 2.58 Bones of foot. (a) Dorsal side. (b) Plantar side. (1) Talus. (2) Calcaneus. (3) Navicular bone. (4) Tuberositas ossis navicularis. (5) Cuboid bone. (6) First cuneiform bone. (7) Second cuneiform bone (8) Third cuneiform bone. (9) First metatarsal bone. (10) Second metatarsal bone. (11) Third metatarsal bone. (12) Fourth metatarsal bone. (13) Fifth metatarsal bone. (14) Tuberosity of fifth metatarsal bone. (15) Base of metatarsal bone. (16) Shaft of metatarsal bone. (17) Metatarsal bone head. (18) Base of phalanges. (19) Shaft of phalanges. (20) Trochlear of phalanges. (21) Proximal phalanges. (22) Middle phalanges. (23) Distal phalanges. (24) Sesamoid bone

a

second dorsal metatarsal artery or second plantar metatarsal artery should be considered as the supplying artery, rather than first dorsal metatarsal artery.

Bones of Foot Bones of foot include tarsals, metatarsals, and phalanges (Fig. 2.58). Tarsal Bone There are seven tarsal bones, which are equivalent to carpal bones of hand, but tarsal bones not only bear weight but also transmit strong jumping force, so their shape, size, and b

52

arrangement are different from carpal bones. Tarsal bones are large and tightly assembled, forming the posterior half of bones of foot. Talus

Above the other tarsal bones, it has three parts: head, neck, and body. The front end is the round head, the back of the head is the neck, and then it is the larger body. The upper part of the body is called trochlea of talus, and the upper part is connected with the inferior tibial articular surface. The medial half-moon articular surface is related to the medial malleolus, and the lateral triangle articular surface is related to the lateral malleolus. There are three articular surfaces below the body, namely, anterior, middle, and posterior, respectively, corresponding with articular surface above calcaneus. There is an oblique and outward sulci tali between the middle and posterior articular surfaces. Calcaneus

The largest, approximately oblong, is located below talus, with the anterior two-third supporting talus and the posterior one-third forming bulge of calcaneus. There are also three articular surfaces on calcaneus, the posterior articular surface corresponds to the posterior articular surface of talus and forms talocalcaneal joint, and the anterior and middle articular surfaces, together with talus and navicular bone, form talocalcaneonavicular joint. There is also a bone groove between middle and posterior articular surface which is conformed with sulci tali and forms tarsal sinus. The medial side of the calcaneus has sustentaculum talus, which supports talus. The posterior end forms calcaneal tubercle, and the anterior articular surface connects with cuboid bone. Navicular Bone

It is located between the head of talus and the three cuneiform bones and is articulated with cuneiform bones on anterior side, the posteriorly adjacent to talus, the medial eminence is tuberositas ossis navicularis, which is easily palpable in vivo. Cuboid Bone

It is an irregular cube between calcaneus and fourth and fifth metatarsals. The posterior part is involved in forming calcaneocuboid joint. The anterior part, fourth and fifth metatarsals form tarsometatarsal joint. The middle part of medial surface may be articulated with third cuneiform bone. Cuneiform Bones

There are three, wedge-shaped, wide at the top and narrow at the bottom, laid between navicular bone and the first, second, and third metatarsal bones. The first and third metatarsal bones are longer, while the second metatarsal bone is the

2 Anatomy of the Hand and Foot

shortest. Therefore, the second metatarsal bone is relatively fixed between the three metatarsal bones. Metatarsal Bones Metatarsal bones, roughly similar to metacarpal bones, are short, tubular bones located between the tarsal bones and phalanges of toe and forms the middle part of foot. There are five pieces, whose shape and arrangement are roughly similar to metacarpal bones but longer and wider. The lateral side of the bottom of fifth metatarsal bone is particularly enlarged, forming tuberosity of the fifth metatarsal bone, which is easily palpable in vivo. Phalanges of Toe The phalanges of toe are roughly similar to phalanges of finger, with a total of 14. Except for phalanges of great toe, which are strong and have two segments, the other phalanges of toe are far smaller than the phalanges of finger, all of which are three segments.

J oints and Ligaments of Foot The joints of foot include talocrural (ankle) joint, intertarsal joint, tarsometatarsal joint, intermetatarsal joint, metatarsophalangeal joint, and interphalangeal joint of foot (Fig. 2.59). Ankle (Talocrural)Joint The bony component of ankle joint is composed of the inferior tibial articular surface, the ankle articular surface and the ankle articular surface of fibula and the upper, medial and lateral ankle articular surface of talus. The lateral malleolus is flat and long, 0.5 cm longer than the medial malleolus, and it moves backward about 1 cm. The articular surface of lower tibia is concave and the medial malleolus is blunt and conical. The joint capsule starts from the inferior articular surface of tibia and the periphery of tibial and fibular anklebone and ends down at the edge of trochlea of talus and above talus neck. The synovial membrane of joint capsule not only covers the inner surface of fibrous membrane, but also reaches interosseous ligament along tibia and fibula. The anterior and posterior walls of the capsule are thin and loose, the lateral walls are tense, and strengthened by tough collateral ligaments, including: (1) Tibial collateral ligament, also known as triangular ligament, is a strong triangular bundle of fibers located on the medial side of the joint and is closely attached to the joint capsule. It starts from the anterior and posterior margin and tip of medial malleolus and fanning down to tarsal bones. According to the different attachment sites of the fibers in each part of the ligament, the ligament can be divided into four parts: posterior tibial part, heel tibial part, navicular tibial part, and anterior tibial part (Fig. 2.59, Table 2.4). (2) Lateral collateral ligament: It is connected between lateral malleolus, talus, and calcaneus, and consisted of three independent ligaments.

2.3 Applied Anatomy of the Foot

53

a

c

b

Fig. 2.59 Ligaments of foot. (a) Medial side view. (b) Lateral side view. (c) Plantar side view. (1) Calcaneotibial ligament. (2) Tibionavicular ligament. (3) Posterior talotibial ligament. (4) Anterior talotibial ligament. (5) Plantar calcaneonavicular ligament. (6) Calcaneocuboid ligament. (7) Plantar ligament longus. (8) Medial talo-

calcaneal ligament. (9) Posterior talocalcaneal ligament. (10) Peroneus longus. (11) Plantar calcaneocuboid ligament. (12) Plantar calcaneonavicular ligament. (13) Tibialis anterior. (14) Tibialis posterior. (15) Peroneus longus. (16) Plantar metatarsal ligament. (17) Plantar metatarsal ligament

Table 2.4 ligaments of talocrural joint and intertarsal joint Name Tibial collateral ligament

Posterior talotibial ligament Calcaneotibial ligament Tibionavicular ligament Anterior talotibial ligament Lateral collateral Anterior talofibular ligament ligament Calcaneofibular ligament Posterior talofibular ligament

Origin Posterior margin of medial malleolus Tip of medial malleolus

Course Oblique backward and down Down

Insertion Medial side of the talus, small nodules on posterior process of talus Parentalus process of calcaneus

Anterior margin of medial malleolus Anterior margin of medial malleolus Anterior margin of lateral malleolus Slightly anterior of tip of lateral malleolus Posterior margin of lateral malleolus

Oblique forward and Tuberositas ossis navicularis, medial margin of down plantar calcaneonavicular ligament Oblique forward Anterior margin of the medial malleolus articular surface of talus Forward and inside Anterior to lateral malleolus articular surface of talus, lateral side of talus neck Oblique backward Small tubercle on the lateral surface of calcaneus and down Transverse backward Process of posterior side of talus and inside

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Intertarsal Joints There are many intertarsal joints, including subtalar (talocalcaneal) joint, talocalcaneonavicular joint, calcaneocuboid joint, transverse tarsal joint, intercuneiform joints, cuneonavicular joint, and cuneocuboid joint.

2 Anatomy of the Hand and Foot

and attaches forwards to the upper part of cuboid bone; (4) Dorsal talonavicular ligament: It is broad and thin, starting from the upper and lateral sides of the neck of talus and above navicular bone. Calcaneocuboid Joint

Subtalar (Talo-Calcaneal) Joint

The bony composition consists of the posterior articular surface of talus and the posterior articular surface of calcaneus. The joint capsule is thin and flabby, attached to the periphery of the joint surface. The synovial layer is independent and does not communicate with other joints. There are four ligaments around the capsule. (1) Anterior talocalcaneal ligament: Posterior to the entrance of tarsal sinus, starting from the neck of talus and ending above calcaneus; (2) posterior talocalcaneal ligament: It starts from posterior process of talus and the groove of lower edge of flexor longus of great toe, and stops at the posterior articular surface of calcaneus. (3) medial talocalcaneal ligament: It is thin and strong, starting from the medial side of posterior process of talus (tibial tubercle), oblique forward and below, ending at the posterior part of calcaneal parientalis; (4) lateral talocalcaneal ligament: It is oblate and short, located anteriorly above calcaneofibular ligament, starting from external process of talus, extending posteriorly and terminating on the lateral surface of calcaneus which has the effect that prevents backward dislocation. Talocalcaneonavicular Joint

The articular head is the navicular articular surface of talus, and the articular fossa consists of the posterior articular surface of navicular bone, the anterior articular surface and the middle articular surface of calcaneus, and the upper part of plantar calcaneonavicular ligament. The capsule attaches to the periphery of the articular cartilage and is thinner at the front and thicker at the back. There are the following ligaments around the joint. (1) Talocalcaneal ligament is made up of a number of strong fibrous bundles. Starting from the top of tarsal sinus, oblique outward and downward, ending in front of the posterior articular surface of calcaneus and migrating with the anterior wall of talocalcaneal capsule. Prevent backward dislocation of foot; (2) plantar calcaneonavicular ligament: It is strong and hypertrophic and consists of fibrous cartilage. Starting from the anterior margin of calcaneal parentalus process and ending below and medial to navicular bone. (3) Bifurcate ligament: It is a strong ligament, divided into two parts, medial and lateral. The medial part is called calcaneonavicular ligament, which is obliquely forward medially and terminates at the lateral side of navicular bone. The upper and lower parts of this ligament fuse with dorsal and plantar calcaneonavicular ligament, respectively. The lateral part is called calcanocuboid ligament

Calcaneocuboid joint is consisted of the cuboid articular surface of calcaneus and the posterior articular surface of cuboid bone. The capsule is attached to the periphery of the articular cartilage. The articular cavity is sometimes communicated with talocalcaneonavicular joint. The peripheral ligaments include: (1) calcaneocuboid part of bifurcate ligament; (2) dorsal calcanocuboid ligament; (3) long plantar ligament, and; (4) plantar calcanocuboid ligament. Slight sliding and rotation of calcaneocuboid joint may occur when the foot is varus or valgus. Calcaneocuboid joint and talocalcaneonavicular joint form transverse tarsal joint, and the joint line is “S” shaped across the middle division of the tarsal bone group. The two joint cavities are not communicated with each other, so they are actually two independent joints anatomically. Clinically, amputation is often performed along this joint line. Cuneonavicular Joint

It is usually syndesmosis, located between the lateral margin of navicular bone and the medial margin of cuboid bone, but the joint formation is not uncommon. There are three ligaments around the joint: (1) dorsal cuneonavicular ligament; (2) plantar cuneonavicular ligament, and; (3) inter cuneonavicular ligament. Cuneocuboid Joint and Intercuneiform Joints

Cuneocuboid joint is located between the outer side of lateral cuneiform bone and the inner side of cuboid bone, and intercuneiform joints are located among the three cuneiform bones. They have a joint capsule and joint cavity in common, and communicate with cuneonavicular joint. The following ligaments around them: (1) Dorsal cuneocuboid ligament; (2) plantar cuneocuboid ligament; (3) dorsal intercuneiform ligaments; (4) inter cuneocuboid ligament; (5) plantar intercuneiform ligament, and; (6) intercuneiform ligaments. Intercuneiform joints, cuneonavicular joint, cuneocuboid joint, and cuneonavicular joint only slide slightly at the start of a run or jump. Tarsometatarsal Joint The structural characteristics of tarsometatarsal joint. Tarsometatarsal joints are located in front of medial cuneiform bone and first metatarsal base, in front of medial and lateral cuneiform bones, and second and third metatarsal base, in front of cuboid bone and fourth and fifth metatarsal base. The first has a separate joint capsule and joint cavity.

2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps

The joint capsule and joint cavity of the second and third parts are communicated with intercuneiform joint and cuneonavicular joint. The following ligaments are around the joint: (1) Dorsal tarsometatarsal ligament; (2) Plantar tarsometatarsoal ligament, and; (3) Inter tarsometatarsal ligaments. Tarsometatarsal are plane joints, that can make slight sliding and flexion and extension movement, rely on medial and lateral tarsometatarsal joints can also make slight adduction and abduction movement. Intermetatarsal Joints There are three intermetatarsal joints, located between the base of second to fifth metatarsal bones. There is no independent joint capsule and joint cavity, often connected with tarsometatarsal joints. There is no joint between first and second metatarsals. The following ligaments are around the joints: (1) Dorsal metatarsal ligament; (2) Plantar metatarsal ligament; (3) Inter metatarsal ligament. Only slight sliding of intermetatarsal joints can be done. Metatarsophalangeal Joints The bony portion of metatarsophalangeal joint consists of the head of metatarsal bone and the proximal phalangeal base. The joint capsule is loose, which is thinner on the dorsal side and thicker on the plantar side, attached to the periphery of the joint surface. The following ligaments are around the joints: (1) Collateral ligaments; (2) Plantar deep transverse ligament; (3) Plantar ligament. Slight flexion, extension, adduction, and abduction of metatarsophalangeal joint can be made. Interphalangeal Joint of Foot There are nine interphalangeal joints, consisting of distal, middle, and proximal phalanges except great toe which consisted of distal phalanx base and proximal phalanx trochlea. The capsule is attached to the edges of the articular surfaces of the two bones. The following ligaments are around the joints: (1) Collateral ligaments; (2) Dorsal ligament; (3) Plantar ligament.

2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps The skin of foot and hand is similar in color and texture, with obvious anatomical signs, constant blood supply, abundant tissue, and sensory nerves inside. Foot (muscle) flap is the most commonly used (muscle) flap in clinic, especially for repairing tissue defects of hand and finger reconstruction. It has the advantage that other parts (muscle) flap cannot be replaced. This section mainly introduces dorsal perforator flaps of foot, dorsal medial and lateral perforator flaps of foot, toe (perforator) flaps, and plantar flaps.

55

2.4.1 Perforator Flap with Dorsalis Pedis Artery Proximal transposition of this flap can repair soft tissue defects of heel, ankle, and posterior tibia, distal pedicled flap can repair soft tissue defect in distal foot, free flap transplantation can be used to repair soft tissue defects in hand and for finger reconstruction.

Applied Anatomy Dorsalis pedis artery is divided into two terminal branches: first dorsal metatarsal artery and deep plantar artery at the proximal side of first and second metatarsal space on the deep surface of extensor hallucis brevis, after passing between extensor digitorum longus tendon and extensor hallucis longus tendon, crossing dorsum of talus, navicular bone, and second cunieform bone. The main cutaneous branches of dorsalis pedis are concentrated in the proximal segment (2 cm below the origin) and the distal segment (2 cm before the initiation of first dorsal metatarsal artery). The main branches of dorsalis pedis artery are medial tarsal artery and lateral tarsal artery. The former originates medially from the artery at the talus plane and runs through the deep surface of extensor hallucis longus tendon to the medial margin of foot. The latter originates laterally from the artery and runs forward and outward on the deep surface of extensor digitalis brevis to the lateral margin of foot. Dorsalis pedis artery has two accompanying veins, great saphenous vein, and small saphenous vein, which form a dorsal venous arch on the distal dorsal side of foot (Fig. 2.60). The dorsal cutaneous nerves are medial dorsal cutaneous nerve and lateral dorsal cutaneous nerve of superficial peroneal nerve. Dissociation of the Flap With the direction of dorsalis pedis artery as the axis, the flap should be designed according to the needs of the recipient site. The pedicle and the outer edge of the flap should be cut first, and the subcutaneous tissue should be lifted from the deep surface of the deep fascia from the outside to the inside of the flap to preserve the integrity of the periapendoneum of tendon. The dermis and deep fascial tissue of the flap should be fixed with several stitches to protect the blood supply of the flap. The small superficial dorsal veins at the edge of the flap should be ligated and cut off. The flap should be separated to the first metatarsal space, the fascia should be cut longitudinally on the lateral side of the space, and the extensor hallucis longus tendon and extensor digitorum longus tendon could be retracted to both sides to expose the trunk of dorsal blood vessels. Two small branches of dorsal blood vessels could be seen to be given off and enter the flap. Pay attention to protect the fascia tissue around the perforators between the pedicle and the flap. Then, to cut open the skin and subcutaneous tissue fascia at the lateral edge of the flap,

56

a

2 Anatomy of the Hand and Foot

b

Fig. 2.60 Dorsalis pedis artery and branches. (a) Course of dorsalis pedis artery and branches. (b) Cutaneous perforator of dorsalis pedis artery. (1) Dorsalis pedis artery. (2) Anterior lateral malleolus artery. (3) Descending perforating branch of fibular artery. (4) Lateral tarsal artery.

(5) Medial tarsal artery. (6) Distal medial tarsal artery. (7) First dorsal metatarsal artery. (8) Deep plantar artery

and lift the flap inward to the vascular pedicle area. Further dissociation of the flap would show that a thick superficial dorsal foot vein enters the flap, which should be sharply separated proximally and carried in the flap. The first dorsal metatarsal artery and the deep plantar artery at the distal end of the flap should be ligated. The flap should be lifted distally to proximally, the extensor retinaculum should be cut open, and the proximal retrograde separation should be performed and branches along the way should be ligated and severed, and long sections of dorsal vessels can be separated.

2.4.2 Perforator Flap with Dorsal Metatarsal Artery

ey Points for Application K The following points should be noted in the clinic: (1) The direction of the dorsalis pedis artery is located at the midpoint of the line between the medial malleolus and lateral malleolus and the midpoint of the space between first and second toe web. The proximal pedicle of the vessel can extend to the proximal side as needed. The rotation axis of the distal pedicle is proximal to first and second metatarsal spaces. The region of the flap can be cut is as follows: upper to the interankle line, lower to the toe web edge, both sides to the inner and lateral edges of dorsum of foot; (2) Allen test must be performed preoperatively to confirm that dorsalis pedis artery and posterior tibial artery, which supply the blood supply to the foot, are normal. Otherwise, this operation is disabled; (3) When repairing the wound of heel, dorsal cutaneous nerve from superficial peroneal nerve should be included in the flap, so as to make the flap have a good sensory function after transfer; (4) Dorsal foot flap donor area is very similar to that of dorsal hand, which can be designed as donor flap containing extensor digitorum tendon for the repair of complex dorsal hand defect.

The flap with dorsal metatarsal artery is a flap supplied by dorsal metatarsal artery and its perforator branches. There are four dorsal metatarsal arteries, and theoretically, all of them can form vascular pedicles independently for perforator flaps. However, in general, except first dorsal metatarsal artery, which is constant, and the extension of dorsalis pedis artery, the other three dorsal metatarsal arteries have great variation, so their clinical application is limited. The most commonly used clinical perforator flap of first dorsal metatarsal artery is located at first toe web. Distal transfer can repair the distal end of foot and tibial side of plantar pedis wounds. Free transplantation can be used to repair small skin and soft tissue defects of hand.

Applied Anatomy First dorsal metatarsal artery is one of terminal branches of dorsalis pedis artery, originated before dorsalis pedis artery penetrates plantar pedis, it moves forward along the surface of first dorsal interossei and divides into three branches at the shaft of proximal phalangeal bone of foot which are: Dorsal artery of great toe, through the deep surface of extensor hallucis longus tendon, distributes to the medial margin of great toe. Tibial dorsal artery of second toe, distributes to the tibial side of second toe. The main trunk is turned to plantar at toe web and can be continued into fibular artery of great toe and tibial common plantar artery second toe, either anastomosed with first plantar metatarsal artery or anastomosed with a proper plantar phalangeal artery on one side (Fig. 2.61). It is varied in origin, insertion, and course of this artery, and its

2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps

a

57

b

Fig. 2.61 The first dorsal metatarsal artery. (a) The course, branch, and distribution of the first dorsal metatarsal artery. (b) Origin and distribution of perforators. (1) The first dorsal metatarsal artery. (2) Fibular dorsal digital artery of the great toe. (3) Tibial dorsal digital artery of

the second toe. (4) Anastomotic branches. (5) Deep fibular nerve. (6) The proximal perforator of the first dorsal metatarsal artery. (7) The distal perforator of the first dorsal metatarsal artery. (8) Cutaneous branch of dorsal digital artery

perforator is mainly given off at the origin of toe web. The flap area is generally 10–12 cm × 5–7 cm. The venous return of first dorsal metatarsal artery flap is mainly through the superficial dorsal vein system, followed by the accompanying vein of first dorsal metatarsal artery. The sensory nerve of the flap comes from cutaneous branch of deep peroneal nerve.

saroneum of dorsal interossei. Carefully identify dorsal artery and vein of foot, dissociate the anastomosis point of first dorsal metatarsal artery and plantar metatarsal artery at toe web, protect the perforator from this point, and observe the type of first dorsal metatarsal artery. Dissociate the medial margin of the flap outwards to meet the contralateral side. Local flap transplantation and free flap transplantation can be selected according to the recipient site.

Dissociation of the Flap According to the shape and size of the wound defect, the flap can be designed on dorsum of first and second metatarsal Spaces with the first metatarsal space as the axis, generally smaller than 4 cm × 4 cm. If necessary, the flap could also be lengthwise expanded, or even removed together with dorsal foot flap or dorsal toe flap. Cut the lateral edge of the flap according to the design line, cut the subcutaneous tissue and the superficial layer of deep fascia, and dissociate medially on the periapendoneum of extensor digitorum tendon and the

ey Points for Application K The following points should be noted in clinic: (1) Preoperative ultrasonographic Doppler should be used to detect the type of the first dorsal metatarsal artery to determine the surgical method. If the first dorsal metatarsal artery is missing, or the terminal artery does not enter the flap but goes directly into plantar pedis and anastomoses with plantar metatarsal artery, the surgical method should be changed. The first choice of second blood supply system is second

58

dorsal metatarsal artery. The plantar artery and its branch that proper plantar phalangeal artery of foot, can also be cut to supply the flap; (2) Be familiar with the anatomical variation of first dorsal metatarsal artery to avoid surgical failure. One is that first dorsal metatarsal artery starts and runs superficial and is thin, which can easily be mistaken for superficial dorsal vein of foot. In the other case, first dorsal metatarsal artery is deep but turns superficial at the head of metatarsal bone. (3) Maintain the integrity of dorsal metatarsal artery and its terminal branch, otherwise, the blood supply to the distal end of the flap will be affected; (4) Sharply dissociate the flap and the dissociation of first dorsal metatarsal artery should be careful, so as not to damage the main trunk and the small cutaneous branches. (5) Paying attention to the protection of aponeurosis which is conducive to the survival of skin grafts. The size of the flap should not be too large.

2 Anatomy of the Hand and Foot

2.4.3 Antemalleolar Flap This perforator flap is suitable in thickness and the subcutaneous tissue is loose which can not only be used for local transfer and repair of foot and lower leg wound, but also for free transplantation to repair wound around dorsal hand and wrist joint. The flap can carry some ligaments to repair extensor retinaculum while repairing the wound surface.

Applied Anatomy The axial vessels of antemallelar perforator flap are the antemallelar perforator vessels originating from proximal dorsal artery of foot (Fig. 2.62, Table 2.5). There are usually two to four branches, among which two branches are more common, accounting for 50.00%. Three branches followed, accounting for 40.00%; four branches accounting for 10.00%. Because of extensor retinaculum and extensor ten-

a

b

c

d

Fig. 2.62 Origin and branches of antemalleolar perforator. (a) Two branches type (lift the flap from inward to outward). (b) Three branches type (lift the flap from outward to inward). (c) Four branch type (lift the flap from outward to inward). (d) Perforator anastomosis. (1) Inferior extensor retinaculum. (2) Extensor hallucis longus tendon. (3) Extensor

digitorum longus tendon. (4) First perforator. (5) Second perforator. (6) Third perforator. (7) Fourth perforator. (8) Dorsalis pedis artery. (9) Anterior tibial artery interossei perforator. (10) Ascending perforating branch of fibular artery. (11) Superficial peroneal nerve

2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps Table 2.5 Measurement data of perforator of antemalleolar artery ( χ ±s )

Name First perforator Second perforator Third perforator Fourth perforator

Occurrence rate (%) 70.00 100.00 60.00

10.00

Initial diameter Initial vessel (mm) Dorsalis pedis 0.4 ± 0.3 artery Dorsalis pedis 0.7 ± 0.3 artery Dorsalis pedis 0.6 ± 0.4 artery/lateral tarsal artery Dorsalis pedis 0.3 ± 0.6 artery

Puncture pointa (cm) 0.1 ± 0.1 1.4 ± 0.6 2.9 ± 0.5

3.2 ± 0.4

Note: a Show the distance between the puncture point and the interankle line

don occlusions, antemalleolar perforators are difficult to directly pass through, relatively concentrated the fiber insulation among inferior extensor retinaculum, extensor hallucis longus tendon, and extensor digitorum longus tendon to subcutaneous, and give off numerous small branches that form three types of anastomosion: (1) The antemalleolar perforator branches anastomose with each other on the surface of inferior extensor retinaculum and inside deep fascia to form a fascial vascular network; (2) Anastomosed with the nutrient vessels of the upper and lower segments of superficial peroneal nerve and supply it; (3) Anastomosed with distal interossei perforator of anterior tibial artery descending perforator of peroneal artery, superficial peroneal artery, and other branches. There are two groups of venous reflux: the deep group is accompanying vein, and the superficial group is great saphenous vein. The sensory nerve is superficial peroneal nerve.

Dissociation of the Flap Preoperative routine Doppler examination should be performed in the range of 0–3 cm on the distal side of the midpoint of the interankle line, and select the thick perforator as the axial point of the flap, and the longitudinal line passing the midpoint of the interankle line should be selected as the axis of the flap. To draw a flap line 1 cm larger than the soft tissue defect according to its preoperative size and shape. First, make a deep to subfascial incision on the medial edge of the flap, and then lift the flap from the inside to the outside along the surface of extensor retinaculum. The perforator can be found between extensor hallucis longus tendon and extensor digitorum longus tendon and nearby of the midpoint of interankle line and the flap design should be adjusted at any

59

moment. Then cut open the other edges of the flap, and dissociate to puncture point until the entire pedicle of the flap is completely dissociated. Deflate tourniquet to confirm blood supply to the flap and transfer the flap to the defect.

ey Points for Application K The following points should be noted in clinic: (1) Because the donor site is located in front of the ankle joint and on the surface of extensor retinaculum and dorsal extensor tendon of foot, the indication should be strictly grasped; (2) Preoperative Doppler detection should be routine to determine the position and size of the perforator, select the thick perforator to design flap pedicle; (3) During free transplantation, the great saphenous vein should be removed to repair the defect of anterior tibial artery (dorsal artery of foot), and the aponeurosis of inferior extensor retinaculum and dorsal extensor tendon of foot should be kept intact as far as possible. If injured, it should be repaired smooth as far as possible. (4) When the donor site cannot be sutured (less than 3 cm, which can usually be directly sutured), skin graft should be performed to prevent affecting the function of ankle joint. When the flap is large, the donor site could be covered by medial supramalleolar flap, lateral supramalleolar flap, superficial peroneal vessel flap, and other lower leg flaps. (5) The tension of the pedicle of the flap should be closely observed after the operation, and extrusion or distortion should be avoided as much as possible. The affected limb should be immobilized and raised if necessary.

2.4.4 Medial Pedis Flap Medial pedis flap is a non-weight-bearing area between the medial part of plantar pedis and the medial part of dorsum of foot. The location is concealed, the skin texture is good, and the blood supply is multi-source. Free transplantation can repair soft tissue defects in hand and wrist. Proximal transfer can repair soft tissue defects of the medial malleolus and Achilles tendon, and distal transfer can repair forefoot wounds.

Applied Anatomy The blood supply of medial foot is multi-source, which is supplied by superficial branch of medial plantar artery, anterior medial malleolar artery, medial tarsal artery, and perforating branches of first plantar metatarsal artery (Fig. 2.63, Table 2.6).

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2 Anatomy of the Hand and Foot

a

b

c

d

Fig. 2.63 Arteries of medial foot. (a–c) Origin, course, branches, and anastomosis of arteries of medial foot; (d) Anastomosis of medial perforating branches of foot. (1) Superficial branch of medial plantar artery. (2) First plantar metatarsal artery; (3) Anterior medial malleolar

artery; (4) Medial tarsal artery; (5) Deep branch of medial plantar artery; (6) Abductor hallucis tendon; (7) Anterior tibial tendon; (8) Perforator; (9) Great saphenous vein

Table 2.6 Nutritional vascular data of medial foot ( χ ± s )

Anterior Medial Malleolar Artery Originated from anterior tibial artery accounts for 56.7%, and the origin is 1.5 cm above intermalleolar line, flat with intermalleolar line or 1.0 cm below the intermalleolar line. Originated from dorsalis pedis artery accounts for 43.3%.

Name Superficial branch of medial plantar artery Anterior medial malleolar artery Medial tarsal artery Perforator of first plantar metatarsal artery

Origin vessel Medial plantar artery Anterior tibial artery, dorsalis pedis artery Dorsalis pedis artery First planter metatarsal artery

Initial diameter (mm) 1.1 ± 0.2

Length (cm) 5.2 ± 0.1

1.6 ± 0.4

5.2 ± 0.6

1.3 ± 0.3

1.4 ± 0.2

1.1 ± 0.2

3.2 ± 0.2

Medial Plantar Artery After the division from malleolar canal by posterior tibial artery, through the deep surface of abductor hallucis tendon, and posterior navicular trochanter, it was divided into the superficial and deep branches. The superficial branch passes under abductor hallucis and intertarsal fascia. The deep branch divides into medial deep branch and lateral deep branch.

Medial Tarsal Artery Starting from the trunk of dorsalis pedis artery, there are one to three branches, of which, 1 branch accounts for 48%, 2 branch accounts for 46%, and 3 branch accounts for 6%. Perforator of First Plantar Metatarsal Artery Oblique backward at the point about 2.3 cm proximal to first metatarsophalangeal joint, between abductor hallucis tendon and first metatarsal bone. Anastomosed with branches of medial tarsal artery, anterior medial malleolar artery, and medial plantar artery branches at the upper margin of abductor hallucis.

Dissociation of the Flap The blood supply of medial foot skin is multi-source, and there are multiple groups of vascular pedicles to be chosen.

2.4 Anatomy of Finger Reconstruction by Transplantation of Foot Flaps

Axial points of flaps are: Near the midpoint of intermalleolar line, where anterior medial malleolar artery originates; 2 cm below the tip of medial malleolar is the superficial outlet of the superficial branch of medial plantar artery; 2 cm on the proximal side of the first metatarsophalangeal joint is the superficial outlet of the perforating branch of first metatarsal artery. The pulsing point of dorsalis pedis artery on the edge of anterior tibial tendon is the issuing point of medial tarsal artery. The axes of flaps are: The anterior and posterior edges of anterior tibial tendon are used to determine the axis of medial tarsal artery and anterior medial malleolar artery. The upper margin of abductor hallucis is used to determine the axes of superficial branch of medial plantar artery and the perforating branch of first plantar metatarsal artery. The flap area: The blood vessel axis is taken as the flap axis, and the flap is extended 2–3 cm to both sides as the design width. Flap range: Anterior to 2 cm proximal to first metatarsophalangeal joint, posterior to the vertical line of medial malleolar tip, lower to the edge of medial plantar non-weight-bearing zone, upper to the medial margin of extensor hallucis longus tendon. Dissociation of the flap: According to the design of the flap, first cut the lower edge of the flap to deep fascia, turn the flap up to the perforating position, and adjust the flap design appropriately. The flap should be pulled back to its original position, and deep fascia would be temporarily sutured to subcutaneous tissue for several stitches to prevent the separation of the fascia from damaging the cutaneous vessels, then the other edges of the flap would be incised. Dissociation is also performed under deep fascia to the perforating position until the entire flap is dissociated except for the pedicle. An incision is made from the axial point to the wound surface, and the skin could be suitably separated subcutaneously on both sides, and the flap would be transferred to the recipient site. The donor site could be covered by skin graft.

ey Points for Application K The following points should be noted in clinic: (1) Preoperative ultrasonographic Doppler should be used to detect the perforating points, and the characteristics of vascular anastomosis of the flap are defined. Different vascular pedicles could be selected according to the recipient site, and the clinical application is flexible. (2) The dissociation of the flap should be performed under deep fascia, especially at the attachment of anterior tibial tendon, where the blood vessels intersect, and the blood vessels are closely attached to the periosteum. The operation should be very careful to prevent damage to the vascular arch of the upper margin of abductor hallucis; (3) Carring medial dorsal cutaneous nerve of foot can not only provide the sensory function of the flap, but also

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the abundant vascular plexus around the cutaneous nerve can significantly increase the direction of the blood supply of the flap and expand the length of medial pedis flap. (4) The flap should not be cut beyond the inside of the head of first metatarsal bone, so as not to damage the weight bearing point of plantar pedis; (5) When the flap area is relatively large, anastomosis of medial foot vein of the flap is recommended to facilitate venous reflux, and too tight bandaging should be avoided after surgery what would block blood circulation.

2.4.5 Lateral Pedis Flap Lateral pedis flap is located on lateral dorsum of foot, which with less subcutaneous fat, no bloated, no sliding, and resistance to pressure abrasion. It can be made into sensory flap. Free transplantation is suitable for repairing the wound surface of hand, and local transfer is suitable for repairing the wound surface around ankle and forefoot.

Applied Anatomy The blood supply of lateral foot is multi-source including lateral calcaneal artery, lateral tarsal artery, anterior lateral malleolar artery, descending perforator of peroneal artery and perforator of fifth metatarsal artery (Fig. 2.64, Table 2.7). Lateral Calcaneal Artery It is the anastomotic branch of posterior tibial artery and the anastomotic branch of peroneal artery converged at the deep surface of the Achilles tendon. It descends from the anterior space of the Achilles tendon, bypasses posterior lateral malleolus, bends forward and upward, goes to the lateral edge of the ankle joint and the lateral edge of foot, reaches the bottom of fifth metatarsal bone at the end, and is anastomotic with the blood vessels of the lateral part of foot. Lateral Tarsal Artery Lateral tarsal artery originates from the dorsalis pedis artery, slanting through the outer edge of navicular bone, the deep surface of extensor digitorum brevis, and running close to the dorsal side of cuboid bone to the bottom of fifth metatarsal bone, divided into the anterior branch and the posterior branch. The connection between the pulsing point of dorsalis pedis artery 2.6 cm below the interankle line and the base of the fifth metatarsal bone is equivalent to the surface projection of lateral tarsal artery. Along the way, lateral tarsal artery not only gives off musculoskeletal branches, but also gives off direct cutaneous and musculocutaneous perforating branches, which enter deep fascia or reach deep fascia through extensor digitorum brevis and shallow out to subcutaneous layer.

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a

b

c

d

Fig. 2.64 Blood vessels of lateral dorsum of foot. (a) Origin, course, and anastomosis of blood vessels of lateral dorsum of foot. (b) Cast specimens. (c) Course and branches of lateral plantar artery. (d) Perforator of fifth plantar metatarsal artery. (1) Dorsalis pedis artery. (2) Lateral tarsal

artery. (3) Anterior branch. (4) Posterior branch. (5) Anterior lateral malleolar artery. (6) Descending perforator of fibular artery. (7) Lateral calcaneal artery. (8) Perforator of fifth plantar metatarsal artery. (9) Fibular brevis tendon. (10) Extensor digitorum brevis. (11) Lateral plantar artery

Table 2.7 Nutritional vascular data of lateral foot ( χ ± s )

Anterior Lateral Malleolar Artery Most time there is only one, originated from dorsalis pedis artery; In a few cases, there are two, originated from anterior tibial artery and dorsalis pedis artery respectively, passing posterior extensor digitorum longus and third peroneal tendon, distributes on the lateral side of ankle, tarsal sinus and the beginning of extensor digitorum brevis, and anastomosed with descending perforator of peroneal artery and lateral tarsal artery.

Name Lateral calcaneal artery Lateral tarsal artery Anterior lateral malleolar artery Descending perforator of fibular artery Perforator of fifth plantar metatarsal artery

Initial diameter (mm) 1.1 ± 0.3

Length (cm) 5.2 ± 0.1

Dorsalis pedis artery Anterior tibial artery, dorsalis pedis artery Perforator of fibular artery

1.9 ± 0.4

5.2 ± 0.6

1.4 ± 0.3

1.4 ± 0.2

1.9 ± 0.2

3.2 ± 0.2

Lateral plantar artery

1.0 ± 0.2

2.6 ± 0.3

Origin vessel Fibular artery

Descending Perforator of Peroneal Artery Terminal branch of peroneal artery punctures out at 5.9 cm above lateral malleolus, passes between extensor digitorum longus and peroneus brevis, and then divides into the ascending branch and descending branch.

2.5 Cutaneous (Perforator) Flaps of Toe

Perforator of Fifth Plantar Metatarsal Artery It is a relatively constant branch of lateral plantar artery. After the origin of lateral plantar artery, it extends outwards to the inner margin of the fifth metatarsal bone, and then extends outwards at the transition of the bottom and the shaft of fifth metatarsal bone, anastomosed with lateral tarsal artery and fourth dorsal metatarsal artery in lateral dorsal foot region. There are abundant anastomoses between the above origin arteries in the flap. Important anastomoses are: (1) Descending perforator of peroneal artery descends anterolateral to lateral malleolus, anastomoses to anterior lateral malleolar artery at a distance of 1.0–2.0 cm above the tip of lateral malleolus; (2) Anterior branch of lateral tarsal artery runs outward along the anterior edge of peroneal brevis tendon, reaching an average of 1.0–3.0 cm posterior to the trochanter of fifth metatarsal, anastomoses to perforator of fifth plantar metatarsal artery; (3) Posterior branch of lateral tarsal artery penetrates the deep surface of peroneal brevis tendon and is anastomosed with the terminal branch of lateral tarsal artery (Table 2.7). There are two groups of venous reflux in the flap: deep and superficial, and the two groups communicate with each other. In the deep group, there are accompanying veins; In the superficial group, there are superficial dorsal veins of foot that emerge into small saphenous veins. The sensory nerve of the flap is lateral dorsal cutaneous nerve of foot.

Dissociation of the Flap Lateral foot skin blood supply is also multi-source, there are also multiple groups of vascular pedicles to be chosen. Axial points of flaps are: Near the midpoint of the interankle line is the place where medial anterior malleolar artery originates; 2 cm below the tip of medial malleolus is the point where superficial branch of medial plantar artery perforates; 2 cm proximal to first metatarsophalangeal joint is the superficial origin of perforator of first metatarsophalangeal artery. The pulsing point of dorsalis pedis artery on the edge of the anterior tibial tendon is the issuing point of medial tarsal artery. Axial points of flaps are: Axial points of flaps are: Near the midpoint of intermalleolar line, where anterior medial malleolar artery originates; 2 cm below the tip of medial malleolar is the superficial outlet of the superficial branch of medial plantar artery; 2 cm on the proximal side of first metatarsophalangeal joint is the superficial outlet of the perforating branch of first metatarsal artery. The pulsing point of dorsalis pedis artery on the edge of anterior tibial tendon is the issuing point of medial tarsal artery. The axes of flaps are: The anterior and posterior edges of anterior tibial tendon are used to determine the axis of medial tarsal artery and anterior medial malleolar artery. The upper margin of abductor hallucis is used to determine the axes of superficial branch of medial plantar artery and the perforating branch of first plantar metatarsal artery.

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The flap area: The blood vessel axis is taken as the flap axis, and the flap is extended 2–3 cm to both sides as the design width. Flap range: Anterior to 2 cm proximal to first metatarsophalangeal joint, posterior to the vertical line of medial malleolar tip, lower to the edge of medial plantar non-weight-bearing zone, upper to the medial margin of extensor hallucis longus tendon. Dissociation of the flap: According to the design of the flap, first cut the lower edge of the flap to deep fascia, turn the flap up to the perforating position, and adjust the flap design appropriately. The flap should be pulled back to its original position, and deep fascia would be temporarily sutured to subcutaneous tissue for several stitches to prevent the separation of the fascia from damaging the cutaneous vessels, then the other edges of the flap would be incised. Dissociation is also performed under deep fascia to the perforating position until the entire flap is dissociated except for the pedicle. An incision is made from the axial point to the wound surface, and the skin could be suitably separated subcutaneously on both sides, and the flap would be transferred to the recipient site. The donor site could be covered by skin graft.

ey Points for Application K The following points should be noted in clinic: When disassociating the lateral tarsal artery, peripheral tissue with a width of 0.5 cm should be carried to protect the accompanying vein from injury. If only to dissociate the flap, the a nterior lateral malleolar artery and lateral tarsal artery should not be dissociated at the same time, so as not to affect the blood supply of extensor digitorum brevis. The lateral dorsal cutaneous nerve of foot is divided into two branches at the lower margin of lateral malleolus, the medial branch should be preserved during surgery.

2.5 Cutaneous (Perforator) Flaps of Toe Cutaneous (perforator) flaps of toe refer to the minor island flap supplied by proper plantar digitorum artery and dorsal digitorum artery. In theory, one to five toes can be used as donor sites of the flap. However, great toe is the most popular donor site of the flap in clinic, followed by the second toe, and the other 3 toes are less used in clinical practice.

2.5.1 Great Toe Flap Great toe can design nail skin flap and toe pulp flap. Nail skin flap was reported by Morrison (1980) and Chen Zhongwei (1982) in China, which has become a mature and classic surgical method for repairing nail defects and finger reconstruction after nearly 40 years of clinical application and

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b

Fig. 2.65 Vascular distribution of great toe. (a) Course, branches, and distribution of first dorsal metatarsal artery. (b) Course, branches, and distribution of first plantar metatarsal artery. (1) First dorsal metatarsal artery. (2) Fibular dorsal digitorum artery of great toe. (3) Tibial dorsal

digitorum artery of second toe. (4) Fibular proper plantar digitorum artery of great toe. (5) Tibial proper plantar digitorum artery of second toe. (6) First plantar metatarsal artery

improvement. Since it was first reported by Foucher et al. (1980) to repair the defect of half thumb, toe pulp flap has been further systematically studied by many scholars on its anatomy and clinic, and now it has become an ideal donor site for repairing the defect of finger.

Surgical Method The range of nail skin flap of great toe should be designed and cut in the ipsilateral according to the size of the thumb defect. The lingual flap containing neurovascular bundle with a width of 1.4–1.7 cm should be retained. First, an “S” incision is made from first toe web to dorsum of foot, and the flap is lifted between deep fascia and the superficial layer of extensor tendon. When it comes to the fibular side of great toe and the bottom of the distal phalangeal bone, begins to dissociate the plantar side. When dissociating the plantar side, sticking to the surface of flexor digitorum longus tendon of great toe. After dissociating to the peroneal side of great toe, turned to the dorsal side by sticking to the phalanx from the inside to the outside, and the nail and nail bed should be lifted to the peroneal side together. Finally, cut off the soft tissue connected to the peroneal side of phalanx. Pay attention that a nourishing artery given off by fibular plantar digitorum artery of great toe at the midpoint of the proximal phalangeal, which should be ligated and severed. At this point, the nail skin flap is dissociated totally and connected to the donor foot only through the vascular pedicle.

Applied Anatomy The blood supply of nail skin flap mainly consists of two branches that are fibular dorsal digitorum artery of great toe and fibular proper plantar digitorum artery of great toe (Figs. 2.64 and 2.65). Fibular dorsal digitorum artery of great toe is a branch of first dorsal metatarsal artery, which originates from the distal end of first metatarsal space near toe web, and then enters the fibular subcutaneous of great toe with an outer diameter of 0.6 mm. Fibular proper plantar digitorum artery of great toe with different origins has a constant course and an outer diameter of 1.1 mm, which is the main blood-supplying artery of the fibular side of great toe. There are extensive traffic and anastomosis between the two arteries. Nail flap artery adopts “dorsalis pedis artery → first dorsal metatarsal artery → fibular dorsal digitorum artery” or “dorsalis pedis artery → deep plantar branch → first plantar metatarsal artery → fibular proper plantar digitorum artery” or one of the distal arteries in the above two sets of blood supply systems. The vein is “dorsal digitorum vein of great toe → dorsal metatarsal vein → dorsal foot vein network (arch)→ great saphenous vein”. The nerve is fibular plantar digitorum nerve→half of common plantar nerve of toe and deep peroneal nerve on the dorsal side.

ey Points for Application K The following points should be noted in clinic: (1) When carrying the distal phalange of great toe, the flap should be lifted and thinned, and the phalange should be split longitudinally before suturing. Otherwise, the tension of the flap would be too large, which is easy to cause necrosis of the edge of the flap. (2) Inactivation of skin transferred at donor site is com-

2.5 Cutaneous (Perforator) Flaps of Toe

mon, improper treatment, easy to fester, and the wound is difficult to heal. Poor basal blood supply is the main reason. It should be noted that the flap should not be cut too deep, and the flexor and extensor tendons must be left with external fascia tissue. The neurovascular bundles in the retained lingual flap should not be damaged. When the first plantar metatarsal artery belongs to Gillert III type, you’d better only cut the distal segment of it, in other words, the continuity of tibial proper artery of great toe, medial plantar artery and first plantar artery at the x-type vascular anastomosis should be preserved to ensure the blood supply to the tibial side of great toe. (3) In addition to covering the distal phalangeal bone surface, the tibial lingual neurovascular bundle flap retained on great toe should be kept on the plantar side as far as possible, which could be widened and expanded after surgery due to the function and contracture of surrounding tissue. (4) In order to reconstruct the shape of thumb, the tissue amount of nail skin flap, especially the distal segment, should be reduced as far as possible. The pedicle in the flap should be cut only on its deep surface, and both sides of the pedicle, especially the pulp of the distal phalanx, could be thinned, and the distal phalanx could be split longitudinally. (5) When the blood supply of great toe wound is poor, the dorsal second toe adjacent pedicled flap is an alternative to repair the plantar wound of great toe. (6) When the thumb distal segment or part of the defect is transplanted with nail skin flap of great toe, the “toe-to-hand” vascular anastomosis is usually adopted. The blood vessels in the recipient site can be dissected first, and the donor site can be cut out according to the required length after understanding the recipient site.

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Fig. 2.66 Distribution of the nutrient branches of second toe. (1) First dorsal metatarsal artery. (2) Tibial dorsal digitorum artery of second toe. (3) Tibial plantar proper digitorum artery of second toe

diameter of 1.0 mm. There are anastomoses in the superficial fascia between dorsal digitorum arteries of both sides, between proper plantar digitorum arteries and between dorsal digitorum artery and proper plantar digitorum artery, and two to three artery arches are usually formed on dorsum of toe. Proper plantar digitorum arteries form vascular network on toe pulp.

The nail skin flap of second toe was reported by Khouri (1992), which is mainly used for the treatment of degloving injury of fingers. Due to its size limitation, the advantage of it alone in repairing degloving injury of whole fingers is not obvious, and it can be remedied by combined with other flaps. Lateral toe flap was first reported by Buncke (1979). Free transplantation is used to repair finger wounds, and the follow-up results proved satisfactory.

Surgical Method According to the location and size of the recipient site, the flap should be designed on the inner or outer fibular side of the toe with proper plantar digitorum artery as the axis. The operation should be performed under tourniquet. The skin and subcutaneous tissue should be cut into at the metatarsal space on the plantar side. First, plantar digitorum arteries and veins, and proper plantar digitorum and metatarsal nerves should be dissociated at toe web. Then the flap should be cut according to the design line, sharply cut from distal to proximal. Once the flap could be completely lifted, it should be dissociated proximally along the plantar neurovascular bundle of the toe till the desired length. Transfer the flap to the recipient site. The donor site could be repaired with full thickness or medium-thickness skin graft.

Applied Anatomy The arteries of second toe are divided into dorsal digitorum artery and proper plantar digitorum artery (Fig. 2.66). Dorsal digitorum artery is divided into tibial and fibular artery which are given off by first dorsal digitorum artery and second dorsal metatarsal artery respectively at toe web. Dorsal digitorum artery is smaller, and the tibial is thicker than the fibular one, with an average diameter of 0.6 mm. Proper plantar digitorum artery is also divided into the tibial and fibular one. The tibial is thicker than the fibular one, with an average

ey Points for Application K The following points should be noted in clinic: (1) The donor toe flap should not exceed half of the toe pulp; (2) When dissociating the neurovascular bundle, it is better to retain some surrounding adipose tissue to ensure the blood supply of the skin island and avoid damage to plantar digitorum artery; (3) When passing through the subcutaneous tunnel, the blood vessel is prevented from torsion and compression. If the tension of the skin flap is high after the tunnel, the skin should be cut open for transfer; (4) When the flap is dissociated, a

2.5.2 Second Toe Flap

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thin layer of tissue should be reserved on the surface of joint capsule and tendon sheath to facilitate skin graft at the donor site.

2.5.3 Extensor Digitorum Brevis Flap Extensor digitorum brevis flap is a composite flap that is pedicled with lateral tarsal artery and dorsalis pedis artery and contains extensor digitorum brevis and part of the skin on dorsum of foot. It is suitable for soft tissue defects of intrinsic muscle of hand, especially thenar, hand, ankle, and heel.

Applied Anatomy Morphology of Extensor Digitorum Brevis Extensor digitorum brevis lies in front of tarsal sinus, starting from the upper and lateral sides of the anterior calcaneus and from the cruciate ligament of the calf. After the muscle bundle starts, the flat thin muscle belly is inclined forward to form four thin tendons. The medial one inserts at the base of the proximal phalanx of great toe and is extensor brevis of great toe. The remaining three tendons insert on second to fourth toe, are extensor digitorum brevis. Extensor digitorum brevis runs on the deep surface of extensor digitorum longus tendon from the lateral proximal dorsum of foot to the distal tibial side. The blood supply and nerves are shown in Fig. 2.67. Blood Supply of Extensor Digitorum Brevis Anterior lateral malleolar artery originates near the lateral wall of inferior extensor retinaculum from dorsalis pe artery. The initial external diameter of this artery is 0.4 mm. It runs along the deep surface of extensor digitorum longus tendon and extensor digitorum brevis and sends out small branches along the way. One to two lateral tarsal arteries are issued from dorsalis pedis artery at the cervical junction of talus bone, and the external diameter of the starting part is 1.5 mm which runs along tarsometatarsal joint on the deep surface of extensor digitorum longus tendon and extensor digitorum brevis, and are divided into anterolateral and posterior lateral branches. The anterolateral branch is terminal branch, terminating at fifth metatarsal bone. The posterior lateral branch anastomoses with anterior lateral malleolar artery to form lateral foot arch (Fig. 2.53). The length of lateral tarsal artery is 6 cm, and it gives off muscular and cutaneous branches in the following three locations: (1) At the beginning, giving off cutaneous branch to the dorsal skin of foot; (2) On the deep surface of extensor digitorum brevis gives off muscular and musculocutaneous perforating branches; (3) At the lateral edge of muscle abdomen of extensor digitorum brevis and the proximal cuboid nodules gives off cutaneous branches.

Fig. 2.67 Blood supply and nerves of extensor digitorum brevis. (1) Extensor digitorum brevis. (2) Extensor digitorum brevis of great toe. (3) Extensor digitorum brevis tendon. (4) Dorsalis pedis artery. (5) Head of talus. (6) Lateral tarsal artery. (7) Deep peroneal nerve. (8) Nerves of extensor digitorum brevis

Nerves of Extensor Digitorum Brevis Deep peroneal nerve divides into medial and lateral branches in the anterior malleolus, and the medial branch is sensory branch, which innervates the skin sensation of first toe web and its vicinity. The lateral branch is muscular branch, which is further divided into extensor brevis branch and extensor digitorum brevis branch. Together with lateral tarsal artery, the extensor big forum brevis branch extends outward to the deep surface of extensor digitorum brevis, and gives off muscular branch to supply extensor digitorum brevis.

2.5 Cutaneous (Perforator) Flaps of Toe

Surgical Methods The line from the midpoint of anterior ankle striatum to cuboid bone is used as the axis of the flap, and the dorsolateral musculocutaneous flap is designed according to the recipient site. The medial edge of the flap is first cut open, the initial part of lateral tarsal artery and the muscular branch of deep peroneal nerve are found in the proximal segment of dorsalis pedis artery, and dissociates proximally until the appropriate length. The distal edge of the flap is cut open and extensor digitorum brevis tendon would be exposed and cut. The lateral edge of the flap is cut open, and the origin of the cutaneous branch of lateral tarsl artery could be dissociated near the cuboid nodule and included in the flap. Extensor digitorum longus tendon and extensor digitorum brevis would be exposed after cutting open the medial edge of the flap, then extensor digitorum longus tendon should be pulled to the tibial side, and the initial part of extensor digitorum brevis is cut off. Dissociation under deep fascia of extensor digitorum brevis, lateral tarsal artery, the flap, extensor digitorum brevis and the muscular branch of deep peroneal nerve should be pulled to tibial dorsum of foot. Dorsalis foot artery or lateral tarsal artery is selected as the pedicle according to the condition of the recipient site. If dorsalis pedis artery is selected as the pedicle, the musculocutaneous flap should be passed from inferior extensor digitorum longus to the tibial side of extensor digitorum longus tendon, and dorsalis pedis artery should be dissociated proximally to an appropriate length. Extensor digitorum brevis of great toe can be left in the foot or it can be cut with extensor digitorum brevis. There is extensor digitoeum brevis between the superficial vein and the deep vein, and the accompanying vein attached to lateral tarsal artery serves as the return vein of the local flap. During the free flap transplantation, the accompanying vein and small saphenous vein or its subordinate branches are used as the return veins of the flap, which should be paid attention to when the lateral and proximal edges of the flap are cut. The muscular branches of deep peroneal nerve accompany lateral tarsal artery. When dissociating lateral tarsal artery, attention should be paid to protect the muscular branches and dissociate them together. The sensory nerve of flap is lateral dorsal cutaneous nerve. When dissociating the proximal edge of the flap, we should pay attention to find it and dissociate the appropriate length to the proximal end. According to the condition of the recipient site, lateral tarsal artery or dorsalis pedis artery is cut off, small saphenous vein (or its branch), and lateral dorsal cutaneous nerve of foot is cut off. When the flap size is small, the donor site can be sutured directly, otherwise, it should be covered by skin graft.

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Keypoints for Application The following points should be noted in clinic: (1) Extensor digitorum brevis is located on the lateral side of the deep surface of extensor digitorum longus tendon of great toe, which is obvious and can be used as a marker to identify extensor digitorum brevis tendon; (2) The proximal branch of lateral tarsal artery is the main vascular pedicle of extensor digitorum brevis and must be protected; (3)The outer diameter of lateral tarsal artery is small and dorsalis pedis artery is often intercepted as the vascular bundle for transplantation; (4) The extensor digitorum brevis branch of deep peroneal nerve disposes at the intermalleolus line and runs forward and outwards, accompanying with the proximal branch of lateral tarsal artery, and enters the muscle on the deep surface of the muscle. In the preparation of muscle flap, if a long nerve is needed, it can be dissociated retrograde along extensor digitorum brevis to get enough length; (5) The course of dorlis peids artery is relatively constant, located on the lateral side of extensor longus tendon of great toe. When peroneal artery perforator replaces dorlis peids artery, changes may occur, which should be paid attention to.

2.5.4 Abductor Hallucis Flap Abductor hallucis flap is a composite flap with medial plantar skin and abductor hallucis pedicled with medial plantar artery and nerve. It is mostly used to repair the intrinsic muscles of hand, especially the thenar, and reconstruct the opponens function of thumb. Abductor hallucis transplantation does not necessarily have to take skin, but because thenar injury cases are often with poor local skin conditions, the skin will be relatively deficient after transplantation, so it is generally muscle and skin transplanted together.

Applied Anatomy Morphology of Abductor Hallucis Abductor hallucis is located in the superficial layer of medial plantar, starting from the medial process of calcaneal tuberosity, the lower margin of bifurcate ligament and scaphoid trochanter, and advancing longitudinally along the medial margin of the plantar, and merging with the medial head of flexor brevis in the middle of first metatarsal bone to form a flat tendon and terminating at the medial base of the proximal phalangeal bone. Blood Supply of Abductor Hallucis Medial plantar and lateral plantar arteries are given off by posterior tibial artery after it runs out of bifurcated ligament. Medial and lateral plantar arteries pass the deep surface of

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b

Fig. 2.68 Abductor halluces myocutaneous flap. (a) Morphology of abductor halluces and medial plantar artery. (b) Simulated operation. (1) Abductor hallucis. (2) Calcaneus tuberosity. (3) Flexor hallucis bre-

vis. (4) Proximal phalangeal bone of great toe. (5) Medial plantar artery. (6) Posterior tibial artery. (7) Lateral plantar artery. (8) Medial plantar nerve. (9) Posterior tibial vein

abductor hallucis and give off branches to it. Then lateral plantar artery and vein pass laterally from the deep surface of flexor digitorum brevis, and medial plantar artery and vein pass to the space between abductor hallucis and flexor digitorum brevis. Medial plantar artery is further divided into deep and superficial branches near medial plantar septum (Fig. 2.68). The deep branch first goes to the deep surface of medial extensor hallucis, sends out the muscular branch and the anastomotic branch with medial tarsal artery, bends forward and laterally, enters the deep plantar, and anastomoses with lateral plantar artery. The superficial branch enters the medial plantar sputum and gives out one to three cutaneous branches, and then divides into the medial branch and the internal superficial arch branch. There are two groups of venous reflux of the flap. The deep group is accompanying vein of medial plantar artery, while the superficial group is the branch of medial dorsal venous arch.

Nerves of Abductor Hallucis Medial plantar nerve travels with medial plantar artery. It originates from tibial nerve at the deep surface of the proximal abductor hallucis, and enters medial plantar septum along with medial plantar artery, giving off multiple cutaneous branches along the way. The nerve supplying abductor hallucis originates from medial plantar nerve deep at the beginning of abductor hallucis. The cutaneous sensory nerves on the surface of abductor hallucis come from the branches of medial plantar nerve, saphenous nerve, and tibial nerve.

Surgical Methods The rotation axis of the flap is located at the intersection of the anterior margin of medial malleolus and the medial margin of the plantar. The abductor hallucis is used as the axis line. The flap should be designed in the non-weight-bearing area of the medial plantar, and the proximal incision line is

2.5 Cutaneous (Perforator) Flaps of Toe

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marked along the vascular direction. First, a distal flap incision is made to look for medial plantar vessels in the space between abductor hallucis and flexor digitorum brevis on the distal side of the flap. The medial plantar vessels are cut off on the distal side of the flap, and the vessels are used as a guide to separate from far to near in the deep surface of the muscle, and the muscle is lifted together with the superficial skin. Proximal incisions are made to dissociate proximally, and the starting point of the muscle is cut off to form an island musculocutaneous flap. Be careful not to damage the medial plantar vessels located deep in the muscle. The origination of medial plantar artery and vein are cut off also do the nerve branches after the proximal separation of the appropriate length, and the sensory branches of the flap are marked with silk threads, and the musculocutaneous flap is transplanted to the recipient site. The muscular branches of abductor hallucis flap should be sutured to the thenar muscular branches of the recipient site or other adjacent muscular branches, and the sensory branches should be sutured to the adjacent sensory nerves.

starting from the plantar fascia and the medial process of calcaneus, with four tendons ending at the middle phalanges of second to the fifth toes. The morphology of flexor digitorum brevis tendon is similar to flexor digitorum superficialis tendon of hand.

Keypoints for Application The following points should be noted in clinic: (1) The nerve of abductor hallucis comes from medial plantar nerve, which is closely accompanied by medial plantar artery trunk or its superficial branches, and the motor branch of the proximal end of the muscle should be protected; (2) The length of the nerve pedicle can be cut as needed. When the pedicle is dissociated to the beginning of medial plantar artery, the length of the pedicle can reach more than 8.5 cm. If a retrograde sharp split is made along the bifurcation of medial plantar nerve, a longer nerve pedicle can be cut; (3) In the design of muscular (cutaneous) flap, the flap in the non-weight-bearing area of the medial plantar could be cut, and the size of the cutaneous flap could be larger than that of the muscular flap.

Nerves of Flexor Digitorum Brevis Flexor digitorum brevis is innervated by the muscle branches of lateral plantar nerve, most of which enter the muscle at the junction of proximal and middle one-third of the muscle.

2.5.5 Extensor Digitorum Myocutaneous Flap Flexor digitorum brevis myocutaneous flap pedicled with lateral plantar artery is located in the non-weight-bearing area of the plantar between metatarsal bone and the heel. It could be widely cut and used to repair chronic ulcers, chronic osteomyelitis, uncured sinus tract, and unstable scar of the heel. Free transplantation is used to reconstruct the function of thenar and soft tissue defect of hand.

Applied Anatomy Morphology of Flexor Digitorum Brevis The flexor digitorum brevis belongs to the middle group of plantar muscle, which is covered by the middle band of plantar aponeurosis. The muscle abdomen is spindle-shaped,

Vassculars of Flexor Digitorum Brevis Blood supply to flexor digitorum brevis comes from lateral plantar artery and medial plantar artery (Fig. 2.69). Medial plantar artery passes between flexor digitorum brevis and abductor hallucis and gives out branches along the way to flexor digitorum brevis. Lateral plantar artery follows the nerve along the line between flexor digitorum brevis and abductor minimi and branches along the way to flexor digitorum brevis. The above vessels are usually divided into 4–12 muscular branches with an outer diameter of 0.4– 0.5 mm. Most of them enter the muscle from the medial and lateral parts of the proximal half of the muscle and anastomose to each other in the muscle. Along the way muscular branches supply flexor digitorum brevis and its surface skin.

Surgical Methods The intersecting point of the anterior margin of medial malleolus and the medial margin of the plantar is the axis point of the flap rotation. A straight line between the point and fourth and fifth metatarsal bones is used as the longitudinal axis of the flap design, and the flap should be designed in the non-weight-bearing area in the mid-plantar. A longitudinal incision is made posterior to medial malleolus, the skin and supporting ligaments are incised to locate the posterior tibial vessels and nerves. The incision is advanced to the anterior and lower part of medial malleolus to connect with the medial incision from which the flap is planned to be removed. The medial and proximal incisions are made to cut off the attachment of plantar fascia and flexor digitorum brevis on calcaneus. After the myocutaneous flap is opened, medial plantar artery and lateral plantar nerve are cut off and ligated the branches from medial plantar artery to flexor digitorum brevis but protect the branches from lateral plantar artery. If the branches from medial plantar artery to are thick and numerous that should be retained and the branches from lateral plantar artery can be cut. The medial plantar incision is extended forward to the front plantar transverse incision. The plantar fascia and flexor digitorum brevis tendons should be cut open, and the distal ends of the severed tendons are sutured and fixed on the respective accompanying flexor digitorum longus tendons. The skin and plantar fascia of the incision on the lateral plantar is cut open, and flexor digitorum brevis should be temporarily sutured on the skin to pre-

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a

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b

Fig. 2.69 (a) Morphology and blood supply of flexor digitorum brevis. (b) Simulated operation. (1) Flexor digitorum brevis. (2) Plantar fascia. (3) Calcaneus tuberosity. (4) Abductor halluces. (5) Abductor digitorum minimi of toe. (6) Lateral plantar artery. (7) Lateral plantar nerve

vent muscle and skin from slipping. Medial plantar artery should be cut off and ligated and preserve the continuity of posterior tibial arteries, veins and nerves as well as the branches to flexor digitorum brevis. The medial plantar vessels are separated from the myoculocutaneous flap, and the vessels between the plantar arch and the lateral plantar vessels should be cut off and ligated at the distal side of the myoculocutaneous flap. At this point, the flexor digitorum brevis flap with lateral plantar nerve and posterior tibial pedicle is completely dissociated. To cover the recipient site with the flap when it is ready. When the donor site cannot be sutured directly, it can be covered with free skin graft.

Keypoints for Application The following points should be noted in clinic: (1) The nerve branches entering the flap should be protected during the operation to ensure good sensory function after the myoculo-

cutaneous flap is transferred; (2) Lateral plantar artery and medial plantar artery are the blood supply of flexor digitorum brevis and its surface skin, and the vascular pedicle is selected as appropriate during the operation; (3) Lateral plantar artery should be carefully preserved in the flap during surgery; (4) When the donor site is too large to be sutured directly, free skin graft should be used to cover it.

2.5.6 Abductor Digiti Minimi Flap Abductor digiti minimi supplied by lateral plantar artery is located on the lateral plantar. Because the lateral margin of the foot is involved in weight bearing, it should be used with caution. Free transplantation can be used to reconstruct the muscle function thenar and hypothenar and soft tissue defect of hand.

2.5 Cutaneous (Perforator) Flaps of Toe

Applied Anatomy Morphology of Abductor Digiti Minimi Abductor digiti minimi is located in the lateral margin of foot, deep surface close to the plantar surface of fifth metatarsal, surrounded by superficial plantar aponeurosis, originates from the plantar surface of calcaneus tuberosity, plantar aponeurosis and adjacent intermuscular septum. The starting point is covered by flexor digitorum brevis, and the muscle fibers move forward to the two short tendons. The lateral tendons reach the trochanter of fifth metatarsal, and the medial tendons join with flexor digitorum brevis tendon and end at the lateral side of the base of the proximal phalangeal of little toe. Vasculars of Aductor Digiti Minimi Most of the arteries (91.37%) are from the branch of lateral plantar artery, and a few (8.63%) are from dorsalis pedis

a

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artery. Along the distance between flexor digitorum brevis and quadratus plantaris, the nerve is divided into two to six branches along the way, with an outer diameter of 0.2– 0.5 mm, to the flexor digitorum brevis and the corresponding skin (Fig. 2.70). Veins of abductor digiti minimi flow into lateral plantar vein. Each abductor digiti minimi has two to seven veins with an outer diameter of 0.6 mm. Nerves of Abductor Digiti Minimi The nerves are 60% from lateral plantar nerve, 30% from medial calcaneal nerve, and 10% from medial plantar nerve. After the nerve starts, it is externally attached to the medial side of calcaneus and enters the muscle at the proximal end of the muscle. The nerve runs through the whole muscle, and the average length of the nerve trunk is 0.75 cm. The transverse diameter at the starting point is 0.6–1.8 mm, and the transverse diameter at the entry point is 0.4–1.8 mm.

b

Fig. 2.70 Abductor digiti minimi myocutaneous flap. (a) Morphology and blood supply of abductor digiti minimi. (b) Simulated operation. (1) Abductor digiti minimi. (2) Calcaneus tuberosity. (3) Flexor digiti minimi brevis. (4) Lateral plantar artery. (5) Lateral plantar nerve

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Surgical Methods A longitudinal incision is made in the lateral plantar non- weight-bearing area. Cut the skin to expose abductor digiti minimi, taking care not to injure lateral plantar artery on the medial side of the muscle. Abductor digiti minimi tendon is cut off near the base of the proximal phalangeal bone of little toe, and the lateral plantar vessels are cut off and ligated at the distal side of the myocutaneous flap, and the proximal branch entering the muscle should be reserved, and flexor digiti flap is dissociated. To cover the recipient site with the flap when it is ready. When the donor site cannot be sutured directly, it can be covered with free skin graft.

2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer

Keypoints for Application The following points should be noted in clinic: (1) More than 90% of the blood supply of the flap comes from lateral plantar artery. The lateral plantar nerve is close to its companion, and the lateral plantar neurovascular pedicle should be the first choice; (2) Separation of skin and muscle should be prevented when the flap is dissociated.

Dorsalis Pedis Artery Dorsalis pedis artery is a direct continuation of anterior tibial artery (95%), a small number of which originate from the branch of peroneal artery (3%) or from the confluence of anterior tibial artery and the branch of peroneal artery (2%). At the proximal end of first metatarsal space, it is divided into first dorsal metatarsal artery and deep plantar branch.

a

Fig. 2.71 Arterial distribution of great toe and second toe. (a) Cast specimens. (b) Schematic diagram. (1) Dorsalis pedis artery. (2) Arcuate artery. (3) Dorsal metatarsal artery. (4) Anastomotic branch. (5) Dorsal digitorum artery. (6) Tibial plantar digitorum artery of second

2.6.1 Thumb Reconstruction by Second Toe Transplantation Arteries There are two commonly used blood supply arteries for toe transplantation, which are, “dorsalis pedis artery → first plantar dorsal artery → dorsal digitorum artery” and “dorsalis pedis artery → deep plantar branch → first plantar metatarsal artery → proper plantar digitorum artery” (Fig. 2.71).

b

toe. (7) Fibular plantar digitorum artery of great toe. (8) Deep plantar branch. (9) First plantar metatarsal artery. (10) Tibial proper plantar digitorum artery of great toe

2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer

Along the way are medial and lateral anterior malleolar arteries, medial and lateral tarsal arteries, and arcuate artery. Dorsalis pedis foot artery is absent or slender (absent less than 1%) in 4.0–6.7%. Dorsalis pedis artery is often palpable lateral to extensor hallucis longus, which is superficial and covered by extensor hallucis brevis. The length of dorsalis pedis artery is 6.5–8 cm and the outer diameter is 2.5 (1.0–3.9) mm. First Dorsal Metatarsal Artery After initiation, the accompanying vein and deep peroneal nerve go forward in first metatarsal space, the vein is superficial, the nerve is middle, and the artery is the deepest. Gilbert classified first dorsal metatarsal artery into three types (Fig. 2.72) according to its depth and branching form

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in the path. The occurrence rate of each type is significantly different in each report, and the comprehensive average is: Type I: 53.5%, first dorsal metatarsal artery runs the superficial surface of interrossei, or is covered with thin layer interrossei at the proximal end. Type II: 38.5%, first dorsal metatarsal artery runs in interossei or the deep surface of the muscle. Type III: 8.0%, dorsal metatarsal artery is small, or absent. The blood supply of the second toe is the plantar metatarsal artery or planter digitorum artery. First dorsal metatarsal artery gradually shallowed at the distal end of first metatarsal space and formed two dorsal digitorum arteries, which, respectively, entered the dorsal subcutaneous side of the opposite edge of great toe and second toe. Another branch near the bifurcation communicated

Fig. 2.72 Gilbert type of first dorsal metatarsal artery. (1) Dorsalis pedis artery. (2) Deep plantar branch. (3) First dorsal metatarsal artery. (4) First plantar metatarsal artery. (5) Transverse metatarsal ligament

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Fig. 2.73 The origin type of 1st plantar metatarsal artery

with plantar digitorum artery, and the anastomosis rate is 86.8–100%. First Plantar Metatarsal Artery According to Xu Dachuan et al.’s report, there are 4 different types at the beginning of first plantar metatarsal artery (Fig. 2.73). Type I: Originating from an artery arch of deep plantar bench and plantar arch accounts for 60%. Type II: Originating from the continuation of dorsalis pedis artery or an artery arch of deep plantar branch and plantar arch accounts for 30.9%. Type III, IV: They are the direct continuation of medial and lateral plantar arteries. The proximal segment of first metatarsal artery is deep, located under adductor hallucis and near the deep surface of the lateral side of first metatarsal bone. A typical “X” type artery anastomosis is formed between flexor hallucis brevis and the branch of medial plantar artery behind the samoid bone (Fig. 2.74). Blood vessels involved in the formation of an “X” type of cross: The lateral of proximal end is the lateral side of the proximal segment of first plantar metatarsal artery. The lateral of distal end is the lateral side of the distal segment of first plantar metatarsal artery: The medial of proximal end is

the branch of medial plantar artery. The meidal of distal end is tibial plantar digitorum artery of great toe. The distal length of first plantar metatarsal artery is 3–4 cm, and the external diameter of the artery is 1.2 (0.7– 2.4) mm. Dorsal and Plantar Digitorum Arteries Dorsal and plantar digitorum arteries have tibial and fibular arteries respectively, which are the continuation of dorsal or plantar metatarsal artery respectively and become terminal branch. Plantar digitorum arteries are constant, thick, and are the main blood supply arteries of toes. Only 2%–6% of dorsal digitorum artery is larger than plantar digitorum artery, the external diameter of plantar digitorum artery is 1.1 (0.6– 2.1) mm, and dorsal digitorum artery is 0.6 (0.3–1.2)mm. There are multiple anastomoses between plantar digitorum artery and dorsal digitorum artery, often two to three arterial arches form traffic on dorsum of toe.

Veins There are superficial and deep veins in the foot and toes. In the deep group, the veins are accompanied by the arteries of the same name, and there are mostly two veins, which are relatively small compared with the arteries. In the superficial group, the veins are thick and rich, but varied in course and

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Fig. 2.74 The course of 1st metatarsal artery and relationship with metatarsal bones and the “X” shaped anastomose

located in superficial fascia. There are extensive anastomotic branches in deep and superficial veins. Dorsal digitorum vein converges at toe wed to form dorsal metatarsal vein, which then joins with the adjacent veins in a network or arched form into great and small saphenous vein. The superficial dorsal foot vein system is used as the venous return system of toe transplantation, which is “dorsal digitorum vein→dorsal metatarsal vein→dorsal venous arch (net)→great saphenous vein” (Fig. 2.49).

Nerves 1. Proper plantar digitorum nerve on both the tibial and fibular side, which is accompanied by proper plantar digitorum artery. The nerve is located inside the artery. Proper plantar digitorum nerves of great toe, second and third toes are all emitted by common plantar digotorum nerve (a branch of medial plantar nerve). Announcements The following points should be noticed in clinic: (1) Incision design should be correct. When there is large soft tissue

defect in the recipient site, flap can be carried on the dorsal side of the toe, skin cannot be used to cover the vascular pedicel, but can be used on the lateral wound. Excess skin should be removed before suturing; (2) When dissociating blood vessels, the unknown direction of the branch should not be easily ligated and cut off; (3) Blood vessels, nerves, tendons, and bones should be measured and severed according to the desired length of the affected area; (4) The subcutaneous tunnel through the vascular pedicle should be spacious to prevent hematoma, so as not to affect the distal blood supply due to vascular compression; (5) Vascular anastomosis ensures quality. One to two more vessels can be anastomosed when conditions are available, such as first dorsal metatarsal artery plus anastomosis of plantar digitorum artery or plantar metatarsal artery; (6) Minimize the anatomy of plantar pedis as much as possible, pay attention to the repair after toe incision, avoid residual complication of donor site; (7) The blood circulation of the reconstructed finger should be observed closely in the early postoperative period. Once vascular crisis occurs, it should be timely managed. When conservative treatment is ineffective and blood vessel

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embolism is suspected, exploration should be active and timely. Thrombosis is the most serious complication. If not treated in time, it will eventually lead to necrosis of the transplanted toe; (8) Under the guidance of rehabilitation physician, early systematic treatment, and efforts to restore hand function.

2.6.2 Finger Reconstruction by Second and Third Toe Transplantation The arterial and venous pedicles of the second and third toes are the same as that of the single second toe transplantation. The blood supply of the third toe is obtained through the vascular traffic branch between the second and third toes.

Arteries The blood supply artery of the second and third toes is the same as that of the second toe alone, which has plantar and dorsal systems. There are two commonly used arteries, “dorsalis pedis artery → first dorsal metatarsal artery → dorsal digitorum artery”, “deep plantar branch of dorsalis pedis artery → first plantar metatarsal artery → plantar digitorum artery”. The position of plantar digitorum artery and plantar metatarsal artery is constant, and the vessel diameter is large. When first dorsal metatarsal artery belongs to Gilbert type III or type II b, its anatomical exposure is relatively difficult and complex, and often needs the plantar artery blood supply system, which is also facilitated by common artery or superficial palmar arch on the palm side. There are anastomoses between the trunk and branches of dorsal metatarsal, dorsal digitorum, and plantar digitorum arteries, communicating the blood supply to the two toes and both sides of the toes. There is also artery communication between second and third toe webs. Second dorsal metatarsal artery gives off branches at toe web to communicate the blood supply of second and third toes. Veins The vein system of the second and third toes is the same as that of the second toe alone, which is “dorsal digitorum vein→dorsal metatarsal vein→dorsal venous arch (net)→great saphenous vein.” Nerves The nerve distribution of the third and second toes is the same. Announcements The following points should be noticed in clinic: (1) Strictly indicated, combined transplantation of second and third toes is suitable for patients with total defect of second to fifth fingers; Or two to four fingers in the adjacent two fingers in

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the proximal phalanx base defect accompanied by the adjacent finger shortage; (2) If two fingers need to be reconstructed, the second toe is cut from each foot to reconstruct, then the foot loss is less, and the foot shape is symmetrical after surgery; (3) Only the anastomosis of first dorsal metatarsal artery, the second and third toes can survive, but the blood supply of the third toe is insufficient after surgery, so it is appropriate to carry out multi-vessel anastomosis; (4) The repair of lateral tendon bands, lumbricals, and interossei should not be neglected.

2.6.3 Metacarpophalangeal Joints Reconstruction by Second and Third Metatarsophalangeal Joints Transplantation Applied Anatomy The Structure of Joints The metatarsophalangeal joint is an elliptical joint consisting of the head of metatarsal bone and the base of proximal phalangeal bone. The head of metatarsal bone can be divided into three parts, with the upper one-third facing upward, the middle one-third facing forward, and the lower one-third facing downward. The highest point of articular surface radian is at the junction of the upper one-third and the middle one- third. The articular surface of the proximal phalangeal base is shallow socket. When the joint is at rest, the articular surface of the proximal phalangeal base is in contact with one- third of the articular surface of the metatarsal bone, making the metatarsophalangeal joint in a dorsiflexion state. The capsule is attached to the periphery of both articular surfaces. The dorsal articular capsule is loose, with the extensor tendon strengthened, and the collateral ligaments strengthened on both sides. The ligaments start from the nodules on both sides of the metatarsal bone and end obliquely at the base of the proximal phalanges and on both sides of plantar plate. Fibrochondral plantar strengthens on the plantar side of the joint capsule, and the back of plantar plate fuses with the joint capsule, which becomes the expansion part of the joint surface of the proximal phalangeal base. When the toe extends, the plantar plate slid to the distal side, and when the toe flexes, the plantar plate slid to the proximal side. The metatarsal surface fuses with the fibrous sheath of flexor digitorum tendon, and together surrounds the fibrous bone tunnel. The proximal end is thinner, attached to the metatarsal neck, and the distal end is thicker, attached to the metatarsal lip of proximal phalanges, and the two sides are connected with the lateral collateral ligament and the deep transverse ligament of metatarsal bone. Due to the thickness and toughness of plantar plate and the structural characteristics of the articular surface, the flexion range of metatarsophalangeal

2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer

joint is much less than the extension range. Active dorsiextension ranges from 50° to 60°, passive dorsiextension ranges from 85° to 95°, active plantar flexion ranges from 30° to 40°, and passive plantar flexion ranges from 45° to 55°. It can be seen that metatarsophalangeal joint and metacarpophalangeal joint is similar in morphological structure but completely different in functional activities. The former is mainly dorsiextension, while the latter is flexion. These structural and functional differences should be noted during metatarsopalangeal joint transplantation. Blood Supply of Joints Arteries: The blood supply of the metatarsophalangeal joint is rich, including dorsal tibial and dorsal fibular branches (three to four branches) from dorsal metatarsal artery, the plantarsal tibial and plantar peroneal branches of plantar metatarsal artery, and the posterior articular artery branches. When each artery reaches the proximal part of the joint, small joint branches with an external diameter of 0.3–0.5 mm are formed. The joint branches are anastomosed with each other in the joint capsule to form a joint vascular network. According to its distribution location, it can be divided into joint capsular branches, condyle branches, and metaphyseal branches, which enter the joint within a range of 5 mm at the distal and proximal ends of the joint capsule. Veins: The veins of the joint are accompanied by the arteries of the same name, most of which are two, smaller in diameter than the arteries, and part of which merge into the deep veins accompanying the arteries, but most of which merge into the dorsal metatarsal vein through the traffic branches between the superficial and deep veins, and serve as the main channel of venous return of metatarsophalangeal joint. Nerves of Joints Second metatarsophalangeal joint is supplied by the dorsal branch of deep peroneal nerve and superficial peroneal nerve and the plantar branch of medial plantar nerve. The nerves of third metatarsophalangeal joint are supplied by the dorsal branch of superficial peroneal nerve and the plantar branch of medial plantar nerve. Each joint has about 8–10 branches, with a diameter of 0.3–0.5 mm. Surgical Methods The surgery is divided into two groups at the same time. One group dissociates the blood vessels, nerves, and tendons in the recipient site, and removed the injured metacarpophalangeal joint to prepare for metatarsophalangeal joint transplantation. Another group dissociates metatarsophalangeal joints. Cut off the diseased metacarpophalangeal joint: The tourniquet is applied to the proximal arm with a pressure of 40 kPa (300 mmHg). An “S” shaped incision is made on the dorsal side of metacarpophalangeal joint to expose extensor

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digitorum tendon. The tendon cap tissue is cut along the ulnar side of the tendon, and the tendon is retracted radially to expose metacarpophalangeal joint below it. The articular tissues such as the deep transverse ligament of the metacarpal are cut off around the joint capsule, and the disaffected joint is removed with bone knife or electric saw from the metacarpal neck and the base of the proximal phalanx. After arthroplasty, bone of metacarpal and phalanx stump should be normal, without sclerosis of bone stump and stenosis of medullary cavity, so as to avoid bone nonunion after joint transplantation. Dissociate the vasculars and nerves of the recipient site: There are two ways to do it: (1) Blood is supplied by palmar common artery and dorsal palmar vein returns, which should be first choice when the metacarpophalangeal joint is less injured and there are normal blood vessels for anastomosis. Dorsal palmar vein and dorsal cutaneous nerve of hand can be dissociated in the incision for reserve. Cut the skin and palmar aponeurosis along proximal palmar print or thenar print on the palmar side, and dissociate common palmar digital artery and nerve between flexor digitorum tendons to the normal part for use. (2) Blood is supplied by the deep palmar branch of radial artery in snuffbox and cephalic vein returns. A 5 cm long oblique incision is made in the snuffbox of the wrist, parallel to the skin margin of first web space of hand. Cephalic vein and superficial branch of radial nerve are dissociated in the incision, the deep fascia is cut open, and the deep branch of radial artery is dissociated under the tendon. The dissociation length of the blood vessel is about 3 cm for use. The subcutaneous tunnel of the two incisions should be opened, and the tunnel should be two transverse fingers wide to avoid compression of the vascular pedicle. When this is done, a tourniquet is released and the bleeding in the wound is stopped completely. Dissociate metatarsophalangeal joint: Elevate the extremities without exsanguination and apply a tourniquet to the upper thigh at 80 kPa (600 mmHg) pressure. A “S” shaped incision is made on the dorsal side of metatarsophalangeal joint, with a length of about 10 cm. If the recipient site is anastomosed with cephalic vein, it can be dissociated to great saphenous vein; if the recipient site is anastomosed with dorsal metacarpal vein, it can be dissociated to dorsal metatarsal vein. Then cut deep fascia, dissociate dorsal metatarsal artery, type I is superficial, located in the superficial layer of interossei, accompanied by deep peroneal nerve; type II in the space between the bone and interossei, only a small segment within the muscle around the originating point, find out the artery, on both sides dissociate it sharply, to 1 cm proximal metatarsophalangeal joints, pay attention to the branch ligation, the trunk should not be damaged. Deep peroneal nerve is also dissociated from the joint. The branch of the toe is cut and ligated at toe web. At the level of proximal phalangeal osteotomy, the tibial lateral

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phalangeal artery of the second toe is cut off and ligated, so that the phalangeal artery and dorsal metatarsal artery would be closely connected with the metatarsophalangeal joint, so as to ensure the blood supply of the graft joint. A branch of superficial peroneal nerve to metatarsophalangeal joint is dissociated subcutaneously on the peroneal side. The ligaments around the joint capsule are cut off along the metatarsophalangeal joint capsule, and the flexor tendon sheath is lengthways cut on the plantar side to keep plantar plate connected to the joint, and the neurovascular bundle should be connected to the skin on the fibular side to ensure the blood supply of the toe. If the recipient site is anastomosed with radial artery, dorsalis pedis artery should be dissociated, extensor tendon should be cut off at the base of metatarsal bone, and dorsalis pedis artery should be found below it. Then, sharp cuts should be made along both sides of the vessels to the desired length. The interossei should be incised at the base of the metatarsal bone, and the deep plantar branches should be cut off and ligated to make dorsal metatarsal artery and dorsalis pedis artery continuous. If dorsalis pedis artery is type III, dissociate plantar metatarsal artery as the pedicle. The metatarsophalangeal joint is truncated with a bone knife or electric saw according to the length of the defect of the recipient site. Release the tourniquet to observe blood supply. In case of a defect of skin and tendon in the recipient site, skin, and tendon grafts can be carried out simultaneously. Joint transplantation: After the preparation of the recipient site, the blood vessels in the donor site are cut off and the removed metatarsophalangeal joint is inserted into the defect of the recipient site. The metacarpophalangeal joint is fixed at the flexion position of 20°–30° by using Kirschner wire or cross steel wire. In order to improve the flexion of the reconstructed metacarpophalangeal joint, the metatarsophalangeal joint can be rotated 180° along the longitudinal axis, or the broken end of the metatarsal bone can be flexed dorsally, and the metatarsal side of the metatarsal bone is made rough surface and relatively fixed with the metacarpal bone. But when the metacarpal defect is larger, the second method cannot be used, because it can cause the wrong metacarpophalangeal joint position. If the dorsal hand defect is repaired with dorsal foot skin flap, the metatarsophalangeal joint cannot be rotated, only the second method can be used. If the metacarpal defect is large and the second method is not available, the treatment method is: (1) When the dorsal hand defect is small, carried plantar skin flap for repair, so that the plantar toe joint rotates 180° and the skin flap is just on the dorsal side to repair the dorsal hand defect; (2) When the dorsal hand defect is large, the dorsal foot flap is designed on the proximal end when metatarsophalangeal joint is cut, so that

2 Anatomy of the Hand and Foot

the skin flap is separated from the joint, which is a series graft, so that after the joint rotated, the flap is still on the dorsal side. If tendons of hand are injuried, can be repaired by toe tendons carried with them. Reconstruction of blood circulation: In order to prevent blood vessel compression after rotation of joint graft to the recipient site, the contralateral foot should be selected for the graft: (1) If the artery is anastomosed with radial artery, dorsalis pedis artery, great saphenous vein and deep peroneal nerve are led into snuffbox incision through the subcutaneous tunnel. Pay attention to that the vessels in the tunnel should not be twisted or compressed, and the layers are arteries, veins, and nerves in turn. The tension of the blood vessels should be adjusted, and the nerves and vasculars should be finely anastomosed under the microscope; (2) If it is anastomosed with common palmar digital artery, after joint rotation, the artery is on the dorsal side and the vein is on the palmar side. The blood vessels should be extracted through metacarpal space, and attention should be paid to avoid pressure and distortion of the blood vessels. The tension of the blood vessels should be adjusted, and the nerves and vasculars should be finely anastomosed under the microscope. Postoperative treatment: (1) Blood circulation should be observed according to the requirements of tissue transplantation; (2) Routine microsurgery treatment; (3) Gypsum support should be fixed for 6–7 weeks, and passive functional exercise should be begun after Kirschner wire is removed. (4) Tendonolysis should be performed when necessary.

Announcements The following points should be noted in clinic: (1) Pay attention to the fixed position of the graft joint to prevent rotation and angulation deformity; (2) If the flap is carried at the same time for transplantation, the position and size of the flap should be designed to prevent the rotation deformity of the graft joint caused by the wrong position of the flap and the blood circulation crisis of the transplanted tissue caused by the small flap; (3) Preoperative surgery should be carefully designed, and the vascular conditions in the recipient site and donor site should be carefully detected with Doppler, and the blood circulation reconstruction method should be designed according to the vascular conditions. (4) Metatarsophalangeal joint transplantation in children, the epiphysis should be included in to avoid damage, so as not to affect joint development; (5) Note that the diseased bone in the recipient site should be completely removed, otherwise bone nonunion is easy to occur after transplantation. (6) Vascular branches are ligated thoroughly to prevent postoperative bleeding and form hematoma to compress blood vessels.

2.6 Anatomy of Finger Reconstruction by the Toe and Joint to Hand Transfer

2.6.4 Metacarpophalangeal/Interphalangeal Joint Reconstruction by Proximal Interphalangeal Joint Transplantation of Second and Third Toe Applied Anatomy The Structure of Joints The proximal interphalangeal joint is a trochlear joint composed of the proximal phalangeal trochlea and the base of the middle phalangeal bone. The junction between the upper one-third and the lower two-thirds is separated by a transverse bulge, with the upper one-third facing forward up and the lower two-thirds facing forward down. When the joint is at rest, the articular surface of the phalangeal base is in contact with the lower two-thirds of the articular surface of the trochlea, showing a micro-flexion state. The dorsal side of the joint capsule is weak, with extensor digitorum tendon apparatus strengthened, and the lateral collateral ligaments strengthen on both sides. The attachment of the plantar plate is the same as that of metatarsophalangeal joint. The joint can be flexed and extended (flexion 80°, extension 0°). Blood Supply of Joints Arteries: They are the joint cystic, condylar and epiphyseal branches from dorsal and plantar digitorum arteries, and their distribution is similar to metatarsophalangeal joints. Each branch enters the joint within a range of 1–4 mm around the joint capsule. Veins: Mainly are dorsal digitorum veins. Nerves of Joints They are dorsal digitorum nerves and proper plantar digitorum nerves, mainly are proper plantar digitorum nerves. There are about eight to nine articular branches.

Surgical Methods The surgery is divided into two groups at the same time. One group dissociates the blood vessels, nerves and tendons in the recipient site, and removed the injured interphalangeal joint to prepare for interphalangeal joint of foot transplantation. Another group dissociates interphalangeal joints of foot. Cut off the Diseased Interphalangeal Joint: The tourniquet is applied to the proximal arm with a pressure of 40 kPa (300 mmHg). An “S” shaped incision is made on the dorsal side of metacarpophalangeal joint to expose extensor digitorum tendon. To determine whether to retain, if retained, the base of middle phalanx should be osteotomy in a stepped manner, and the dorsal portion of middle phalanx should be

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retained to ensure that the insertion point of extensor digitorum tendon on it is not damaged. Osteotomy is performed in the middle of proximal phalanx, the damaged palmar plate is removed, and the periarticular tissue is cut off around the joint capsule, and the proximal interphalanx joint is amputated. After arthroplasty, bone of metacarpal and phalanx stump should be normal, without sclerosis of bone stump and stenosis of medullary cavity, so as to avoid bone nonunion after joint transplantation. Dissociate the vasculars and nerves of the recipient site: There are two ways to do it: (1) Blood is supplied by palmar common artery and dorsal palmar vein returns. Dorsal palmar vein and dorsal cutaneous nerve of hand can be dissociated in the incision for reserve. Cut the skin and palmar aponeurosis along proximal palmar print or thenar print on the palmar side, dissociate common palmar digital artery and nerve between flexor digitorum tendons to the normal part for use. (2) The proper palmar artery is used to supply blood, and the proper palmar artery and nerve are dissociated on the lateral side of finger pulp, and dissociated 2–3 cm for use. The dorsal digital vein is dissociated on the dorsal side of the finger, and dissociated 2–3 cm for use, to the normal part of the structure and dynamic force. Release the tourniquet to observe blood supply. In case of defect of skin and tendon in the recipient site. Dissociate interphalangeal joint: Elevate the extremities without exsanguination and apply a tourniquet to the upper thigh at 80 kPa (600 mmHg) pressure. A “S” shaped incision is made on the dorsal side of interphalangeal joint, with a length of about 10 cm. Dissociate dorsal metatarsal vein or dorsal digitorum vein to interphalangeal joint, dissociate the proximal end of the vein according to the required length of the recipient site, then cut open deep fascia, dissociate first dorsal metatarsal artery, and dissociate interphalangeal joint just like the way dissociating metatarsophalangeal joint. In most cases, only the proper plantar digitorum artery needs to be dissociated, and proper plantar digitorum artery and nerve should be dissociated on the tibial side of the plantar side of the toe, proximal to toe web, and distal to distal interphalangeal joint, and then cut and ligated. Dissociate the joint along the joint capsule and pay attention to not damage the peroneal blood vessels, to ensure the blood supply of the distal toe. The interphalangeal joint is truncated with a bone knife or electric saw according to the length of the defect of the recipient site. Release the tourniquet to observe blood supply. In case of a defect of skin and tendon in the recipient site, skin and tendon grafts can be carried simultaneously. Joint transplantation: After the preparation of the recipient site, the blood vessels in the donor site are cut off and the removed metatarsophalangeal joint is inserted into the defect

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of the recipient site. The metacarpophalangeal joint is fixed at the flexion position of 20°–30° by using Kirschner wire or cross steel wire. Reconstruction of blood circulation: Anastomosis of blood vessels of toe and finger (such as replantation of a severed finger), adjusting the tension of blood vessels, and fine anastomosis of blood vessels and nerves under a microscope. Postoperative treatment: (1) Blood circulation should be observed according to the requirements of tissue transplantation; (2) Routine microsurgery treatment; (3) Gypsum support should be fixed for 6–7 weeks, and passive functional exercise should be begun after Kirschner wire is removed. (4) Tendonolysis should be performed when necessary.

Announcements The following points should be noted in clinic: (1) Pay attention to the fixed position of the graft joint to prevent rotation

2 Anatomy of the Hand and Foot

and angulation deformity; (2) If the flap is carried at the same time for transplantation, the position and size of the flap should be designed to prevent the rotation deformity of the graft joint caused by the wrong position of the flap and the blood circulation crisis of the transplanted tissue caused by the small flap; (3) Preoperative surgery should be carefully designed, and the vascular conditions in the recipient site and donor site should be carefully detected with Doppler, and the blood circulation reconstruction method should be designed according to the vascular conditions. (4) Metatarsophalangeal joint transplantation in children, the epiphysis should be included in to avoid damage, so as not to affect joint development; (5) Note that the diseased bone in the recipient site should be completely removed, otherwise bone nonunion is easy to occur after transplantation. (6) Vascular branches are ligated thoroughly to prevent postoperative bleeding and form hematoma to compress blood vessels.

3

Preoperative Treatment for Finger Reconstruction

Abstract

Indications for finger reconstruction are expanding while contraindications are shrinking with the development of comprehensive ability and technical level of microsurgeon with their unremitting exploration and efforts and the success rate remains very high. Excellent medical techniques, cooperation of patients, and reasonable functional exercise would reduce the disability rate and improve quality of life. But patients with incomplete fingers especially the thumb missing is still common in clinic, which would seriously affect the appearance and function of hand, and even be severe psychological trauma. For now, the success rate is above 95% for not only simple reconstruction with toe replantation but also complete reconstruction of finger with different parts. Relative to finger replantation, expectations of patients and demands for medical staff would be higher. So how to complete finger reconstruction with present quality, the prerequisite for success is sufficient preoperative treatment to master surgical indications contraindications, and complete preoperative assessment, preoperative examination, design of operation plan, corporation of surgeon, OR team, and patients are also essential. Keywords

Preoperative treatment · Finger reconstruction

Now we described that as follows:

3.1 Design and Choice of Operation Plan Indications and contraindications for finger reconstruction are very important and should be the foundation of preoperative assessment and design of the operation plan.

We conclude as follows (according to our experience and literature):

3.1.1 Systemic Assessment The general condition of patients should be assessed by complete physical examination, and laboratory tests to exclude systemic diseases that cannot tolerate surgery such as severe organic heart disease, liver, kidney dysfunction, and so on; exclude hematologic disorders and lower extremity vascular disease such as hemophilia, thromboangiitis, and so on; exclude local infectious disease such as fungal infection of foot, etc.; exclude the history of trauma that affects operation such as severe burns, scalds, frostbite, etc.; exclude mental and emotional disorders such as self-mutilation, propensity for violence, schizophrenia, depressive disorder, etc.

3.1.2 Assessment of Finger Stump Assessment of finger stump is very important for design of reconstruction and function recovery since the structure of hand is delicate and complex, and the cause of injury is multiple.

I ndex of Thumb and Other Fingers Defect (Fig. 3.1) Index of Thumb Defect I degree defect: defect in the distal segment of thumb, it is divided into I1 and I2 by the midline of the distal segment of thumb. II degree defect: defect in interphalangeal joint of thumb. III degree defect: defect in the proximal segment of thumb. IV degree defect: defect in metacarpophalangeal joint of thumb. V degree defect: defect in the first metacarpus. VI degree defect: defect in carpometacarpal joint of thumb.

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82 Fig. 3.1 Index of the thumb and other fingers defect. (a) Index of the thumb defect. (b) Index of the other fingers defect

3 Preoperative Treatment for Finger Reconstruction

a

b

Index of Other Finger Defect I degree defect: defect in distal segment. II degree defect: defect in distal interphalangeal joint. III degree defect: defect in middle segment. IV degree defect: defect in proximal interphalangeal joint. V degree defect: defect in proximal segment. VI degree defect: defect in metacarpophalangeal joint. VII degree defect: defect in metacarpus.

Assessment of Bone and Joint

Assessment of Skin Condition of Finger Stump

It is very important to get a comprehensive understanding of vascular condition of donor and recipient site for those toe- to-hand reconstruction patients, especially donor site to complete preoperative plan design.

To observe the appearance of finger stump and find if there is keloid, pigmentation, infection, rupture, bone exposure, skin graft, transfer flap, xerosis, scar sticking to bone, etc. Assessment of Nerve of Finger Stump

To judge if there is a nerve defect, residual traumatic neuroma, and hyperesthesia according to pain sensation, temperature sensation, and tow-points discrimination. Assessment of Tendons

To judge if there is tendon defect, adhesion of tendon, and the adhesion site according to the history of disease and surgery and examination of finger motion.

To judge if there is bone defect, fragment, osteomyelitis, joint stiffness, ankylosis, and joint fusion according to X-ray and joint range of motion.

3.1.3 Assessment of Vascular Condition of Donor and Recipient Site

Observation and Touch Normally, relatively large veins in the dorsum of the hand and foot could be easily observed, and the existence of dorsalis pedis artery, posterior tibial artery, radial artery, and ulnar artery could be felt by touch. ortable Color Doppler Ultrasonography (Fig. 3.2) P Portable color Doppler ultrasonography is non-invasive equipment that is small in size and easy to be carried.

3.1 Design and Choice of Operation Plan

a

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b

Fig. 3.2 CDFI location images. (a) Perforators can be identified by color ultrasonography of cutaneous artery penetrating deep fascia into subcutaneous area; (b) The complete anatomical morphology, (1) The

peroneal artery; (2) Perforators; (3) The cutaneous artery; The yellow arrow indicates measuring root diameter

Doppler could be used to detect routine and type of first dorsal metatarsal artery. Generally speaking, strong sound of Doppler means that the artery is large, strong, and superficial, obviously, what weak sound means is just on the contrary. Of course, the judgment of sound is based on experience accumulation and actual anatomy. Gilbert type I: when first dorsal metatarsal artery is superficial, strong-intermediate sound could be continuously detected in first intermetatarsal space. Gilbert type II: when first dorsal metatarsal artery is located on deep surface of the interossei, strong sound could be detected at the site of dorsalis pedis artery and deep plantar artery, then turn to intermediate-weak, and turn to intermediate at toe web. Gilbert type: when first dorsal metatarsal artery is small or even absent, strong sound could be detected at the site of dorsalis pedis artery and deep plantar artery, then turn to weak even disappeared, and turned to intermediate at toe web. According to literature reports, accuracy rate of portable color Doppler ultrasonography is only 50–70% and is closely related to operator’s clinical experience which means it could only be reference for surgeons.

details of blood vessels in all parts of body clearly which is non-invasive and easily operated. CTA is important in vascular variation and diseases that are worth to be popularized where the conditions are permitted.

T Angiography (CTA) (Fig. 3.3) C CTA is enhanced CT scan technique combined with a thin scan, large range, and fast scan technique that could display

CE-MRA (Fig. 3.4) CE-MRA can basically obtain the same effect as CTA, which is more expensive but without radiation. Doctors could make choices according to actual circumstances.

3.1.4 Operation Design Operation design is very important since the purpose of finger reconstruction is to reconstruct fingers that is close to the original ones in appearance and function. A reasonable and mature operation design should have the following features: (a) To choose the right toe or part of the toe to reconstruct the finger according to its degree of defect, the appearance and function should be considered as also. (b) The function and arch of donor foot should not be affected. The protection of vessels, nerves, and tendons should pay attention to when dorsal pedis flap is needed.

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3 Preoperative Treatment for Finger Reconstruction

a

b

c

d

Fig.3.3 A The CTA images. (a) A branch from the middle and upper 1/3 of the peroneal artery (the yellow arrow); (b) The plane and anatomical morphology of the perforators were shown (the yellow arrow);

(c) Projective technique demonstrated the perforators of the peroneal artery (the yellow arrow); (d) Some percutaneous perforators cannot be determined by CTA images alone

(c) The design of two-end flaps should be reasonable since the circumference of the finger and toe is not matched usually so as to avoid soft tissue defects and exposure around the toe-to-hand site. (d) To cut vessels, nerves, and tendons should be better long than short as the principle.

(e) Vascular pedicle should be covered with excellent skin. (f) Anatomic variation and various abnormal conditions should be considered and the way to deal with should be prepared, sometimes flexible capacity is also needed to complete the operation.

3.1 Design and Choice of Operation Plan

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Fig. 3.4 CE-MRA

3.1.5 Indications and Contraindications Indications The premise is that the patient must have the desire and requirement for finger reconstruction and is aged from 3 to 60 years old with the good general condition. After that the followings should be considered: (a) Thumb defect should be above degree I2. (b) Defects happen on all five fingers and the stumps are non-function. (c) Defects in the middle of the proximal phalangeal bone of the other four fingers except thumb, or the residual finger could not complete opponens function with thumb. (d) Defect in the middle of the proximal phalangeal bone of index finger, middle finger, and ring finger, and the little finger could not complete opponens function with thumb. (e) Single residual finger or two fingers without opponens function. (f) Congenital absence of finger that meets above conditions. (g) Those who have needs of occupation, beauty, and communication.

Contraindications (a) Local infection. (b) Patients with systemic diseases who cannot tolerate the operation. (c) Patients with active tinea pedis or psoriasis. (d) Severe burn and frostbite on foot and hand. (e) Severe hematological disorders, such as hemophilia, leukemia, etc. (f) Vascular diseases in limb and foot, such as thrombus vasculities, etc.

(g) Patients with serious mental or psychological disease that is not under control. (Note: Finger reconstruction should not be performed on those who are without desire for reconstruction.)

3.1.6 Preoperative Preparation Preparation of Surgical Team Surgeons should check patients’ general condition, degree of injury, and associated supplementary examinations to clear indications and contraindications before the operation to make operation design according to the injury situation and patients’ desire. All details of the operation such as the risks, complications, responses, etc., should be communicated with patients and their families, and then sign a detailed informed consent. Good rest and excellent microsurgical technique of surgical team are the basis of a successful reconstruction. If the condition permits, the surgical team may consist of multiple groups so that donor and recipient sites could be operated at the same time which could reduce operation time. Preparation of Patients Patients and their families should totally understand the surgical methods and postoperative rehabilitation programs, also be prepared for possible complications and unexpected matters such as side injury, sequela, vascular crisis, failure of the operation, second stage operation, etc. The majority of patients need to stay in bed for 7–10 days, so they should get used to being in bed to practice diet and defecation before the operation. Hands and feet cleaning and quitting smoking are also necessary to reduce the danger of infection and vasospasm. The patients with other diseases such as malnutrition, anemia, etc., should get into top physical shape which is good for postoperative recovery.

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reparation of Operation Room and Anesthesia P A spacious operating room that is enough for microscope and multiple groups of surgeons for operation should be arranged for finger reconstruction. Microsurgical equipment should also be prepared. An experienced anesthesiologist is also needed for safety of operation since the long period of finger reconstruction.

3 Preoperative Treatment for Finger Reconstruction

Further Reading Cheng GL, Replantation and reconstruction of finger. The second edition, Beijing, People’s Medical Publishing House, 2005 Pei GX, Microsurgical orthopaedics. Beijing, People’s Medical Publishing House, 2016. Lin J, Zheng HP, Xu YQ, Zhang TH. Special type of finger replantation. Springer, 2018.

4

Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction

Abstract

To repair and reconstruct the appearance and function of a traumatic amputated limb is always the common aspiration of both doctors and patients. But absolutely the simple suture and bone fixation cannot achieve our aim. It came true with the development of microsurgery that solved the problem of the vascular anastomosis to reconstruct circulation until the 1960S. In early time, Carrell’s three stay sutures end-to-end anastomosis or sleeve insertion is a major method for the repair of vascular which is suitable for large blood vessels and is very difficult for those blood vessels under 1.5 mm. The low recanalization rate and survival rate promote the development of the microscope, microsurgery instruments, microsurgical suture material, new methods of suture, anti-coagulation, etc. Nylen and Hoimgrem first performed inner ear surgery under microscope in 1921 which developed slowly due to limited space. Barraquer and Pertt performed cornea suture under microscope in 1950 meant new suture stage coming. Microsurgery entered a new stage of development in the 1960s with the development of microsurgical techniques. Jacobson and Suarez sutured animal vessels whose diameters were from 1.6 mm to 3.2 mm under 25 times microscope and the recanalization was 100% of what attached attention of surgeons. After that Lee (1961), Gonzales (1962), and Abbott et al. performed portocaval shunt, kidney transplant, and heart transplant in animals successively. Malt successfully replanted an amputated upper limb for a 12-year-old child in 1962. Zhongwei Chen successfully replanted a completely amputated forearm under the naked eye in 1963. Shuhua Wang and Jiaze Lu completed the first replantation of a rabbit ear in 1964 and successfully

replanted a completely amputated finger of a child in the same year. Buncke and Schultz performed a successful toe-to-thumb reconstruction for a monkey in 1965. Dongyue Yang and Jianqiu Tang et al. were the first to perform second-toe-to-thumb reconstruction which was a cooperation with Huashan hospital and Zhongshan hospital in Shanghai on February 13, 1966, and was the beginning of a new era for thumb reconstruction in China. Keywords

Instruments · Equipments · Materials · Finger reconstruction

4.1 Commonly Used Microsurgical Instruments, Equipment, and Materials 4.1.1 Operating Microscope (Figs. 4.1 and 4.2) istory of Operating Microscope H Microscope is an instrument that could produce an enlarged image of an object by means of a physical method. It was invented in the late sixteenth century and has been over 400 years of history that has been an important instrument in science research. In 1876, Edvin Seamisch who was an ophthalmologist made the first wearable magnifiers for assistance in surgery that were only two to eight times larger, compared with that time the wearable magnifiers used now are 2–20 times larger. In 1953, the first operating microscope named OPMI 1 (Operating Microscope Number One) came out what was

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4 Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction

Fig. 4.1 Surgical microscope

Fig. 4.2 Surgical microscope made in China

with the help of Doctor Hans Littmann and professor Horst Wullstein. At the expo in Amsterdam, professor Horst Wullstein introduces an operating microscope to the public for the first time. Since then, the operating microscope had been expanded rapidly into other areas of microsurgery. Although the first operating microscope was designed for middle ear surgery, it is still considered to be the ancestor of universal microscope.

(b) Low angle double microscope can protect a doctor’s neck. (c) Computer technology helps doctors set and preserve working parameters better and also regulate the function of operating a microscope better. (d) APO achromatic lens could correct three primary lights (red, yellow, and blue) at the same time, to solve the color difference due to different refractive and magnification so as to present a perfect image.

dvantages of Operating Microscopes A (a) The application of electromagnetic brake provides a flexible movable joint for operating a microscope which makes it more convenient for doctors to operate.

equirements for Operating Microscope R (a) Magnification is about 10 times, which is best between 6 and 40 times to meet different needs. When doubling there is no need to refocus to make the image clear.

4.1 Commonly Used Microsurgical Instruments, Equipment, and Materials

(b) A long working distance to facilitate the operation should be between 200 mm and 400 mm, usually about 275 mm. If deeper operation is performed, the objective lens with a longer working distance can be replaced. (c) Light sources should meet requirements of high luminance and enough range which should better be a cold light source to prevent tissue burns during a long period of operation. (d) The enlarged image should be a stereo-orthophoto image which is convenient for accurate operation and two eyeglasses are required for observation from different angles. (e) Two pairs of double microscopes and a unified field of view are required for assistance’s corporation. (f) Eyeglasses can be used to adjust the visibility and pupillary distance to meet different needs. (g) Photographic and video equipment is required. (h) The microscope should be easily moved and equipped with a manual, foot, or voice control device.

4.1.2 Operating Magnifying Glasses Binocular Loupe (Fig. 4.3b) utilizes an optical stereoscopic convergence technique that focuses the Binocular line of sight stereoscopic into a narrow cavity to produce a bright,

a

Fig. 4.3 (a) Surgical magnifier. (b) Head loupe

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magnified 3D field of vision which could provide a unique stereoscopic depth image for examination and treatment. There are three types of operating magnifying glasses that are usually used in clinic. (a) General operating magnifying glasses (Fig. 4.3a) A magnifying lens is installed on a bracket through which the surgeons could perform the operation, but this kind of magnifying glass is seldom used in the clinic since its occupation of large space, short working distance, low magnifying power and inconvenience for use. (b) Lens type of operating magnifying glasses Two rectangular lenses with the same magnification power are installed in front of the glasses usually used by the surgeon whose magnification power is generally no more than two times and it can be also modified into the frontal band type for those who do not wear glasses. (c) Telescope-type operating magnifying glasses It is composed of a negative lens and a positive lens installed on the spectacle frame of the forehead frame. The pupil distance can be adjusted by the crossbar of the glasses to meet the need of different surgeons. Generally, the working distance is 240–350 mm, and the magnification of each pair is different which provides different options for surgeons. It is helpful for the operation of all kinds of tiny blood vessels and nerves suture and it has the advantages of being easy to carry and low price.

b

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4 Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction

a

b

c

d

e

f

Fig. 4.4 Microsurgical instruments. (a) Micro forceps. (b) Micro-scissors. (c) Micro-needle-holder. (d) Microvessel clamp. (e) Micro-irrigator. (f) Microretractor

Fig. 4.5 Artificial tendon

4.1.3 Microsurgical Instruments (Figs. 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10 and 4.11) (a) Micro forceps The width of forceps is 0.15 mm which is suitable for the suturing of small vessels and lymph vessels of less than 0.5 mm in diameter. The width of forceps is 0.2–0.3 mm which is suitable for the suturing of small vessels and lymph vessels of more than 1 mm in

diameter. The main function of microforceps is to pinch different tiny tissues and coordinate with micro-scissor for the separation and resection of various tissues. When the vessels, nerves, and other pipelines are sutured, the outer membrane should be pinched not the tube wall or nerve tissues. (b) Micro-scissors It is mainly used for dissociating and pruning under the microscope. This kind of scissors is very delicate and should only be used for the dissociation of vascular, nerve tissue, and clipping microsuture. (c) Micro-needle-holder The narrow 0.2 mm needle holder head has certain advantages for the needle clamp 11–0 and 12–0, which is not allowed to clamp the ordinary needles. (d) Blood vessel clamp The normal pressure is 2.5 ± 0.4 g/ mm2, and the small vessels with a diameter of less than 0.5 mm are enough to block the blood flow and suture the 1–1.5-H vessel wall without pressure marks. a larger caliber of blood vessels can be used to adjust the pressure of the mini-fold. (e) Micro-irrigator 4.5# needle should be used for blood vessels within 0.5 mm and a 5# needle could be used for those larger than 2 mm.

4.1 Commonly Used Microsurgical Instruments, Equipment, and Materials

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Fig. 4.6 Artificial blood vessels

Fig. 4.7 Artificial neural

4.1.4 Microsurgical Suture Materials Microsurgical suture materials are mainly used for the suture and repair of tiny blood vessels, pipelines, and nerves. In order to maintain patency rate and reduce injury, noninvasive suture needles and sutures of different sizes should be selected according to the diameter of sutured tissues.

Fig. 4.8 Artificial nerve sheath tube

(a) Suture needle Requirements for suture needle include sharp tip, high hardness, being able to penetrate all kinds of vascular walls and other tissues, and withstand the clamping of micro-needle-holder without deformation. The section of needle could be made into circle, triple, etc., the radian of needle could be 1/2, 3/8, 1/4, 5/8, etc. The needle and sutures should be uniform in thickness is the principle.

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4 Commonly Used Instruments, Equipment, and Materials for Finger Reconstruction

Fig. 4.10 Ultrasonic Doppler used in surgery

Fig. 4.9 Ultrasonic Doppler

Fig. 4.11 The operation table for hand surgery

Further Reading

(b) Sutures 5-0 to 12-0 suture stitches are commonly used in clinic. 5-0 and 6-0 are suitable for vascular vessels with diameter larger than 5 mm, 7-0 and 8-0 are suitable for vascular vessels with diameter 3-4 mm, 9-0 and 10-0 are suitable for vascular vessels with diameter larger than 1–2 mm, 10-0 and 11-0 are suitable for vascular vessels with diameter larger than 0.6-1 mm, 12-0 is suitable for vascular vessels with diameter within 0.5 mm.

Further Reading Gu YD. Hand repair and reconstruction. Shanghai, Shanghai Medical University Press, 1995.

93 Suarez E L, Jacobson J H. Results of small artery endarterectomy- microsurgical technique. [J]. Surgical forum, 1961, 12. Buncke H J, Buncke C M, Schulz W P. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascular anastomoses. [J]. British Journal of Plastic Surgery, 1966, 19(4). Cheng GL. Replantation and reconstruction of finger. Beijing, People’s Medical Publishing House, 1997. Liu JF, Chen B, Ni Y. Advancement and development prospect of operating microscope. Chinese Medical Equipment Journal, 2013, 34(10): 85-87. Chen Q, You RN, Mao KJ, et al. Design of a kind of binocular medical magnifying glasses. China Medical Devices, 2016, 21(11): 38-41, 45. Mozersky, D.J. et al, Ultrasonic artehography, Arch. Surg.103:663-667,1971. Barber F E, Baker D W, Nation A W C, et al. Ultrasonic Duplex Echo- Doppler Scanner[J]. IEEE Transactions on Biomedical Engineering, 2007, BME-21(2):109-113.

5

Common Medicines Used for Finger Reconstruction

Abstract

A successful operation of finger reconstruction is based on not only the microsurgery technique but also the medicines used postoperatively (Table 5.1). Three kinds of medicines are generally used after an operation, which are antibiotics, antispasmodics, and anticoagulant drugs. Antibiotics must be used intraoperatively and postoperatively because of complexity and the long duration of the operation. The common reasons why antispasmodic drugs and anticoagulant drugs should be used after an operation are: (1) As a body’s protective physiological response, blood coagulability is increased after injury and operation; (2) Adrenaline is released after the injury and operation; therefore, patients are prone to experiencing vasospasm, an increase in platelets and an increase in blood coagulation, which easily leads to thrombosis; (3) Because of the small diameter, spasticity and thrombosis can be easily induced, which is commonly 1–3 mm (a minimum of 0.2–0.5 mm), and easy susceptibility to physicochemical factors; (4) There is a higher possibility of thrombosis because of the small scouring force to anastomotic stoma caused by the small diameter and low blood flow. Using antispasmodic drugs and anticoagulant drugs is necessary because experiments have proved that the smaller diameter of the vessel, the more likely it is that thrombosis will occur because the 1-mm vessel has a platelet absorption density twice as high as the 2 mm vessel. Keywords

Common medicines · Finger reconstruction

In Table 5.1, the commonly used drugs are shown. Characteristics, indications, adverse reactions, and precautions for these drugs are described as follows.

Table 5.1 Commonly used drugs (Reproduced with permission from Lin J, Zheng HP, Xu YQ, Zhang TH. Special type of finger replantation. Springer, 2018) Antibiotic drugs Penicillin, cephalosporins, macrolide, et al., used alone or in combination Anticoagulant 6% dextran 40 iv drip (500–1000 mL/day); or drugs aspirin (3 times/day, each 0.5–1 g); or 5% glucose injection 1000 mL + low molecular heparin 1500 IU (for children: 11–150 U/kg + 5% glucose injection 500 mL), maintained for 24 h Antispasmodic Benzazoline 25 mg or papaverine 30 mg/6–8 h, drugs intramuscular injection, used alone or in combination

5.1 Antibiotic Drugs Antibiotics are mainly used in replantation to prevent and treat infection, because of the particularity of finger reconstruction, sometimes there may be fungal infection and other serious infections in donor site, then antifungal drugs and special antibiotics are needed. Therefore anti-inflammatory drugs here should be called antibiotic drugs.

5.1.1 Penicillin It is suitable for common G+ coccus such as group A hemolytic streptococcus, pneumoniae streptococcus, grass green streptococcus, enterococcus, etc., some G+ bacilli such as diphtheria, anthrax, tetanus, etc., G− coccus such as meningitis, gonorrhea, etc., and some other special infections.

Adverse Reactions (1) Anaphylaxis: Anaphylaxis is common and includes all kinds of rashes such as urticaria, etc., leukopenia, interstitial nephritis, asthma attacks, etc. Anaphylactic shock occasionally occurs but must perform on spot rescue which includes

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keeping the airway open, oxygen, and use of epinephrine, glucocorticoids, etc., if it happens. (2) Toxic effects: Toxic effects occasionally occur but high concentrations of CSF would cause twitch, muscular clonus, coma, severe psychiatric symptoms, etc., when a large dose of intravenous drip or intrathecal administration is given which is more common in infants, the elderly and patients with renal insufficiency. (3) Superinfection: Superinfection would occur such as penicillin- resistant staphylococcus aureus, gram-negative bacilli, candida, etc. (4) High dose of penicillin of penicillin may cause heart failure because of a high intake of sodium.

Notices (1) To inquire about allergic history in medicine in detail and take skin test before drug use that is contraindicated for positive reactions. (2) People who are allergic to one type of penicillin may also be allergic to other types of penicillin and penicillamine. Patients with asthma, eczema, hay fever, urticaria, and other allergic diseases should use it with caution. (3) Penicillin solution is not stable at room temperature which means it should be prepared when needed. (4) Electrolytes should be tested regularly when penicillin is used in large doses. (5) Interference with diagnosis: (a) False positives may occur in the determination of urine sugar by copper sulfate solution method, but are not affected by the glucose enzyme method during treatment with penicillin. (b) Sodium in blood would increase when it is intravenous injection of penicillin.

5.1.2 Cephalosporins The class of antibiotics is a broad-spectrum antibiotic that is effective against Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, Bacillus diphtheriae, Bacillus pneumoniae, Proteus, Bacillus influenza, etc. At present, first-generation cephalosporins are the most widely used in clinical, and third-generation cephalosporins can be directly used to prevent infection in severely polluted wounds regularly used for 5–7 days.

Adverse Reactions Anaphylaxis is most common including rashes, hives, drug eruptions, eosinophilic leukocytosis, etc. Anaphylactic shock occasionally occurs. Notices (1) Cross allergy: It is forbidden to be used in those who have a history of hypo-lactam antibiotic shock; (2) It has a synergistic bactericidal effect with aminoglycoside antibiotics, but its simultaneous use increases renal toxicity; (3) Long-term use may cause imbalance of flora; (4) Too large dose may stimulate the brain and cause convulsions.

5 Common Medicines Used for Finger Reconstruction

5.1.3 Macrolide Antibiotics Macrolide antibiotics are generally referred to broad- spectrum antibiotics produced by Streptomyces, which have basic lactone ring structure and are effective against gram- positive and gram-negative bacteria, especially mycoplasma, chlamydia, legionella, spirochetes, and rickettsiae. Macrolides have the following characteristics: (1) Gastric acid stability, high oral bioavailability; (2) Plasma, tissue fluid, and intracellular drug concentration are high and persistent; (3) The plasma half-life is prolonged the enhance patients’ compliance; (4) Gastrointestinal side effects are mild.

Adverse Reactions (1) Macrolide antibiotics mainly show gastrointestinal symptoms and hepatotoxicity; (2) Allergic reaction, this product can cause drug rash and drug fever, occasionally can cause temporary deafness, dermatitis, perineal erosion, and even shock which is associated with high blood concentrations; (3) Cardiac toxicity which is a special type of adverse reaction; (4) In recent years, rapid hemocytopenia and leukopenia have been reported in patients treated with erythromycin. Notices (1) Pregnant women and children should use with caution; (2) If patients using aminophylline can increase the concentration of theophylline, or even poisoning, should be appropriately reduced the dose of aminophylline; (3) Those who are allergic to macrolide drugs, pregnancy, lactation or with severe liver dysfunction should use with caution; (4) Certain heart disease and water-electrolyte disorder patients also should be listed as contraindication; (5) Severe damage of liver and kidney should be used with caution.

5.1.4 Polypeptide Antibiotic A group of antibiotics isolated from different bacteria of the genus polymyxobacteria that can be divided into 8 kinds named A, B, C, D, E, F, K, M, P according to their chemical structures, among which only polymyxin B and E have lower toxicity which has complete cross-resistance. Bacteria are slowly to develop resistance to these antibiotics, drug- resistance strains of Pseudomonas aeruginosa are occasionally seen. Vancomycin is the main representative in clinic.

Adverse Reaction (1) Ototoxicity which is the most serious toxic reaction; (2) Renal toxicity that mainly damages the renal tubules and which will be more obvious when used in combination with aminoglycosides; (3) Anaphylaxis: Rapid intravenous infu-

5.2 Anticoagulant Drugs

sion can lead to upper body skin flushing, itching and a drop in blood pressure (called red man syndrome) which can be effectively treated with antihistamines and corticosteroids; (4) Oral administration may cause vomiting and a sense of bad breath; Intravenous administration may easily cause thrombophlebitis Granulocytopenia occasionally occurs.

Notices (1) This product cannot be intramuscular injection, and should not be intravenous injection; (2) The speed of intravenous infusion should not be too fast; (3) Patients with renal insufficiency should be used with caution; (4) Interference to diagnosis since blood urea nitrogen may increase; (5) Hearing, urine protein, tube type, cell number, and urine relative density should be tested regularly during the treatment.

5.1.5 Antifungal Drugs Fungal infections can be divided into superficial fungal infections and deep fungal infections. Superficial fungal infections are caused by tinea bacteria invasion of skin, hair, finger (toe), and other parts of the body, the incidence of which is higher but less harmful; Deep fungal infections are caused by candida and cryptococcus invasion of internal organs and deep tissues, the incidence of which is lower but more harmful.

Adverse Reactions (1) Gastrointestinal reactions are common such as nausea, vomiting, abdominal pain, or diarrhea; (2) Anaphylaxis; (3) Hepatotoxicity; (4) Dizziness and headache; (5) Renal dysfunction; (6) Changes in peripheral hematologic such as transient neutropenia and thrombocytopenia may occur occasionally in patients with serious underlying diseases such as AIDS and cancer. Notices (1) This product may cross-react with other pyrrole drugs, so it is not recommended for those who are allergic to any pyrrole drug; (2) Renal function should be checked regularly during treatment, for patients with renal impairment, renal reduction is required; (3) At present, long-term use of this product in immunodeficient patients has led to the increase of resistance of candida to fluconazole and other pyrrole antifungal drugs, so it is necessary to master the indications; (4) Liver function should be checked before and during treatment, in case of continuous abnormal liver function or clinical symptoms hepatotoxicity, this product should be stopped immediately; (5) If this product is used in combination with hepatotoxic drugs, the incidence of hepatotoxicity may be increased when it is administered for more than 2 weeks or at

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multiple times the usual dose, liver function should be checked before treatment and every 2 weeks during treatment regularly; (6) The course of treatment depends on the site of infection and individual’ response to treatment. In general, the treatment should be continued until clinical manifestations and laboratory indicators of fungal infection show that fungal infection has disappeared; (7) For patients with renal impairment, adjust the dosage. Hemodialysis patients can be given a daily dose of this product after each dialysis because 3 h’ of hemodialysis can reduce the blood concentration by about 50%.

5.2 Anticoagulant Drugs At present, there is still a lack of a reasonable anticoagulant program with a definite curative effect and few complications after finger reconstruction. A good anticoagulant program should have the following characteristics: effective prevention of thrombosis; reduction of incidence of vascular crisis; lower risk of bleeding tendency; fewer adverse reactions; reasonable price.

5.2.1 Low Molecular Dextran Low molecular dextran can inhibit platelet and erythrocyte aggregation, reduce blood viscosity, and have an inhibitory effect on blood coagulation factor II, thus preventing thrombosis and improving microcirculation. The general dose is 1000 mL/day, which can be reduced gradually according to the condition, lasting for 7–10 days.

Adverse Reactions (1) Anaphylaxis: Skin pruritus which is refractory pruritus, the disease course of individual patients may last more than 6 months which is the most prominent complication. This type of pruritus is characterized by prolonged duration, no effective palliative therapy, and patients often find it difficult to tolerate, which may be the main reason why it is not the first choice in clinic. There are still a few cases of anaphylactic shock, so the first infusion should be closely observed for 5–10 min, once symptoms are found the drug should be stopped as soon as possible; (2) Occasional febrile reactions; (3) Excessive dosage can lead to bleeding such as epistaxis, skin and mucous membrane bleeding, gingival bleeding, wound bleeding, hematuria, etc. The daily dosage should not exceed 1500 mL. Notices (1) Patients with congestive heart failure and hemorrhagic disease are contraindicated; (2) Patients with liver and kidney diseases should use with caution.

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5 Common Medicines Used for Finger Reconstruction

5.2.2 Heparin

5.3 Antispasmodic Drugs

Heparin is a powerful anticoagulant made from an allogenic mucopolysaccharide that has the following characteristics: rapid anticoagulation, short maintenance time, and no accumulative effect. At present, high-dose heparin has been abandoned but instead of low-dose heparin in clinic which should be used for 3–7 days.

The vascular smooth muscular cells will recover their contractility within 24 h after finger reconstruction but lack the ability to relax, once stimulated by the outside world such as neurophysiological factors, cold, pain, smoking, fluctuation of blood pressure, etc., they will be in a spasmodic state immediately which is called hypersensitivity. Timely and effective management of the arterial crisis is the key to success of reconstruction.

Adverse Reaction (1) Bleeding: It is the most common and important complication with an incidence of 8–33% caused by overdose, aging, heart failure, liver insufficiency, and trauma; (2) Thrombocytopenia; (3) Drop of AT-III plasma levels which may lead to ineffective anticoagulation of heparin; (4) Anaphylaxis. Notices (1) Patients who are allergic to heparin, with spontaneity hemorrhage tendency, blood clotting delay, canker disease, postpartum hemorrhage, and serious liver dysfunction are forbidden to be used; (2) Coagulation time should be checked regularly during treatment; (3) Low molecular weight heparin (LMWH) is recommended in clinic.

5.2.3 Aspirin The pharmacological action of aspirin can be summarized as: (1) Inhibition of platelet aggregation and vasodilation; (2) Prolonged bleeding time and coagulation time; (3) Analgesia; (4) Anti-inflammation.

Adverse Reaction (1) Gastrointestinal symptoms: The most common adverse reactions include nausea, vomiting, abdominal discomfort, or pain; (2) Anaphylaxis which is common in middle-aged persons or rhinitis, nasal polyp patients; (3) Central nervous system: Neurological symptoms generally appear when the dosage is large, the so-called salicylic acid action including headache, dizziness, tinnitus, vision and hearing loss, when the dosage is too large, can appear neurological disorder, convulsion, even coma, etc., which can be completely recovered after drug withdraw 2–3 days; (4) Liver damage; (5) Kidney damage; (6) Effects on blood: Long-term use can lead to iron deficiency anemia; (7) Cardiac toxicity; (8) Cross anaphylaxis. Notices This product should be taken with food or water to reduce gastrointestinal irritation. Aspirin and alcohol should not be taken at the same time, as this can lead to increased pain over the body and liver damage.

5.3.1 Papaverine Papaverine belongs to opioid alkaloids but has no obvious anesthetic properties. It is a kind of non-specific vasodilator that has a direct non-specific relaxation effect on blood vessels, heart, and other smooth muscles that are usually given by intermittent and repeated intramuscular injection or intravenous infusion after dilution in clinic.

Adverse Reactions (1) Due to the strong stimulation of papaverine, local edema appears after long-term intramuscular injection which will bring great pain to patients; (2) Liver damage; (3) Excessive dosage will cause blurred vision, double vision, lethargy, or(and) weakness; (4) It can inhibit the mitochondrial oxidation reaction and cause severe lactic acidosis, an increase of blood ketone, mild hyperglycemia and hypoglycemia after large intake; (5) It can cause breath to deepen and thrombocytopenia. Notices (1) Interference to diagnosis; (2) Patients with glaucoma should check their intraocular pressure regularly; (3) Patients with gastrointestinal symptoms or jaundice should check their liver function regularly when liver dysfunction is found it should be stopped.

5.3.2 Tolazoline As α-receptor blockers can expand smooth muscle directly and be used interchangeably with papaverine.

dverse Reactions and Notices A (1) It can cause central nerve to be excited and produce disgusting, vomiting, fidgeting, fear cold, palpitation, and postural hypotension, patients with ulcer disease and insufficient coronary blood supply are contraindicated; (2) Orthostatic hypotension may occur at high doses which should be treated with lying prostrate with low head, electrolyte solution, and ephedrine. Epinephrine should not be used because it may aggravate hypotension.

Further Reading

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5.4 Other Drugs

5.4.2 Analgesia Pump

Analgestic and sedative management can be carried out on the crying patients who could not cooperate with treatment to make them quiet which also has a positive effect on the success of finger reconstruction.

Analgesia pump is divided into epidural pump and venous pump because of different drugs in it. Epidural pump is often used with local anesthetics and morphine while venous pump is used with fentanyl and the use of the two kinds of pump should be strictly distinguished, otherwise, it will be dangerous.

5.4.1 Hibernation Drugs

Adverse Reactions (1) Incomplete anesthesia; (2) Nausea and vomiting; (3) Sleepiness; (4) Urinary retention; (5) Skin itching; (6) Lower limb numbness.

The drugs commonly used in clinic consist of chlorpromazine 50 mg, promazine 50 mg, pethidine 100 mg, and 5% glucose solution 250 mL.

Adverse Reaction (1) The main side effects include dry mouth, upper abdominal discomfort, fatigue, sleepiness, constipation, and palpitation. Lactation, breast enlargement, obesity, and amenorrhea, etc., occasionally occur; (2) Postural hypotension may be induced by injection or oral administration of large doses; (3) Liver damage. Notices (1) Patients should lie still for 1–2 h after drug administration, when the blood pressure is too low, noradrenaline or ephedrine can be used but not epinephrine; (2) Liver function should be checked regularly when it is long-term used.

Notices (1) No one except the anesthesiologist is allowed to change the way the pump is administered; (2) Maintain the smoothness of T-joint; (3) The epidural pump should be removed by anesthesiologists.

Further Reading Medling BD, Bueno -RA JR, Russell RC, et al. Replantation outcomes[J]. Clinics in Plastic Surgery,2007,34(2):177–185. Kroll SS, Schusterman MA, Reeee GP, et a1. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996, 98:1230–1233. Cheng GL. Finger replantation and reconstruction. 2nd edition. Beijing: People’s Medical Publishing House; 2005. p. 113.

6

Selection of Anesthesia for Finger Reconstruction

Abstract

Finger reconstruction is the operation to reconstruct the structure and function of the defective finger by composite tissue transplantation, which including cut, assembly and reconstruction. The anesthesia effect request is relatively high due to the complicated duration, fine operation, long time, and complete immobilization of the surgical site. The principle for anesthesia is safe, painless, simple, and convenient for monitoring. Keywords

Anesthesia · Finger reconstruction

6.1.3 Prevention of Vasospasm Keeping room temperature and limb temperature, appropriate sedation can prevent vasospasm effectively, and vasoconstrictor should be used with caution during operation.

6.1.4 Postoperative Analgesia Pain after anesthesia would cause vascular crisis so postoperative analgesia is an important part of anesthesia that should be paid attention to.

6.2 Methods of Anesthesia Now we will introduce some types of anesthesia for finger reconstruction as follow

6.1 Requirements for Anesthesia 6.1.1 No Pain at the Surgical Site Finger reconstruction is delicate and needs patients to be comfortable and quiet without pain especially the time under the microscope.

6.1.2 Adequate Limb Perfusion The key point of finger reconstruction is the reconstruction of blood circulation which needs to maintain good hemodynamics that requires good blood pressure, enough blood volume, and lower blood viscosity.

Finger reconstruction is generally carried out in the limbs and ilioinguinal area, so all those anesthesia methods that could achieve painless effects at the above sites can be selected. At present, the following anesthesia methods are commonly used.

6.2.1 General Anesthesia General anesthesia is suitable for children, surgery involving multiple sites, surgery lasted a long time, uncooperative patients, patients refusing local block anesthesia. For finger reconstruction, trachea intubation is often required. General anesthesia can be divided into inhalation anesthesia, intravenous anesthesia, combined intravenous and inhalation anesthesia according to different drug routes. There are many kinds of anesthetics which are used for sedation, analgesia, and muscle relaxation. Generally speaking, a combination of several kinds of drugs is needed to achieve an

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ideal anesthetic effect, which will reduce the dosage of each drug to reduce or eliminate the side effects of them. Ketamine is safe for general anesthesia in children but will cause dreaminess, hallucinations, and other symptoms when used in adults. During general anesthesia, physiological changes would occur on the whole human body organs which need close observation by anesthetists. The serious complications after general anesthesia include laryngospasm, aspiration, interruption of airway access, etc., which rarely occur. On the other hand, nausea, vomiting, drunkenness and postoperative pain, etc., are more common.

6.2.2 Region Block Anesthesia Region block anesthesia is commonly used in hand surgery which has fewer effects on body’s physiological activities and major organs such as the heart, liver, and kidney and can be used in those patients with severe cardiovascular diseases, respiratory diseases, and kidney diseases. Its mechanism is to block local nerve conduction, on one hand, blocking nerve impulses of operation position to the central nervous system, on the other hand, blocking nerve impulses of contraction from central nervous system to local blood vessels which relieves patients’ pain, improves blood circulation and reduce vasospasm. The advantages of region block anesthesia including: (1) During anesthesia, the patient is conscious and a variety of protective reflexes are present. For patients with full stomachs, there is a risk of aspiration pneumonia once consciousness is lost under general anesthesia. (2) Compared with general anesthesia, region block anesthesia has fewer complications such as nausea, vomiting, atelectasis, forgetfulness, lethargy, and restlessness. (3) The difficulty and workload of nursing of region block anesthesia are relatively small. Most of the patients could back to their wards directly instead of going to the post-anesthesia care unit (PACU). (4) Region block anesthesia can provide postoperative analgesia for patients which will reduce the possibility of sympathetic tension caused by early pain after reconstruction and vascular crisis caused by vasospasm. Although region-block anesthesia has these advantages, there are still many factors that limit its use of it: (1) It takes a long time for region-block anesthesia to begin to work, and there is a possibility of incomplete anesthesia. Sometimes it may be changed to general anesthesia due to intraoperative needs. (2) Multiple site operation which requires a combination or multiple anesthesia. (3) Finger reconstruction takes a long time and needs patients to maintain a stable position at the same time, otherwise, the movement of patients would interfere with the operation. (4) During the operation, there will still be a sense of vibration or proprioception, or even a sense of pressure which will cause patients to be nervous.

6 Selection of Anesthesia for Finger Reconstruction

Region block anesthesia includes subarachnoid block anesthesia, epidural block anesthesia, and peripheral nerve block anesthesia.

ubarachnoid Block Anesthesia S Local anesthetic drugs injected into the subarachnoid space mainly act on the spinal nerve root and achieve anesthetic effect. In toe-to-hand reconstruction, it can be used instead of epidural block anesthesia when the toe is cut off. Announcements: To maintain the IVs flowing smoothly so as to supply medicines and necessary treatment timely; To keep blood pressure stable in first 20 min by supplementing the blood volume since blood vessel dilates that effective circulation is relatively insufficient; When the anesthetic plane is too high, the patients may appear chest tightness, shortness of breath or pronunciation obstacle which should be treated with oxygen mask, etc.; Strict aseptic techniques must be required. Contraindications: Patients with severe hypovolemia; Patients with coagulation disorder; Patients with infection at the puncture site; Diseases of central nervous system, especially of spinal cord or spinal radiculopathy, may be followed by long-term paralysis after anesthesia; Patients with spinal cord trauma or history of severe low back pain and unexplained spinal cord compression; Patients with severe infections. pidural Block Anesthesia E Local anesthetic drugs injected into the epidural space that blocks the conduction of part of the spinal nerves which has a stage function. Lower epidural block anesthesia or sacral canal block anesthesia are often used in toe-to-hand reconstruction of donor site. Announcements: Proficient in puncture technology, strictly prevent penetration of the dura mater; The experimental dose of local esthetic drugs should be injected after catheterization, and then the required dose could be continued to be injected if no signs of subarachnoid block anesthesia appear 5 min later; Rescue medicine and equipment should be prepared in case of occurrence of total spinal block. The contraindications of epidural block anesthesia are the same as that of subarachnoid block anesthesia. Peripheral Nerve Block Anesthesia Brachial Plexus Block Brachial plexus block is the most commonly used anesthesia in hand surgery. The brachial plexus is mainly consisted of the anterior branches of C5-8 and T1 which supplies sensation and movement of the upper limbs. The brachial plexus nerve is enclosed by the sheath formed by the prevertebral fascia and the scalenus facia in the interscalene. The anes-

6.2 Methods of Anesthesia

thetic drugs must be injected into the sheath to be effective including 4 ways that are supraclavicular approach´ subclavian approach, interscalene approach, and axillary approach. 1. Supraclavicular brachial plexus block: The needle should be inserted 0.5 cm above the midpoint of the clavicle and to find the first rib, along which, move the needle from the outer edge of the scalenus anterior to the anterior edge of the scalenus medius, when anesthesia occurs, inject 10–20 mL solution. The advantages of this method are good anesthetic effect, quick onset, small side effects, and fewer complications. When Supraclavicular brachial plexus block is applied, the affected limb can be placed on the side of body without moving. The disadvantages are the possibility of pneumothorax, phrenic nerve block, Honer syndromes, etc. 2. Subclavian brachial plexus block: After finding the groove between the scalenus muscles, then move the fingers downward and touch pulse of the subclavian artery and the needle should be inserted from the posterior margin of the subclavian artery. If the pulse is not touched, the needle could be inserted in front of the scalenus medius. When anesthesia occurs, inject 20–40 mL solution. The advantages of this method are simple operation, small dose of anesthetic, quick onset and the disadvantages are pneumothorax, phrenic nerve block, recurrent laryngeal nerve block, etc. 3. Interscalene brachial plexus block: Find the interscalenus sulcus and insert the needle between the index finger and the middle finger at the level of cricoid cartilage which is the level of the transverse process of the sixth cervical vertebra. Insert slowly until anesthesia appears and inject solution. The advantages of this method are simple operation, especially suitable for fat patients; good effect with small dose, especially suitable for surgery on upper limb and shoulder; avoid causing pneumothorax; avoid causing infection and spread of tumor. The disadvantage is that the ulnar block is not complete or has no effect at all. The remedy is to increase the volume of anesthetics of block the ulnar nerve in the elbow. 4. Interscalene brachial plexus block: The main methods of operation include axillary artery puncture, anesthesia around axillary artery, and extensive infiltration around axillary artery. The advantages of this method are simple and safe, however, there are relatively more arteries and veins in this area which may be injured, and there is even possibility that a large dose of local anesthetics will enter blood and cause systemic toxicity.

ciatic Nerve Block Anesthesia S The sciatic nerve generally passes through the infrapiriformis foramen, in this position, it is located on the ventral side

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of the gluteus maximus which is relatively superficial that is often used for ultrasound-guided subgluteal sciatic nerve block anesthesia. For cases requiring tourniquet, it is recommended to reduce the discomfort of patients to the tourniquet. Sciatic nerve block alone cannot reduce the tourniquet response, so it is necessary to combine femoral nerve and obturator nerve block.

emoral Nerve Block Anesthesia F The traditional method is to find the pulse of femoral artery and insert the needle between lateral of femoral artery and inferior of the inguianl ligament, the appearance of anesthesia or motor reaction means the correct position of the needle tip is. Under the guidance of ultrasound, the femoral nerve, artery, and vein can be clearly seen that can ensure the local anesthetic fluid to wrap around the whole femoral nerve avoid blood vessels injury. ateral Femoral Cutaneous Nerve Block L Anesthesia The traditional method is to insert the needle 2 cm below the anterior superior iliac spine, when the resistance disappears, suggesting that the needle tip has passed through the fascia lata. Move the needle to inject 10–15 mL local anesthetics in a fan both inside and outside. Ultrasound-guided method has two ways: the inferior inguinal ligament approach and the inferior superior ligament approach. Existing evidence suggests that the superior ligament approach is more complete and stable than the inferior inguinal ligament approach in blocking the lateral femoral cutaneous nerve. bturator Nerve Block Anesthesia O The traditional method is not easy to operate and the effect is not stable. Under the guidance of ultrasound which can clearly judge the anatomical structure and improve the success rate of obturator nerve block. eri-Ankle Nerve Block Anesthesia P The peri-ankle nerves include the tibial nerve, sural nerve, superficial peroneal nerve, deep peroneal nerve, and saphenous nerve. Peri-ankle nerve block alone is usually used for foot surgery without tourniquet, and the operation time is short, or as a remedial measure for incomplete nerve block. eri-Elbow Nerve Block Anesthesia P The ulnar nerve, median nerve, radial nerve, medial, and lateral cutaneous nerve can be blocked around the elbow joint. This method is generally only used as a supplement in the case of incomplete brachial plexus block for the reason that the volume of anesthetics used to block multiple nerves at the same time is no less than that used in brachial plexus block and patients cannot tolerate the pain of the tourniquet.

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eri-Wrist Nerve Block Anesthesia P It is simple and common in hand surgery which can keep fingers active during surgery. The median, ulnar and radial nerve can be blocked.

6.3 Selection of Anesthesia General anesthesia is the most commonly used in finger reconstruction which has advantages of quick effect, convenient management, and high safety. General anesthesia drugs have a vasodilating effect which is good for the blood perfusion of reconstructed tissue. Patients can be completely calm which is also good for suture of small blood vessels and nerves. However, patients in emergency surgery usually have

6 Selection of Anesthesia for Finger Reconstruction

full stomachs which are not suitable for general anesthesia since it will increase the possibility of regurgitation and aspiration which can be life-threatening. In these cases, nerve- block anesthesia or nerve-block anesthesia combined with sedation is more commonly used. In particular, the second method can not only satisfy the need for a completely painless surgical site but also keep patients calm during the operation. After general anesthesia, patients usually experience severe pain at the surgical site, so many hospitals are carrying out nerve block anesthesia combined with general anesthesia which first solve the problem of postoperative analgesia, second the dose of anesthetics is far less than application of general anesthesia alone which reduce side effects of the drug dose-related, shorten the awake time, be more comfortable after anesthesia.

7

Fundamental Skill for Finger Reconstruction

Abstract

The basic skills of finger reconstruction mainly include the basic techniques in operation and the proficiency of anatomy. We will just discuss the training of operating skills. The characteristics of operation skills in microsurgery including: (1) It is generally operated under a microscope which needs an adjustment process; (2) The field of vision and the operating space are relatively small to be found again once moved; (3) The field of vision will turn to vague if the lens or eyes move up and down a little which needs to be adapted again; (4) Slight instability or movement of surgeon’s hands would affect the quality of suture. Therefore, a microsurgeon must experience a certain period of formal training before participating in operation. As finger reconstruction is one of the most complicated and difficulty operation in microsurgery, the training of skills is especially necessary. Keywords

Surgical skill · Finger reconstruction

7.1 Micro-Suture Operation Training of Small Blood Vessels Micro-suture of small blood vessels is a standard of basic skill for microsurgeon. An excellent microsurgeon must have experienced hundreds of times training in micro-suture operation.

7.1.1 Training Should Be Step by Step Don’t be in a rush for quick results, instead of going step by step at the early stage of training. The position of sitting, head, neck, shoulder, elbow, wrist, hand, and how to take the micro equipment need gradual training and repeated practice under guidance of superior physician so as to be mastered. The height of the microscope and the angle of the eyepiece

should be adjusted according to the height of surgeons, it will be more comfortable when the eyepiece is viewed at head level or slightly lower within 30°. A comfortable sitting position should be with chest and waist relaxed. A good position for operation should be with shoulders relaxed, elbows, forearms, and hands supported. Follow the principle from low to high, from big to small, and from coarse to fine when trained. Practice of microscope needs to use a lower magnification of the eyepiece, generally starting from four to six times which is with a bigger vision and better light that is easier for eye-to-hand coordination training. Then increase the magnification and suture smaller vessels step by step. To practice suturing about 20 anastomotic sites every day and you will be more skilled 1 week later.

7.1.2 Placement and Use of Microsurgery Instruments Microsurgery requires that the operation is generally divided into a square table (upper limb operation area) and a operation table (trunk and lower limb operation area). The table surface should be smooth, with appropriate height, and the position of which should be reasonable with the surgeon’s position. Blood-stained gauze, used equipment, even cotton balls and thread ends will affect the operation under the microscope so it is very important to keep the table surface clean. Put the microforceps and scissors on the front of the left-hand side of the surgeon, the needle and thread on the right side, and the other instruments should be placed on the instrument table that could make the surgeon get and put down the instruments much more easily without having to take their eyes off the microscope. There are two ways to find the needle again and continue to sutrue: one is to put the needle in the field of vision of the microscope, see the needle clearly and continue to suture; the other way is just like the normal way of surgical suture which is more suitable for beginners since their eyes can take a short break from the lens to avoid eye strain.

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7.1.3 Select Needle and Thread According to Vessel Diameter The quality and patency rate are directly affected by the thickness of needle and thread. If the thread is too thick, the vascular cavity will be occupied, and the foreign body reaction will make the vascular cavity narrow if the thread is too thin, the tension will be too small to be tight which will cause thrombosis. Therefore, the appropriate suture needle and thread should be selected according to the vessel diameter. Generally, 7-0 to 8-0 nylon needle and thread are suitable for vessels of 2–3 mm in diameter; 9-0 nylon needle and thread is suitable for vessels of about 1 mm in diameter; 9-0 to 10-0 nylon needle and thread is suitable for vessels of 0.5 mm in diameter; 12-0 nylon needle and thread is suitable for vessels of under 0.3 mm in diameter.

7.1.4 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate The number of stitches should be determined according to diameter of the blood vessel. On this basis, Distance between suture stitches, breadth of suturing margin should be properly mastered. It has been reported that the number of stitches, distance between suture stitches, breadth of suturing margin are not properly master all will affect the quality of anastomosis. The vessel diameter should be measured first, then the number of stitches could be determined, after the distance between suture stitches, the breadth of suturing margin could be determined based on it. For example, when the vessel is 1 mm in diameter, 8–9 stitches will be suitable if 9-0 nylon needle is used, and distance between suture stitches, breadth of suturing margin should be 0.3 mm; 12–14 stitches will be suitable If 12-0 nylon needle is used, and distance between suture stitches, breadth of suturing margin should be 0.2 mm.

7.2 Skill and Key Points for Small Blood Vessel Suture 7.2.1 Clear Exposure of Blood Vessels No matter where the vascular injury is, it must be clearly exposed for easy operation under microscope. Tissues 1–2 cm around anastomosed site should be dissociated along the blood vessel. Any tissue that affects vision should be

7 Fundamental Skill for Finger Reconstruction

sutured and fixed on both sides or excised. Light blue or yellow silicon rubber sheet can be set under the blood vessel makes the vision more clear to be sutured.

7.2.2 The Suture Must Be in the Normal Vascular Segment The blood vessels should do a debridement again before sutured. A section (generally 0.5–0.8 cm) on the proximal and distal end should be dissociated and observed. Following situation means the vascular wall, especially the intima has been damaged in different degrees which will cause thrombosis after anastomosis should be excised: Peripheral bleeding, hematoma of the outer membrane mostly caused by vascular branch tear and vascular wall damage; “red line sign” indicates that there is compression, twist, contusion or tear in the vascular wall; “stain ribbon sign” indicates that there is rupture of the muscularis due to tension or rotation injury. Even if the appearance of the vessel seems normal, when it is washed, there is a flocculent floating substance in the lumen, or mural thrombus that cannot be washed out, etc. which also indicates that the intima is damaged and needs to be excised until the intima is smooth, complete, pink, and there is no floating substance and mural thrombus, etc. In order to ensure the success rate of anastomosis, it is necessary to suture in normal vascular segment.

7.2.3 The Size of Anastomosed Vessels Should Be Similar The size of end-to-end anastomosed vessels should be similar, if it is not, anastomosis will be more difficult and probe to thrombosis. When the diameter difference is more than 1/3, the smaller end should be cut into inclined plane or fish mouth to increase the diameter.

7.2.4 The Tension of Blood Vessels Should Be Proper Due to the physiological elasticity of blood vessels when they are cut, the ends will retract to both sides and the degree of retraction is related to vascular nature, diameter, length of dissociation, and limb position. Generally, arteries with a diameter of about 1 mm, dissociated by about 2 cm, can naturally retract a distance between 0.5 and 1 cm which will still meet the physiological requirement of tension. However, most of the damaged vessels would be with defects, after

7.3 Suture Methods

debridement, the defects may reach about 1 cm. If they are dissociated and peripheral tissue is sewn up with a few stitches to reduce tension, the vascular suture may be still allowed. When the actual defect is over 2 cm, it should be repaired by vascular replantation.

7.2.5 The Operation Should Be Steady, Accurate, Light, and Skillful The so-called non-injury operation refers to the reduction of iatrogenic injury to the minimum in the process which needs surgeons to be steady, accurate, light, and skillful. Every involved in the operation, including assistants, nurses, anesthesiologists as well as the patients must keep the operating table steady and quiet. Avoid clumsy and awkward movements as possible as you can, such as backhand suture and finger knotting, etc.

7.2.6 Distance Between Suture Stitches, Breadth of Suturing Margin, and Number of Stitches Should Be Appropriate Just described as above (Sect. 7.1.3).

7.2.7 Proper Trim of Outer Membrane at Broken End and Flushing The outer membrane at broken end is easily inserted into lumen which should be properly trimmed. The outer membrane has a supporting and nourishing effect on the vascular wall, when it is trimmed too much, it is not conducive to the stability and healing of the anastomotic site. In the process of suture, heparin saline solution (12.5 mg of heparin per 100 mL of normal saline solution should be regularly dripped to keep anastomotic site wet and clean, however, the dripping liquid should not be too much so as not to affect the stitching and knotting.

7.2.8 Maintain the Vascular Bed Healthy and Flat The anastomotic site must be surrounded by smooth and healthy tissue for patency and healing. The vascular is uneven, even on the uneven fracture end or steel plate screw, and the surrounding tissue with poor blood supply can stimu-

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late vasospasm or thrombosis. Therefore, before suturing blood vessels, muscles and fascia with good blood supply should be paved under the blood vessels or cover the bones or fixations first. After the suture is completed, it is better to be covered with surrounding healthy muscles, fascia, and other soft tissues to leave no ineffective cavity which can not only prevent vasospam but also be helpful for healing.

7.2.9 Stitching and Knotting Should Be Accurate and Proper When the needle is inserted, the needle tip and vascular wall should be vertical, preferably no less than 60°-70°, in this way, the distance between the needle and vascular wall is shortest, resistance is small, and the damage is light. Knotting tightness should be proper, align with the two broken ends, slightly eversion on the outside, and align with the inner membrane are good.

7.2.10 The Sequence of Stitches Should Be Proper No matter what suture method is used, the principle is the sequence of stitches should be simple, easy to master the distance between suture stitches, breadth of suturing margin and number of stitches, small damage to vascular vessels.

7.3 Suture Methods There are many microvascular suture methods, just described as follows, which can be chosen according to own preferences.

7.3.1 End-to-End Anastomosis End-to-end anastomosis is the most common method for microvascular at present which conforms to the physiological blood flow direction and can maintain the maximum blood flow rate. Because of the doctors’ habit, the suture method and needle sequence are different.

hree Stay Sutures End-to-End Anastomosis T (Fig. 7.1) It is invented by Carrel in 1902. The advantages of this method are that it is convenient to add stitches by lifting traction line at each point, avoiding the suture to the opposite

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7 Fundamental Skill for Finger Reconstruction

Fig. 7.1 Three stay sutures end-to-end anastomosis (Carrel)

Fig. 7.3 Suture the lateral wall and needle sequence at equidistant two points (Wang 1982)

Fig. 7.2 Two stay sutures end-to-end anastomosis

Fig. 7.4 Nonequidistant two stay sutures end-to-end anastomosis

side wall, and the vascular rotation is less. However, the disadvantage is that it is not easy to grasp the isometric three fixed points, so the number of needles, needle spacing, edge spacing are difficult to achieve uniform.

onequidistant Two Stay Sutures End-to-End N Anastomosis (Fig. 7.4) It is invented by Cahett in 1967. The advantage of this method is that the anterior wall of the vessel between two traction lines is smaller at 120°, while the posterior wall is larger at 240°. In this way, when the anterior wall is sutured, the posterior wall will drop down and leave the anterior wall, avoiding the suture to the posterior wall. However, the disadvantage is that the number of needles is not easy to grasp, and the vessel needs to be rotated 180°to suture the posterior wall which is easy to damage the vessel.

wo Stay Sutures End-to-End Anastomosis T (Figs. 7.2 and 7.3) It is 180° equidistant two fixed points suture method. The advantages of this method are more clear to expose, more convenient to suture, and easy to grasp needle spacing and edge spacing. However, the disadvantages are that when the two-needle traction line is raised, the lumen will be deviated and the tube wall will close together, especially the thin- walled vein, which is easily be sewn to the opposite side; When it is stitched to the opposite wall, the blood vessels need to be rotated 160°-180°, which is easy to damage the blood vessels.

I sometric Four Stay Sutures End-to-End Anatomosis of the Anterior Wall (Fig. 7.5) The advantages of this method are that the exposure is clear, easy to operate, needle spacing, edge spacing, and needle number are easy to grasp. The disadvantage is that the vessel

7.3 Suture Methods

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Fig. 7.5 Isometric four stay sutures end-to-end anatomosis of the anterior wall

Fig. 7.7 Insertion anastomosis (Lauritzen 1978) and sleeve insertion anastomosis (The arrow points to the direction of blood flow)

Fig. 7.6 Isometric four stay sutures end-to-end anatomosis of the posterior wall and twine sutures

Fig. 7.8 Isometric four stay suture exstrophy mattress anatomosis (Wang 1982)

needs to be rotated 180° to suture the posterior wall which is easy to damage the vessel.

I sometric Four Stay Sutures End-to-End Anatomosis of the Posterior Wall (Figs. 7.6 and 7.7) The advantage of this method is that the lumens can be seen clearly with each stitch, and the suture to the opposite side wall can be avoided. But its disadvantage is that number of needles is not easy to grasp, the needle spacing, and edge spacing is also difficult to achieve uniform. ontinuous Anastomosis (Figs. 7.8 and 7.9) C It is advisable to use continuous anastomosis to keep the tightness of each stitch at the length that can be used for knotting after cutting, when the posterior wall is finished, cut

Fig. 7.9 Isometric four stay suture end-to-side exstrophy mattress anatomosis and needle sequence (Wang 1982)

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all the lines and tie them or cut one at a time which can improve suture speed and avoid the suture to the opposite side wall, but the number of needles and margins are not easy to grasp, and its appearance is messy.

Side Wall Stayed Sutures Anastomosis End-to-Side Anastomosis When one of the vessel should not be cut off or the diameter of the two broken ends is too large, end-to-side anastomosis can be used. Lateral opening (window): When end-to-side anastomosis is adopted, it should be opened more than 2 cm away from the vascular ligation site to prevent blood clots formed at the ligation site from affecting the patency of suture. And the opening should be slightly larger than or equal to the diameter of the broken end to be anastomosed, so as not to cause stenosis. The angle of this method is generally about 45°, but some people think there is difference between 45° and 90°. However, the angle should not be too small which will be more difficult to suture and affect blood flow. Sleeve Insertion Anastomosis In 1978, Lauritzen and Mayer conducted an experimental study on femoral vessels of rats with diameter less than 1 mm with the method of sleeve insertion anastomosis at almost the same time and achieved good results. In 1980, Chen zhongwei conducted an experimental study on 100 femoral arteries of rats with diameter 0.6–0.8 mm with this method and obtained a 98% long-term potency rate which attracted much attention and became one of the most commonly used suture methods. The advantages of this method are that there are no or few suture line in lumen, and no damage to the vascular intima; The operation is simple and time saving; Generally speaking, the diameter of about 1 mm needs only 3–4 stitches which can be completed within 8–10 min. However, it also has some disadvantages that it is not suitable for end-to-end anastomosis; when the vascular length is insufficient and the diameter varies too much, it cannot be used; When the diameter is less than 0.5 mm or larger than 3 mm, the patency rate is lower than that of end-to-end anastomosis. Small Vessel Transplantation In the process of limb vascular injury or severed limb (finger) replantation, blood vessels with severe contusion are often encountered which must be removed, resulting in a shortage of blood vessels; or in the process of transplantation since the vascular pedicle is short and cannot be sutured with the recipient vessel, small vessel transplantation is required. Autogenous vein graft is most commonly used, autogenous artery graft is also used in special cases.

7 Fundamental Skill for Finger Reconstruction

Notices

1. A detailed examination must be conducted before the vascular resection which should be of appropriate diameter and length according to the condition of the recipient area for transplantation. 2. Autologus superficial vein is the best material for small vessel transplantation. The great saphenous vein, the small saphenous vein, and the cephalic vein are often used to supply the large vascular defects in limbs; The superficial veins of forearm, dorsal of hand, and dorsal of foot are the common donor areas for small vessel defect transplantation. 3. When cutting blood vessels, non-invasive operation and open cutting must be insisted on, excessive pulling and squeezing of blood vessels should not be done, which can reduce vascular stimulation and injury. 4. The diameter and length of transplanted vessels should be appropriate. 5. The transplanted vessels should be placed in healthy soft tissue, covered or wrapped by surrounding muscles, fascia, etc., which can reduce vascular stimulation and facilitate vascular healing. 6. Spasmodic and anticoagulant drugs should be used after small vessel transplantation. 7. In the process of operation, the bleeding should be stopped thoroughly to avoid hematoma and a drainage strip should be placed if necessary. Postoperative antibiotics should be routinely used to prevent infection.

References Lauritzen. A new and easier way to anastomose microvessels. An experimental study in rats. Scand J Plast Reconstr Surg. 1978, 12:291–294. Wang CQ. Study on microvascular suture method. People’s Military Surgeon, 1982(1).

Further Reading Chen ZW, Yang DY, Tian TS et al. Microsurgery, Shanghai, Shanghai Science and Technique Publishing House, 1985. Huang JS. Huang Jiasi Surgery. People’s Medical Publishing House, 1985. Hou SJ, Cheng GL, Fang GR, et al. Reconstruction and repair of finger defects with free toe transplantation. Chinese Journal of Hand Surgery, 2001,17(4): 212-214. Wang ZT, Cai JF, Cao XC, et al. Reconstruction of digits by the second toe and 4 composite flaps with the same vessel pedicle. Chinese Journal of Hand Surgery, 2002,18(2): 85-87. Wang CQ, Wang JL, Wang ZT, et al. Analysis of the thumb and finger reconstruction with the pedal digit transplantation in 495 cases. Medical Journal of Chinese People’s Liberation Army, 1996: 364–366.

8

Postoperative Management for Finger Reconstruction

Abstract

Almost every patient who had decided to reconstruct his finger fought with himself to make the decision which means an overwhelming desire for success that is consistent with the goal of the surgeon team. The best result would be achieved only when the doctors and the patients work together and cooperate with each other. But the end of surgery is just the beginning of success, postoperative treatment, observation and nursing are as important as an operation which would lead to failure if we don’t pay attention to. Keywords

Postoperative management · Finger reconstruction

8.1 Postoperative Treatment and Management As the importance and specificity of finger reconstruction, the hospital environment should meet certain requirements such as being quiet and clean, constant temperature(23–25 °C), fresh air circulation, keeping humidity at 60%, etc. Otherwise, a 40–60 W incandescent lamp can be used to keep the reconstructed finger warm, and the distance should be kept between 40–50 cm to avoid heat burn of tissue. Smoking is absolutely forbidden in the ward in order to prevent postoperative vascular crisis. Visitors and visit time should also be controlled to enable the patient to have good rest and avoid emotional fluctuations. The bedtime for patients is generally 7–10 days which means they should be turned over slowly and regularly to avoid occurrence of pressure ulcer. For a long time lying in bed, a more comfortable position for the affected limbs is essential. Generally speaking, the affected limb should be placed at a position slightly higher than the heart and maintained in the resting position which could be also

adjusted according to the surgical site. Improper placement of affected limb will cause compression or distortion to anastomotic blood vessels which would affect blood circulation. The fingers should be loosely bandaged to expose the reconstructed finger for observation. The root of reconstructed fingers and the suture of skin should not be compressed to avoid affecting arterial infusion and venous return. To change the wound dressing regularly so as to avoid blood scab compressing the wound which would cause vascular crisis.

8.1.1 Postoperative Observation and Management (Figs. 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8 and 8.9) bservation and Treatment of a Systemic O Condition Observation of Vital Signs Blood pressure, respiration, pulse, and consciousness should be closely observed which would fluctuate in early stage after the operation because of anesthesia, surgical reactions, blood loss, hunger, fatigue, etc. Observation of Blood Volume and Peripheral Circulation To observe patients’ skin and mucous membrane for cyanosis and pallor, routine blood and biochemical examinations should also be performed after the operation to find if there is anemia which should be corrected by blood transfusion. Observation of the Amount of Liquid in and out Volume enlargement is routinely required after operation. Postoperative infusion should be controlled at 40–60 mL/kg and the speed should be constant and kept for 24 h and maintain the balance of water and electrolysis and avoid acid-base metabolic disorders.

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_8

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Fig. 8.4 Raise the lower limbs Fig. 8.1 The pad for raising the upper limbs

Fig. 8.2 Raise the upper limbs

Fig. 8.5 Heating lamp

Fig. 8.3 The pad for raising the lower limbs

Observation of Uncomfortable Symptoms Abdominal bloating, anorexia, nausea, constipation and body aches, etc. at the same time depression, dysphoria, and other emotional fluctuations due to long-term bedtime should be observed and treated in time to avoid vascular crisis.

8.1 Postoperative Treatment and Management

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Fig. 8.6 Lamp shade

Fig. 8.8 Microinjection pump

mal, from the fourth day, it could be changed to observe and record every 2 h. Generally speaking, blood circulation of reconstructed fingers would be stable after 7–10 days.

Fig. 8.7 Keeping warm by heating lamp

ocal Observation of Reconstructed Fingers L First 72 h after the operation is a high incidence period of vascular crisis and it is required to observe and record the changes in blood circulation every hour. If everything is nor-

Changes of Color If blood circulation of reconstructed fingers is normal, the color would be the same as that of normal finger or be slight red. If the color changes to pale, it means arterial blood supply disorder, and if the color changes to dark purple, it means venous blood supply disorder. Changes of Temperature The temperature of reconstructed fingers would be 1–2 °C higher than normal ones. If temperature decreases, the possibility of vascular crisis could be judged by a combination of changes in color.

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Fig. 8.9 Continuous intravenous administration

Changes of Skin Tension If skin tension drops apparently, even finger (toe) pulp is shriveled, it means arterial blood supply disorder. If skin tension increased significantly, even tension blisters appear, it means venous blood supply disorder. Blood-Letting Test When there is arterial blood supply disorder, no blood flow or only small amount of dark red blood would ooze. When there is venous blood supply disorder, blood would ooze rapidly, which would be dark red or purple-black venous blood first and then be bright red arterial blood. Observation of Wound Bleeding The dressing should be kept as dry as possible, if the dressing is rapidly permeated and active bleeding is observed, it must be treated in time, most of which could be stopped by local pressure. However, if it is bleeding around the anastomosed site, it must be treated carefully. First is to avoid local pressure leading to vascular crisis, second is to avoid excessive blood loss leading to anemia and even shock, once the treatment is not effective, it is necessary to go into the operation room for exploration.

8.1.2 Drug Treatment Prevention of Infection Most finger reconstruction belongs to type I incision operation except for emergency construction, however, once

infected, it may lead to failure of surgery. Therefore, prophylactic use of antibiotics is routinely recommended, which means the use of the first generation cephalosporin to prevent infection 24 h before and after surgery.

Antipasmodic Therapy Antipasmodic therapy is a routine treatment after microsurgery which is effective for the treatment and prevention of postoperative vasospasm. Anticoagulation Therapy Anticoagulation therapy can prevent postoperative embolism, which is still a routinely recommended treatment and should be used from 24 h after surgery. It is not recommended immediate use of heparin or low molecular heparin which would easily cause bleeding in the surrounding tissue and result in vascular crisis. And the drug should be stopped in time if wound bleeding significantly increased or other tissue bleeding happens. Postoperative Analgesia Pain causes the body to release 5-HT which has a strong vasoconstrictor effect and would lead to vasospasm if it is not treated in time. So postoperative analgesia is very necessary. The routine method is let the anesthesiologist install a postoperative analgesia pump and assisted with parecoxib, compound diclofenac sodium, and other analgesia, even opioids could be used when necessary. For those with lower pain domain, spirit of high tension or infants and children, hibernation therapy could be used for analgesia when necessary.

8.1 Postoperative Treatment and Management

Neurotrophic Therapy Neurotrophic medicines could be used after surgery such as mecobalamin, etc. Blood Volume Augmentation Therapy It is generally recommended to use crystoloid solution with 40 mL/kg/day to expand blood volume to avoid vascular crisis after finger reconstruction.

8.1.3 Judgment and Management of Vascular Crisis Vascular crisis is a pathological phenomenon in which anastomotic blood vessels are blocked and the survival of transplanted and replanted tissues is endangered, which is divided into arterial crisis and venous crisis in clinic, according to the pathological classification it can be divided into vascular embolism type and vasospasm type. The common vascular crisis in clinic includes five types: arterial thrombosis, arterial spasm, venous thrombosis, venous spasm, and arteriovenous thrombosis. Vascular crisis is one of the most common and dangerous complications after microsurgery which would directly lead to failure if it is not treated in time.

Arterial Crisis Arterial Spasm Most of them occur within 72 h after surgery often due to insufficient blood volume, pain, cold, mental stress or children crying, and other factors. The clinical manifestation of arterial spasm is the color of the severed finger changes from ruddy to pale, skin temperature drops, the capillary reaction slows down, finger pulp is shriveled, and elasticity drops which is not easy to be distinguished from arterial thrombosis in early stage. Treatments: Arterial spasm should be first considered once arterial crisis occurs. To look for the cause of spasm first and carry out symptomatic treatment:if the room temperature is low, then raise it in time and strengthen the heat preservation measures; if the spasm is caused by pain, analgesic drugs should be given in time; if the spasm caused by changes of mood, the sedative should be used in time, etc. After the above treatments, papaverine of 30–60 mg should be immediately intramuscularly injected, generally speaking, spasms can be relieved after 20–30 min. If it is not relieved after 30–60 min, refractory spasm or arterial thrombosis should be considered, and surgical exploration should be performed immediately. We have encountered and reported that the blood supply of replanted or reconstructed fingers would be restored and finally survived without exploration after performing brachial plexus block anesthesia, therefore nerve root block anesthesia also could be a method

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of treatment for arterial spasm. During the operation, if arterial spasm is observed, papaverine could be injected into the vascular outer membrane of the spasm segment or excised it, the wound could be applied with warm salt water and papaverine wet gauze. If it still cannot be alleviated, the subcutaneous tunnel should be completely cut open, after the thrombosis is eliminated, the method of segmental hydraulic expansion, external membrane antipulling, continuous application of wet and warm papaverine could be adopted. After operation, in addition to routine treatment, hibernation mixture should be used to make patients fall asleep and relieve anxiety. If spasm occurs again, it is generally difficult to be treated but should be excised and repaired with blood vessel transplantation. Arterial Thrombosis Arterial thrombosis is usually caused by incomplete debridement, poor quality of anastomosis, high tension, local hematoma compression, excessive swelling and compression of finger body, prolonged arterial spasm, and local infection which is common within 24 h and hard to be distinguished from arterial spasm. Treatments: Once arterial thrombosis is found or suspected, rapid intravenous infusion of 250 mL normal saline plus 200,000 units of urokinase or intravenous injection of 20 mL normal saline plus 100,000 units of urokinase from brachial artery, if no improvements in 15–30 min, exploration should be performed immediately. During exploration, the factors such as hematoma expression or skin compression should be relieved first. Embolus usually extends to the proximal end which could be still seen even after 3–5 mm resection. At this time, the surgeons could use two micro tweezers to gently pull the thrombus to the distal end and prevent it from breaking. When the thrombus is completely pulled out, a powerful blood spraying can be seen. If the proximal thrombus is not completely removed, it should be blocked again with vascular clamp, and flocculent substance can still be seen after rinsing, then the segment of the artery should be excised until the artery with a bright and complete lumen and a powerful blood spraying can be seen. After the above treatments, if the blood vessel can be anastomosed without tension, it can be anastomosed again directly. If there is defect, blood vessel transplantation should be performed. Venous Crisis The majority of clinical venous crisis are caused by venous thrombosis which is also the most common vascular crisis after finger reconstruction. Venous crisis is mainly caused by low-quality of vein anastomosis, tortuous vein, high tension, unreasonable flap design, extensive swelling of finger(toe) body. Once venous crisis occurs, it should be dealt with in time, otherwise, it will quickly develop into arteriovenous crisis.

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Treatments: If the reconstructed finger is seriously swollen and has tension blisters, the affected limb can be raised and tension blisters can be punctured, and also incisions at the distal end of toe body to relieve the reflux pressure; If the skin is too tight, suture far away from the anastomosed site could be removed, and remove the blood scab. At the same time, rapid intravenous infusion of 250 mL normal saline plus 200,000 units of urokinase or intravenous injection of 20 mL normal saline plus 100,000 units of urokinase from brachial artery, if no improvements in 15–30 min, exploration should be performed immediately. During the exploration, 2–3 mm at the proximal side could be resected and flushed with 1: 100 heparin normal saline until the lumen is bright and complete. Embolus usually extends to the distal end which could be still seen even after 3–5 mm resection. At this time, the surgeons could use two micro tweezers to gently pull the thrombus to the distal end and prevent it from breaking. When the thrombus is completely pulled out, venous blood will spill out. Sometimes exploration is too late, venous thrombus extends too long to the distal end that is difficult to be taken out with forceps, the surgeons can squeeze the toe from far to near so that the thrombus could be extruded and continuous venous blood flow can be seen. After the above treatments, if the blood vessel can be anastomosed without tension, it can be anastomosed again directly. If there is a defect, blood vessel transplantation should be performed. Sometimes arterial crisis and venous crisis exist at the same time, so we must be ready to judge and deal with them both. Treatments after Exploration In order to prevent the occurrence of vascular crisis again, while strengthening psychological counseling, sedation treatment generally can be given, commonly used hibernation mixture, so that patients can fall asleep and get adequate rest. Since the vascular intima is injured in different degrees after exploration, thrombolytic treatment with small dose of urokinase can be used, 100,000 units of urokinase plus 100 mL of normal saline can be used once or twice a day, for 3–5 days. In patients with condition, hyperbaric oxygen can be added 3 days after exploration which can be used 1–2 times a day, and continue for 7–10 days.

8.2 Cause Analysis and Prevention of Vascular Crisis With the development and improvement of finger reconstruction, many scholars have reported a high success rate, but there are still some cases of failure. The incidence of vascular crisis after reconstruction is still high which is an important factor that affects the success rate of surgery.

8 Postoperative Management for Finger Reconstruction

8.2.1 Cause Analysis There are many reasons for vascular crisis, which may be single or multiple exist at the same time, which are summarized as follows: 1. Physical mechanical factor: It is a major risk factor for vascular crisis including pedicle compression, excessive skin suture tension, skin graft compression, vascular pedicle tortuous, hematoma compression, etc. 2. Mental and psychological factor: Among the patients of finger reconstruction, a large part of them have experienced failure of finger replantation which has left a certain psychological shadow more or less. So a lot of patients and their families are in the spirit of irrepressible tension which would lead to anxiety, difficulty in falling asleep, overstimulation of the sympathetic nerve, increased blood catecholamine concentration, and contraction of small vascular smooth muscle, resulting in spasm or even intractable spasm. 3. Vascular variation in the foot: The most common blood supply system in toe-to-hand transfer is the dorsalis pedics artery- deep plantar artery-first dorsal metatarsal artery system. Variation of dorsalis pedics artery is fine or lack of, which reported between 4% and 6.7%. If there is no preoperative CTA or MRA to assess variation accurately, it will increase the risk of postoperative vascular crisis since the difficulty in directly anastomosis with radial artery needs a vein graft bridge vessel. 4. Intraoperative vascular damage: It will happen in the process of dissociating tissue and dissection, surgeons do not protect blood vessels enough, operate roughly, pull blood vessels too much, forceps clamp damages, or even cut or ligate blood vessels by mistake. 5. Unreasonable design of finger-toe joint flap: Since the diameters of fingers and toes are not the same, the flap must be designed reasonably. Otherwise, the skin suture tension with be too large or the soft tissue will be exposed which needs to be covered by skin graft. It is easy to cause mechanical compression or exposure leading to occurrence of vascular crisis. 6. Vascular crisis cannot be identified and explored in time: Vascular crisis of finger reconstruction usually occurs within 1–3 days after surgery, and the high incidence is within 12 h. Therefore, an experienced nurse should be arranged to observe the blood circulation every hour within 24 h after surgery and record it. Once any abnormality is found, it should be reported to the surgeon for immediate treatment. If there is no improvement after conservative treatment, surgical exploration should be carried out immediately. According to incomplete statistics, try to explore as early as possible, the earlier the

Further Reading

exploration is the higher the success rate will be, and the prognosis will be poor after more than 8 h. 7. Poor quality of vascular anastomosis: The level of microvascular anastomosis is an important factor affecting the patency rate of blood vessels. The common problems in clinic include uneven suture distance, vascular wall cavitation suture, high tension suture, vascular tortuosity, vascular intima injury, incomplete ligation, etc., which may lead to vascular crisis. 8. Unreasonable postoperative dressing change: When changing the dressing, it must be done gently, avoid cold stimulation, remove the blood clot around the wound with warm saline, avoid irritating disinfectants such as alcohol, etc. Some surgeons give the dressing work to inexperienced doctors or interns who may operate roughly, use irritating disinfectant or cold saline to wash the wound, or not remove the blood scab around the wound in time which may cause spasm. 9. Unreasonable postoperative medication: The early use and too large dose of heparin after surgery will cause extensive bleeding, subcutaneous hematoma leading to vascular crisis, even hemorrhagic shock in severe cases. According to our experience, anticoagulant therapy may be avoided if vascular anastomosis is of high quality or it is better to be used 12 h later after surgery and it should be stopped if excessive bleeding of the wound is found. 10. Higher incidence of vascular crisis in children: Since children’s toe tissue structure is small and the difficulty in dissociating blood vessels that mean the incidence of vascular injury is high, coupled with the poor corporation after surgery lead to higher incidence of vascular crisis. 11. Get out of bed too early: In general, patients should stay in bed for 7–10 days after finger reconstruction. But some patients have poor self-discipline after surgery, and their defecation habit is not well trained, they secretly get out bed to defecate which would lead to vascular crisis because of the position change. 12. Smoking: Some patients have a long history of smoking before surgery, due to anxiety and smoking addiction attack, they smoke secretly after surgery, or someone of visitors smoke which may lead to vascular crisis. Therefore, postoperative smoking ban must be paid enough attention.

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revention of Vascular Crisis P 1. Inquire the history in detail to understand the patients’ mental state, sleep condition and smoking history, etc. Positive psychological guidance will make them eliminate tension and actively corporate with treatment. Smoking patients should be forced to quit smoking, and bed defecation should be well-trained. 2. Careful preoperative evaluation of vascular condition of the foot by Doppler ultrasound, CTA or MRA so as to be confident in surgical design and operation. 3. In the process of dissociation, the surgeon should be careful and gentle to prevent vascular damage, especially in those with variation, the surgeon should be calm and take various measures to rebuilt vascular circulation. 4. Precise and accurate anastomosis should be carried out for each blood vessel, and the proportion of arteries and veins should be coordinated. Vessels with the same or similar diameter should be selected for anastomosis as far as possible so as to avoid tension and vascular tortuous. Wrong anastomosis of arteries and veins must be avoided. 5. Reasonable preoperative design for donor and recipient site is an important fact for successful reconstruction. 6. In the process of dissociation of toes, it is inappropriate to carry too much subcutaneous tissue, especially around the vascular pedicle, which would cause compression. 7. Strengthen training and communication between doctors and nurses, enhance postoperative observation of blood circulation and management experience, so as to find vascular crisis and treat it in time. 8. Ward is rest environment for patients that should be light, clear, quiet, sweet, comfortable, etc. Sedative drugs or hibernation therapy could be applied for those who are with mental strain and children. Smoking is forbidden.

Further Reading Cheng GL. Replantation and reconstruction of finger. 2nd edition, Beijing, People’s Publishing House, 2005. Pei GX. Microsurgical Orthopaedics. Beijing, People’s Publishing House, 2016. Lin J, Zheng HP, Xu YQ, Zhang TH. Special Type of Finger Replantation. Springer, 2018.

9

Functional Rehabilitation for Finger Reconstruction

Abstract

Rehabilitation is to make those who lost some function caused by illness, injury disability to restore and reconstruct as soon as possible by means of coordinated application of medicine, education, society, and occupation, etc. Rehabilitation should not only focus on the disease but also on the whole person which should be comprehensive recovery from physical, psychological, social, and economical capacity. Finger reconstruction is an effective method to reconstruct the damaged finger body caused by mechanical injuries, traffic accidents, and other causes. However, reconstruction surgery would just obtain the recovery of appearance, functional rehabilitation still relies on systematic physical rehabilitation after surgery. Keywords

Functional rehabilitation · Finger reconstruction

9.1 Staging of Function Rehabilitation After Finger Reconstruction Both of the reconstructed finger and the walking ability of donor foot require the rehabilitation exercise by stages. The rehabilitation task of early stage is to reduce muscular atrophy and joint contractures, promote tissue recovery, and maintain health. One to 2 weeks after surgery is rehabilitation intervention stage for rehabilitation team to know about the cause of injury, surgical method, and demands of surgeons and patients to make early function assessment and judgment of function expectation. Proper placement of shoulder, elbow, and ankle joints could prevent stiffness of joints. Psychological counseling would alleviate anxiety and depression of the patients and their families which would also obtain understanding and cooperation with rehabilitation plan. Physiotherapy measures are not very needed in this

stage. Three to 4 weeks after surgery, in this stage, physical measures should be carried out according to the principle of early rehabilitation after fractures and nerve injury. Six weeks after surgery, physical measures should be carried out according to the principle of middle and later rehabilitation after fractures and nerve injury. Sometimes special reformed tools could be used for better activity of daily living recovery, such as extended toothbrushes and combs. Otherwise, walking in bed with soft soles or walking in bed mat with bare feet for 5–10 min/tid is also needed.

9.2 Common Rehabilitation Methods There are many functional rehabilitation methods for finger reconstruction, including physical therapy, exercise therapy, occupational therapy, traditional rehabilitation, occupational and social rehabilitation, artificial limbs, psychological therapy, and rehabilitation robots. 1. Physical therapy (Figs. 9.1, 9.2, and 9.3) It is a method that takes use of natural or artificial factors, such as electricity, light, sound, magnetism, heat, and motion act on the body to reach the goal of rehabilitation which could be chosen as needed: (1) To promote growth of granulation tissue and healing of skin and soft tissue is usually with ultraviolet, infrared, and laser irradiation; (2) To promote healing of fractures is usually with ultrashort wave electrotherapy and magnetic therapy; (3) Ultraviolet and laser irradiation are often used for superficial inflammation, and short wave, ultrashort wave, and microwave are often used for deep inflammation; (4) Traditional Chinese medicine fumigation could be used in 2–4 weeks after operation to improve skin nutrition, relieve swelling, and pain; (5) Audio frequency-current therapy could be used to soften scar and improve itching and pain symptoms which should pay attention to the position of electrodes and feeling of patients to avoid electric burning; (6) Ultrasound therapy is performed by mobile method,

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Fig. 9.1 Audio electrotherapy

Fig. 9.4 Joint activities during the rehabilitation

Fig. 9.2 Ultrasound therapy

Fig. 9.5 ADL training

Fig. 9.3 Keratherapy

1–1.5 W/cm2, 5–15 min for each site, once a day, and 15–20 times for a course of treatment; (7) Wax therapy is usually used before exercise therapy to improve blood circulation, soften scars, and relieve pains. But above all, reasonable application of physical therapy is the right way to achieve good results of rehabilitation.

2. Exercise therapy (Figs. 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10, 9.11, 9.12, 9.13, 9.14, 9.15, 9.16, 9.17, 9.18, 9.19, 9.20, 9.21, 9.22, 9.23, and 9.24) which is also called functional exercise is basic rehabilitation method, including range of motion exercise (ROM exercise), muscle function exercise, full-body exercise, and sensory exercise. (a) ROM exercise: Each joint of hand has different contracture law because of its special structure and function: (1) Thumb is prone to adduction contracture which would lose abduction and opposition function; (2) Collateral ligaments of metacarpophalangeal joints are relaxed during flexion and tense during extension while interphalangeal joints are just opposite, so metacarpophalangeal joints are easily to construct in extended or overextended position and interphalangeal joints are easily to construct in flex-

9.2 Common Rehabilitation Methods

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Fig. 9.6 Exercise separating and paralleling fingers

Fig. 9.7 Holding function

ion position. Rehabilitation method: (1) Active or passive motion, or a combination of both can contract fibrous tissue and recover joint function gradually in the early postoperative period (1 week after surgery); (2) If joint function cannot be restored after early exercise, manipulation or joint release can be performed after anesthesia, and then early continuous passive movement (CPM) can be performed after surgery. CPM is a relatively new treatment method which fix affected limb on special equipment that drives the limb to do CPM for a long time, mainly for prevention and treatment of joint adhesion and contracture caused by braking, to promote the repair of articular cartilage, ligament, and tendon, and reduce swelling. Attention when applying CPM: (1) The method of exercise can be selected according to the degree of articular contracture adhesion. In the early stage, when passive movements of joints show greater elasticity

which will cause tension and pain, combination of passive and active movements can be used. In those with long course, since the lack of elasticity, passive movements will not cause pain, joint traction and other methods are needed to restore joint function gradually; (2) Range of motion exercise or CPMs should be stared 2–3 days after joint release, not continuous fixation; (3) New pain should be avoided that would lead to new injuries and muscle spasms which could affect the outcome. (b) Muscle function exercise: Posttraumatic immobilization and the cessation of movement of adjacent joints can rapidly lead to incapacitating muscular atrophy except direct muscle damage or damage to its innervation. Incapacitating muscular atrophy is usually reversible, but there is degeneration of the muscle in those long-term and severe muscle atrophy which is irreversible, such as the median nerve and ulnar nerve injuries, of which intrinsic hand muscles usually cannot be recovered that still left to be solved. Muscle contractions are usually divided into isotonic and isometric contractions which are necessary for daily life and also can be used to prevent and treat muscle atrophy. In recent years, there are also isokinetic exercises and hand internal muscle exercises using special equipment: (1) Isotonic exercise: Exercise muscles with isotonic contractions which can be done by pulley system equal tension moment arm components and so on; (2) Isometric exercise: Exercise muscles with isometric contractions, such as the use of walls and strength training equipment for isometric contractions, further use of equipment for multiple angle isometric exercises in order to achieve hand exercises in various aspects; (3) Isokinetic exercise: Using a special isokinetic training equipment when exercising, the limb pushes the lever of the device around

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Fig. 9.8 Hand muscle developer

Fig. 9.9 Extension and flexion function exercise of the interphalangeal joints

Fig. 9.11 Roller exercises for the joint function

Fig. 9.10 Opponens function exercise by using the mobile phone

Fig. 9.12 Playing mahjong exercises pinch, holding function

9.2 Common Rehabilitation Methods

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Fig. 9.13 Autonomic exercises

Fig. 9.14 Writing exercises

Fig. 9.15 Griping exercise

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Fig. 9.16 Pinch, holding function exercise

Fig. 9.17 Extension and flexion function exercise of fingers by using the mouse

the mechanical axis consistent with the axis of joint movement; (4) Intrinsic hand muscles training: There are only a few methods of training for intrinsic hand muscles which are presented by the ball and the rub-

ber band net that can exercise the extensor, flexor, and all the intrinsic hand muscles. Attention for muscle function exercise: (1) The method should be selected according to the condition of patients and equipment, and corresponding changes should be made with diseases; (2) The size of exercise should be proper. (c) Full-body exercise: From the point of biology, human being is a kind of higher animal which has a high dependence on muscle movement in the process of its race and individual development. Lack of exercise, especially because of injury in bed, can cause a series of adverse reaction, such as changes in cardiopulmonary function, muscle atrophy, lack of appetite, decreased immunity and the ability of adapt, depressed mood, and various laid-in-bed complications––pneumonia, pressure sores, deep vein thrombosis, urinary tract infection which would be life threatening when it is serious but it can be prevented by following measures: (1) Finger reconstruction is upper limb injury, and there is no need to stay in bed

9.2 Common Rehabilitation Methods

Fig. 9.18 Chinese medicine rehabilitation exercise

Fig. 9.19 Plantar function exercise Fig. 9.20 Arch rehabilitation exercises

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Fig. 9.21 Foot stress exercise

Fig. 9.22 The great toe function exercise

except the first week after surgery; (2) Healthy exercise in the bed, including deep breath, active movement of uninjured limbs, chest, and waist, etc., which can be carried out collectively, and including routing nursing; (3) Aerobic exercise, including walking, jogging, walking up and down stairs, and exercise with the help of equipment. (d) Sensory exercise: (1) Sensory reeducation: The patients should be educated not to touch sharp or hot

Fig. 9.23 CPM function exercise

9.4 The Significance of Functional Rehabilitation

Fig. 9.24 Foot and ankle function exercise

objects with fingers; (2) Tactile stimulation: To restore the sense of stillness, eye should be kept open and the skin around the affected finger should be pressed with a rubber cylinder at the appropriate pressure, and then eye should be kept close to feel the difference; (3) Temperature sensory exercise: The difference between opening eyes and closing eyes should be felt when touching the cold and warm bottles with the affected finger, 10 min each time, 2 times/day; (4) Compound sensory exercise: Glass marbles, small wooden blocks, red dates, hexagonal nuts, rubber, peanuts, screws, sandpaper, and coins are embedded in rice to test whether the patients could correctly judge the objects they are touching. 3. Occupational therapy: Occupational therapy is an important part of rehabilitation treatment, and it is also a link between patients’ families and the society. Occupational therapy is a bridge form hospitals to the society for patients, including the ability of self-care, the ability to create value in the professional work, and recreational activities which should meet following demands: (1) Purposeful and meaningful activities; (2) Have appropriate difficulty to play a training role; (3) It can be achieved through efforts of patients; (4) Be interesting; (5) The amount of activity can be adjusted. 4. Application of braces: Braces, also known as orthopedic devices, are used to assist or treat motor organs with the help of external mechanical structures which can be relatively or strictly immobilized to ensure tissue healing, antiinflammatory, and pain relief, and facilitate movements of other joints, creating conditions for early movements of the entire limb, continuous correction of some malformed joints or deformity prevention. With the development of the times, the braces are made more and more beautiful,

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light, comfortable and can be washed and removed conveniently which is easy to be accepted by public. 5. Occupational rehabilitation: the patients’ occupation should be obtained and the job demand should be analyzed. Corresponding pre-job training should be conducted based on the patients’ functional conditions and job requirements. To restore the finger function and self-care ability as maximum as possible, the disabled workers’ professional ability should be improved as far as possible so as to promote them to fully return to work and the society. 6. Chinese traditional rehabilitation: Based on the basic theory traditional Chinese medicine, the patient will recover according to syndromes differentiation according to the pathological characteristics of diseases, disabilities, and other syndromes by using acupuncture, massage, traditional sports, qigong, diet, nature, traditional physics, and entertainment. 7. Psychological counseling: Psychological methods for sleep, pain, and emotional management to promote communication and improve patient compliance and confidence. 8. Rehabilitation robot: Rehabilitation robot is a combination of industrial robot and medical robot. At present, the research mainly focuses on rehabilitation manipulator, hospital robot system, intelligent wheelchair, artificial limb, and rehabilitation robot. It mainly uses the new artificial intelligence technology to complete the regular passive movement of different degrees to replace artificial rehabilitation activities which has a certain regularity, persistence, unity, convenience, but lack of flexibility and practicality (high cost) that is not yet widely available.

9.3 Rehabilitation Features of Finger Reconstruction Compared with the exercise after finger replantation, the requirements of postoperative rehabilitation are more strict and complex, because the blood supply may be unstable in the early stage after surgery, and other complications may occur, otherwise, the rehabilitation of lower limb in donor site should also be considered which focuses on the normal life functions of the affected finger, including the improvement of finger flexibility, grip strength, pinch strength, the enhancement of endurance, the recovery of functional touch, as well as the lower limbs walking, squatting, sitting, lying, and standing.

9.4 The Significance of Functional Rehabilitation The hand is not only an important organ of labor but also an important organ of expression. The purpose of thumb and finger reconstruction is not only to improve the appearance

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Cheng GL, Fang GR, Lin S, et al. Thumb and finger reconstruction by anastomosing the digital arteries of the toe transplant and finger. Chinese Journal of Surgery. 1994, 79-81. Cheng GL, Replantation and reconstruction of finger. The second edition, Beijing, People’s Medical Publishing House, 2005. Pei GX, Microsurgical orthopaedics. Beijing, People’s Medical Publishing House, 2016. Lin J, Zheng HP, Xu YQ, Zhang TH. Special type of finger replantation. Springer, 2018. SUAREZ E L, JACOBSON J H. Results of small artery endarterectomy- microsurgical technique. [J]. Surgical forum, 1961, 12. Liu JF, Chen B, Ni Y. Advancement and development prospect of operating microscope. Chinese Medical Equipment Journal, 2013, 34(10): 85-87. Chen Q, You RN, Mao KJ, et al. Design of a kind of binocular medical magnifying glasses. China Medical Devices, 2016, 21(11): 38-41,45. Mozersky, D.J. et al., Ultrasonic arteriography, Arch. Surg. 103:663-667,1971. Barber F E , Baker D W , Nation A W C, et al. Ultrasonic Duplex Echo-Doppler Scanner [J]. IEEE Transactions on Biomedical Engineering, 2007, BME-21(2):109-113. Medling BD, Bueno RA JR, Russell RC, et al. Replantation outcomes [J]. Clinics in Plastic Surgery,2007,34(2):177-185. Kroll SS, Schusterman MA, Reeee GP, et a1.Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996, 98:1230-1233. Cai YM. The development and present situation of limb replanting Further Reading and reconstruction in China. Chinese Journal of Reparative and Reconstructive Surgery. 2018,32(7): 798-802. Huemer GM. Carl Nicoladoni and the concept of toe-to-hand trans- Zhang J, Huang J, Pan JD, et al. Vascular crisis after multiple tissue fer at the turn of the nineteenth century. Plast Reconstr Surg. transplantation for thumb and other finger reconstruction by toe-to- 2005;115(5):1432-3. hand transfer. 2017,31(3): 323-326. Buncke HJ Jr, Buncke CM, Schutz WP. Immediate Nicoladoni pro- Hou SJ, Cheng GL, Fang GR, et al. Etiology and management of vascedure in the Rhesus monkey, or hallux-to-hand transplantation, cular compromise in toe-to-hand transfer (an analysis of 164 cases). utilising microminiature vascular anastomoses. Br J Plast Surg. Chines Journal of Microsurgery. 2005,28(2): 130-132. 1966;19(4):332-7 Zhang YX, Zhang HL, Hou SJ, et al. Comparison of intratracheal Yang DY, Gu YD, Wu MM. Thumb reconstruction with free second toe general anesthesia with brachial plexus block combined with transplantation in 40 cases. Zhonghua Wai Ke Za Zhi. 1977;15:13- non-intratracheal general anesthesia in child thumb and fingers 18 (in Chinese). reconstruction. Chines Journal of Modern Medicine. 2002,12(21): Cobbett JR. Free digital transfer. Report of a case of transfer of a 22-24. great toe to replace an amputated thumb. J Bone Joint Surg Br. He JT, Zhang TH, Fu ZQ, et al. Comparative study of the clinical appli1969;51(4):677-9. cation effect of full-shaped finger reconstruction. Chinese Journal of Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps. Plast Anesthetic and Plastic Surgery. 2017,28(2): 73-77, 95. Reconstr Surg. 1979;63(5):607-12. Restelli L, Pinciioli D, Conoscente F, et al. Insufficient venous drainHamilton RB, Morrison WA. Microvascular segmental thumb reconage following axillary approach to brachial plexus blockade. Br J struction: a case report. Br J Plast Surg. 1980;33(1):64-7. Anaesth, 1984, 56:1051-1053. Wang LY, Tian GL, Wang MY, et al. Analysis of the morphologic Reiz S. Nath S. Cardiotoxicity of local anaesthetic agents. Br J Anaesth, differences of the second toe and digits of the hand, and evalua1986, 58:736-746. tion of potential surgical intervention to minimize the differences Quinlan JJ, Oleksey K, Murphy FL. Alkalinization of mepivacaine for using computer-aided design technology. Plast Reconstr Surg. axillary block. Anesth Analg, 1992, 74:371-374. 2014;134(6):902e-12e. Thompson CE, Rorie DK. Functional anatomy of the brachial plexus Sosin M, Lin CH, Steinberg J, et al. Functional donor site morbidity sheaths. Anesthesiology, 1983, 59(2):117-122. after vascularized toe transfer procedures. A review of the literature Randalls B. Continuous brachial plexus blockade. A technique that uses and biomechanical consideration for surgical site selection. Ann an axillary catheter to allow successful skin grafting. Anaesthesia, Plast Surg. 2016;76(6):735-42. 1990, 45:143-144 Woo SH, Yoo MJ, Paeng JW. Recent advances in immediate toe-to- Jeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral hand transfer. J Hand Surg.2016;21(3):292-299. nerve blocks. Br J Anaesth. 2010, 105 (1):97-107. Wei FC, Aldeek NF, Lin YT, et al. Metacarpal-like hand: Classification Alemanno F, Capozzoli G, Egarter-Vigl E, et al. The middle interscaand treatment guidelines for microsurgical reconstruction with toe lene block: cadaver study and clinical assessment. Reg Anesth Pain transplantation. Plast Reconstr Surg. 2018;141(1):128-135. Med. 2006, 31(6):563-568. Dautel G. Vascularized toe joint transfers to the hand for PIP or MCP Farquhar-Thomson DR, Baker AK, Satapathy AR, et al. Minimum reconstruction. Hand Surg Rehab. 2018. https://doi.org/10.1016/j. volume of local anaesthetic required for an axillary brachial plexus hansur.2018.03.008 block. Br J Anaesth. 2010, 105(3):382-383. Chen ZW, Yang DY, Zhang TS, et al. Microsurgery, Shanghai, Shanghai Quinlan JJ, Oleksey K, Murphy FL. Alkalinization of mepivacaine for Scientific & Technical Publishers, 1978. axillary block. Anesth Analg, 1992, 74:371-374.

but also to recover the function. In a word, because of the particularity of the patients with severed fingers and the particularity of hands in human organs, once the function is lost, it is likely to cause a family’s dilemma and increase the social burden. However, finger reconstruction only creates the necessary conditions and foundation for the recovery of hand function. In order to achieve good function, systematic and standard physical rehabilitation therapy is essential. Figures of commonly used hand function rehabilitation (Figs. 9.1, 9.2, 9.3, 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10, 9.11, 9.12, 9.13, 9.14, 9.15, 9.16, 9.17, and 9.18). Commonly methods for foot function rehabilitation exercise (reproduced with permission from https://image. baidu.com/search/index?tn=baiduimage&ipn=r&ct=201 326592&cl=2&lm=-1&st=-1&fm=result&fr=&sf=1&fm q=1664518974649_R&pv=&ic=0&nc=1&z=&hd=&lates t=©right=&se=1&showtab=0&fb=0&width=&heig ht=&face=0&istype=2&dyTabStr=&ie=utf-8&sid=&wo rd=%E8%B6%B3%E5%BA%B7%E5%A4%8D) (Figs. 9.19, 9.20, 9.21, 9.22, 9.23, and 9.24).

Further Reading Arthur DS, Mcnicol LR. Local anesthetic techniques in paediatric surgery. Br J Anaesth, 1986, 58(9):760-778. Barutell C, Vidal F, Raich M, et al. A neurological complication following interscalene brachial plexus block. Anesthesia, 1980, 35(7):365-367. Brown DL, Cahill DR, Bridenbaugh LD. Superclavicular nerve block, anatomic analysis of a method to prevent pneumothorax. Anesth Analg, 1993, 76:530-534. Gillespie JH, Menk EJ, Middaugh RE. Reflex sympathetic block dystrophy. A complication of interscalene block. Anesth Analg, 1987, 66:1316-1317. Green DP. Diagnostic and therapeutic value of carpal tunnel injection. J Hand Surg, 1984, 9(A):850-854. Hickey R, Candido KD, Ramamurthy S, et al. Brachial plexus block with a new local anaesthetic.0.5 percent ropivacaine. Can J Anesth, 1990, 37:732-738. Hickey R, Garland TA, Ramamurthy S. Subclavian perivascular block, influence of location of paresthesia. Anesth Analg, 1989, 68:767-771. Chen ZW, Yang DY, Tian TS et al. Microsurgery, Shanghai, Shanghi Science and Technique Publishing House, 1985. Huang JS. Huang Jiasi Surgery. People’s Medical Publishing House, 1985. Hou SJ, Cheng GL, Fang GR, et al. Reconstruction and repair of finger defects with free toe transplantation. Chinese Journal of Hand Surgery, 2001,17(4): 212-214. Wang ZT, Cai JF, Cao XC, et al. Reconstruction of digits by the second toe and 4 composite flaps with the same vessel pedicle. Chinese Journal of Hand Surgery, 2002,18(2): 85-87. Wang CQ, Wang JL, Wang ZT, et al. Analysis of the thumb and finger reconstruction with the pedal digit transplantation in 495 cases. Medical Journal of Chinese People’s Liberation Army, 1996: 364-366. Pei GX. Microsurgical Orthopaedics. Beijing, People’s Publishing House, 2016. Chiu HY, Shieh SJ, Hsu HY. Multivariate analysis of factors influencing the function recovery after finger replantation or revascularization. Microsurgery,1995,16(10):713-717.

129 Bandura A. Self-efficacy: Toward a Unified Theory of Behavioral Change. Psychol Rev, 1977,84(2):191-211. Nicholas JJ. Physical modalities in rheumatological rehabilitation. Arch Phys Med Rehabil, 1994,75(9):994-1001. Smith RA, Cokkinides V, Brooks D. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA: A Cancer J Clin, 2010, 60(2):99-119. Fu YH. The influence factors and nursing countermeasures for the functional recovery of hand injury patients. Chinese Journal of Medical Guide, 2009, 11(9): 1580-1582. Tao Q, Cheng AL, Zhang JZ, et al. Clinical study of early motion on hand function recovery following repair of the injured flexor tendon. Chinese Journal of Hand Surgery, 2001, 17(3): 156-158. Silva MJ, Boyer MI, Gelberman RH. Recent progress in flexor tendon healing. J Orthop Sci, 2002, 7(4):508-508. Gan BS, Huys S, Sherebrin MH. The effects of ultrasound treatment on flexor tendon healing in the chicken limb. J Hand Surg Am, 1995,20(6):809-814. Rupinder G, Serena S, Jaime A. Passive and active rehabilitation for partial lacerations of the canine flexor digitorum profundus tendon in zone 2. J Hand Surg Am,1999,24(4):743-750. Mark N, Paul R, Hideaki Kubota. Effect of immobilization, immediate mobilization, and delayed mobilization on the resistance to digital flexion using a tendon injury model. J Hand Surg Am, 1997,22(3):464-472. Shieh SJ, Chiu HY, Lee JW, et al. Evaluation of the effectiveness of sensory reeducation following digital replantation and revascularization. Microsurgery,1995,16(8):578-582. Xiao XL, Yang CH, Xia XX, et al. The reliability and validity of the Chinese version of the upper extremity functional index. Chinese Journal of Physical Medicine and Rehabilitation, 2012,34(12): 903-906. Qiu ZY, Chen D, Zhu J. Theory and Approach of Measurement of Functioning and Disability Using ICF Model. Chinese Journal of Rehabilitation Theory and Practice, 2010, 16(7): 675-677. Gu YD, Wang SH, Shi D. Operative Hand Surgery. 2nd edition, Shanghai, Fudan University Press, 2010.

Part II Different Types of Finger Reconstruction

Reconstruction of Thumb Defects

Abstract

Since the successful operation of thumb reconstruction with free second toe transplantation in 1966, toe transplantation has been widely used to reconstruct thumb and fingers, and obtained good clinical effects. Due to various factors, many patients and doctors are not very satisfied with the reconstructed fingers. In order to make the reconstructed finger as close as possible to the shape and function of the finger. Hand microsurgeons have done a lot of work to improve the appearance and function of toes. With continuous in-depth research, a number of improvements and innovations have been made in the reconstruction techniques and methods, and the surgical methods have been continuously developed from extensive to detailed, so that finger reconstruction with free second toe transplantation has been continuously improved. Keywords

Finger reconstruction · Thumb defect

10.1 Reconstruction of Type I Defect of the Thumb Finger is the most flexible organ of the human body, hand trauma is common, which is a very painful thing, not only affects the quality of life of patients but also makes patients have inferiority complex. The thumb accounts for about 40% of the function of the hand and the defect of the thumb will seriously affect the function of the hand. The traditional view is that type I defect will lose 20–30% of the function of the thumb and about 10% of the function of the side hand which cannot to be reconstructed. However, with the development of society and economy, people are paying more and more attention to the pursuit of appearance beauty on the basis of satisfying their material needs, and there are more and more

10

patients with type I defect of thumb need repair and reconstruction. Considering the psychological, occupational, aesthetic, and social needs of the patients, reconstruction of the terminal segment of the thumb with anastomotic toe-finger arteriovenous blood circulation can be adopted to obtain satisfactory appearance and function. There are many types of injuries to the terminal segment of the thumb, including terminal segment defect, finger pulp defect, nail defect, and degloving injury. Commonly used methods are partial great toe transplantation and second toe transplantation.

10.1.1 Indications (1) Adult, young, and middle-aged is better; (2) No basic disease, mental disease, peripheral vascular disease; (3) Type I defect of thumb; (4) The patient has a strong desire for reconstruction; (5) The wound is clean and the surrounding tissues are free from infection; (6) There is no history of trauma, surgery, or infection in the donor toe and the appearance is normal.

10.1.2 Surgical Design The main purpose of the reconstruction of Type I defect of thumb is to look beautiful, and the selection of the donor toe is mainly to consider the matching of the shape of the defect and the shape of the toe. Commonly used reconstructive techniques include partial great toe grafts and partial second toe grafts, and the terminal great toe is usually preferred as the donor site. The transplant length should be based on the normal thumb length, and it is better to be short than long. 1. Incision design in the recipient site: (a) If a first-stage emergency reconstruction is performed on a patient with open injury. A complete debridement should be performed on the stump, and the irregular and redundant

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skin should be temporarily retained; (b) If reconstruction is elective, since the thumb stump is thick, ring or coronal incision should be made at the stump (Fig. 10.1). After the skin is lifted to the dorsal palmar, the skin should be properly trimmed. An oblique incision should be made on the dorsal proximal segment of the thumb to expose the dorsal digital vein and on the ulnar side of the thumb to expose the proper ulnar digital artery or the principal artery of thumb. 2. Incision design in the donor site: The terminal segment of great toe graft should be selected, and the skin incision should be designed according to the length of the thumb defect and the skin and soft tissue conditions at the residual end (Fig. 10.2). A ring incision should be designed at 1 cm posterior to the toenail fold as the furthest end, the plantar side can do different plane design according to the defect degree, and a lingual flap about 14–17 mm wide on the tibial side of the great toe is retained from the root and gradually converges toward the toe end and across the midline.

10.1.3 Surgical Method The patient should have complete preoperative examinations without contraindications to surgery and anesthesia, and is carried out under general anesthesia in the operating room.

Fig. 10.1 Incision design of thumb stump

Fig. 10.2 Incision design in the donor site

reparation for the Recipient Site P Coronal incision is made at the stump, scar should be removed, and the skin is lifted to the dorsum. The proper digital nerves and the principal arteries of thumb should be marked on both sides. An arc incision is made on the dorsal proximal segment to separate one or two thicker dorsal phalanx veins for use.

10.1 Reconstruction of Type I Defect of the Thumb

he Cutting of the Toe T (a) The cutting of part of the great toe: The surgical incision of great toe should be designed according to the size of the healthy thumb. The tibial lingual flap and the arteries and nerves under it should be reserved. The proper digital nerves and arteries should be dissociated to the desired length on the peroneal side. If necessary, the first dorsal metatarsal artery or the first plantar metatarsal artery could be reserved to make the length of the vessel to be sufficient before pedicle amputation. For nail skin flap of great toe, only flap tissue should be removed. The donor site is directly sutured or covered with skin grafts. (b) The cutting of part of the second toe: According to the required length of the reconstructed finger, an arcshaped transverse incision is made on the dorsal side of the second toe, and an “S”-shaped longitudinal additional incision is made to the proximal end. One or two thicker dorsal digital veins of foot should be to the dorsum of proximal segment. Additional incisions to proximal at the midline of the both sides of the toe are made to dissociate and mark the proper digital nerves of foot. The proper tibial digital artery can be dissociated and if it is necessary you can reach the first dorsal metatarsal artery or the first plantar metatarsal artery. The distal segment or interphalangeal joint should be cut as required. For nail skin flap of great toe, only flap tissue should be removed. The donor site is directly sutured or covered with skin grafts (Fig. 10.3).

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Fig. 10.4 After suturing the reconstructed finger

Transplantation (a) For partial great toe and second toe transplantation, a single Kirschner wire is used to fix the toe and finger bones through. The dorsal digital vein of foot is led to the dorsum of finger through subcutaneous tunnel, and one or two veins are anastomosed with 11-0 or 12-0 nylon monofilament under the microscope, and then suture the skin; the proper nerves should be anastomosed with 9-0 nylon monofilament; the digital arteries should be anastomosed with 12-0 with nylon monofilament and close the wound. (b) For nail skin flap transplantation, the lateral wound of the flap should be sutured first, and then the bone should be. The vascular and nerve anastomosis method is the same as before (Fig. 10.4).

Fig. 10.3 Closure of wound in the donor site

Postoperative Treatment (a) Postoperative heat preservation, nursing should be strengthened; (b) Postoperative antispasticity and anticoagulation therapy should be performed, and anti-infection therapy should be added to those with wounds; (c) Blood supply observation of reconstructed finger is recommended for 6 h/ time, lasting for 1 week; (d) Two weeks after the operation, the suture should be removed and function exercise should be begun.

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10.1.4 Operation Characteristics (a) High level of microsurgical technique is required, especially anastomosis technique for the small vessel; (b) Operation is performed under a magnifying glass or a microscope, and usually requires special surgical instruments; (c) The operation is non-functional reconstruction, usually should not be performed in emergency; (d) The operation does not need to cut the metatarsal bone, which would not affect foot loading and walking; (e) Only the phalanges part in the donor site required to be dissociated, and the blood vessel anatomy is constant. It is not affected by the variation of the first dorsal metatarsal artery, and the operation is simple; (f) The structure of the toes and fingers is similar, the appearance of the reconstructed thumb is good, which is close to the normal, and sometimes it can achieve just-as-good effect; (g) It is easy to take samples, the trauma of the donor site is small, which heals quickly, and the patient has no pain when walking on the ground after a week.

10.1.5 Announcements (a) Young patients with good surgical tolerance and compliance should be selected, especially those with high requirements for the appearance and function of donor sites and reconstructed fingers; (b) When transplanting great toenail flap, pay attention to protect the donor site to ensure that the wound can be directly sutured to embedded the bone, otherwise the phalange should be shortened; (c) The great toe size ratio is different for each patient, and the size should be designed according to the normal side; (d) Preoperative and intraoperative hemostasis and vasoconstrictor drugs should not be given to patients. All the patients who chose the distal segment of great toe reconstruction should choose the same side toe; (e) The design of the lingual flap on the tibial side should be appropriate; (f) The enlarged part on both sides of the base of the distal segment of great toe should be corrected appropriately. In addition, the hypertrophy of adipose tissue at the toe base should be trimmed to make the tibial side wound look like the thumb on the healthy side after suturing; (g) During the dissociation of the toe, the movements should be gentle, so as not to pull and damage the vascular pedicle, so as to reduce the occurrence of spasm after vascular anastomosis; (h) After the anastomosis of the reconstructed toe, the wound bleeding must be stopped completely to avoid the occurrence of postoperative hematoma; (i) The free release of the extensor and flexor tendons in the

10 Reconstruction of Thumb Defects

recipient site must be complete, and the passive pulling muscles must have elastic retraction; (j) Postoperative bandaging must be loose to prevent vascular crisis due to postoperative swelling and over-tight bandaging of the reconstructed finger.

10.1.6 Case Description Case 1 Type I defect of the right thumb. A 33-year-old female patient was admitted to hospital in emergency for 1 h due to fingertip defect caused by punching injury. Physical examination: She was in good general condition, with stable vital signs, a defect at the distal end of the right thumb and an exposed fracture. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by the great toe nail flap under general anesthesia in emergency, and the donor site was covered by free full-thickness skin graft. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 10.5). Case 2 Type I defect of the right thumb. A 29-year-old female patient was admitted to hospital in emergency for 2 h due to pain and bleeding caused by the machine. Physical examination: She was in good general condition, with stable vital signs, traumatic loss of the distal segment of the right thumb from the nail root, irregular skin of the stump, exposed bone, active bleeding, and moderate pollution. After admission, the thumb stump was debrided under brachial plexus anesthesia, the bone was smoothened, and the dorsal metacarpal tendon and the ulnar proper neurovascular bundle were ready for disconnection. The thumb was reconstructed by the ipsilateral great toe nail flap. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely with plaster external fixation. Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the

10.1 Reconstruction of Type I Defect of the Thumb

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Fig. 10.5 Reconstruction of type I defect of the right thumb. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative design (dorsal side). (d) Preoperative design (lateral side). (e) Preoperative design (plantar side). (f) Dissociation of the flap. (g) Free left great toe composite tissue flap. (h) Blood vessels and nerves. (i) Thumb reconstruction with free trans-

plantation. (j) The dorsal view of the reconstructed thumb 8 months after the operation. (k) The palmar view of the reconstructed thumb 8 months after the operation. (l) Appearance contrast of the reconstructed thumb. (m) Opponens function of the reconstructed thumb 8 months after the operation. (n) The situation of the donor site 8 months after the operation

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Fig. 10.6 Reconstruction of type I defect of the right thumb by the ipsilateral great toe nail skin flap. (a) Preoperative dorsal condition of thumb defect, (b) Preoperative palmar condition of thumb defect. (c) Design of the free great toe nail skin flap. (d) Design of the free great

toe nail skin flap. (e) Dissociation of the flap. (f) Transplant the flap. (g) The appearance of the reconstructed finger. (h) Dorsal view of the donor site. (i) Palmar view of the donor site

reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.6).

and soft tissue defect. The emergency operation was successful, and the incision was free of infection and necrosis 10 days after the operation. A further procedure of “reconstruction of the defect of the end of the right thumb by transplanting free great toenail skin flap combined with tibial tissue flap of the second toe” was performed at a selected time. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given

Case 3 Type I defect of the right thumb. A 31-year-old female patient was admitted to hospital in emergency for 2 h due to pain and bleeding caused by the machine. Physical examination: She was in good general condition, with stable vital signs. The soft tissue distal to nail bed of the right thumb was cotton like, the distal phalanx bone fractured, and the nail bed was damaged, with part of the distal phalanx bone

10.1 Reconstruction of Type I Defect of the Thumb

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Fig. 10.7 Reconstruction of type I defect of the right thumb by transplanting free great toenail skin flap combined with tibial tissue flap of the second toe. (a) Type I defect of the right thumb. (b) Design of the flap. (c) Design of the flap. (d) Dissociation of the flap. (e) The recon-

structed finger after the operation. (f) Appearance contrast of the reconstructed thumb. (g) The situation of the donor site. (h) The situation of the donor site

after the operation. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.7).

scabbed. Blood circulation in the remaining fingers was normal. After admission, routine preoperative preparation for reconstruction was given, free big toe to thumb reconstruction was performed at a selected time and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger sur-

Case 4 Type I defect of the right thumb. A 28-year-old female patient was admitted to hospital for 5 days after debridement. The distal segment of the right thumb was defective. After debridement, the wound was sutured and

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Fig. 10.8 Reconstruction of type I defect of the right thumb by free great toe nail skin flap combined with fibular side flap of great toe. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative lateral condition of thumb defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Design of the fibular flap of the thumb. (f) Dissociation of

the vascular pedicle. (g) The dorsal view of the reconstructed thumb after the operation. (h) The lateral view of the reconstructed thumb after the operation. (i) Nail condition 1 year after the operation. (j) Finger pulp condition 1 year after the operation. (k) X-ray 1 year after the operation. (l) The situation of the donor site 1 year after the operation

vived successfully. After 1-year follow-up, the donor site and reconstructed thumb are completely healed with excellent function and appearance (Fig. 10.8).

the bacterial culture were negative, the left foot was designed and transplanted the first toenail flap compound flap under general anesthesia to reconstruct the left thumb. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. After 4 months’ follow-up, the function and appearance were excellent, and the donor site healed completely (Fig. 10.9).

Case 5 A 34-year-old male patient was admitted to hospital for non-healing of the wound 11 months after the operation due to fish bone injury of the left thumb. Physical examination: She was in good general condition, with stable vital signs. The finger tip of the left thumb was missing with inflammatory exudation. After three times debridement and

10.1 Reconstruction of Type I Defect of the Thumb

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Fig. 10.9 Reconstruction of type I defect of the infected left thumb by free great toe nail skin flap. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) The defect after debridement. (d) Preoperative design (dorsal side). (e) Preoperative design (lateral side). (f) Preoperative design (plantar side). (g) Dissociation of the flap. (h) Dissociation of the blood vessels and

nerves. (i) Dissociation of the flap. (j) Cover the recipient site with the flap. (k) Cover the recipient site with the flap. (l) Suture the donor site directly. (m) The palmar side of the reconstructed thumb 4 months after the operation. (n) The dorsal side of the reconstructed thumb 4 months after the operation. (o) The donor site healed 4 months after the operation

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10.2 Reconstruction of Type II Defect of the Thumb

and is carried out under general anesthesia in the operating room.

Type II defect is the defect at the interphalangeal joint of the thumb, which is often caused by various injuries, leading to 50% loss of thumb function and 20% loss of the hand function, and there are definite indications of reconstruction. Even most of the length of the thumb is preserved, with the development of society and economy, people now pay more and more attention to the pursuit of their own appearance beauty on the basis of satisfying their material needs. More and more patients require reconstruction and repair. Considering the psychological, occupational, aesthetic and social needs of patients, the distal segment of the thumb can be reconstructed by anastomosing toe-finger arteriovenous blood circulation, which can obtain satisfactory appearance and function. In the donor site, great toe or the distal segment of the second toe could be transplanted, great toe could be transplanted for those with large stump, and the second toe could be transplanted for those with small stump. When selecting the distal segment of great toe, it is often necessary to trim the larger condyles on both sides of the base of the phalanx of the great toe.

reparation for the Recipient Site P For the defect of the distal segment of the thumb, a coronal incision could be made at the stump to remove the scar and lift the skin to the dorsal side. The proper digital nerves should be marked on both sides and principal arteries of thumb should be dissociated within the incision. An arc incision is made on the dorsal proximal segment to separate one or two thicker dorsal phalanx veins for use. If it is an emergency operation, the stump should be debrided completely to remove the polluted and inactivated tissue, and then debrided again under the operating microscope, and the proper digital proper nerves and digital arteries should be marked. An arc incision is made on the dorsal proximal segment to separate one or two thicker dorsal phalanx veins for use.

10.2.1 Indications (1) Adult, young, and middle-aged is better; (2) No basic disease; (3) No mental disease, peripheral vascular disease; (4) Type II defect of thumb; (5) The patient has a strong desire for reconstruction and the wound is clean and the surrounding tissues are free from infection; (6) There is no history of trauma, surgery, or infection in the donor toe and the appearance is normal.

10.2.2 Surgical Design The surgical design of type II defect of thumb is similar to that of type I, transplantation of partial great toe and the terminal part of the second toe, which are commonly used.

10.2.3 Surgical Method The patient should have complete preoperative examinations without contraindications to surgery and anesthesia,

he Cutting of the Toe T (a) The cutting of part of the great toe: The surgical incision of great toe should be designed according to the size of the healthy thumb. The tibial lingual flap and the arteries and nerves under it should be reserved. The proper digital nerves and arteries should be dissociated to the desired length on the peroneal side. If necessary, the first dorsal metatarsal artery or the first plantar metatarsal artery could be reserved to make the length of the vessel to be sufficient before pedicle amputation. For nail skin flap of great toe, only flap tissue should be removed. The donor site is directly sutured or covered with skin grafts. (b) The cutting of part of the second toe: According to the required length of the reconstructed finger, an arc-shaped transverse incision is made on the dorsal side of the second toe, and an “S”-shaped longitudinal additional incision is made to the proximal end. One or two thicker dorsal digital veins of foot should be dissociated to the dorsum of proximal segment. Additional incisions to proximal at the midline of the both sides of the toe are made to dissociate and mark the proper digital nerves of foot. The proper tibial digital artery can be dissociated and if it is necessary you can reach the first dorsal metatarsal artery or the first plantar metatarsal artery. The distal segment or interphalangeal joint should be cut as required. For nail skin flap of great toe, only flap tissue should be removed. The donor site is directly sutured or covered with skin grafts (Fig. 10.3).

10.2 Reconstruction of Type II Defect of the Thumb

Transplantation (a) For partial great toe and second toe transplantation, a single Kirschner wire is used to fix the toe and finger bones through. The dorsal digital vein of foot is led to the dorsum of finger through subcutaneous tunnel, and one or two veins are anastomosed with 11-0 or 12-0 nylon monofilament under the microscope, and then the skin should be sutured; Anastomose the proper nerves with 9-0 nylon monofilament; Anastomose the digital arteries with 12-0 with nylon monofilament and close the wound. (b) For nail skin flap transplantation, the lateral wound of the flap should be sutured first, and then the bone should be covered. The vascular and nerve anastomosis method is the same as before (Fig. 10.4). Postoperative Treatment (a) Postoperative heat preservation, strengthen nursing; (b) Postoperative antispasticity and anticoagulation therapy should be performed, and anti-infection therapy should be added to those with wounds; (c) Blood supply observation of reconstructed finger is recommended for 6 h/time, lasting for 1 week; (d) Two weeks after the operation, the suture should be removed and function exercise should be begun.

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10.2.5 Announcements (a) The amputated site of the transplanted toe is far away, and the toe arteries and veins are thin, so it is easy to be damaged during dissociation, especially the dorsal digital veins of foot. Therefore, attention should be paid to protect the continuity of the vein network, and not to cut too much tissue to avoid pressure in the tunnel; (b) The stump of the proper arteries in the recipient site should be debrided to the normal lumen to avoid postoperative embolization. The subcutaneous tunnel should be loose, so as to avoid venous distortion and compression; (c) Skin margin suture should be smooth and excess skin must be removed, so as to avoid the swollen skin after healing, which would affect the appearance; (d) Postoperative vascular crisis should be treated actively, but not be long observation, so as not to delay the opportunity of treatment.

10.2.6 Case Description

Case 1 A 27-year-old male patient was admitted to hospital in emergency for 1.5 h due to distal segment defect of the right thumb with pain and bleeding caused by Injection molding machine injury. Physical examination: He was in good general condition, with stable vital signs, traumatic 10.2.4 Operation Characteristics loss of the distal segment of the right thumb from the interphalangeal joint, exposed bone, tendons, irregular wound, (a) High level of microsurgical technique is required, espe- and active bleeding. There was skin contusion and laceration cially anastomosis technique for the small vessel; (b) at distal segment of the index finger, and blood circulation of Operation is performed under a magnifying glass or a micro- other fingers was normal. Emergency debridement under scope, and usually requires special surgical instruments; (c) general anesthesia was performed and the operation was sucThe operation is non-functional reconstruction, usually cessful. One week after debridement, preoperative preparashould not be performed in emergency; (d) The operation tion for routine reconstruction was given. The left second toe does not need to cut the metatarsal bone, which would not to thumb transplantation was designed and performed under affect foot loading and walking; (e) Only the phalanges part general anesthesia and the donor site was sutured directly. in the donor site required to be dissociated, and the blood The operation was successful, after the tourniquet relaxed, vessel anatomy is constant. It is not affected by the variation the reconstructed finger was ruddy with moderate tension, of the first dorsal metatarsal artery, and the operation is sim- wrapped with the sterile cotton, bulked, and stuffed with the ple; (f) The structure of the toes and fingers is similar, the broken cotton gauze around, and he returned to the ward appearance of the reconstructed thumb is good, which is safely. Routine reconstruction treatment was given after the close to the normal, and sometimes it can achieve just-as- operation. Two weeks after the operation, the reconstructed good effect; (g) It is easy to take samples, the trauma of the finger survived successfully. Regular follow-up was condonor site is small, which heals quickly, and the patient has ducted to guide functional exercise. The appearance and no pain when walking on the ground after a week. function of the reconstructed finger were satisfactory. The

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10 Reconstruction of Thumb Defects

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Fig. 10.10 Reconstruction of Type II defect of the right thumb by free second toe transplantation. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative design. (d) Dissociation of the second toe. (e) The dorsal view of the reconstructed thumb after the operation. (f) The palmar view of the reconstructed thumb after the operation. (g) The palmar

view of the reconstructed thumb 13 months after the operation. (h) The dorsal view of the reconstructed thumb 13 months after the operation. (i) Fisting function 13 months after the operation. (j) Flexion function of the reconstructed thumb 13 months after the operation. (k) The dorsal view of the donor site 13 months after the operation. (l) The plantar view of the donor site 13 months after the operation

donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.10).

interphalangeal joint, exposed bone, irregular wound, and active bleeding. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by the right second toe combined with the fibular flap of the great toe free transplantation under general anesthesia in emergency, and the donor site was sutured directly combined with covered by free full-thickness skin graft. The operation was successful, after

Case 2 A 47-year-old male patient was admitted to hospital in emergency for 0.5 h due to distal segment defect of the left thumb caused by machine punch injury. Physical examination: He was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left thumb from the

10.3 Reconstruction of Type III Defect of the Thumb

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Fig. 10.11 Reconstruction of type II defect of the left thumb by free second toe transplantation. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative design. (d) Dissociation of the vascular pedicle. (e) Dissociation of the fibular flap of the great toe to repair stenosis. (f)

Thumb reconstruction by free second toe transplantation. (g) The palmar view of the reconstructed thumb 3 months after the operation. (h) The dorsal view of the reconstructed thumb 3 months after the operation. (i) Opponens function of the reconstructed thumb 3 months after the operation

the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. After 3 months’ follow-up, the appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.11).

to the proximal phalange, about 80% loss of thumb function and about 30% loss of hand function, which should be reconstructed. Due to the retention of metacarpophalangeal joint, the function is mostly satisfactory. The contralateral second toe transplantation reconstruction is the best indication, which could preserve flexion and extension function of the reconstructed thumb, it is the preferred surgical method for this type of defect.

10.3 Reconstruction of Type III Defect of the Thumb Type III defect of thumb is located in the proximal phalange, there are only two segments of phalanges, and the proximal segment is longer; the loss of thumb function would be about 60–90%. The need for residual function and reconstruction varies with the degree of defect. For the defect located distal

10.3.1 Indications (1) Adult, young, and middle-aged is better; (2) A severed thumb that cannot be replanted; (3) The patient has a strong desire for reconstruction, whose general conditions are good, and without systemic organic disease; (4) No basic disease, mental disease, peripheral vascular disease; (5) Type III defect of thumb; (6) There is no history of trauma, surgery, or infection in the donor toe and the appearance is normal.

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10.3.2 Surgical Design According to the defect of the thumb, the second contralateral toe is designed to reconstruct the length and appearance of the thumb, as well as the flexion and extension function. 1. Incision design in the recipient site: Depending on the thumb stump, a dorsal volar V-shaped or coronal incision can be made (Fig. 10.1). If a V-shaped incision is used, the two upper ends are located on the upper edge of the ulnar and radial sides of the thumb end, and the lower end of V is a triangle. The purpose of the V-shaped incision is to remove the V-shaped skin on the dorsal side of the finger and suture it with the skin on both sides of the reconstructed toe after the skin is fully released to avoid gooseneck deformity. If the stump is coronal scar shape, the original scar should be cut along to facilitate the appearance. A longitudinal incision is made in the snuffbox to expose the cephalic vein and dorsal branch of the radial artery. In case of emergency reconstruction, complete debridement should be performed in the thumb stump wound, the contused skin and soft tissue should be retained according to the condition. 2. Incision design in the donor site: According to the defect of the thumb, the required length of the reconstructed finger, and the shape and length of the second toe, a V-shaped incision is made at the dorsal metatarsal at the proximal part (Fig. 11.1), and the V-shaped incision should be slightly larger than the V-shaped size of the recipient site. An arc extension incision is made at the proximal end of the V-shaped tip of the dorsal foot to dissociate the dorsal artery of foot and the great saphenous vein bundle.

10.3.3 Surgical Method

10 Reconstruction of Thumb Defects

tissue of the stump should be removed, and the broken bone should be treated with fresh treatment. Proximal flexor digitorum profundus should be explored and marked, and bilateral proper digital arteries, nerves and veins should be dissociated under microscope.

he Cutting of the Toe T The incision line is drawn on the donor toe according to the shape and length of the thumb defect. The dorsal skin of the toe is first cut along the incision line to expose the vein, and two– three dorsal digital veins of foot should be dissociated proximally to an appropriate length to be cut off. Then the plantar skin is cut open, and one or two plantar digital veins of foot are dissociated for use. The proper arteries, nerves, and flexor digitorum profundus of foot are dissociated, and then cut off according to the defect degree the fingers. The blood vessel stump of the toe should be ligated, the toes are completely amputated, and the toe stump is sutured and bandaged. Transplantation The wound surface of the transplanted toe should be repaired to make the length and size appropriate. Kirschner wires with a diameter of 0.8–1.0 mm are used for crossover and longitudinal fixation, or steel wires with a diameter of 0.4 mm are used for crossover fixation. The extensor tendon is sutured with nylon thread. The flexor pollicis longus tendon is sutured by modified Kessler. Under the microscope, anastomosis should be performed on toe-finger proper digital nerves, three–five dorsal and palmar digital veins, and the arteries on both sides. Postoperative Treatment (a) Postoperative heat preservation, strengthen nursing; (b) Blood volume should maintained and “three anti” therapy should be carried out; (c) Do not get out of bed within 1 week after the operation; (d) Smoking is prohibited during the perioperative period.

The patient should have complete preoperative examinations without contraindications to surgery and anesthesia, and is carried out under general anesthesia in the operating room.

10.3.4 Operation Characteristics

reparation for the Recipient Site P In case of emergency surgery, a complete debridement of the injured finger is performed first. The tendon of extensor digitorum, flexor digitorum profundus, bilateral proper digital nerves, and arteries, and 2–5 veins should be explored and marked for use. Then debridement and irrigation should be performed again under surgical microscope to make the wound surface in the recipient site meet or close to the standard of class I incision. If it is a selected surgery, the scar

Type III defect of the thumb is the best indication for free second toe transplantation. Since the proximal muscle group of the thumb is intact and the metatarsal bone and transverse ligament are not involved in the second toe transplantation, it can not only reconstruct the shape and function of the thumb but also cause little damage to the function of the foot. When conditions permit, the gooseneck deformity of the reconstructed finger can be repaired by the fibular flap of the great toe.

10.3 Reconstruction of Type III Defect of the Thumb

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10.3.5 Announcements

10.3.6 Case Description

(a) Preoperative design is very important. Individual design should be carried out according to the defect condition of the finger, which is not only beneficial to the function and beauty of the reconstructed finger, saving the operation time, but also is helpful to reduce the injury of the donor foot; (b) The donor toes should be without trauma history, excessive small or deformity, and their appearance should be as close as possible to the recipient site; (c) Emergency doctors and anesthesiologists should have good communication, and patients should not use hemostasis and vasoconstrictor drugs before and during operation; (d) Detailed menstrual history of female patients should be asked and avoided; (e) Remove the V-shaped skin of the thumb stump and release it to both sides. The excess skin must be cut off. If the second toe is thin, the gooseneck deformity can be repaired with the fibular flap of the great toe; (f) The microcirculation of the reconstructed thumb and fingers should be closely observed, so that timely detection and treatment can be achieved; (g) After transplantation, the length should not exceed 1/2 of the proximal segment of the index finger, otherwise the appearance will be affected due to the excessive length of the reconstructed finger; (h) The secondstage plastic repair is needed in the patients with enlarged abdomen of the second toe and the deformity of goose neck.

Case 1 A 22-year-old male patient was admitted to hospital in emergency for 4 h due to left thumb defect with pain and bleeding caused by cutting machine injury. Physical examination: He was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left thumb, irregular skin of the stump, exposed bone, active bleeding, and the blood supply of the rest finger was normal. Successful emergency debridement under general anesthesia was performed. The patient was discharged after wound healing. One month after the operation, the patient was admitted to the hospital for thumb reconstruction and given preoperative preparation for routine reconstruction. The right foot was designed and the second toe was transplanted to reconstruct the type III of the left thumb under general anesthesia at a selected time and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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 and the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.12).

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Fig. 10.12 Reconstruction of type III defect of the left thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Dessociation of the second toe according to the design. (c) Dessociation of the dorsal metatarsal artery-deep plantar branch-dorsal

artery of foot system. (d) Dissociation of the vascular pedicle. (e) Transplantation of the second toe; Radial palmar covered with skin graft. (f) The appearance of the reconstructed thumb 10 months after the operation

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Fig. 10.13 Reconstruction of type III defect of the necrotic thumb after replantation by free second toe transplantation. (a) Necrotic thumb after replantation. (b) Preoperative design. (c) Reconstructed thumb. (d) Appearance of the reconstructed thumb 13 months after the opera-

tion. (e) Opponens function of the reconstructed thumb 13 months after the operation. (f) Holding function of the reconstructed thumb 13 months after the operation

Case 2 A 19-year-old male patient was admitted to hospital for 3 days due to necrosis of the left thumb after replantation. Physical examination: He was in good general condition, with stable vital signs, withered, and necrotic finger body from the proximal segment. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation, and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the

reconstructed finger were satisfactory 13 months after the operation (Fig. 10.13). Case 3 An 18-year-old male patient was admitted to hospital 1 month after stumping wrapping for the right thumb and index finger due to cutting injury. Physical examination: He was in good general condition, with stable vital signs, type III defect of the thumb, type VI defect of the index finger, and type V defect of the middle finger. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by free left second toe transplantation and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and

10.3 Reconstruction of Type III Defect of the Thumb

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Fig. 10.14 Reconstruction of Type III defect of the right thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) Dissociation of blood vessels and nerves. (d) Dissociation of the second toe. (e) The palmar view of the reconstructed thumb. (f) The dorsal view of the reconstructed thumb. (g) The

palmar view of the reconstructed thumb 6 weeks after the operation. (h) The dorsal view of the reconstructed thumb 6 weeks after the operation. (i) Holding function of the reconstructed thumb 6 weeks after the operation

he returned to the ward safely. Routine reconstruction treatment was given after the operation and the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.14).

general condition, with stable vital signs and type III defect of the thumb. The thumb was reconstructed by free left second toe transplantation and the donor site was sutured directly at a selected time. Routine reconstruction treatment was given after the operation and the reconstructed finger survived successfully. Regular 10 months’ follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.15).

Case 4 A 22-year-old male patient was admitted to hospital 5 weeks after stumping wrapping for the right thumb due to cutting injury. Physical examination: He was in good

150 Fig. 10.15 Reconstruction of type III defect of the right thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) The appearance of the reconstructed thumb 10 months after the operation. (d) Holding function of the reconstructed thumb 10 months after the operation

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Case 5 A 20-year-old male patient was admitted to hospital 6 months after stumping wrapping in another hospital for the left thumb due to machine injury. Physical examination: He was in good general condition, with stable vital signs, total thumb body defect, and wound healing. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by free left second toe transplantation and the donor site was sutured directly at a selected time. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. After the operation, the patient was ordered to lie in bed absolutely, the finger was irradiated with a roasting lamp, and blood supply was observed. At the same time, routine treatment was given. No vascular crisis occurred after the operation, and the reconstructed finger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.16).

Case 6 A 24-year-old male patient was admitted to hospital for 10 years due to deformity of the left thumb after trauma. Physical examination: He was in good general condition, with stable vital signs. The left thumb was smaller and shorter than the healthy side. The flexion of the interphalangeal joint was limited. The peripheral blood supply and sensation were available. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by free contralateral great toe flap transplantation under general anesthesia at a selected time. The deformed finger was truncated at the proximal segment of the original finger. The operation was successful, after the operation, the patient was ordered to lie in bed absolutely, the finger was irradiated with a roasting lamp, and blood supply was observed. At the same time, routine treatment was given. No vascular crisis occurred after the operation, and the reconstructed finger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.17).

10.3 Reconstruction of Type III Defect of the Thumb

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Fig. 10.16 Reconstruction of type III defect of the left thumb by free second toe transplantation. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative palmar condition of thumb defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Dissociation of the toe. (f) The dorsal view of the reconstructed thumb 3 days after the operation. (g) The palmar view of the reconstructed thumb 3 days after the

operation. (h) The palmar view of the reconstructed thumb 4 months after the operation. (i) The dorsal view of the reconstructed thumb 4 months after the operation. (j) Opponens function of the reconstructed thumb 4 months after the operation. (k) Holding function of the reconstructed thumb 4 months after the operation

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Fig. 10.17 Reconstruction of type III defect of the left thumb by free contralateral great toe flap transplantation. (a) Preoperative appearance of thumb defect. (b) Preoperative appearance of thumb defect. (c) Preoperative design. (d) Dissociation of the flap. (e) Dissociation of the flap. (f) The donor site after flap dissociation. (g) The donor site after

flap dissociation. (h) The recipient site. (i) The reconstructed thumb after the operation. (j) The appearance and function of the reconstructed thumb 6 months after the operation. (k) The appearance and function of the reconstructed thumb 6 months after the operation. (l) The function of the reconstructed thumb 6 months after the operation

10.4 Reconstruction of Type IV Defect of the Thumb

with the volar lumbrical muscle of the second toe to restore the opponens function. If the thumb stump is associated with Dupuytren contracture, composite flaps (such as dorsal foot flaps) can be used for repair when the second toe with metatarsophalangeal joint transplantation is used for reconstruction.

Type IV defect of thumb located in the first metacarpophalangeal joint, because the thumb is completely missing, the loss of hand function counts to 40%, which will cause serious impact on the daily life of patients and is the absolute indication to choose reconstruction surgery. The second toe with metatarsophalangeal joint transplantation is preferred. Type IV defect of thumb is often accompanied by soft tissue defect which requires tissue transplantation with dorsal flap. The opponens pollicis is intact which could be sutured

10.4.1 Indications Type IV defect of thumb and the other indications are moderate type III defect of thumb.

10.4 Reconstruction of Type IV Defect of the Thumb

10.4.2 Surgical Design The reconstruction of thumb by free transplantation of toe tissue with dorsal foot flap is based on the dorsal foot artery and its continuation of the first dorsal metatarsal artery. Due to the limitation of the length of the vascular pedicle, there are certain requirements for the wound surface: (a) The defect is proximal to the metacarpophalangeal joint or avulsion injury of thumb; (b) Combined with the soft tissue defect of the palm, with tendons and bones exposed, and the repaired area is slightly smaller than that of the dorsal skin; (c) No variation in dorsal artery of foot and first dorsal metatarsal artery; (d) The vascular condition in the recipient site is permissible. The recipient site: 1. The stump without contracture scar can be longitudinal sagittal plane either a V-shaped incision can be made (Fig. 10.18). 2. For patients with contracture of the web or scar on soft tissue of the radial side, the scar tissue skin should be completely removed with an arc, and the incision is usually designed with an “S” shaped (Fig. 10.18). In case of emergency reconstruction, the thumb stump wound should be debrided thoroughly, and the contusion and necrotic soft tissue should be completely removed. The donor site: If the soft tissue condition of the recipient site is good, V-shaped incisions can be made on both the plantar and dor-

Fig. 10.18 Routine incision for type IV defect of thumb

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sal sides of the donor site (Fig. 10.19). If the soft tissue condition is not good, the defect after scar resection can be repaired by composite tissue flap of the foot dorsum according to its shape (Fig. 10.20).

10.4.3 Surgical Method General condition: The patient should be in good general condition without contraindications related to surgery or anesthesia, and the anesthesia is performed under brachial plexus anesthesia plus epidural anesthesia or general anesthesia. The operation could be performed in two groups: the recipient group and the donor group.

reparation for the Recipient Site P The length of the healthy thumb and the shape and size of the soft tissue defect should be measured preoperatively. The tendon of extensor digitorum and flexor digitorum profundus tendon should be explored and marked intraoperatively, and bilateral proper digital nerves, arteries, and 2–5 veins should be dissociated under a magnifying glass or microscope for use. The operation area is routinely disinfected, laid towel, and the tourniquet on the recipient side is elevated after driving the blood. Firstly, the thumb stump incision should be made according to the design, the skin and subcutaneous soft tissue are cut (if there is scar, the scar tissue should be com-

Fig. 10.19 The incision of the donor site when the soft tissue condition of the recipient site is good

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Fig. 10.20 According to the different conditions of soft tissue defect in the recipient site, the flap could be designed flexibly in the donor site

pletely removed), the first metacarpal bone is fully extended by free release, and the digital nerves are found and released in the wound of the stump and marked. The flexor pollicis longus tendon, extensor pollicis longus tendon, and extensor pollicis brevis tendon should be found and fully relaxed in the palm and dorsal side, respectively. Abductor pollicis brevis should be exposed and completely released to recover the elasticity; About 0.5–1 cm of bone could be removed from the metacarpal stump, and the incision is extended proximally or make a separate one at the snuffbox to expose the cephalic vein and dorsal branch of the radial artery. If the defect of extensor pollicis longus tendon, flexor tendon, and digital nerves is caused by retrograde avulsion, nerve and tendon transplantation of adjacent finger can be used to reconstruct the extensor and sensory function. Extensor pollicis longus tendon could be repaired and reconstructed by transposition of the proper extensor tendon of the index finger and transposition of flexor digitorum superficialis of the ring finger (Fig. 10.21). The ulnar proper digital nerve of the index finger could be transferred to reconstruct the ulnar sensory function of the toe (Fig. 10.21).

he Cutting of the Toe T The second toe with dorsal flap should be designed according to the size and shape of the defect. According to the soft

tissue condition after debridement of the wound in the recipient site, a V-shaped incision is made on the dorsal metacarpal or corresponding to the defect in the recipient site according to the design, the medial skin is cut open to find the great saphenous vein in the flap, and the unrelated branches should be ligated. The excision of the flexor and extensor tendons and nerves of the second toe is similar to the excision of type III defect of thumb. When the toe is completely dissociated except for the vascular pedicle, the tourniquet should be relaxed to observe the blood supply of the toe. Finally, the second toe is dislocated, and the vascular pedicle is cut off according to the required length and appropriate position of the recipient blood vessels; the toe should be transplanted to the recipient site.

Transplantation The transplanted toe should be adjusted to make the length and size suitable. The bone of the connected part of the bone should be removed appropriately, and the flap is adjusted to cover the wound without tension. Kirschner wires with diameters of 0.8–1.0 mm are used for crossover and vertical fixation, or wires with diameters of 0.4 mm are used for crossover fixation. The extensor tendon is sutured with nylon thread. The flexor tendon is sutured with modified Kessler. Vessels and nerves are anastomosed under microscope. The

10.4 Reconstruction of Type IV Defect of the Thumb

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Fig. 10.21 The proper extensor tendon of index finger and flexor digitorum superficialis of the ring finger are used to reconstruct the flexor and extensor function of the reconstructed thumb

blood circulation of the reconstructed finger is observed, and then the incision should be closed directly. In the donor site, the stump of the second metatarsal can be further removed according to the situation. The medial tissues of the first metatarsal and the lateral tissues of the 3–5 metatarsal can be pulled to the center to suture the transverse metatarsal ligament as far as possible. The first-stage direct suture or free skin graft is used to close the wound.

Postoperative Treatment After the operation, lie in bed for 7 days, continued lamp irradiation, the blood supply of the reconstructed finger, routine 3 antitherapy, dressing change every 2–3 days, and suture removal 2 weeks later were observed.

10.4.4 Operation Characteristics (a) The second toe with dorsal flap transplantation is two flap of single pedicle to repair palmar defect and reconstruct thumb at the same time, avoiding the risk of two composite flaps transplantation, and broadening the surgical method

and shortening the operation time, and the palm flap is not fat, which needs not to be thinned in second stage, that is satisfied in clinic; (b) Type IV defect of the thumb accompanied by skin defect of the web could be reconstructed by the second toe combined with the metatarsophalangeal joint and dorsal foot flap transplantation. If there is no skin defect at the stump, V-shaped skin is still removed to prevent gooseneck deformity; (c) The first metacarpal head and part of the first metacarpal should still be excised in the cases of complete capsule retained to avoid the method of the articular surface connected with the proximal phalangeal articular surface and suture capsule to repair; (d) The application of this surgical method is relatively limited, which is only applicable to some special types of hand trauma with thumb defect, and the donor site is damaged greatly.

10.4.5 Announcements (a) Preoperative Doppler and CTA should be used to examine the dorsal artery of foot and the first dorsal metatarsal artery to determine the vascular course and no variation; (b)

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Fig. 10.22 Reconstruction of Type IV defect of the right thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) The survived reconstructed thumb 6 weeks after the operation. (d) The dorsal view of the reconstructed

thumb 3 months after the operation. (e) The palmar view of the reconstructed thumb 8 months after the operation. (f) Holding function of the reconstructed thumb 3 months after the operation

Complete debridement during operation is an important factor to ensure the success of the operation; (c) The shape of dorsal foot flap should be designed according to the defect of the hand, and the blood supply of the flap needs to be paid attention to; (d) When the first dorsal metatarsal artery is Gilbert III, the toe should be cut by the dorsal artery of foot- deep plantar branch-first plantar metatarsal artery, or the “second blood supply system” and the deep plantar branch is anastomosed with the plantar digital artery of foot or the proper digital artery of foot; (e) The operation should be fine and gentle, pulling the blood vessels should be avoided, and vasospasm should be prevented; (f) The blood supply of the reconstructed finger should be closely observed after the operation, and timely treatment should be carried out in case of vascular crisis.

with stable vital signs, loss of the right thumb from the metacarpophalangeal joint, and covered with flap. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. The operation was successful and routine reconstruction treatment was given after the operation. Six weeks after the operation, the reconstructed finger survived successfully. Regular followup was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.22).

10.4.6 Case Description Case 1 A 16-year-old male patient was admitted to hospital for 2 months after debridement and covered with flaps due to the right thumb defect caused by grass trimmer injury. Physical examination: She was in good general condition,

Case 2 A 25-year-old female patient was admitted to hospital in emergency for 3 h due to pain and bleeding of the right thumb caused by printing press crushing. Physical examination: She was in good general condition, with stable vital signs, traumatic loss of the right thumb from the proximal segment, comminuted fractures, and loss of soft tissue. The other fingers were normal. Debridement and stump repair were performed in emergency, and the wound healed well before she was discharged. One month later, the patient returned to the hospital for reexamination and was admitted to hospital again

10.4 Reconstruction of Type IV Defect of the Thumb

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Fig. 10.23 Reconstruction of type IV defect of the right thumb by free second toe transplantation. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative palmar condition of thumb defect. (c)

Preoperative design. (d) Dissociation of first dorsal metatarsal artery- deep plantar branch-dorsal artery of foot. (e) Cutting of the second toe. (f) The thumb reconstruction by free second toe transplantation

due to requiring finger reconstruction. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation (Fig. 10.23).

operative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia selectively and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.24).

Case 3 A 27-year-old female patient was admitted to hospital in emergency for 4 h due to pain and bleeding of the left thumb caused by machine. Physical examination: She was in good general condition, with stable vital signs, traumatic loss of the left thumb from the metacarpophalangeal joint, exposed bone fracture and tendons, irregular skin of the stump, active bleeding, and the other fingers were normal. Debridement and stump repair were performed in emergency, and the wound healed well before she was discharged. Seven weeks later, the patient returned to the hospital for reexamination and was admitted to hospital again due to requiring finger reconstruction. After admission, routine pre-

Case 4 A 30-year-old female patient was admitted to hospital in emergency for 6 h due to pain and bleeding of the left thumb caused by the machine. Physical examination: she was in good general condition, with stable vital signs, traumatic loss of the left thumb from the metacarpophalangeal joint, exposed bone fracture and tendons, irregular skin of the stump, active bleeding, and the other fingers were normal. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthe-

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Fig. 10.24 Reconstruction of type IV defect of the left thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) Cutting of the second toe. (d) Thumb reconstruction by free second toe transplantation. (e) The palmar view of the reconstructed thumb 10 months after the operation. (f) The dorsal

view of the reconstructed thumb 8 months after the operation. (g) Holding function of the reconstructed thumb 10 months after the operation. (h) Opponens function of the reconstructed thumb 10 months after the operation. (i) The situation of the donor site 10 months after the operation

sia in emergency and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. One month after the operation, the reconstructed finger survived successfully. Thirteen months’ regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.25).

Case 5 A 30-year-old male patient was admitted to hospital for 6 months after stump repair operation in outer hospital due to the right thumb defect caused by the machine. Physical examination: The right thumb totally missed and the wound healed well. The other fingers were normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely with plaster exter-

10.4 Reconstruction of Type IV Defect of the Thumb

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Fig. 10.25 Reconstruction of type IV defect of the left thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative condition of thumb defect. (c) Dissociation of the second toe. (d) Cutting of the second toe. (e) Cutting of the second toe. (f) Debridement of the recipient site. (g) The radial view of the reconstructed thumb 1 month after the operation. (h) The dorsal view of the

reconstructed thumb 1 month after the operation. (i) The situation of the donor site 13 months after the operation. (j) The dorsal view of the reconstructed thumb 13 months after the operation. (k) The palmar view of the reconstructed thumb 13 months after the operation. (l) Holding function of the reconstructed thumb 8 months after the operation

nal fixation. After the operation, the patient was ordered to lie in bed absolutely, the finger was irradiated with a roasting lamp, and blood supply was observed. At the same time, routine triple antitreatment was given. No vascular crisis occurred

after the operation, and the reconstructed finger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.26).

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Fig. 10.26 Reconstruction of type IV defect of the right thumb by free second toe transplantation. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative palmar condition of thumb defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Dissociation of the sec-

ond toe. (f) The reconstructed thumb 1 week after the operation. (g) The reconstructed thumb 1 week after the operation. (h) The dorsal view of the reconstructed thumb 3 weeks after the operation. (i) The palmar view of the reconstructed thumb 3 weeks after the operation

Case 6 A 32-year-old female patient was admitted to hospital for 2 weeks after stump repair operation in outer hospital due to the left thumb defect caused by sawing machine injury. Physical examination: The left thumb totally missed and the wound healed well. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia selectively. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the

sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely with plaster external fixation. After the operation, the patient was ordered to lie in bed absolutely, the finger was irradiated with a roasting lamp, and blood supply was observed. At the same time, routine triple antitreatment was given. No vascular crisis occurred after the operation, and the reconstructed finger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.27).

10.4 Reconstruction of Type IV Defect of the Thumb

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Fig. 10.27 Reconstruction of type IV defect of the left thumb by free second toe transplantation. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative palmar condition of thumb defect. (c) Preoperative design. (d) Dissociation of the blood vessels and nerves in the donor site. (e) Dissociation of the second toe. (f) The dorsal wound in the donor site covered by skin graft. (g) The plantar wound was

sutured directly. (h) The appearance of the reconstructed thumb 2 years after the operation. (i) Opponens function of the reconstructed thumb 2 years after the operation. (j) Holding function of the reconstructed thumb 2 years after the operation. (k) The appearance of the donor site 2 years after the operation

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10.5 Reconstruction of Type V Defect of the Thumb This type thumb defect is located in the first metacarpal bone, which is often accompanied by skin defect, web contracture, and thenar injury. Due to the complete loss of part of the metacarpal bone and the total thumb, about 40% of the hand function would be lost, which would affect the daily life of patients, and surgical reconstruction is the best indication. The second toe of the opposite foot transplantation combined with the dorsal flap and the metatarsophalangeal joint is the first choice for reconstruction, and combined with the forefoot flap could also be another choice. According to the defect location of the metacarpal, it can be divided into three subtypes: type I: located in the head of the metacarpal, type II: located in the middle of the metacarpal; and type III: located in the proximal base of the metacarpal.

10.5.1 Indications (1) Adult, young, and middle-aged is better; (2) The severed thumb cannot be replanted; (3) The patient has a strong desire for reconstruction, and no basic disease, peripheral vascular disease; (4) No mental disease; (5) There is no history of trauma, surgery or infection in the donor toe and the appearance is normal. Fig. 10.28 The cup-shaped Y incision in the recipient site

10.5.2 Surgical Design Type V defect of the thumb is often accompanied by skin and soft tissue defect and contracture of the web, etc. Preoperative design needs to adopt the corresponding form of second toe transplantation with dorsal skin flap for reconstruction and repair according to different defects. Incision Design in the Recipient Site One cup-shaped Y incision should be designed on the radial side of the second metacarpal, the mouth to distal, Y base tip to the proximal lengthened longitudinal incision. The U-shaped opening is located proximal to the second metacarpophalangeal joint and is about 3 cm wide (Fig. 10.28). Incision design in the donor site With the contralateral second metatarsophalangeal joint as the center, triangular incisions should be made on both sides of the first and second toe web, making them connected in a diamond shape, with the distal and proximal angles of about 120°, and the length of the sides of about 3–4 cm. The proximal incisions extend in an “S” shape, and the plantar incisions are in a V shape (Fig. 10.29).

10.5.3 Surgical Method reparation for the Recipient Site P The length of the thumb defect, the size and range of the soft tissue defect and the residual function of the thumb should be measured preoperatively. Intraoperative debridement should be performed to remove all necrotic tissue, trim the bone stump, and protect the residual function. Radial artery and accompanying vein, cephalic vein, superficial branch of radial nerve, and proper digital nerve should be exposed for use (Fig. 10.30). he Cutting of the Toe T Several issues should be noted during the operation: (a) When the second toe is removed, the perforator branch of dorsal artery of foot should be protected; (b) When the flexor tendon and plantar digital nerve are cut, they should be kept as long as possible to prevent insufficient length in transplantation; (c) The transverse ligament of the metatarsal bone must be repaired to reduce the functional damage of the foot; (d) When the flap and the second toe are removed, the peri- tendon tissue should be protected. If the tendons and bones are exposed, local or free flap should be applied (Figs. 10.31 and 10.32).

10.5 Reconstruction of Type V Defect of the Thumb

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Fig. 10.29 The incisions in the donor site

Fig. 10.30 Lift the lingual flap and trim the bone stump

Fig. 10.31 The incisions in the donor site

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changed every 2–3 days and stitches are removed 2 weeks after the operation.

10.5.4 Operation Characteristics (a) Type V defect of the thumb is often accompanied by soft tissue defect, which requires careful preoperative evaluation and accurate design of the second toe skin flap; (b) Various forms of dorsal foot flap, plantar-side V-shaped flap, and lingual flap on the first web space of hand should be reasonably adjusted between the three flaps to make full use of the effective area of these skin not only to form the first web space but also to eliminate the wound, and the excess skin should be excised; (c) Do not damage the vascular pedicle of donor toe; (d) The injury is large to the donor foot; when the wound is closed, we must be careful to avoid causing hallux valgus deformity.

10.5.5 Announcements

Fig. 10.32 Dissociation of the second toe with dorsal flap

Transplantation The bone should be fixed with Kirschner wire or cross steel wire, and the extensor tendon is sutured with “8” method, and the flexor tendon is sutured with modified Kessler. Anastomosis of plantar digital nerve to proper digital nerve, dorsal artery of foot to radial artery, great saphenous vein to cephalic vein, and the accompanying veins should be performed under microscope. The suture tension of the flap should not be large. If the flexor pollicis longus tendon is too short or not found, it can be repaired by transposition of superficial flexor tendon of the ring finger. Postoperative Treatment (a) Postoperative heat preservation, nursing should be strengthened; (b) Postoperative antispasticity and anticoagulation therapy should be performed, and anti-infection therapy should be added to those with wounds; (c) Absolute bed rest for 7 days after the operation; (d) Smoking is prohibited during the perioperative period. Dressings are

(a) Preoperative planning is very important, which must be designed in advance. A full preoperative evaluation can be made to design a reasonable and effective composite dorsal foot flap. A relative longer second metatarsal bone needs to be removed, which may affect the foot function, that means this operation should be carefully considered for those with high functional requirements of the foot; (b) During the dissociation of the toe, the movements should be gentle, so as not to pull and damage the vascular pedicle which would reduce the spasm after vascular anastomosis; (c) The plantar digital nerve and the proper digital nerve should be anastomosed as far as possible to restore and reconstruct the palmar sensation of the finger; (d) After the anastomosis of the reconstructed toe is completed, the bleeding must be stopped completely to avoid the occurrence of postoperative hematoma; (e) The release of the extensor and flexor tendons in the recipient site must be complete, and the muscles must have elastic retraction when pulled passively; (f) The reconstruction of the first web space of hand should make full use of the composite flap carried by the donor toe, and attention should be paid to the incision location of the U-shaped skin flap in the hand. Free skin graft can be considered if there is a large area of scar on the wound surface; (g) The closure of the foot wound must be paid attention to. During the operation, the surrounding aponeurosis should be protected. The hemostasis should be completely stopped. When the wound cannot be sutured directly, attention should be paid to the tightness when applying free skin graft, and the blood circulation of the foot should be observed after the operation; (h) Postoperative environment of patients should pay attention to heat preservation, keeping quiet, no smoking, and the patients should absolutely lie in bed for a week.

10.5 Reconstruction of Type V Defect of the Thumb

10.5.6 Case Description Case 1 A 31-year-old male patient was admitted to hospital in emergency for 6 h due to the right thumb defect with pain and bleeding caused by heavy object injury. Physical examination: He was in good general condition, with stable vital signs, traumatic loss of the right thumb from the first metacarpal, irregular wound, bleeding, comminuted fractures, and loss of soft tissue. The other fingers were normal. Debridement and finger reconstruction by the left second toe transplantation were performed in emergency under general anesthesia, and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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 opera-

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tion. The reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.33). Case 2 A 28-year-old male patient was admitted to hospital for 6 weeks after stump repair due to the right thumb defect caused by cutting injury. Physical examination: He was in good general condition, with stable vital signs and type V defect of the right thumb. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. The operation was successful and the patient returned to the ward safely. Routine reconstruction treatment was given after the operation. Four months after the operation, the reconstructed finger survived suc-

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Fig. 10.33 Reconstruction of Type V defect of the right thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) The reconstructed thumb after the operation. (d) The appearance of the reconstructed thumb 6 months after the

operation. (e) Flexor function of the reconstructed thumb 3 months after the operation. (f) Opponens function of the reconstructed thumb 6 months after the operation. (g) Opponens function of the reconstructed thumb 6 months after the operation

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Fig. 10.34 Reconstruction of type V defect of the right thumb by free second toe transplantation. (a) Preoperative palmar view of thumb defect. (b) Preoperative X-ray. (c) Preoperative dorsal view of thumb defect. (d) Preoperative design. (e) The removed second toe. (f) The

reconstructed thumb 14 days after the operation. (g) The appearance of the reconstructed thumb 4 months after the operation. (h) Holding function of the reconstructed thumb 4 months after the operation

cessfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.34).

and the patient returned to the ward safely. Routine reconstruction treatment was given after the operation. Five months after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.35).

Case 3 A 32-year-old female patient was admitted to hospital for 5 weeks after stump repair due to the right thumb defect caused by machine injury. Physical examination: She was in good general condition, with stable vital signs and type V defect of the right thumb. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. The operation was successful

Case 4 A 35-year-old female patient was admitted to hospital for 6 weeks after stump repair due to finger defect caused by machine injury. Physical examination: She was in good general condition, with stable vital signs, stump repair view of the left hand, and loss of the second metacarpal bone, the thumb, and the index finger. After admis-

10.5 Reconstruction of Type V Defect of the Thumb

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Fig. 10.35 Reconstruction of type V defect of the right thumb by free second toe transplantation. (a) Preoperative palmar view of thumb defect. (b) Preoperative dorsal view of thumb defect. (c) Preoperative design. (d) Dissociation of the second toe. (e) The palmar view of the

reconstructed thumb. (f) The dorsal view of the reconstructed thumb. (g) Opponens function of the reconstructed thumb 5 months after the operation. (h) Holding function of the reconstructed thumb 5 months after the operation

sion, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the left foot under general anesthesia selectively and the donor site was sutured directly. After the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.36).

Case 5 A 32-year-old male patient was admitted to hospital in emergency for 1 h due to pain, bleeding, and deformity of the right thumb caused by machine injury. Physical examination: He was in good general condition, with stable vital signs. The right thumb was crushed, flat deformity, accompanied by some soft tissue and bone defects, without the condition of finger replantation. Debridement and stump repair were performed in emergency, and the wound healed well before he was discharged. One month later, the patient returned to the hospital for reexamination and was admitted to hospital again due to requiring finger reconstruction. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia

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Fig. 10.36 Reconstruction of type V defect of the left thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) Dissociation of the second toe. (d) Thumb reconstruction by free second toe transplantation. (e) The appearance of

the reconstructed thumb 8 weeks after the operation. (f) Opponens function of the reconstructed thumb 8 weeks after the operation. (g) The situation of the donor site 8 weeks after the operation

selectively and the donor site was sutured directly. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of

the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 10.37). Case 6 A 23-year-old male patient was admitted to hospital in emergency due to pain, bleeding, and damaged of the left thumb caused by heavy object injury. Physical examination: The wound of the left thumb was seriously polluted, and the contusion of the finger from the middle part of the metacar-

10.5 Reconstruction of Type V Defect of the Thumb

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Fig. 10.37 Reconstruction of type V defect of the right thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Cutting of the second toe. (c) Thumb reconstruction by free second toe transplantation. (d) The palmar view of the reconstructed thumb 10 months after the operation. (e) The dorsal view of the reconstructed

thumb 8 months after the operation. (f) Opponens function of the reconstructed thumb 10 months after the operation. (g) Holding function of the reconstructed thumb 10 months after the operation. (h) The situation of the donor site 10 months after the operation

pal which was flat and without blood circulation. No obvious abnormality was observed in the other fingers. Debridement and stump repair were performed in emergency, and the wound healed well 1 week after the operation. So the thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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 with plaster external fixation. After the operation, the patient was ordered to lie in bed absolutely, the finger was irradiated with a roasting lamp, and blood supply was observed. At the same time, routine triple antitreatment was given. No vascular crisis occurred after the operation, and the reconstructed finger successfully survived. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.38).

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Fig. 10.38 Reconstruction of type V defect of the left thumb by free second toe transplantation. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative design. (d) Preoperative design. (e) Dissociation of the second toe. (f) Dissociation of the second toe. (g) The blood circulation of the reconstructed finger. (h) The blood circulation of the recon-

structed finger. (i) The dorsal view of the reconstructed thumb 3 weeks after the operation. (j) The palmar view of the reconstructed thumb 3 weeks after the operation. (k) Holding function of the reconstructed thumb 6 months after the operation. (l) Opponens function of the reconstructed thumb 6 months after the operation

10.6 Reconstruction of Type VI Defect of the Thumb

10.6 Reconstruction of Type VI Defect of the Thumb Type VI defect locates at the wrist or the first carpometacarpal joint. The defect length is longer, the soft tissue defect is larger, and the first carpometacarpal joint is destroyed, which make less function residual. Therefore, its treatment is more difficult and the effect is worse than that of type I–V defect. Since the first metacarpal and thumb are missing, all the function of the thumb would be lost, which would seriously influence the patient’s daily life. The appearance would also cause serious psychological impact on the patients, so this type defect of thumb is the absolute indication for reconstruction. The classic way is free second toe transplantation with dorsal flap, which is same as type V defect of thumb. Due to inadequate coverage of dorsal flap, additional pedicled flap or free flap is often required. The difference is a defect or partial defect of the wrist in type VI. Reconstruction of the bony structure requires the attachment of the second metatarsal with trapezium bone, scaphoid, or base of the second metacarpal.

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The donor site: With the contralateral second metatarsophalangeal joint as the center, triangular incisions are made on both sides of the first and second toe webs, so that they are connected in a diamond shape, the distal and proximal angles are about 90°, and the length of the sides is about 3–4 cm. The proximal incision extends in an “S” shape, and the plantar incision is V shaped.

10.6.3 Surgical Method The reconstruction method is basically the same as that of type V defect, so it will not be repeated. Since the first carpometacarpal joint has been lost, fixation of the second metatarsal with trapezium bone or scaphoid should be performed after the second toe transplantation (Fig. 10.39).

10.6.1 Indications (1) Adult, young, and middle-aged is better; (2) A severed thumb that cannot be replanted; (3) The patient has a strong desire for reconstruction, whose general conditions are good, and without systemic organic disease; (4) No basic disease, mental disease, peripheral vascular disease; (5) There is no history of trauma, surgery, or infection in the donor toe and the appearance is normal.

10.6.2 Surgical Design Surgical design is similar to typeV defect. Soft tissue defect needs to be taken into account, which often requires additional design of forearm reverse pedicle flap or free flap. The recipient site: A U-shaped incision is designed on the radial side of the second metacarpal, with the mouth to distal and the U-shaped base tip to proximal and lengthened. The U-shaped mouth is located at the proximal end of the second metacarpophalangeal joint, about 3 cm wide. The radial artery and cephalic vein are exposed by a transverse or longitudinal incision centered on the radial artery in the snuffbox or distal forearm.

Fig. 10.39 Fixation of the second metatarsal bone and trapezium bone

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10 Reconstruction of Thumb Defects

bone should be fixed with trapezium bone or scaphoid or the second metacarpal bone which could omit the reconstruction of opponens function; (c) Various forms of dorsal foot flap, plantar-side V-shaped flap and tongue flap on the first finger web should be reasonably adjusted among the three flaps to make full use of the effective area of these skin not only to form the first finger web but also to eliminate the wound, and the excess skin should be excised; (d) The injury to the foot is large, when it is closed we should be careful to avoid causing hallux valgus deformity.

10.6.6 Announcements

Fig. 10.40 Fixation of the second metatarsal bone and the second metacarpal bone

In the absence of these two bones, the second metatarsal bone can also be used for bony fixation with the radial palmar of the middle segment of the second metacarpal bone (Fig. 10.40); thus, the step of reconstruction of opponens function can be omitted.

10.6.4 Postoperative Treatment (a) After the operation, continuous light irradiation should be given and the peripheral blood supply should be observed; (b) The patients should be treated with “three anti” therapy; (c) After the operation, lie in bed for 7 days absolutely, attention should be paid to heat preservation; (d) Smoking is prohibited during the perioperative period. Dressings are changed every 2–3 days and stitches are removed 2 weeks after the operation.

10.6.5 Operation Characteristics (a) The surgeon should flexibly design different forms of dorsal flap to cover the wound and reconstruct the first finger web according to the skin defect; (b) The second metatarsal

(a) The size of soft tissue defect should be measured carefully before operation and pedicle flap or free flap should be designed accurately; (b) If the forearm pedicle flap is needed, it should cover the wound without obstructing the blood circulation of the finger; (c) If the free flap is removed, the recipient vessels need to be considered; (d) After the toe transplantation, the bleeding must be stopped completely to avoid the occurrence of postoperative hematoma; (e) The reconstruction of the first finger web should make full use of the composite flap carried by the donor toe, and attention should be paid to the incision location of the hand U-shaped flap. Free skin graft can be considered if there is a large area of scar on the wound surface and the soft tissue defect is large after debridement; (f) Attention must be paid to the closure of the foot wound. The surrounding aponeurosis tissue should be protected and the hemostasis should be complete during the operation; (g) If the wound cannot be closed directly and free skin graft is applied, the tightness should be paid attention to, and the blood circulation of the foot should be observed after the operation to prevent the occurrence of vascular crisis; (h) Heat preservation, keeping quiet, strict smoke prohibiting must be paid attention to, patients absolutely lie in bed for a week; (i) Postoperative dressing change should be gentle, pay attention to the use of warm disinfectant disinfection and clean scab.

10.6.7 Case Description Case 1 A 24-year-old male patient was admitted to hospital for 2 years due to the left thumb, index finger and middle finger defect caused by machine injury. Physical examination: He was in good general condition, with stable vital signs, the thenar, thumb, index finger, and middle finger defect. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia selectively and the thenar was reconstructed by reversed

10.6 Reconstruction of Type VI Defect of the Thumb

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Fig. 10.41 Reconstruction of type VI defect of the left thumb by free second toe transplantation. (a) Preoperative palmar view of thumb defect. (b) Preoperative dorsal view of thumb defect. (c) Preoperative design. (d) Cutting of the second toe. (e) Reconstruction of the thenar.

(f) The thumb reconstructed by second toe transplantation. (g) The appearance of the recipient site 3 months after the operation. (h) The appearance of the recipient site 3 months after the operation. (i) The situation of the donor site 3 months after the operation

forearm dorsal interosseous artery pedicle flap. The donor site was covered by skin graft. The operation was successful and routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were improved and the donor site healed in the first stage (Fig. 10.41).

forearm dorsal interosseous artery pedicle flap. The donor site was covered by skin graft. The operation was successful and routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were general and the donor site healed in the first stage (Fig. 10.42).

Case 2 A 34-year-old male patient was admitted to hospital for more than 3 years due to the left thumb defect caused by machine injury. Physical examination: He was in good general condition, with stable vital signs, the thenar, and thumb defect. The thumb was reconstructed by free second toe transplantation of the right foot under general anesthesia selectively and the thenar was reconstructed by reversed

Case 3 A 20-year-old female patient was admitted to hospital in emergency for 3 h due to pain and bleeding of the right forearm and hand caused by machine injury. Physical examination: She was in good general condition, with stable vital signs, irregular open wound at distal forearm, exposed bone fracture and tendons, severe contusion of the right thumb, soft tissue extirpation, no peripheral blood supply, and the

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Fig. 10.42 Reconstruction of type VI defect of the left thumb by free second toe transplantation. (a) Preoperative condition of thumb defect. (b) Preoperative design. (c) Preoperative design. (d) Dissociation of the flap. (e) Dissociation of the second toe. (f) The reconstructed thumb. (g)

The appearance of the reconstructed thumb 11 months after the operation. (h) Holding function of the reconstructed thumb 11 months after the operation. (i) The situation of the donor site 11 months after the operation

other fingers were normal. “Right forearm debridement with internal fixation and thumb stump repair” was performed under general anesthesia in the first-stage emergency department. The operation was successful and the patient was discharged after good postoperative wound healing. Three month later, the patient returned to the hospital due to requiring finger reconstruction. The thumb was reconstructed by free second toe transplantation combined with the great toe nail flap of the left foot under general anesthesia selectively and the right radius defect was repaired by free fibular flap transplantation. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned

to the ward safely. Two weeks after the operation, the reconstructed finger and fibular flap survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 10.43). Case 4 A 28-year-old female patient was admitted to hospital for 1 month after stump repair due to the left thumb defect caused by mold crush injury. Physical examination: She was in good general condition, with stable vital signs and the left thumb defect. After admission, routine preoperative preparation for reconstruction was given. The thumb was reconstructed by free great toe transplantation of the right foot under general anesthesia selectively and the donor site was

10.6 Reconstruction of Type VI Defect of the Thumb

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Fig. 10.43 Reconstruction of type VI defect of the right thumb by free second toe transplantation combined with great toe nail flap. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative X-ray. (d) X-ray after primary emergency fixation. (e) Design of great toe nail flap. (f) Design of fibular flap. (g) Dissociation of great toe nail flap. (h) The dorsal view

of the reconstructed thumb. (i) The palmar view of the reconstructed thumb. (j) The situation of the donor site. (k) The palmar view of the reconstructed thumb 6 months after the operation. (l) The dorsal view of the reconstructed thumb 6 months after the operation. (m) Holding function of the reconstructed thumb. (n) X-ray 3 months after the operation

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Fig. 10.44 Reconstruction of type VI defect of the left thumb by free great toe transplantation. (a) Preoperative palmar condition of thumb defect. (b) Preoperative dorsal condition of thumb defect. (c) Preoperative design. (d) The thumb reconstruction by free great toe transplantation. (e) The dorsal view of the reconstructed thumb 3 weeks

after the operation. (f) The palmar view of the reconstructed thumb 3 weeks after the operation. (g) The situation of the first finger web 3 weeks after the operation. (h) The situation of the donor site 3 weeks after the operation

covered by free skin graft. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cot-

ton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation (Fig. 10.44).

Reconstruction of Single Finger Defects

Abstract

Single finger defect reconstruction is in order to let the patients have a complete finger body and resume the function of hands. The doctor uses microscopic instruments for the actual operation to reconstruct the lost finger by own toe transplantation under a microscope. Because toes are the closest in shape and function to fingers, and the absence of a single toe does not affect normal walking function. Through functional rehabilitation and exercise, limbs and fingers can be close to the normal state. Keywords

Finger reconstruction · Single finger defect

11.1 Reconstruction of Type I Defect Type I defect refers to the partial defect locates in the distal segment of the finger. The traditional view is that the partial defect of the finger has little effect on the function of the finger, but mainly affects the appearance. The blood vessels and nerves of the distal segment are relatively small, that is difficult for replantation and the success rate is low, so there is no need for replantation. But with the development of microsurgery, especially super microsurgery technology, the reconstruction of type I defect is no longer a difficult problem, which is gradually accepted since the survival rate has reached more than 90%. Common surgical methods include great toe tip transplantation and second toe tip transplantation. Due to the small size of the second toenail, the shape of the reconstructed fingertip is not ideal. This chapter focuses on great toe tip transplantation.

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11.1.1 Indications (1) Type I defect of the finger; (2) The patient is young and has no basic disease; (3) The patient has high requirements for fingers and a strong desire to reconstruction; (4) There is no obvious deformity of the donor toe.

11.1.2 Surgical Design A composite toenail flap with partial phalanx is designed on the toe tip of the fibular side of great toe according to the defect of the finger. Because the great toe tip is larger than the finger tip, a lingual flap is left on the tibial side of great toe to reduce the circumference of the reconstructed finger; at the same time, the lingual flap could be used to repair the wound at the donor site and increase the length of great toe. The great toenail is wider than the finger nail. According to the actual defect size of the finger nail, a great toenail is designed on the fibular side of the great toe. The end of the distal phalanx should be included in the flap to form a real toenail composite tissue rather than a simple great toenail flap. The superficial plantar digital vein of great toe or fibular superficial dorsal digital vein of great toe is used as the reflux vein of the flap, and the artery and nerve of the flap are used as the fibular plantar digital artery of great toe and fibular plantar digital nerve of great toe.

11.1.3 Surgical Method reparation for the Recipient Site P Scar tissue of fingertip should be removed, fingernail stump should be trimmed, and part of bone at the end of phalanx should be removed to normal cancellous bone. Dissociate the

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_11

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digital arteries and nerves on both sides of the finger under a magnifying glass or microscope, and remove the occluded digital artery until bleeding once the tourniquet is released. Remove the neuroma at the broken end of the proper digital nerve, and dissociate it to an appropriate length for use. An arc incision is made on the dorsum of middle segment of the finger or the dorsum of proximal segment of the thumb, and 1–2 dorsal digital veins are dissociated for use.

he Cutting of the Toe T First, the dorsal digital vein if great toe is dissociated proximally to an appropriate length before being cut off, and then dissociated along the branches to the fibular tip of the great toe. The dorsal metatarsal artery and plantar metatarsal artery are dissociated at the toe web, and then the fibular plantar digital artery and nerve are dissociated to distal. To ligate and cut off the branches, dissociate the neurovascular bundle to distal until the fibular design line of toe tip. The skin is cut along the design line in the toe pulp, and several superficial plantar digital veins are carefully dissociated and to proximal for 1–2 cm before being cut off for use. The subcutaneous tissue of the toe pulp is further cut deep to the bone. Cut off the phalange with a bone knife, lift the toe body, and cut off the arteries and nerves at the appropriate proximal part. Transplantation Trim the trochanter on both sides of great toe tip to make the outer diameter close to that of the finger. The phalange of toe is fixed on the phalange of finger with a diameter of 0.8 mm Kirschner wire. The toenail and the fingernail stump are trimmed together which should be tightly matched without any space. Postoperative Treatment (a) After the operation, strengthen nursing, keep warm, closely observe the blood circulation of the reconstructed finger; (b) After the operation, the patients should be treated with “three-anti” therapy; (c) Do not get out of bed for 1 week after the operation; (d) No smoking during the perioperative period.

11.1.4 Operation Characteristics As great toe has a relative larger size and a larger toenail, only part of the toenail can be transplanted to reconstruct the fingernail. The great toenail can be divided into two parts, one of which is transplanted to the finger to reconstruct the fingertip, and the other one remained to maintain the appearance and function of the great toe. Compared with the reconstruction by the distal segment of the second toe, this method has less

11 Reconstruction of Single Finger Defects

influence on the appearance and function of the foot, and the shape of the reconstructed fingertip is more realistic.

11.1.5 Announcements For reconstruction of type I defect of finger by great toe tip transplantation, the difficulty of operation is dissociation of veins. Dorsal digital vein of foot cannot be directly used for great toe tip transplantation which is without dorsal skin flap. Although there are superficial subcutaneous veins in the toe pulp, they are too thin and close to the skin, that is difficult to be dissociated and anastomosed. The solution is: (a) First, the dorsal digital vein of great toe should be dissociated, and then its branch is traced to the distal end of the fibular side to the tip of the toe; (b) A triangular flap to the proximal end of the toe tip tissue flap of great toe could be attached, and the vein on the flap could be used to anastomose with the dorsal digital vein in the middle segment of the finger.

11.1.6 Case Description Case 1 A 23-year-old male patient was admitted to hospital in emergency for 1 h due to pain and bleeding of the left index finger caused by machine crush injury. Physical examination: He was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left index finger from the nail root, irregular skin of the stump, active bleeding, lightly polluted. The sensation, movement, and blood circulation in the other fingers were good. The left index finger was reconstructed by free nail skin flap of great toe transplantation under combined brachial plexus and epidural anesthesia in emergency. The donor site was closed by local dorsal flap of foot. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 11.1). Case 2 A 35-year-old male patient was admitted to hospital in emergency for 2 h due to pain and bleeding of the left ring finger defect caused by the machine. Physical examination: He was in good general condition, with stable vital signs, traumatic loss of the finger tip, exposed bone and nail bed,

11.1 Reconstruction of Type I Defect

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Fig. 11.1 Reconstruction of type I defect of the left index finger by free nail skin flap of great toe transplantation. (a) Preoperative palmar condition of finger defect. (b) Preoperative dorsal condition of finger defect. (c) Preoperative design of the flap. (d) Preoperative design of the

flap. (e) Palmar view of the reconstructed finger. (f) Dorsal view of the reconstructed finger. (g) Dorsal view of the donor site. (h) Palantar view of the donor site

active bleeding, moderate pollution. After admission, the finger stump was debrided under general anesthesia, and it was reconstructed by free ipsilateral nail skin flap of great toe transplantation. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 11.2).

examination: She was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left index finger, approximately 1/2 of proximal nail bed remained, exposed bone, active bleeding, moderate pollution. After admission, the finger stump was debrided under general anesthesia, and it was reconstructed by free ipsilateral nail skin flap of great toe transplantation. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 11.3).

Case 3 A 27-year-old female patient was admitted to hospital in emergency for 2.5 h due to pain and bleeding of the left index finger defect caused by punch press injury. Physical

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Fig. 11.2 Reconstruction of type I defect of the left ring finger by free nail skin flap of great toe transplantation. (a) Preoperative dorsal condition of finger defect. (b) Preoperative palmar condition of finger defect. (c) A closer look. (d) A closer look. (e) Preoperative dicing of the flap. (f) Preoperative dicing of the flap. (g) Dorsal view of the reconstructed finger 1 month after the operation. (h) Palmar view of the reconstructed

finger 1 month after the operation. (i) Dorsal view of the reconstructed finger 2 months after the operation. (j) Palmar view of the reconstructed finger 2 months after the operation. (k) Dorsal view of the reconstructed finger 6 months after the operation. (l) Palmar view of the reconstructed finger 6 months after the operation. (m) Function of the reconstructed finger. (n) Appearance of the donor foot

11.2 Reconstruction of Type II Defect

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a

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Fig. 11.3 Reconstruction of type I defect of the left index finger by free nail skin flap of great toe transplantation. (a) Preoperative condition of finger defect. (b) Preoperative design. (c) Dissociation of the flap. (d) Finger reconstruction with free transplantation. (e) Dorsal view

of the reconstructed finger 10 months after the operation. (f) Palmar view of the reconstructed finger 10 months after the operation. (g) Function of the reconstructed finger 10 months after the operation

11.2 Reconstruction of Type II Defect

ease; (4) The patient has high requirements for fingers and a strong desire to reconstruction; (5) There is no obvious deformity of the donor toe.

Type II defect locates in the distal interphalangeal joint of the finger and the distal finger body, while theoretically loses 45% of the function of the finger, and the loss of hand function in different degrees that has little effect on the function of the whole hand. However, with the development of microsurgery and the continuous improvement of the level of finger reconstruction, the reconstruction of type II defect is no longer a difficult problem. Therefore, reconstruction is recommended for patients with high requirements for finger appearance and strong desire for reconstruction. The classical method of reconstruction is the second toe transplantation, but also the third or fourth toe transplantation could be considered.

11.2.1 Indications (1) Type I defect of the finger; (2) The severed finger cannot be replanted; (3) The patient is young and has no basic dis-

11.2.2 Surgical Design The design of the operation is similar to the type I defect. When the toe is cut, more bone and distal interphalangeal joint should be retained; flexor and extensor tendons should be retained to reconstruct flexion and extension function. 1. Incision design in the recipient site: The incision should be made according to the shape of the scar and soft tissue conditions in the finger stump. If the scar is in the coronal direction, the incision should be cut and exposed according to the coronal plane of the original scar (Fig. 11.4). If the scar is sutured in the sagittal plane, the incision design should be sagittal or V-shaped. A transverse or oblique incision is made on the dorsal side to expose the dorsal

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digital vein and a longitudinal incision is made on the lateral side to expose the proper digital artery. 2. Incision design in the donor site: According to the length of the defect of the finger, the second toe with similar shape is selected as the donor toe, and the incision design in the donor site is determined according to the soft tissue conditions and incision shape in the recipient site. V-V incision, sagittal plane-V incision, and coronal plane- coronal incision could be used (Fig. 11.5).

Fig. 11.4 Incision design in the recipient site

Fig. 11.5 Incision design in donor recipient site

11 Reconstruction of Single Finger Defects

11.2.3 Surgical Method General condition: The patient should be in good general condition without contraindications related to surgery or anesthesia, and the anesthesia is performed under brachial plexus anesthesia plus epidural anesthesia or general anesthesia. The operation could be performed in two groups: the recipient group and the donor group. The recipient group: The routine operation area is disinfected, then the towel is laid, and the tourniquet on the affected limb should be elevated with a pressure of 30–37 kPa. First of all, the finger stump incision is made according to the design, the skin and subcutaneous soft tissue are cut open, and the peripheral area is appropriately disintegrated and released, and the stump of the proper digital neurovascular bundle of the finger should be found on both sides of the finger and marked. In case of type II defect, the stump of extensor digitorum tendon and flexor digitorum longus tendon should be released and marked. The bone at the stump should be removed appropriately, and the medullary cavity should be opened. The proximal segment of finger should be cut according to the design to expose the proper digital neurovascular bundle and dorsal digital vein of finger, and the subcutaneous tunnel should be opened. The donor group: Elevate the lower limb and tourniquet with or without exorcism, with a pressure 47 kPa. Make a dorsal incision according to the design, extend it proximally to find the dorsal metatarsal vein, and ensure the continuity; at the same time ligate the unneeded branches. Then expose extensor tendons, plantar metatarsal arteries and nerves on both sides, and also flexor tendon and mark them (Fig. 11.6). The plantar metatarsal arteries and nerves and tendons should be cut off with a enough length. The phalangeal bone or the interphalangeal joint should be cut off according to the defect length of the finger. At this time, the donor toe is completely dissociated except for the vascular pedicle, and the tourniquet should be relaxed to observe the blood supply of the toe. After the recipient group is prepared, the donor site should be cut off from the vascular pedicle, and the donor toe is transplanted to the recipient site (Fig. 11.7).

11.2 Reconstruction of Type II Defect

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Fig. 11.6 Dissociation of dorsal vein of foot and the exposure of plantar digital nerve, tendon, and blood vessels of toe

Fig. 11.7 Anastomosis of the palmar nerve, blood vessels, and flexor tendons and the appearance of the reconstructed finger

11.2.4 Operation Characteristics (a) The requirement of microscopic technique is high and good small vessel anastomosis technique is needed; (b) All patients with type II defect require reconstruction, and also

have high requirement for finger appearance; (c) The operation needs to be performed under a magnifying glass or microscope, that does not involve metatarsal bone and transverse ligament, and has no obvious effect on foot weight bearing and walking; (d) Do not damage the vascular pedicle.

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11 Reconstruction of Single Finger Defects

11.2.5 Announcements

11.2.6 Case Description

(a) Preoperative planning is critical. It must be designed in advance and fully evaluated before operation. (b) The operation should be gentle and careful to avoid pulling or injury of the vascular pedicle to prevent the occurrence of vascular crisis. (c) The vascular pedicle must be straighten out to avoid torsion; (d) Nerve anastomosis must be carried out without tension; (e) Pay attention to stop hemostasis to prevent postoperative bleeding and scab that affect blood supply; (f) Bandaging must be loose to prevent vascular crisis due to postoperative swelling and over-tight bandaging of the reconstructed finger; (g) After the operation, the surrounding environment of the patients should pay attention to heat preservation, keep quiet, strictly smoke-free environment, and the patients must lie in bed for a week; (h) Pay attention to the blood supply of the reconstructed finger to prevent the occurrence of vascular crisis.

Case 1 A 38-year-old male patient was admitted to hospital in emergency for 30 days after stump repair due to the right index finger defect caused by machine injury. Physical examination: He was in good general condition, with stable vital signs. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The index finger was reconstructed by the left second toe transplantation under general anesthesia electively, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.8).

a

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Fig. 11.8 Reconstruction of type II defect of the right index finger by the free second toe transplantation. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side).

(e) Palmar view of the reconstructed finger 1 week after the operation. (f) Dorsal view of the reconstructed finger 1 week after the operation. (g) Palmar view of the reconstructed finger 10 months after the operation. (h) Dorsal view of the reconstructed finger 10 months after the operation

11.2 Reconstruction of Type II Defect

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Fig. 11.9 Reconstruction of type II defect of the left index finger by the free second toe transplantation. (a) Preoperative condition of the finger defect. (b) Preoperative X-ray. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) Dissociation of the blood vessels and nerves. (f) Remove the second toe. (g) Transplantation

of the second toe. (h) Palmar view of the reconstructed finger. (i) Dorsal view of the reconstructed finger. (j) Palmar view of the reconstructed finger 3 months after the operation. (k) Dorsal view of the reconstructed finger 3 months after the operation

Case 2 A 27-year-old female patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the left index finger caused by machine crush injury. Physical examination: She was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left index finger from the middle plane of the middle segment of the finger, exposed bone, irregular skin of the stump, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The index finger was

reconstructed by the left second toe transplantation under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.9).

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Fig. 11.10 Reconstruction of type II defect of the left index finger by the free second toe transplantation. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) Dissociation of the blood vessels and nerves. (f) Dissociation of the second toe. (g) Palmar view of the

reconstructed finger. (h) Dorsal view of the reconstructed finger. (i) Palmar view of the reconstructed finger 9 months after the operation. (j) Dorsal view of the reconstructed finger 9 months after the operation. (k) Function of the reconstructed finger 9 months after the operation. (l) Appearance of the donor and recipient site 9 months after the operation

Case 3 A 31-year-old female patient was admitted to hospital in emergency for 2.5 h due to pain and bleeding of the left index finger caused by machine crush injury. Physical examination: She was in good general condition, with stable vital signs, traumatic loss of the distal segment of the left index finger from the middle plane of the middle segment of the finger, exposed bone, irregular skin of the stump, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The index finger

was reconstructed by the left second toe transplantation under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.10).

11.3 Reconstruction of Type III Defect

11.3 Reconstruction of Type III Defect Type III defect loses 50–80% of the function of the finger, and the loss of hand function is different in different fingers. For patients with high requirements for appearance, toe transplantation can be selected for reconstruction, among which, the second toe transplantation is the most commonly used. The donor site of the foot retains the metatarsal head and transverse ligaments, so it has little effect on the function of the foot.

11.3.1 Indications (1) Type III defect of the finger; (2) The patient is young and has a strong desire for reconstruction; (3) The patient has no basic disease and there is no obvious deformity of the donor toe.

11.3.2 Surgical Design The ipsilateral or contralateral second toe could be selected to reconstruct the length and shape of the finger, also part of flexion and extension function according to the degree of finger defect.

11.3.3 Surgical Method reparaion for the Recipient Site P In case of emergency operation, a complete debridement of the injured finger should be performed first to remove the contaminated, contusion and deactivated tissue, and a large amount of normal saline should be used to flush the wound, and then disinfect and lay the sheet again. The extensor digitorum tendon, flexor digitorum profundus tendon, bilateral proper digital nerves and arteries, and 2–5 veins are explored and marked for use. Then debridement and irrigation are performed again under surgical microscope to make the wound surface in the recipient site meet or close to the standard of class I incision. If selected, the scar tissue of the stump should be removed, and the broken bone should be treated with fresh treatment. Proximal flexor tendons are explored and marked, and bilateral digital arteries, nerves, and veins are dissociated under microscope. he Cutting of the Toe T The incision line is drawn on the donor toe according to the shape and length of the finger defect. The dorsal skin of the toe is first cut along the incision line to expose the

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veins, and 2–3 veins for anastomosis are dissociated, and then cut off at an appropriate length. Then the plantar skin is cut open, and one or two veins for anastomosis are dissociated and marked. The bilateral proper arteries, nerves, and flexor tendons are dissociated and cut off according to the degree of defect of the fingers. The blood vessel stump is ligated, the broken phalange or joint is dissociated, the toe is completely disintegrated, and the toe stump is sutured.

Transplantation The wound surface of the transplanted toe is repaired to make the length and size appropriate. Kirschner wires with a diameter of 0.8–1.0 mm are used for crossover and longitudinal fixation, or steel wires with a diameter of 0.4 mm are used for crossover fixation. The extensor tendon is sutured with nylon thread. Modified Kessler suture is used to suture the flexor digitorum profundus tendon. Under microscope, anastomosis is performed on bilateral proper nerves, veins, and arteries. Postoperative Treatment (a) Postoperative intensive nursing and heat preservation; (b) Blood volume should be maintained and “three anti” therapy is performed; (c) Do not get out of bed within 1 week after the operation; (d) Smoking is prohibited during the perioperative period.

11.3.4 Operation Characteristics Type III defect of finger is a good indication for second toe transplantation. Because the second toe is removed without involving the metatarsal and transverse ligaments, there is little damage to the foot function.

11.3.5 Announcements (a) Because of the difference in the distribution of blood vessels and nerves between fingers and toes, the blood vessels and nerves in donor and recipient sites should be kept to a certain length to facilitate the matching of the anastomotic site; (b) Most of the blood vessels are small and require higher microscopic technique; (c) Most flexor digitorum profundus tendons are obviously retracted during elective operation, requiring longer flexor digitorum tendons or tendon transposition; (d) There are obvious differences in the shape of toes and fingers, which can be repaired in second stage or modified reconstruction (see the section of modified reconstruction).

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11 Reconstruction of Single Finger Defects

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Fig. 11.11 Reconstruction of type III defect of the right index finger by the free second toe transplantation. (a) Preoperative condition of the finger defect. (b) Remove the second toe. (c) Palmar view of the reconstructed finger. (d) Palmar view of the reconstructed finger 11 months

after the operation. (e) Dorsal view of the reconstructed finger 11 months after the operation. (f) Function of the reconstructed finger 11 months after the operation

11.3.6 Case Description

examination: He was in good general condition, with stable vital signs, middle and distal segment of the right index finger destroyed. The index finger was debrided and reconstructed by the left second toe transplantation under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.12).

Case 1 A 31-year-old male patient was admitted to hospital in emergency for 4 h due to pain and bleeding of the right index finger defect caused by machine injury. Physical examination: He was in good general condition, with stable vital signs, middle and distal segment of the right index finger destroyed. The index finger was debrided and reconstructed by the left second toe transplantation under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.11). Case 2 A 43-year-old male patient was admitted to hospital in emergency for 4 h due to pain and bleeding of the right index finger defect caused by machine injury. Physical

Case 3 A 34-year-old male patient was admitted to hospital in emergency for 4 h due to pain and bleeding of the right ring finger defect and the right middle finger injury caused by machine injury. Physical examination: He was in good general condition, with stable vital signs, the right ring finger destroyed from the middle segment. The right hand was debrided and the ring finger was reconstructed by the right second toe transplantation under general anesthesia in emer-

11.3 Reconstruction of Type III Defect

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Fig. 11.12 Reconstruction of type III defect of the right index finger by the free second toe transplantation. (a) Preoperative condition of the finger defect. (b) Remove the second toe. (c) Transplantation of the second toe. (d) Condition of the reconstructed finger 7 days after the operation. (e) Condition of the reconstructed finger 7 days after the

operation. (f) Appearance of the donor site 15 months after the operation. (g) Palmar view of the reconstructed finger 15 months after the operation. (h) Dorsal view of the reconstructed finger 15 months after the operation. (i) Function of the reconstructed finger 15 months after the operation

gency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.13).

good general condition, with stable vital signs, the right index finger destroyed from the middle segment. The index finger was reconstructed by the right second toe transplantation under general anesthesia electively, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.14).

Case 4 A 28-year-old male patient was admitted to hospital for more than 2 years due to the right index finger defect caused by heavy object. Physical examination: He was in

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11 Reconstruction of Single Finger Defects

a

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Fig. 11.13 Reconstruction of type III defect of the right ring finger by the free second toe transplantation. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect.

(c) Remove the second toe. (d) Transplantation of the second toe. (e) Transplantation of the second toe. (f) The condition of the reconstructed finger

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b

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Fig. 11.14 Reconstruction of type III defect of the right index finger by the free second toe transplantation. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger

defect. (c) Preoperative design. (d) Remove the second toe. (e) Transplantation of the second toe. (f) Condition of the reconstructed finger

11.4 Reconstruction of Type IV Defect

11.4 Reconstruction of Type IV Defect Type IV defect loses more than 80% of the function of the finger, and the loss of hand function is different in different fingers. The method for finger reconstruction is similar to that for type III defect but requires the proximal interphalangeal joint (PIP) reconstruction.

11.4.1 Indications (1) Type IV defect of the finger; (2) The patient is young and has a strong desire for reconstruction; (3) The patient has no basic disease and there is no obvious deformity of the donor toe.

11.4.2 Surgical Design The ipsilateral or contralateral second toe could be selected to reconstruct the length and shape of the finger, also part of flexion and extension function according to the degree of finger defect.

11.4.3 Surgical Method reparaion for the Recipient Site P In case of emergency operation, a complete debridement of the injured finger should be performed first to remove the contaminated, contusion and deactivated tissue, and a large amount of normal saline should be used to flush the wound, and then disinfect and lay the sheet again. The extensor digitorum tendon, flexor digitorum profundus tendon, bilateral proper digital nerves and arteries, and 2–5 veins are explored and marked for use. Then debridement and irrigation are performed again under surgical microscope to make the wound surface in the recipient site meet or close to the standard of class I incision. If selected, the scar tissue of the stump should be removed, and the broken bone should be treated with fresh treatment. Proximal flexor tendons are explored and marked, and bilateral digital arteries, nerves, and veins are dissociated under microscope. he Cutting of the Toe T The incision line is drawn on the donor toe according to the shape and length of the finger defect. The dorsal skin of the toe is first cut along the incision line to expose the veins, and

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2–3 veins for anastomosis are dissociated, and then cut off at an appropriate length. Then the plantar skin is cut open, and one or two veins for anastomosis are dissociated and marked. The bilateral proper arteries, nerves, and flexor tendons are dissociated, and cut off according to the degree of defect of the fingers. The blood vessel stump is ligated, the broken phalange or joint is dissociated, the toe is completely disintegrated, and the toe stump is sutured.

Transplantation The wound surface of the transplanted toe is repaired to make the length and size appropriate. Kirschner wires with a diameter of 0.8–1.0 mm are used for crossover and longitudinal fixation, or steel wires with a diameter of 0.4 mm are used for crossover fixation. The extensor tendon is sutured with nylon thread in figure 8 method. Modified Kessler suture is used to suture the flexor digitorum profundus tendon. Under microscope, anastomosis is performed on bilateral proper nerves, veins, and arteries. Postoperative Treatment (a) Postoperative intensive nursing and heat preservation; (b) Blood volume should be maintained and “three anti” therapy is performed; (c) Do not get out of bed within 1 week after the operation; (d) Smoking is prohibited during the perioperative period.

11.4.4 Operation Characteristics Type IV defect is a good indication for second toe transplantation, which needs to be removed near the proximal interphalangeal joint; the function of the foot is relatively damaged.

11.4.5 Announcements (a) Because of the difference in the distribution of blood vessels and nerves between fingers and toes, the blood vessels and nerves in donor and recipient sites should be kept to a certain length to facilitate the matching of the anastomotic site; (b) Most of the blood vessels are small and require higher microscopic technique; (c) Most flexor digitorum profundus tendons are obviously retracted during elective operation, requiring longer flexor digitorum tendons or tendon transposition; (d) There are obvious differences in the shape of toes and fingers.

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11 Reconstruction of Single Finger Defects

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Fig. 11.15 Reconstruction of type IV defect of the right middle finger by the free second toe transplantation. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect. (c) Remove the second toe. (d) Transplantation of the second toe. (e) Condition of the reconstructed finger. (f) Condition of the

reconstructed finger. (g) Appearance of the reconstructed finger 10 months after the operation. (h) Appearance of the reconstructed finger 10 months after the operation. (i) Function of the reconstructed finger 10 months after the operation

11.4.6 Case Description

The efficacy was satisfactory and the donor site healed in first stage (Fig. 11.15).

Case 1 A 29-year-old male patient was admitted to hospital for more than 1 year due to the right middle finger defect caused by machine injury. Physical examination: He was in good general condition, with stable vital signs, the right middle finger destroyed from the proximal interphalangeal joint, and the stump healed well. The index finger was reconstructed by the right second toe transplantation under general anesthesia electively, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully.

Case 2 A 41-year-old female patient was admitted to hospital in emergency for 3 h due to pain and bleeding of the right index and middle fingers caused by machine injury. Physical examination: She was in good general condition, with stable vital signs, the right index finger destroyed from the proximal interphalangeal joint, and the skin defect and tendon exposed in the middle and distal phalanx of the right middle finger. The right hand was debrided and the index finger was reconstructed by the right second toe transplantation and the middle finger repaired by reverse digital artery island flap under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked

11.5 Reconstruction of Type V Defect

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Fig. 11.16 Reconstruction of type IV defect of the right index finger by the free second toe transplantation. (a) Preoperative condition of the finger defect. (b) Remove the second toe. (c) Transplantation of the second toe. (d) Repair the middle finger. (e) Condition of the reconstructed finger. (f) Dorsal view of the reconstructed finger 13 months

after the operation. (g) Palmar view of the reconstructed finger 13 months after the operation. (h) Function of the reconstructed finger 13 months after the operation. (i) Situation of the donor site 13 months after the operation

and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory and the donor site healed in first stage (Fig. 11.16).

stump length. If the injured finger is short and the stump of the proximal finger is long, while the length of the second toe can meet the needs of reconstruction, the finger can be reconstructed according to type IV defect. On the another situation that the injured finger is long and the stump of the proximal finger is short, while the length of the second toe cannot meet the needs of reconstruction, bone graft should be considered to reconstruct the length.

11.5 Reconstruction of Type V Defect Type V defect of the finger would lose most or all of the function of the finger, according to the degree of different finger defects, functional effects and the requirements of the patient, operation should be carefully selected. For operation, the range of type V defect is large, and the operation plan should be selected according to different finger and

11.5.1 Indications (1) Type V defect of the finger; (2) The patient is young and has a strong desire for reconstruction; (3) The patient has no basic disease and there is no obvious deformity of the donor toe.

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11.5.2 Surgical Design Different methods should be selected according to the length of the second toe and the residual length of injured finger. If the length of the second toe can meet the needs of reconstruction, choose the reconstruction method for type IV defect. If the length of the second toe is not sufficient for reconstruction, iliac bone grafts could be used.

11.5.3 Surgical Method reparaion for the Recipient Site P In case of emergency operation, a complete debridement of the injured finger should be performed first to remove the contaminated, contusion and deactivated tissue, and a large amount of normal saline should be used to flush the wound, and then disinfect and lay the sheet again. The extensor digitorum tendon, flexor digitorum profundus tendon, bilateral proper digital nerves and arteries, and 2–5 veins are explored and marked for use. Then debridement and irrigation are performed again under surgical microscope to make the wound surface in the recipient site meet or close to the standard of class I incision. If selected, the scar tissue of the stump should be removed, and the broken bone should be treated with fresh treatment. Proximal flexor tendons are explored and marked, and bilateral digital arteries, nerves, and veins are dissociated under microscope. he Cutting of the Toe T If the length of the second toe can meet the needs of reconstruction, cut it according to type IV defect. If the length of the second toe cannot be satisfied, the dorsal flap of the foot should be carried and cut according to the method of type V defect of the thumb. Transplantation The wound surface of the transplanted toe is repaired to make the length and size appropriate. Kirschner wires with a diameter of 0.8–1.0 mm are used for crossover and longitudinal fixation, or steel wires with a diameter of 0.4 mm are

11 Reconstruction of Single Finger Defects

used for crossover fixation. The extensor tendon is sutured with nylon thread in figure 8 method. Modified Kessler suture is used to suture the flexor digitorum profundus tendon. Under microscope, anastomosis is performed on bilateral proper nerves, veins, and arteries.

Postoperative Treatment (a) Postoperative intensive nursing and heat preservation; (b) Blood volume should be maintained and “three anti” therapy is performed; (c) Do not get out of bed within 1 week after the operation; (d) Smoking is prohibited during the perioperative period.

11.5.4 Operation Characteristics The proximal segment of the finger is long, and the range of type V defect of the finger is large, accounting for about half of the finger. Therefore, the surgical plan should be determined according to the length of the residual stump.

11.5.5 Announcements (a) Because of the difference in the distribution of blood vessels and nerves between fingers and toes, the blood vessels and nerves in donor and recipient sites should be kept to a certain length to facilitate the matching of the anastomotic site; (b) Most of the blood vessels are small and require higher microscopic technique; (c) Most flexor digitorum profundus tendons are obviously retracted during elective operation, requiring longer flexor digitorum tendons or tendon transposition; (d) There are obvious differences in the shape of toes and fingers.

11.5.6 Case Description Case 1 A 35-year-old female patient was admitted to hospital for more than 1 year due to the right index finger defect caused by heavy object. Physical examination: She was in good general condition, with stable vital signs, the right

11.5 Reconstruction of Type V Defect

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Fig. 11.17 Reconstruction of type V defect of the right index finger by the free second toe transplantation. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect.

(c) Remove the second toe. (d) Palmar view of the reconstructed finger 6 months after the operation. (e) Dorsal view of the reconstructed finger 6 months after the operation

index finger destroyed from middle plane of the proximal interphalangeal and the stump healed well. The index finger was reconstructed by the left second toe transplantation under general anesthesia electively, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory and the donor site healed in first stage (Fig. 11.17).

was in good general condition, with stable vital signs, type V defect of the right middle, ring and little fingers, irregular skin of the stump, exposed bone, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the middle and ring fingers were reconstructed by the bilateral second toes transplantation and the little finger was performed stump repair under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed fingers survived successfully. The efficacy was satisfactory (Fig. 11.18).

Case 2 A 26-year-old female patient was admitted to hospital in emergency for 3 h due to pain and bleeding of the right middle, ring and little fingers defect caused by injection molding machine crush injury. Physical examination: She

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Fig. 11.18 Reconstruction of type V defect of the right middle and ring fingers by the free second toes transplantation. (a) Preoperative palmar condition of the fingers defect. (b) Preoperative dorsal condition of the fingers defect. (c) Preoperative X-ray. (d) Preoperative design (dorsal side). (e) Preoperative design (plantar side). (f) Preoperative design. (g) Phalanx formation with free iliac bone. (h) Dissociation of the medial plantar flap. (i) Transposition of the medial plantar flap. (j) Transposition of the medial plantar flap to repair the

little finger. (k) Direct suture of the flap donor site. (l) Condition of the donor sites. (m) Palmar view of the reconstructed fingers 60 months after the operation. (n) Dorsal view of the reconstructed fingers 60 months after the operation. (o) Lateral view of the reconstructed fingers 60 months after the operation. (p) Function of the reconstructed fingers 60 months after the operation. (q) Situation of the donor sites 60 months after the operation. (r) Situation of the donor site of the medial plantar side of the right foot

11.6 Reconstruction of Type VI Defect

11.6 Reconstruction of Type VI Defect Type VI defect is the absence of metacarpophalangeal joint area, and its reconstruction effect is relatively poor. Whether to reconstruct is still controversial. The reasons are many: the movement direction of the metatarsophalangeal joint and metacarpophalangeal joint are not consistent; the toes are significantly shorter than the fingers; the cutting of metatarsal bone may affect the function of the foot; the malfunction of the reconstructed fingers may affect the function of the normal fingers; and the difference of appearance is great.

11.6.1 Indications (1) Type VI effect of the finger; (2) The patient is young and has a strong desire for reconstruction.

11.6.2 Surgical Design The ipsilateral second toe is cut off to carry the metatarsophalangeal joint and part of the metatarsal bone. Whether to carry the dorsal flap is decided by the condition of the residual finger.

11.6.3 Surgical Method reparation for the Recipient Site P Preoperative accurate measurement of the length of the finger defect, whether there is soft tissue defect and the range. Complete debridement should be performed during the operation to remove all necrotic tissue and trim the metacarpal stump. If the second or third finger is reconstructed, the radial artery and accompanying veins, cephalic vein, superficial branch of radial nerve, and proper nerve should be exposed for use. If the fourth or fifth finger is reconstructed, the ulnar artery and accompanying vein, dorsal vein of hand, dorsal branch of the ulnar nerve, and proper nerve should be exposed for use. he Cutting of the Toe T If the second or third finger is reconstructed, the ipsilateral second toe is removed. If the fourth or fifth finger is reconstructed, the contralateral second toe is removed. The method is the same as before. Transplantation The wound surface of the transplanted toe is repaired to make the length and size appropriate. Kirschner wires with a diameter of 0.8–1.0 mm are used for crossover and longitudinal fixation, or steel wires with a diameter of 0.4 mm are used for crossover fixation. The extensor tendon is sutured with nylon thread in figure 8 method. Modified Kessler suture is used to suture the flexor digitorum profundus tendon. Under microscope, anastomosis is performed on bilateral proper nerves, veins, and arteries.

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Postoperative Treatment (a) Postoperative intensive nursing and heat preservation; (b) Blood volume should be maintained and “three anti” therapy is performed; (c) Do not get out of bed within 1 week after the operation; (d) Smoking is prohibited during the perioperative period.

11.6.4 Operation Characteristics The proximal segment of the finger is longer, type VI defect refers to a larger range, higher functional requirements, reconstruction of the finger both in terms of length, or the number of joints are more complex, and the difficulty is relatively higher.

11.6.5 Announcements (a) Because of the difference in the distribution of blood vessels and nerves between fingers and toes, the blood vessels and nerves in donor and recipient sites should be kept to a certain length to facilitate the matching of the anastomotic site; (b) Most of the blood vessels are small and require higher microscopic technique; (c) Most flexor digitorum profundus tendons are obviously retracted during elective operation, requiring longer flexor digitorum tendons or tendon transposition; (d) There are obvious differences in the shape of toes and fingers; (e) Previous satisfaction rate is low which needs to explain to the patient in detail.

11.6.6 Case Description Case 1 A 36-year-old female patient was admitted to hospital in emergency for 2.5 h due to pain and bleeding of the second to fifth fingers defect caused by injection molding machine crush injury. Physical examination: She was in good general condition, with stable vital signs, type VI defect of the right second to fifth fingers, irregular skin of the stump, exposed bone, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the index finger was reconstructed by the right second toe transplantation and forearm dorso-ulnar flap was designed and repaired the rest defect under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 11.19).

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Fig. 11.19 Reconstruction of type VI defect of the right index finger by the free second toe transplantation. (a) Preoperative palmar condition of the fingers defect. (b) Preoperative dorsal condition of the fingers defect. (c) Preoperative design (dorsal side). (d) Preoperative design of the flap. (e) Preoperative design (plantar side). (f) Dissociation of the toe. (g) Phalanx formation with free iliac bone. (h) Design of the forearm dorso-ulnar flap. (i) Dissociation of the forearm dorso-ulnar flap. (j) Transposition of the forearm dorso-ulnar flap. (k) Skin graft in

the donor site of the forearm dorso-ulnar flap. (l) Condition of the donor foot. (m) Condition of the donor foot. (n) Palmar view of the reconstructed fingers 24 months after the operation. (o) Dorsal view of the reconstructed finger 24 months after the operation. (p) Flexor function of the reconstructed finger 24 months after the operation. (q) Holding function of the reconstructed finger 24 months after the operation. (r) Holding function of the reconstructed finger 24 months after the operation

Reconstruction of Multi-Finger Defects

Abstract

Multiple finger reconstruction is the operation refers to two or more fingers defect caused by a variety of reasons in people’s daily life. In order to maximize the recovery of the function and appearance of the injured hand, doctors use microscopes and microsurgical instruments to carry out vascular, nerve anastomosis, and other operations on the patient’s own toe transplantation to reconstruct and restore the original tissue anatomical structure and function. Reconstruction of multi-finger defects is still a difficult point in hand surgery, and its treatment is controversial. Two key issues need to be considered: First, the reconstruction of partial function of the hand and second, avoid damage to foot function. The aim of the reconstruction of multi-finger defect should be to reconstruct the pinching function, and not to pursue the quantity and ideal appearance of the reconstructed finger. The more proximal the plane of toe transplantation and the greater the number of toe grafts, the greater the influence on the function of the foot, which requires careful selection. The classic method of reconstruction of two fingers with the second toe of both feet and tissue flap in this chapter, which can not only rebuild part of the hand function, but also have little effect on the function of the donor site. Keywords

Finger reconstruction · Multi-finger defect

12.1 Indications (a) Multi-finger defect, but the condition of nerves, blood vessels, and forearm muscle is good; (b) the patient is young who has a strong desire for reconstruction and a psychological recognition of the appearance of the reconstructed fingers; (c) the appearance and function of the donor toes are complete.

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12.2 Surgical Design The aim of the reconstruction scheme is to rebuild the function of the hand and reduce the damage to the function of the donor foot. The principle should be “less but better” instead of “more and better”. In the case of 1–5 fingers defect, except the thumb, the middle finger or ring finger is usually selected as the another reconstructed finger; if 2–5 fingers defect is in the same plane, the middle and ring fingers should be reconstructed; The index, middle finger or ring and little finger defect can be reconstructed at the same time; type VI finger defect, resulting in any 2–3 fingers defects, is not recommended for reconstruction. If 2–5 fingers defected at the same time, only the second toe with metatarsophalangeal joint should be selected for reconstruction of 1–2 fingers, while the second and third toes with metatarsophalangeal joint should not be cut at the same time for reconstruction. From a functional point of view, the donor toe should be placed on the finger where the metacarpophalangeal joint is residual, which can prevent excessive toe cutting.

12.3 Surgical Method 12.3.1 Preparation for the Recipient Site For multi-finger reconstruction operation, the injury of the donor site should be minimized to prevent the damage of the foot function and avoid affecting the walking function. A complete debridement should be performed on the affected hand and fingers, that the extensor and flexor tendons, digital nerves, and the blood vessels should be dissociated, respectively. The phalanx plane should be trimmed. The condition of the blood vessels in the recipient site after debridement should be judged, at the same time the required length, diameter, and subcutaneous path of the blood vessels for anastomosis should be confirmed. Two arteries and two to four veins should be prepared for each

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reconstructed finger. In the dissociation of the donor toe and tissue flap, sharp separation of neurovascular bundles and tendons is used to avoid carrying too much unneeded soft tissue. Pay attention to protect the intermetatarsal ligament and the treatment of nerve stump; for patients with dorsal foot wounds, full thickness skin grafts or flaps should be used as far as possible to minimize damage to the donor site.

12.3.2 The Cutting of the Toe According to the needs of the wound in the recipient site to choose whether to carry dorsal foot flap. Design the incisions along the bilateral second toe; first of all dissociate foot vein from distal to proximal, then cut off and ligate the unrelated veins of the second toe, but keep the continuity of the dorsal vein of the second toe, dorsal metatarsal vein, dorsal venous arc of foot, and great saphenous vein, cut off and ligate the unrelated branches of great saphenous vein until the ankle. When carrying dorsal flap dissociate the artery from distal to proximal. The dorsal artery of foot could be found between the extensor hallucis longus tendon and the extensor digitorum longus tendon, along which cut open the tube sheath and cut off the extensor hallucis longus tendon, along the way, to cut off and ligate the anterior lateral malleolus artery, the anterior medial malleolus artery, the lateral tarsal artery, and the medial tarsal artery. The companying vein of the deep plantar branch should be carefully dissociated and ligated. The first dorsal metatarsal artery, the common digital artery of toe, the tibial dorsal digital artery, and the plantar digital artery of the second toe are dissociated. The other branches of the first dorsal metatarsal artery dividing into the tibial side of the second toe should be reserved to ensure sufficient blood supply for the second toe. When the “V-shaped” plantar flap is lifted, the plantar digital nerve of the second toe could be found on both sides, along which the common nerves of the first and second toe should be carefully and bluntly dissociated, that is cut off at a high position and marked. If the dorsal flap is not needed, the common digital nerve and artery, the tibial dorsal digital nerve, and the plantar digital nerve and artery can be dissociated directly at the webs on both sides of the second toe. The extensor longus and brevis tendons of the second toe should be sharply separated at the dorsum of the foot and are cut off at a high position, at the same time some peri-tendon tissues are retained. The flexor digitorum tendon sheath is cut open, and the flexor digitorum longus tendon and flexor digitorum brevis tendon should be cut at a high position according to the residual condition of flexor digital tendons in the recipient site. Then remove the toe in different plane according to the length of the reconstructed finger.

12 Reconstruction of Multi-Finger Defects

12.3.3 Transplantation Internal fixation with Kirschner wire is used for bone fixation of the reconstructed finger. If the metatarsophalangeal joint is needed to be carried, the plantar plate should be sutured with the periosteum to prevent hyperextension of the metatarsophalangeal joint. During bone and joint fixation, the opponens function of the reconstructed thumb should be paid attention to before fixation. The extensor and flexor tendons are repaired with 2/0 nylon single thread. Adjust the tension of extensor and flexor tendons to prevent the flexion deformity of the reconstructed finger. Two flexor tendons would be sutured to the insertion of the lumbrical muscle of the second toe to reconstruct the function of the lumbrical muscle. The blood vessels and nerves are anastomosed under a microscope.

12.3.4 Postoperative Treatment (a) The operation of multi-finger reconstruction takes a longer time and has greater trauma, so the whole body condition and vital signs should keep stable after the operation; (b) Postoperative routine heat preservation and “three anti” treatment should be carried out; (c) In addition to reasonable immobilization after surgery, physical therapy should be carried out as soon as possible, that could be supplemented by functional rehabilitation exercise, to promote subsidence of swelling and prevent tendon adhesion and joint rigidity.

12.4 Operation Characteristics The characteristics of operative methods are flexible, and individual treatment plan needs to be formulated according to the actual conditions of each patient.

12.4.1 Announcements (a) Close postoperative observation, timely treatment of vascular crisis; (b) Preoperative routine imaging examinations should be used to examine the caliber, depth, and hemodynamic indexes of dorsal artery of foot and the first dorsal metatarsal artery, to help design the surgical plan and guide the intraoperative operation; (c) For elective surgery cases, the operation must be performed after the hand swelling has subsided, so as to avoid vascular pedicle compression caused by postoperative swelling; (d) Non-invasive operation to avoid vascular pedicle injury; (e) The blood supply of foot tissue flaps is independent to avoid chain reaction after vascular crisis. High-quality vascular anastomosis is required; (f) Pay attention to postoperative rehabilitation.

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12.4.2 Case Description Case 1 A 39-year-old male patient was admitted to hospital for more than 2 months due to the second to fifth fingers defect of the left hand caused by the machine injury. Physical examination: He was in good general condition, with stable vital signs, the second to fifth fingers defect from the metacarpophalangeal joints. The index finger and the middle finger were reconstructed by the left second and third toes transplantation electively and the donor site was sutured directly. The operation was successful; after the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed fingers survived successfully. The efficacy was satisfactory (Fig. 12.1). Case 2 A 43-year-old male patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the right first to fifth fingers defect caused by injection molding machine crush injury. Physical examination: He was in good general condition, with stable vital signs, type IV defect of the thumb and type V defect of the second to fifth fingers, irregular skin of the stump, exposed bone, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by the left great toe nail flap

and the middle and ring fingers were reconstructed by the free right second and third toes transplantation under general anesthesia in emergency, and the donor site was sutured directly. The operation was successful; after the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 12.2). Case 3 A 23-year-old male patient was admitted to hospital in emergency for 1 h due to pain and bleeding of the right index and middle fingers defect caused by punch press injury. Physical examination: She was in good general condition, with stable vital signs, type V defect of the index and middle fingers, irregular skin of the stump, exposed bone, active bleeding, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the index and middle fingers were reconstructed by the bilateral second toes transplantation under general anesthesia in emergency, and the donor sites were sutured directly. The operation was successful; after the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 12.3).

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Fig. 12.1 Reconstruction of the left index and middle fingers by the free second and third toes transplantation. (a) Preoperative condition of the fingers defect. (b) Preoperative condition of the fingers defect. (c)

Preoperative design. (d) Remove the toes. (e) The condition of the reconstructed fingers. (f) The condition of the donor site

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Fig. 12.2 Reconstruction of the right middle and ring fingers by the free second and third toes transplantation. (a) Preoperative palmar condition of the fingers defect. (b) Preoperative dorsal condition of the fingers defect. (c) Preoperative X-ray. (d) Preoperative design (dorsal side). (e) Preoperative design (plantar side). (f) Dissociation of the toes. (g) Palmar view of the reconstructed fingers. (h) Dorsal view of the reconstructed fingers. (i) Palmar view of the reconstructed fingers 3

years after the operation. (j) Dorsal view of the reconstructed fingers 3 years after the operation. (k) View of the first finger web 3 years after the operation. (l) Holding function of the reconstructed fingers 3 years after the operation. (m) Study function of the reconstructed fingers 3 years after the operation. (n) Appearance of the left donor site 3 years after the operation. (o) Appearance of the right donor site 3 years after the operation

12.4 Operation Characteristics

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Fig. 12.3 Reconstruction of the right index and middle fingers by the free bilateral second toes transplantation. (a) Preoperative condition of the fingers defect. (b) Preoperative X-ray. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) Dissociation of the right second toe. (f) Dissociation of the left second toe. (g) Palmar view of the reconstructed fingers after the operation. (h) Dorsal view of the reconstructed fingers after the operation. (i) Palmar view of the recon-

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structed fingers 2 years after the operation. (j) Dorsal view of the reconstructed fingers 2 years after the operation. (k) Holding function of the reconstructed index finger 2 years after the operation. (l) Holding function of the reconstructed middle finger 2 years after the operation. (m) Dorsal view of the donor sites 2 years after the operation. (n) Plantar view of the donor sites 2 years after the operation. (o) Appearance of the donor sites and recipient sites 2 years after the operation

Reconstruction of Finger Joint Defects

Abstract

Hand joint injury is a common injury type while its clinical treatment has always been one of the difficult problems in hand surgery, and is also a more intractable problem in repair and reconstruction surgery. There are options for joint fusion and artificial joint replacement to repair the damaged joints, but the effect is not very ideal. Among the joints of the hand, the range of motion of metacarpophalangeal joints has the greatest influence on the hand function, and the proximal interphalangeal joints of the second to fifth fingers are also the main mobile joints of the hand. After joint injury, if arthrodesis is performed, part of the function of the hand will be certainly lost, resulting in poor strength, range of motion, and joint stability of the injured finger. In recent years, according to different types of finger joint injury, tissue homology, and functional similarity, different methods of second toe transplantation connected with interphalangeal joint have been used to treat finger joint defect while its clinical feasibility and effectiveness have been explored. Single finger joint reconstruction is most common in clinic. The single finger joint defect caused by various reasons is common that would lose flexion and extension function of the finger, which affects the play of hand function. Interphalangeal joint transplantation is a special application of toe transplantation, which fits the principle of supplying the shortage. At present, the most common method is to reconstruct the finger joint defect by transplanting the proximal interphalangeal joint of the second toe. Keywords

Finger reconstruction · finger joint defect

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13.1 Indications (a) Partial or total interphalangeal joint defect of hand; (b) single finger joint damage caused by various diseases; (c) the patient is young who has no vascular disease and has high requirement of hand function; (d) the length of the finger is seriously shortened after the interphalangeal joint is fused and the effect is not good; (f) there is no obvious deformity of the donor toe.

13.2 Surgical Design Surgical design follows the principle of supplying the shortage. The length of the finger joint defect and the size of the combined defect of the finger should be carefully measured before operation, and the range of the donor toe should be accurately designed.

13.3 Surgical Method 13.3.1 Preparation for the Recipient Site The wound in the recipient site should be debrided completely to remove necrotic, seriously polluted, and inactivated tissues. Try to preserve as much skin and soft tissue as possible to make the appearance full and close to the original after repair. For all those hemiarticular defects, the residual articular surface should be nibbled away to prepare for total joint graft. The blood vessels, nerves, and tendons of the finger should be dissociated and marked for later use. To evaluate the blood supply status of the distal part of the finger and

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preserve the necessary blood supplying artery and soft tissue that would prevent the ischemia of the finger. Measure the length of the bone and joint defect, joint position, and required length of the tendons, blood vessels, and nerves.

13.3.2 The Cutting of the Toe Design the proximal interphalangeal joint of the second toe according to the length of the bone joint needed for the defect. Mark the level of dissociation on the skin surface, and the second toe is cut in the same way as the conventional method. When dissociating the dorsal and plantar digitorum arteries of one side of the toe, attention should be paid to the protection of the joint capsule branch entering the interphalangeal joint, and the condylar branch and metaphyseal branch supplying the proximal phalangeal bone, middle phalangeal bone, and epiphysis.

13.3.3 Transplantation Cross wire internal fixation or Kirschner wire fixation can be used for osteoarticular operation. Then suture the tendons. Then, under the microscope, the dorsal and plantar digitorum arteries and nerves are anastomosed with the corresponding digital arteries and nerves, respectively, and the dorsal digitorum vein is anastomosed with the dorsal digital vein.

13.3.4 Postoperative Treatment (a) Intensive nursing and heat preservation should be performed routinely after the operation; (b) “three anti” therapy should be performed after the operation; (c) the blood supply of the flap should be observed regularly after the operation. If there is vascular crisis, timely treatment or exploration should be conducted.

13.4 Operation Characteristics (a) To repair the interphalangeal joint of the fingers by the interphalangeal joint of the toes transplantation; (b) the cutting of the toe did not involve the metatarsophalangeal joint and the transverse ligament as far as possible; (c) the blood supply of the finger should be carefully evaluated before operation, and the blood supply of the distal part of the finger must be retained intraoperatively to prevent the distal necrosis.

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13.5 Announcements (a) Bone fixation should not only be firm and reliable, but also conducive to early functional exercise after the operation. Cross wire fixation is recommended; (b) Since the condylar and metaphyseal branches that supply the proximal phalanges and the distal phalanges are all distributed within the distance of 0.5 cm from the joint, the distance of 0.5 cm from the donor joint should be avoided when the joint is removed, so as to avoid damaging these branches; (c) When bone defect in the recipient site is relatively larger and longer phalangeal bone is needed, special attention should be paid to prevent the separation of skin and bone joints during the operation to avoid affecting the blood supply; (d) Intraoperative movements should be gentle and delicate to prevent vascular pulling and damage; (e) The peripheral blood supply of the transplanted tissue and the affected finger should be observed while the occurrence of vascular crisis should be dealt within time after the operation; (f) Pay attention to early rehabilitation exercise which is helpful for improving joint function.

13.6 Case Description Case 1 A 45-year-old male patient was admitted to hospital for more than 7 months due to bone exposure of the right index finger with movement limitation. Physical examination: He was in good general condition, with stable vital signs, about 1.0 × 0.8 cm soft tissue defect on the dorsal side of the proximal interphalangeal joint of the index finger with bone exposure. The proximal interphalangeal joint was reconstructed by the interphalangeal joint of the second toe of the left foot combined with composite flap under general anesthesia selectively, and the donor site was sutured directly. The operation was successful, and he returned to the ward safely. Routine reconstruction treatment was given after the operation, and the reconstructed joint survived successfully and the donor site healed in the first stage. The efficacy was satisfactory (Fig. 13.1). Case 2 A 22-year-old female patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the left index finger defect caused by punch injury. Physical examination: She was in good general condition, with stable vital signs, composite tissue defect of the index finger, irregular skin of the stump, exposed bone, and active bleeding. And the other fingers were normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the index finger was reconstructed by the inter-

13.6 Case Description

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Fig. 13.1 Reconstruction of the interphalangeal joint defect of the right index finger by the interphalangeal joint of the second toe transplantation. (a) Preoperative condition of the defect. (b) Exposure of the interphalangeal joint of the finger. (c) Dissociation of the interphalan-

geal joint of the second toe. (d) X-ray after the operation. (e) Appearance of the reconstructed joint 8 months after the operation. (f) Function of the reconstructed joint 8 months after the operation

phalangeal joint of the second toe of the right foot combined with composite tissue flap and fibular flap of the great toe under general anesthesia in emergency, and the donor site was covered by transposition of the lateral tarsal flap. The operation was successful. After the tourniquet was relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Fourteen days after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 13.2).

reconstructed by the metacarpophalangeal joint of the second toe of the right foot combined with composite tissue flap and dorsal metatarsal flap under general anesthesia in emergency, and the donor site was covered by free skin graft. The operation was successful. After the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 13.3).

Case 3 A 41-year-old male patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the right first to third fingers caused by punch injury. Physical examination: He was in good general condition, with stable vital signs, soft tissue defect on the dorsal side of the first and second finger webs, metacarpophalangeal joint of the index finger defect, exposed bone, irregular skin of the stump, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the index finger and soft tissue defect of the thumb were

Case 4 A 47-year-old male patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the left thumb defect caused by milling machine injury. Physical examination: He was in good general condition, with stable vital signs, soft tissue and interphalangeal joint defect of the thumb, exposed bone and articular surface, irregular wound, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by the interphalangeal joint of the great toe of the right foot combined with composite tissue flap under general anesthesia in emergency, and the donor site was shortened and closed. The operation was successful. After the tourniquet was relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the

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Fig. 13.2 Reconstruction of joint defect of the left index finger by the interphalangeal joint of the second toe and composite tissue flap transplantation. (a) Preoperative palmar condition of the defect. (b) Preoperative dorsal condition of the defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Dissociation of the toe. (f) Dissociation of the flap. (g) Situation of the donor site after the operation. (h) Dorsal situa-

tion of the reconstructed finger after operation. (i) Palmar situation of the reconstructed finger after operation. (j) Postoperative X-ray. (k) Donor and recipient site 14 days after the operation. (l) Dorsal appearance of the reconstructed finger 14 months after the operation. (m) Palmar appearance of the reconstructed finger 14 months after the operation

13.6 Case Description

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Fig. 13.3 Reconstruction of the joint defect of the index finger by the metatarsophalangeal joint of the second toe and composite tissue flap transplantation. (a) Preoperative dorsal condition of the hand defect. (b) Preoperative palmar condition of the hand defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Remove the metatarsophalangeal joint. (f) Dissociation of the flap. (g) Reconstructed finger after the operation. (h) First finger web after the operation. (i) X-ray of the

reconstructed finger after the operation. (j) X-ray of the donor site after the operation. (k) Extensor function of the reconstructed finger 30 months after the operation. (l) Flexor function of the reconstructed finger 30 months after the operation. (m) Comparison of the left index finger and the reconstructed finger 30 months after the operation. (n) Appearance of the donor site 30 months after the operation

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13 Reconstruction of Finger Joint Defects

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Fig. 13.4 Reconstruction of the joint defect of the thumb by the interphalangeal joint of the great toe combined with composite tissue flap transplantation. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect. (c) Preoperative X-ray. (d) Preoperative design. (e) Dissociation of the blood vessels and nerves. (f) Dissociation of the composite tissue flap. (g) Dorsal view of

the reconstructed finger. (h) Palmar view of the reconstructed finger. (i) Palmar view of the reconstructed finger 3 months after the operation. (j) Nail appearance and extensor function of the reconstructed finger 15 months after the operation. (k) Flexor function of the reconstructed finger 15 months after the operation. (l) Situation of the donor site 15 months after the operation

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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 13.4).

and little fingers defect caused by punch injury. Physical examination: He was in good general condition, with stable vital signs, the ring finger defect from the middle plane of the proximal segment, exposed bone and articular surface, transverse wound at the proximal palmar print of the little finger, straight deformity, irregular wound, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were

Case 5 A 35-year-old male patient was admitted to hospital in emergency for 2 h due to pain and bleeding of the left ring

13.6 Case Description

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Fig. 13.5 Reconstruction of joint defect of the ring finger by the metatarsophalangeal joint of the second toe combined with composite tissue flap transplantation. (a) Preoperative condition of the finger defect. (b) Preoperative design. (c) Dissociation of the toe. (d) Palmar view of the reconstructed joint 1 week after the operation. (e) Dorsal view of the

reconstructed joint 1 week after the operation. (f) Palmar view of the reconstructed joint 40 months after the operation. (g) Dorsal view of the reconstructed joint 40 months after the operation. (h) Dorsal view of the reconstructed joint 40 months after the operation

excluded. After complete debridement, the ring finger was reconstructed by the metatarsophalangeal joint of the second toe of the right foot combined with composite tissue flap under general anesthesia in emergency, and the donor site was closed by stump repair. The operation was successful. After the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 13.5).

eral condition, with stable vital signs, composite tissue defect of the middle finger, exposed bone and articular surface, irregular wound, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the middle finger was reconstructed by the interphalangeal joint of the second toe of the right foot combined with composite tissue flap under general anesthesia in emergency, and the donor site was closed by stump repair. The operation was successful. After the tourniquet was relaxed, the reconstructed fingers 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 13.6).

Case 6 A 27-year-old male patient was admitted to hospital in emergency for 2.5 h due to composite tissue defect, pain and bleeding of the right middle finger caused by punch injury. Physical examination: He was in good gen-

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Fig. 13.6 Reconstruction of interphalangeal joint defect of the middle finger by the interphalangeal joint of the second toe combined with composite tissue flap transplantation. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design (dorsal side). (d) Preoperative design

(plantar side). (e) Dissociation of the blood vessels and nerves. (f) Palmar view of the reconstructed joint after the operation. (g) Dorsal view of the reconstructed joint after the operation. (h) Palmar view of the reconstructed joint 3 weeks after the operation. (i) Dorsal view of the reconstructed joint 3 weeks after the operation

Reconstruction of Nail Defects

Abstract

The tip of the finger is exposed to the farthest end of the limb, which is the most vulnerable to injury in labor and life. The traditional method is finger amputation, which often results in type I or type II defect; Such as the use of local flap, the length of finger body is retained, but the finger end is dry, the flap has no feeling, the dorsum of the finger is without fingernails that would cause a certain degree of disability. Because the function of the hand is special, in addition to labor and life, it is also an important organ of social activities and mutual communication just like the face. Therefore, the standard of the repair and reconstruction of thumb and finger defects should be improved correspondingly. Instead of simply repairing the wound surface, anatomical and physiological repair with consistent function and appearance should be pursued. In 1980, Morrison et al first applied the great toenail flap graft to repair the skin sleeve avulsion of the thumb successfully, and it has been widely used because it reappears the complete shape of the thumb. Traditionally, fingernail defect has no obvious effect on finger function that doesn’t need to be reconstructed. However, with the development of microsurgical technology, there is no problem with the technique of toenail transplantation to reconstruct the fingernail, and its surgical method and difficulty are similar to that of the fingertip reconstruction. Therefore, nail reconstruction is feasible for nail defect patients with high demand for finger aesthetics. The commonly used methods for nail defect reconstruction include: great toenail flap transplantation, half great toenail flap transplantation, second toenail flap transplantation, and other toenail flap transplantation. Generally speaking, great toenail flap is large, which has a great influence on great toe; The second toenail flap is small and the shape is poor after reconstruction. Half great toenail flap has relatively high technical requirements, better shape, and less injury. Specific plan should be selected according to the size of fingernail bed, soft tissue defect, and bone defect.

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Keywords

Finger reconstruction · Nail defect

14.1 Reconstruction of Nail Defect by Split-Thickness Toenail Bed Transplantation The fingernail bed defect is very common in clinic, and the reasons are various. The types and defect sizes caused by different causes are different, so it is necessary to select the appropriate surgical method according to the actual conditions of the injuries. In the past, due to the limitations of medical conditions, the nail bed defect was often repaired by shortening the phalanx or scarring. The former caused the incomplete end of the finger, which had a great impact on the function and appearance of the finger. The latter is prone to wound infection and residual nail deformity due to the longtime of dressing change after the operation. Later, skin flap transplantation was also used to treat nail bed defects, and the length of the finger body was effectively preserved, but the problem of missing nails still failed to be solved. With the development of microsurgical technology, nail reconstruction was realized. Before the toenail flap was used to repair the nail bed defect, some scholars proposed to directly transplant the nail bed to repair the damaged nail bed, but the regenerated nails were not smooth and had growth deformity after the operation. On this basis, Shepard proposed to remove the full thick nail bed and then transplant the nails, postoperative followup showed good growth and no deformity. Subsequently, some scholars used the split-thickness nail bed transplantation for the treatment of post-traumatic nail deformity, which also achieved good clinical effects. After that, the full- thickness nail bed transplantation was gradually eliminated in clinical practice, and the split-thickness nail bed transplantation has become a common surgical method to repair the fingernail bed defect.

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_14

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14.1.1 Indications (a) Patients who are with partial nail defect; (b) The germinal layer of the nail root is not damaged; (c) Patients who have a strong desire for reconstruction; (d) Patients who don’t have dermatophytosis or other nail-related disease.

14.1.2 Surgical Design

14 Reconstruction of Nail Defects

The lower limb is lift to inflate the, the nail plate should be removed, and the toenail bed is cut according to the defect area and shape of the nail bed and the thickness is about 0.6–0.8 mm (about 1/2–1/3 of the full thickness of the nail bed (Fig. 14.3). Loosen the tourniquet, transplant the free toenail bed to the recipient site, adjust the position, and prune appropriately according to the size of the wound in the recipient site, then suture it without tension (Fig. 14.4).

The recipient site: according to the patient’s fingernail condition, the wound is circularly cut to the normal nail bed margin (Fig. 14.1). The donor site: the incision should be designed according to the defect of nail bed after debridement.

14.1.3 Surgical Method The anesthesia methods are brachial plexus block combined with epidural anesthesia or general anesthesia. The tourniquet of the affected limb is raised to stop the bleeding. The wound is debrided completely according to the injury of the affected finger, and then the nail bed area of the donor site should be designed and cut according to the defect area of the nail bed after debridement (Fig. 14.2).

Fig. 14.2 The design for the donor nail

Fig. 14.1 Patial defect of the nail

Fig. 14.3 The dissection of the nail bed

14.2 Reconstruction of Nail Defect by Superficial Dermal Fascia Composite Tissue Transplantation

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14.1.6 Announcements

Fig. 14.4 Transplantation and suture

(a) During debridement, the periosteum of the exposed bone should be kept as far as possible to ensure the blood supply to the base of the transplanted nail bed, so as to improve the survival rate. (b) If the distal edge of the nail bed defect is the lower edge of the nail, the distal edge of the nail plate should be slightly higher than the lateral edge of the lower nail skin when suturing to avoid pain symptoms during future nail plate growth. (c) The operation should be performed under a magnifying glass or microscope to reduce suture tension in the nail bed and avoid rupture. (d) Choose the right donor toe and the range of removed toe nail should be accurate. The most commonly used donor toe is the great toe. The thickness of the nail bed is generally about 2.0 mm, and the thickness of the transplanted nail bed is 0.6–0.8 mm (1/2 of the thickness of the nail bed in the donor site). The size of the donor nail should be slightly larger than the edge of the defect area by 1.0 mm to facilitate tension-free suture. (e) For patients combined with phalanx fracture, the fracture can be reduced and fixed first, and then to repair the nail bed. In patients with bone defects and deformities, bone grafts are used to support the nail bed.

14.2 Reconstruction of Nail Defect by Superficial Dermal Fascia Composite (a) Intensive nursing, heat preservation should be performed Tissue Transplantation 14.1.4 Postoperative Treatment

routinely after the operation; (b) Three-anti therapy should be performed after the operation; (c) The blood supply of the flap should be observed regularly after the operation. If there is vascular crisis, timely treatment or exploration should be conducted.

14.1.5 Operation Characteristics (a) Free toenail bed transplantation which is without anastomosis of blood vessels and nerves, simple operation, with less postoperative complications. (b) The survival rate is high. Compared with full-thickness nail bed transplantation, it is thinner and easier to survive. (c) The injury of the donor site is small, because only the split-thickness nail bed is taken, and the whole toenail can still grow after the operation, which does not affect the donor site. (d) The appearance of the nail is not as good as that of toenail flap transplantation. (e) The thickness is different from the original nail bed which would affect the adhesion of the new nail.

Nail (also known as the nail plate) belongs to the attached tissue of the finger and has the barrier function, which can defend the finger from trauma damage, protect and maintain the stability of the finger pulp, enhance the tactile sensitivity of the finger pulp, and help the finger to do grasping, pinching, pressing and other actions. The nailbed is rich in nutrient blood supply, which can regulate the body temperature, the blood supply to the extremities, and the function of the nutrient nail plate. Once the nail bed is traumatized, the function and appearance of the finger may be seriously affected. With the great improvement of material life, people pay more and more attention to their own external beauty and have higher and higher requirements for the repair effect of nail defects. Clinically, we have been looking for a fingernail reconstruction method that can not only cover the wound and grow the nail, but also reduce the damage to the donor site and do not increase the burden of the patient. Reverse-free transplantation of superficial dermal fascia composite tissue for fingernail reconstruction has a satisfactory effect and has been widely used.

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14.2.1 Indications The defect of nail bed with intact nail matrix, no injury of phalanx, and good soft tissue in the palmar and distal end.

14.2.2 Surgical Design The recipient site: The circumferential resection should be carried out to the normal nail bed margin according to the patient's fingernail condition (Fig. 14.5). The donor site: a transverse incision is made on the medial side on the ipsilateral upper arm to facilitate the appearance after suture (Fig. 14.6).

14.2.3 Surgical Method Anesthesia: Brachial plexus anesthesia or general anesthesia should be selected. After the anesthesia is stable, the patient is placed in the supine position, and the affected side is driven by the tourniquet. First, the wound should be completely debrided.

14 Reconstruction of Nail Defects

Treatment of bone exposure: a 0.8 mm Kirschner wire is used to drill holes on the dorsal side of the distal phalanx. All the holes should be arranged into squares, and the distance of each hole is 0.8 mm. If accompanied by phalanx fracture, the fracture site, and its distal end are not suitable for drilling, so as not to cause local blood circulation disturbance, affecting bone healing and graft survival. To measure the range of fingernail loss, the skin of the same size on the proximal medial side of the upper arm of the patient is generally taken as donor site. A transverse incision is made according to the design. The epidermal layer of the skin is carefully removed with a sharp knife to expose the dermis, and the graft is removed along the subsuperficial fascia. The donor site can be sutured directly. The tissue structure of the donor should be reversed, with the superficial fascia layer on the top and the dermis layer on the bottom to bury the bone of the phalanx on the wound surface, and the donor is sutured intermittently with the skin on the wound edge. Vaseline gauze pieces or cotton balls wrapped with vaseline gauze are packed and compressed. Use 4-0 mush thread intermittent suture, should not suture too tight and dense, so as not to tear the tissue, affect the blood supply and the survival rate of composite tissue.

14.2.4 Operation Characteristics

Fig. 14.5 The situation of the nail defect and the appearance after debridement

(a) Convenient sampling: the whole body can be sampled, the method is simple, without special equipment or technology; (b) Less complications at the donor site: the donor site can be sutured directly, with fast healing and no obvious complications; (c) Multi-purpose of “one skin”: the split skin of removed skin can be used to cover the skin defect area; (d) It can avoid the scar healing after the nail bed defect, keep the length and appearance of the finger, and retain the integrity of the nail bed, without affecting the attachment ability of the nail body, and without obvious local tenderness. (e) Survival of the fascia layer restores the smooth surface of the nail bed and gives the nail a more realistic appearance.

14.2.5 Announcements

Fig. 14.6 The design for the incision of the donor site

(a) The bone surface of nail bed defect should be drilled to provide enough blood for nutrition and ensure dermal survival. (b) When removing the skin, the dermis should be of a certain thickness, which is equivalent to the thickness of the nail bed. If it is too thick, it is not easy to survive, or it may cause uneven nail growth.

14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation

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(c) When the dermis covers the defect area, it should be turned over and the Germanic layer should be outward to ensure close adhesion with the new nail and prevent the nail from separating. (d) After suture, a pressure package should be made to make the dermis closely adhere to the bone surface to ensure the survival of the dermis. (e) Reasonable use of antibiotics after the operation to prevent wound infection and tissue necrosis; (f) When the wound is infected or bleeding or hemoceles under the wrap, the suture should be removed immediately, the wrap should be opened, the cause should be checked and remedial treatment should be made in time. (g) Local immobilization of the affected limb, such as plaster external fixation, which is prohibited to remove at will to limit the movement of the affected finger.

nail defects or deformities. after the operation, it was found that the nail was successfully reconstructed, with no deformities in appearance and good functional recovery. In 2002, Chinese scholar Yuan Guanghai et al. designed a half toenail flap for half or partial defect of the fingernail bed, which had a good postoperative effect. The current clinical design for nail bed defects is a kind of miniature toenail flap including nail bed, blood vessels, and nerves, and its therapeutic effect has been widely recognized clinically.

14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation Nail is one of the important parts of the finger. The defect of the nail will affect the appearance and function of the finger. Repair and reconstruction of nail bed defects have always been a hot topic in the clinical work of hand surgeons. Just the wound repair is relatively simple. Various pedicled skin tubes, pedicled skin flaps, and adjacent finger flaps can be used to cover the wound surface in clinic, but that can only solve the problem of the wound surface, while the repair and reconstruction of the defect of the nail bed cannot meet the requirements of appearance and function. With the development of microsurgery, the clinical use of free toenail flap transplantation to reconstruct the defect of fingernails is satisfactory and has been a classic way of repair, which has been gradually miniaturization after continuous improvement and development. In 1988, Koshima designed a free toenail flap containing blood vessels and nerves on the basis of great toenail flap for Fig. 14.7 The defect of the nail and the design for the donor toe

14.3.1 Indications (a) Most or total (necrotic) defects in the fingernails; (b) Patients have a strong desire for reconstruction and a high requirement for the appearance of the finger; (c) The toenails are normal, and the blood vessels have no obvious deformity; (d) The optimal age is under 60 years old.

14.3.2 Surgical Design According to the size of the fingernail defect, to determine the removed toenail and range. For the reconstruction of thumbnail defect, the ipsilateral great toenail is usually used. For the reconstruction of other fingernails, the second toenail can be selected. In addition, according to the defect area and shape of the skin and nail on the dorsal side of the thumb or the other finger, the great toe or the second toe on the ipsilateral or opposite side combined with the dorsal nail flap can be designed to repair the corresponding thumb or fingernail defects on the dorsal side. Arteries: the first dorsal metatarsal artery—the fibular dorsal digitorum artery great toe or the tibial dorsal digitorum artery of the second toe; veins: dorsal digitorum vein—dorsal digitorum vein of the great toe; for nerve defects, dorsal branch of deep peroneal nerve of great toe can be grafted for repair (Fig. 14.7).

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14.3.3 Surgical Method reparation for the Recipient Site P To retain healthy tissue as far as possible while debridement is performed. Then emergency operation or scheduled transplantation 3–5 days later is selected according to the situation. The size and shape of the nail defect should be carefully measured before operation, and whether there is bone defect or skin defect. reparation for the Donor Site P Appropriate great toenail flaps, half-toenail flaps, and toenail flaps are designed according to the defect in the recipient site, and the donor site should be cleaned and prepared to ensure that transplanted tissue is without local infection and damage. he Cutting of the Toe (Take the Toenail Flap T of the Great Toe for Example) The skin and subcutaneous incision are made on the fibular side of the great toe and the dorsal side of the first toe web. The plantar digitorum artery and dorsal digitorum vein of the great toe are dissociated from distal to proximal. If necessary, it could be extended to the dorsal metatarsal vein which should be cut off at an appropriate distance and ligated at the proximal end. Cut open the skin at the toe pulp according to the design, combined with subcutaneous tissue of appropriate thickness is lifted to the fibular side of the bottom of the toe. At the deep surface of neurovascular bundle (The artery and nerve are included in the flap) dissociation is performed to the edge of nails, according to the design line incision is made along the nails (from root to the free edge) to the surface of the bone, and dissociate to the

Fig. 14.8 The blood vessels and nerves

14 Reconstruction of Nail Defects

fibular side and merge with toe pulp flap. If the phalanges need to be cut, the end of the extensor digitorum longus tendon of the great toe should be dissociated when the skin is cut at the dorsal side. First, the half of the phalanx is cut laterally far from the termination point, and then the toenail and the deep part of the phalanx are cut longitudinally to form the toenail (bone) flap pedicled with the fibular artery or plantar metatarsal artery and nerve of the great toe which is dissociated proximally with appropriate length and cut off for later use.

Transplantation After the toenail flap is cut, the subcutaneous fat should be removed under the operating microscope. The fibrous tissue between the flap and toenail is cut off to make the flap fully open so as to accommodate the phalanx. When moving to the hand, the toenail is first fixed to the residual phalanx with a Kirschner wire. Dissociate the proximal nail margin and lift it up to fix the surrounding tissue to form a bilateral symmetry of the semi-arc. Then, the free edge of the toe is removed about 0.2 cm, and the epidermis is inverted with the edge of the nail bed. If there is still some residual soft tissue on one side of the affected finger, the nail fold will be reconstructed by a mattress suture. If there is just residual nail fold on the affected finger, the toenail will be disengaged and repaired, and inserted into it. If there is still some residual nail bed on the affected finger, the nail plates of about 0.3 cm on both sides of the nail bed will be removed respectively. The exposed nail bed is sutured distally from the methyl with a 5-0 noninvasive suture. Trim the distal free edge of toenail to make both sides symmetrical. Anastomosis of digital and digitorum vessels and nerves is performed (Figs. 14.8, 14.9, and 14.10).

14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation

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tive operation is to solve the aesthetic problem. Therefore, this operation has a higher requirement for appearance and requires a fine design to meet the requirements of the patient; (b) The risk of operation is high, and the requirement for microsurgical technique is higher; (c) The appearance of reconstructed nails after the operation is realistic and the effect is good; (d) It is suitable for the whole nail bed, part of the nail bed defect, and also for patients with phalanx and skin defects. Fig. 14.9 The dissection of the donor toe nail and the blood vessels and nerves for anatomosis

14.3.5 Announcements

Fig. 14.10 The appearance after the transplantation

Postoperative Treatment (a) Strengthen nursing, closely observe the blood supply for the nail; (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.

14.3.4 Operation Characteristics (a) The defect of fingernail itself has little effect on the function of finger. The main purpose of the reconstruc-

(a) Precise surgical method is designed to protect the donor site and reduce damage to the great toe. If phalanges were needed, iatrogenic fractures should be avoided. (b) When cutting the nail bed, try to leave a thin layer of the nail bed to facilitate the re-growth of the toenail bed. A little skin should be attached around the nail to facilitate the suture and fixation with the fingertips. (c) Protect the connection between the nail bed and the artery. After the pedicle is cut off, the nail flap should be trimmed under a microscope to remove the excess toe bone and soft tissue. At the same time, pay attention to maintaining the integrity of the nail bed when the nail bed is separated from the toe bone. (d) To ensure the anastomosis quality of blood vessels, be careful not to be too long or rotated or twist, 8 needles of 11-0 sitch is appropriate while the ratio of arteriovenous can be 1:1 or 1:2. (e) The arteries and veins of the donor site should be appropriately longer when cutting in order to have a larger diameter and healthier blood vessels for anastomosis. (f) The tunnel where the toenail flap is fixed with the vascular nerve pedicle should be loose, which even can be opened if necessary; (g) Avoid injuring the nail matrix when cutting, otherwise, it will lead to the development of deformity of the reconstructed nail and affect the appearance. (h) After the operation, lie in bed absolutely for a week and pay attention to indoor heat preservation, a quiet and smoke-free environment is also required.

14.3.6 Case Description Case 1 The 20-year-old female patient was admitted to the hospital for more than 2 h due to pain and bleeding of the right index and middle fingers with movement limitation caused by the heavy objection. Physical examination: She was in good general condition, with stable vital signs. The contusion of the right index finger was serious, with the trau-

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Fig. 14.11 Reconstruction of the right index fingernail defect by free great toenail flap transplantation. (a) Preoperative condition of the finger defect. (b) Preoperative design. (c) Dissociation of the great toenail

flap. (d) The dorsal view of the reconstructed finger after the operation. (e) The palmar view of the reconstructed finger after the operation. (f) The dorsal view of the donor site. (g) The plantar view of the donor site

matic loss of the nail plate and nail bed, phalanx exposed, uneven wound margin, slow bleeding, serious soft tissue contusion of the dorsal end of the wound, blue on the finger pulp, general in capillary reaction, numbness of feeling; Open injury was on the dorsal side of the right middle finger, with the traumatic loss of the nail plate, oblique crack nail bed exposed, slow bleeding, general in peripheral blood supply. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the index finger was reconstructed by the toenail flap transplantation of the right great toe. Debridement and suture of right middle finger were performed and the defect in the donor site was repaired with ipsilateral dorsal metatarsal flap. The operation was successful, after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the opera-

tion. Two weeks after the operation, the reconstructed nail flap survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 14.11). Case 2 The 23-year-old male patient was admitted to the hospital in emergency for 1 h due to pain and bleeding of the right thumb defect caused by mould injury. Physical examination: he was in good general condition, with stable vital signs, traumatic loss of the thumb from the nail root, irregular skin of the stump, exposed bone, and active bleeding. And the other fingers were normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by half toenail flap transplantation of the left great toe under general anesthesia in emergency, and the donor site was covered by transposition of the local flap. The operation was successful, after the tourniquet relaxed, the reconstructed fingers were ruddy

14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation

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a

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Fig. 14.12 Reconstruction of the right thumbnail defect by free great toenail flap transplantation. (a) Preoperative condition of the finger defect. (b) Preoperative design. (c) Dissociation of the great toenail flap. (d) The condition of the reconstructed finger after the operation.

(e) The appearance of the reconstructed finger 23 months after the operation. (f) The opponents function of the reconstructed finger 23 months after the operation. (g) The holding function of the reconstructed finger 23 months after the operation. (h) The situation of the donor site

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. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 14.12).

skin of the stump; soft tissue defect on the finger pulp of the index finger, exposed bone, in irregular skin of the stump, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by toenail flap transplantation of the left great toe under general anesthesia in emergency, and the donor site was covered by transposition of the lateral tarsal flap. Debridement and skin graft were also performed on the index finger. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The

Case 3 The 39-year-old male patient was admitted to hospital in emergency for 1.5 h due to pain and bleeding of the left thumb and index finger defect caused by punch injury. Physical examination: He was in good general condition, with stable vital signs, soft tissue defect on the dorsal side of the distal segment of the thumb, exposed bone, in irregular

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14 Reconstruction of Nail Defects

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Fig. 14.13 Reconstruction of the left thumbnail defect by free great toenail flap transplantation. (a) Preoperative condition of the finger defect. (b) The condition of nail defect after debridement. (c) Preoperative design. (d) Dissociation of the pedicle. (e) Dissociation of

the lateral tarsal flap. (f) The appearance of the reconstructed finger after the operation. (g) The appearance of the reconstructed finger 1 month after the operation. (h) The appearance of the donor site 1 month after the operation

donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 14.13).

cessful, after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 14.14).

Case 4 The 26-year-old female patient was admitted to hospital in an emergency for 1.5 h due to pain and bleeding of the left thumb caused by punch injury. Physical examination: she was in good general condition, with stable vital signs, type III defect of the thumb, exposed bone, in irregular wound, seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by toenail flap transplantation of the left great toe combined with the second phalangeal bone and joint composite tissue transplantation under general anesthesia in emergency. The foot donor site was designed to be repaired by the residual composite tissue flap of the second toe, and the second toe donor area was directly sutured. The operation was suc-

Case 5 The 21-year-old male patient was admitted to hospital in emergency for 2 h due to pain and bleeding of the right thumb defect caused by punch injury. Physical examination: he was in good general condition, with stable vital signs, nail defect and soft tissue defect of the finger pulp of the thumb, exposed bone, in irregular wound, and seriously polluted. After admission, routine preoperative preparation for recon-

14.3 Reconstruction of Nail Defect by Toenail Flap Transplantation

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Fig. 14.14 Reconstruction of the left thumbnail defect by free great toenail flap transplantation. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect. (c) Preoperative X-ray. (d) Preoperative design (the dorsal side). (e) Preoperative design (the plantar side). (f) Dissociation of the composite tissue flap. (g) Transplantation of the flap. (h) The palmar appearance of

the reconstructed finger after the operation. (i) The dorsal appearance of the reconstructed finger after the operation. (j) The situation of the donor site. (k) The dorsal appearance of the reconstructed finger 14 months after the operation. (l) The palmar appearance of the reconstructed finger 14 months after the operation

struction was given, and surgical contraindications were excluded. After complete debridement, the thumb was reconstructed by toenail flap transplantation of the right great toe combined with the fibular flap of the great toe transplantation under general anesthesia in emergency. The foot donor site was covered by the dorsal flap of foot. The operation was successful, after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the

sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 14.15).

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Fig. 14.15 Reconstruction of the right thumbnail defect by free great toenail flap transplantation. (a) Preoperative condition of the finger defect. (b) Preoperative design. (c) Dissociation of the flap. (d) The

appearance of the reconstructed finger after the operation. (e) The appearance of the reconstructed finger 2 years after the operation. (f) The function of the reconstructed finger 2 years after the operation

Reconstruction of Finger Pulp Defects

Abstract

The finger pulp defect of thumb and other fingers is common in clinic, which affects the integrity of fingertip and the holding function. Traditional local flaps, reverse flaps, and free flaps can all be used to repair the wound surface, but the function and appearance are difficult to satisfy patients. The reason is that the finger pulp has its special structure: the skin surface of the finger pulp has a large number of fine skin lines; the dermis of the finger pulp is composed of dense connective tissue; the deep dermis of the finger pulp is closely connected with the subcutaneous tissue, and the deep subcutaneous fat tissue is separated by many vertical fiber bundles which attach to the deep fascia. Therefore, when the finger pulp is to be reconstructed, the above structures need to be reconstructed. Obviously, only the toe pulp is the ideal donor site. At present, the commonly used donor sites in clinical practice include fibular flap of the great toe and tibial flap of the second toe. The former one has larger soft tissue volume, and the donor site is easy to be sutured directly which is focused on in this chapter.

15

that surgeons can use this technology to complete the reconstruction of the finger pulp defect better. The palmar finger flap is a skin flap containing bilateral palmar proper arteries and nerve bundles, which can be dissociated and moved forward to repair and reconstruct the finger pulp defect. Due to the dense skin structure on the palm of the finger, the postoperative finger pulp is plump and wear resistant, and the feeling is good.

15.1.1 Indications (a) Simple finger pulp defect caused by trauma or finger pulp ischemic necrosis, the range is not more than 1.5 cm; (b) The defect in the distal segment of the finger.

15.1.2 Surgical Design Longitudinal lines are drawn in the middle of both sides of the affected finger, and the proper neurovascular bundles of both sides should be included in the palmar flap.

Keywords

Finger reconstruction · Finger pulp defect

15.1 Reconstruction of Finger Pulp Defect by Local Thumb Flap Finger pulp is the most sensitive part of hand touch, the touch function of the hand completely depends on the finger pulp to complete. Therefore, the finger 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 finger pulp, so

15.1.3 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 flexor tendon sheath anesthesia can be used. (c) The design of the flap: A line should be drawn along the middle line on both sides of the finger stump wound to the root of the finger. (d) Surgical steps: The operation is performed under the control of a tourniquet. After debridement of the finger 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 superficial surface

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_15

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15 Reconstruction of Finger Pulp Defects

Fig. 15.1 Surgical design

of the sheath of the flexor digitorum tendon. It should be noted that both proper digital arteries and nerve bundles are contained within the flap. The dissociated length of the flap to the finger root depends on the need of the wound surface, but it is necessary to ensure that the flaps advancing forward have no tension. In general, to repair distal segment injury, the flap should be dissociated to the middle of the proximal segment of the finger, while it should be dissociated to the root of the finger to repair the finger pulp defect. After the flap is dissociated, the tourniquet should be loosened to observe the blood flow and stop the bleeding. Then the interphalangeal joint should be put in flexion 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 flap 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 finger flap advancement to reconstruct the finger pulp defect could preserve the length of the finger. In addition, the flap contains vascular and nerve bundles and has a good feeling after the operation. The skin on the palm of the finger is dense, and the postoperative finger 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 flap is not suitable for repairing the finger pulp defect which is over 2 cm2. (d) There is no significant increase in the trauma of the affected finger, only a prolonged incision on both sides.

15.1.5 Announcements (a) The dissociation of the flap should be carried out on the superficial surface of the tendon sheath of flexor digitorum tendon, and the neurovascular bundles on both sides should be included in the skin flap. If necessary, 3-0 silk

15.1 Reconstruction of Finger Pulp Defect by Local Thumb Flap

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Fig. 15.2 Reconstruction of the right thumb pulp defect by V–Y flap advancement. (a) Preoperative dorsal condition of the finger defect. (b) Preoperative palmar condition of the finger defect. (c) Preoperative design. (d) Preoperative repair of the donor site. (e) Dissociation of the

flap. (f) Nail bed enlargement. (g) The palmar view of the reconstructed finger 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

thread can be used to suture the wound edge of the skin flap for several stitches to avoid the separation and injury to the neurovascular bundles. (b) The width of the flap should be equal to the width of the finger pulp defect. (c) There should be no tension in the suture after the flap is advanced. The interphalangeal joint should be in flexion position to avoid tension. (d) The affected finger is fixed in flexion position of the interphalangeal joint (e) Function exercise should be strengthened after wound healing to prevent flexion deformity of finger.

15.1.6 Case Description 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 finger pulp of the right thumb was defective with exposed bone, and the defect area was 2.0 × 1.6 cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement, V-Y flap was designed on the palmar side of the thumb which was cut according to the design line to advance to reconstruct the finger pulp defect and repair the

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15 Reconstruction of Finger Pulp Defects

nail bed, and the donor site was sutured directly. The flap area was 2.2 × 1.8 cm. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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 finger were satisfactory (Fig. 15.2). Case 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 finger pulp of the right thumb was defective with exposed bone, and the

defect area was 3.3 × 2.3 cm. 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 flap based on cutaneous branch, and the donor site was covered by skin graft. The flap area was 3.5 × 2.5 cm. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Twelve months’ regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 15.3).

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Fig. 15.3 Reconstruction of the right thumb pulp defect by transposition of dorsal digital flap based on cutaneous branch. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design. (d) The palmar appearance of the reconstructed finger after the operation. (e) The donor site cov-

ered by skin graft. (f) The appearance of the reconstructed finger 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 finger pulp 12 months after the operation

15.2 Reconstruction of Finger Pulp Defect by Transposition of Local Finger Flap

15.2 Reconstruction of Finger Pulp Defect by Transposition of Local Finger Flap Finger pulp is the most sensitive part of hand touch, the touch function of the hand completely depends on the finger pulp to complete. Therefore, the finger 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 finger pulp, so that surgeons can use this technology to complete the reconstruction of the finger pulp defect better. The palmar finger flap is a skin flap containing bilateral palmar proper arteries and nerve bundles, which can be dissociated and moved forward to repair and reconstruct the finger pulp defect. Due to the dense skin structure on the palm of the finger, the postoperative finger pulp is plump and wear resistant, and the feeling is good.

15.2.1 Indications (a) Simple finger pulp defect caused by trauma or finger pulp ischemic necrosis, the range is not more than 1.5 cm; (b) The defect in the distal segment of the finger.

15.2.2 Surgical Design Longitudinal lines are drawn in the middle of both sides of the affected finger, and the proper neurovascular bundles of both sides should be included in the palmar flap.

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 flexor tendon sheath anesthesia can be used. (c) The design of the flap: A line should be drawn along the middle line on both sides of the finger stump wound to the root of the finger. (d) Surgical steps: The operation is performed under the control of a tourniquet. After debridement of the finger 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 superficial surface of the sheath of the flexor digitorum tendon. It should be noted that both proper digital arteries and nerve bun-

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dles are contained within the flap. The dissociated length of the flap to the finger root depends on the need of the wound surface, but it is necessary to ensure that the flaps advancing forward have no tension. In general, to repair distal segment injury, the flap should be dissociated to the middle of the proximal segment of the finger, while it should be dissociated to the root of the finger to repair the finger pulp defect. After the flap is dissociated, the tourniquet should be loosened to observe the blood flow and stop the bleeding. Then the interphalangeal joint should be put in flexion 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 flap 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 finger flap advancement to reconstruct the finger pulp defect could preserve the length of the finger. In addition, the flap contains vascular and nerve bundles and has a good feeling after the operation. The skin on the palm of the finger is dense, and the postoperative finger 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 flap is not suitable for repairing the finger pulp defect which is over 2 cm2. (d) There is no significant increase in the trauma of the affected finger, only a prolonged incision on both sides.

15.2.5 Announcements (a) The dissociation of the flap should be carried out on the superficial surface of the tendon sheath of flexor digitorum tendon, and the neurovascular bundles on both sides should be included in the skin flap. If necessary, 3-0 silk thread can be used to suture the wound edge of the skin flap for several stitches to avoid the separation and injury to the neurovascular bundles. (b) The width of the flap should be equal to the width of the finger pulp defect.

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15 Reconstruction of Finger Pulp Defects

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Fig. 15.4 Reconstruction of the right index and middle fingers pulp defect by transposition of proper digital flap based on dorsal branch. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design. (d) Dissociation of the flaps. (e) Transposition of the flaps. (f) The palmar

(c) There should be no tension in the suture after the flap is advanced. The interphalangeal joint should be in flexion position to avoid tension. (d) The affected finger is fixed in flexion position of the interphalangeal joint. (e) Function exercise should be strengthened after wound healing to prevent flexion deformity of finger.

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 fingers caused by punch injury. Physical examina-

view of the reconstructed finger after the operation. (g) The dorsal view of the reconstructed finger after the operation. (h) The palmar view of the reconstructed finger 2 months after the operation. (i) The dorsal view of the reconstructed finger 2 months after the operation

tion: Finger pulp defect of the right index and middle fingers with exposed bone, and the defect areas were 1.6 × 2.0 cm and 1.5 × 1.8 cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement, the fingers were reconstructed by transposition 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 1.8 × 2.2 cm and 1.6 × 2.0 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. 15.4).

15.2 Reconstruction of Finger Pulp Defect by Transposition of Local Finger Flap

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Fig. 15.5 Reconstruction of the left ring and little fingers pulp defect by transposition of proper digital flap based on dorsal branch. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design. (d) Dissociation of the flaps. (e) Transposition of the flaps. (f) The palmar

view of the reconstructed finger after the operation. (g) The dorsal view of the reconstructed finger after the operation. (h) The palmar view of the reconstructed finger 2 months after the operation. (i) The dorsal view of the reconstructed finger 2 months after the operation

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 × 1.2 cm and 1.6 × 1.3 cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement, the fingers were reconstructed by transpo-

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 × 1.6 cm 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).

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15 Reconstruction of Finger Pulp Defects

15.3 Reconstruction of Thumb Pulp Defect by Transposition of Dorsal Index Finger Flap The dorsal index finger flap is located on the dorsal side of the proximal segment of the index finger with the first dorsal metacarpal artery and dorsal digital vein as the blood supply and two dorsal digital nerves issued by the superficial branch of the radial nerve. The flap can form an island flap with a neurovascular pedicle or an axial flap for local transposition. In 1979 index finger dorsal flap was first 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 flap, at the same time the dorsal island flap of index finger with fan-shaped fascia, and vascular nerve pedicle was designed, which increased clinical application.

15.3.1 Indications (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 finger flap runs on the dorsal side of the first metacarpal space. The blood supply in this area is mainly the branches of the dorsal radial artery of the index finger and the proper digital artery, and the sensory nerve is the terminal branch of the superficial 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 2.5 cm along this line, which is the starting point of the dorsal radial artery of the index finger, and also the passing point of the vein and nerve of the skin flap, which can be regarded as the key point of the flap. The distal line of the key point is the dorsal radial artery of the index finger, which is also the surface projection of the axial vessels of the flap. The width of the flap on the dorsum of the finger is 2–3 cm, and the width of the flap on the dorsum of the hand is based on the vascular projection as the central axis, 1.5 cm to the ulnar side and 2.5 cm to the radial side. The distal end of the flap 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 flap: The flap 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 finger, and the two sides should not exceed the midline of the lateral finger, and the proximal end can extend upward as needed. The area of skin flap can be cut: island flap 3 × 6 mm and axial flap 9 × 10 cm. (d) Dissociation of the flap: In the case of the island flap, the forearm is not exorcised and the operation is performed under the control of an inflatable tourniquet. The dorsal metacarpal vein on the dorsal side of the second metacarpal is used as a mark to make an S-shaped incision, which is about 3–4 cm. To dissociate the first dorsal metacarpal artery and vein and superficial branches of radial nerve with some perivascular soft tissue and the interosseus membrane of the first dorsal interosseous muscle on the superficial surface of the first dorsal interosseous muscle. The vessel pedicle should be as long as possible to ensure no tension after the transposition of the flap. After the vascular pedicle is exposed, the skin

15.3 Reconstruction of Thumb Pulp Defect by Transposition of Dorsal Index Finger Flap

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Fig. 15.7 Full-thickness skin graft. (a) Design of the flap. (b) Dissociation of the flap. (c) Transplantation of the flap

should be cut along the designed line, and the flap is lifted retrograde on the superficial surface of the extensor digitorum tendon. The tourniquet should be relaxed for hemostasis and the blood supply of the flap should be observed. Then the flap 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. Full- thickness 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 flap 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 finger flap 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 flap is long which is flexible to be transferred. (c) Without suturing blood vessels, the operation is simple, the effect is stable, safe, and reliable.

(d) The size of the flap is small, and only a linear scar can be left in the donor site.

15.3.5 Announcements (a) Because the first dorsal metacarpal artery is relatively thin and does not form a bundle with the dorsal metacarpal vein and radial nerve branch, it is appropriate to dissociate with the peripheral tissues together to form a neurovascular bundle, rather than disassociate the first dorsal metacarpal artery alone. (b) In the process of dissociation, the action should be gentle 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 postoperative swelling which would affect blood supply. (e) If the flap area is larger, it can be extended proximally. (f) Postoperative environment of patients should pay attention to heat preservation, keep quiet, strictly smoke-free environment, patients absolutely lie in bed for a week (g) The blood supply of reconstructed finger 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.

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Fig. 15.8 Reconstruction of the left thumb pulp defect by transposition of the dorsal index finger flap. (a) Preoperative palmar condition of the thumb defect. (b) Preoperative design. (c) Dissociation of the flap.

(d) The appearance of the reconstructed finger after the operation. (e) The flap survived 10 days after the operation

15.3.6 Case Description

thumb the index finger 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 flap pedicled with the proper digital artery is used, also known as the digital artery flap without the digital nerve which can keep the sensory function of the donor finger after the flap is removed, so the flap can be selected from the side of any finger adjacent to the wound surface, with flexible design and convenient transposition. If the flap contains the dorsal branch of the proper palmar digital nerve, it also has a good sensory function. In addition, fingertip or finger pulp defect can be reconstructed by reverse lateral digital flap.

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 × 2.3 cm. 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 finger flap, and the donor site was covered by skin graft. The flap area was 3.5 × 2.5 cm. 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 finger were satisfactory (Fig. 15.8).

15.4 Reconstruction of Finger Pulp Defect by Digital Artery Island Flap Lateral digital flap is on the side of the finger, which contains proper digital artery and nerve. The ring finger neurovascular island flap for sensation reconstruction of finger tip of the

15.4.1 Indications (a) Small fingertip or finger 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 first-stage emergency reconstruction should

15.4 Reconstruction of Finger Pulp Defect by Digital Artery Island Flap

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be performed to complete debridement of the thumb and finger 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 finger, an island flap 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 flap 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 finger.

15.4.3 Surgical Method roper Digital Neurovascular Island Flap P (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 flap: This flap 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 fingers. The flap is designed on the ulnar side of the middle finger or ring finger according to the needs of the sensory area wound of the thumb. The range of the flap is within the midline of the dorsum of the finger, 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 flap should be designed slightly larger than the recipient site. (d) Surgical steps: The operation is performed under an inflatable 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 flap, the skin should be cut along the design line of the flap, which is dissociated from the palmar side to the dorsal side on the superficial surface of the flexor and extensor tendons. After the flap 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 finger 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 flap 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 fixed under pressure (Figs. 15.9 and 15.10)

Fig. 15.9 Design of proper digital neurovascular island flap

Fig. 15.10 Dissociation of proper digital neurovascular island flap

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15.5 Proper Digital Artery Island Flap Anastomosed with Dorsal Digital Nerve Without sacrificing the main trunk of the proper digital nerve, but the branch of dorsal digital never is cut while the flap is removed, which anastomosed with the proper digital nerve of the finger stump and form the reverse proper digital artery island flap to reconstruct finger pulp. The incisional method: The traffic branches of the two proper digital arteries are anastomosed with each other, so the lateral digital flap can be designed at the proximal end, and the distal proper digital artery can be the pedicle to form a reverse digital artery island flap to repair the soft tissue defect of the finger tip. According to the size of the wound, the flap should be designed on the lateral and dorsal sides of the proximal and distal ends of the middle segment. The long axis of the flap is perpendicular to the proper digital artery, or slightly oblique to the proximal end. The pedicle of the flap is designed into an arc or triangle, including the proper digital artery and nerve bundle which is about 1cm long. Most of the flap is located on the dorsal side, and should be designed to the distal finger as far as possible. The flap is dissociated from the distal to the proximal in the superficial layer of the aponeurosis of the extensor digitorum tendon. At the proximal end of the flap, the dorsal branch of proper digital nerve is dissociated for 1cm to the proximal end and cut off. The flap is rotated to the distal end to reconstruct the finger pulp, and the dorsal branch of proper digital nerve of the flap is sutured with the proper digital nerve on the other side of the finger tip. The donor site can be covered by fullthickness skin graft (Figs. 15.11, 15.12, 15.13, and 15.14).

15 Reconstruction of Finger Pulp Defects

Postoperative Treatment After the operation, lie in bed for 7 days, continued lamp irradiation, the blood supply of the reconstructed finger pulp should be observed, routine treatment of “three anti” therapy, dressing change every 2–3 days, and suture removal 2 weeks after the operation.

15.5.1 Operation Characteristics (a) The digital artery island flap with proper palmar artery and nerve pedicle (mainly using ulnar flap of middle and ring finger) to repair the defect of thumb and index finger can restore the sensory function of the two fingers, and the color, texture, and appearance of the repaired flap are also better. (b) The vascular pedicle of the donor site is constant and convenient. (c) The operation is simple and safe without anastomosis of blood vessels. (d) The appearance of the reconstructed finger pulp is not bloated, the texture is similar, the appearance is realistic, and the better feeling can be restored. (e) It aggravated the hand trauma and affected the hand aesthetics.

15.5.2 Announcements (a) This method should be used with caution in patients with damage to one side of the proper digital artery.

Fig. 15.11 Proper digital artery Island flap anastomosed with dorsal digital nerve

Fig. 15.13 Dissociation of proper digital artery Island flap

Fig. 15.12 Design of proper digital artery Island flap

Fig. 15.14 The appearance after the operation

15.5 Proper Digital Artery Island Flap Anastomosed with Dorsal Digital Nerve

(b) Noninvasive procedures should be performed to sharply dissociate the vascular bundle and prevent the separation of the blood vessel from the flap so as not to interfere with blood supply. (c) When dissociating the main trunk of the proper palmar digital nerve, to try to retain the soft tissue around the artery, in order to prevent injury with the accompanying veins. (d) The vascular pedicle of the reconstructed finger pulp should be long enough to prevent pulling, crimping or compression during rotation and transposition. (e) The subcutaneous tunnel should be loose, and the tunnel can be cut open if the flap is difficult to pass through, and then suture after the flap is transferred. (f) Postoperative environment of patients should pay attention to heat preservation, keep quiet, strictly smoke-free environment, and patients absolutely lie in bed for a week. (g) The blood supply of reconstructed finger 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.

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15.5.3 Case Description Case 1 A 35-year-old male patient was admitted to hospital for two hours due to pain and bleeding of the right first to fifth fingers caused by punch injury. Physical examination: He was in good general condition, with stable vital signs. The right thumb and index finger were damaged from proximal segment, most of the soft tissue of the finger pulp of the middle finger was contused and defect, and the distal segment of the ring finger was damaged. After complete emergency debridement, the first and second fingers were performed stump repair, the third finger was reconstructed by dorsal metacarpal flap and the fourth finger pulp was reconstructed by digital artery island flap. The operation was successful, and routine reconstruction treatment was given after the operation. Three months’ regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 15.15).

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Fig. 15.15 Reconstruction of the left ring finger pulp defect by transposition of the digital artery island flap. (a) Preoperative palmar view of the finger defect. (b) Preoperative dorsal view of the finger defect. (c) The palmar view of the reconstructed fingers 1 week after the operation.

(d) The dorsal view of the reconstructed fingers 1 week after the operation. (e) The palmar view of the reconstructed fingers 3 months after the operation. (f) The dorsal view of the reconstructed fingers 3 months after the operation

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15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition The flap is pedicled with the blood vessel and nerve of the fibular plantar of the great toe, including the flap on the fibular side of the great toe. The fibular plantar artery of the great toe originates from the first plantar metatarsal artery, which anastomoses with the medial plantar artery in an X-shaped intersection at the plantar side of the first metatarsal bone. The first metatarsal artery is anastomosed with the deep plantar branch of the dorsal foot artery at the proximal plane of the first and second metatarsal bones, which has important clinical value. Clinically, the reconstruction of the finger pulp defect by free great toe pulp flap is satisfactory. The reconstructed finger pulp is similar to the original one, with full appearance and ribbed, and can also restore sensation.

15.6.1 Surgical Design The flap is designed in the middle or slightly dorsal side of the fibular side of the great toe, the distal end is slightly upward from the anterior middle, the tibial side is slightly upward from the middle or super middle of the plantar side of the great toe, and the proximal side is made an oval mark at the toe crease of the great toe.

15.6.2 Surgical Method he Thumb Pulp Defect T (a) Anesthesia: It is performed under general anesthesia or combined brachial plexus epidural anesthesia. (b) The recipient site: In emergency cases, the wound surface of the injured thumb finger should be debrided thoroughly, and the contaminated and destroyed tissues are removed. In selected cases, the scar or dry necrotic tissue of the affixed bone should be removed to eliminate the hook nail deformity, and the skin is separated from the surrounding dermal margin. The obviously depressed skin is removed and the dermal margin is trimmed. Two thick subcutaneous veins could be carefully searched at the proximal finger pulp and marked. An oblique incision could also be made at the radial dorsal side of the proximal segment of the thumb to expose the dorsal digital vein. The recipient vein should be prepared in two ways: it can be found either in the palmar side or the dorsal side. If no anastomotic vein can be found in the palmar side, a thicker vein that can be anastomosed must be found in the dorsal side. An extended incision could be made to proximal on the ulnar side of the wound margin to separate the normal ulnar digital artery or the main artery of the thumb.

15 Reconstruction of Finger Pulp Defects

(c) The donor site: The flap should be designed according to cloth pattern on the fibular side of the ipsilateral great toe. The fibular plantar digital artery and nerve of the great toe are included in the flap. After cutting open the skin, the thick subdermal vein of the plantar side should be carefully searched and dissociated in the proximal incision of the plantar side, which should be dissociated to proximal for a certain length to maintain vein continuity and network structure. If a suitable vein could not be found on the plantar side, an extended incision could be made along the proximal edge of the flap to the fibular dorsal side, and the small veins in the flap are carefully dissociated to converge to the fibular dorsal side to form thicker veins. The above operation can be completed under the naked eye, that can also be done under a magnifying glass or surgical microscope if with problems. The dissociation of the flap is the key to the success of this operation, and the injury must be prevented. After dissociation of the vein, the plantar digital nerve, the plantar digital artery, and their continuation that is dorsal (plantar) metatarsal artery are dissociated along the proximal fibular incision of the flap to a sufficient length, and then the flap is lifted along the incision, and at this time the skin flap is completely dissociated except for the nerves and vessels. The tourniquets should be relaxed to observe the blood supply of the flap. (d) Repair by transplantation: When the recipient site is ready and the bleeding has been completely stopped, the great toe pulp flap is moved to the recipient site. The position of the flap should be adjusted according to the position of the blood vessel and nerve pedicle, and the 3-0 suture is used to suture the skin margin of the recipient site, and the ribbing should be aligned. The ulnar digital nerve should be first repaired, and then the veins and arteries are sutured to rebuild blood supply under the microscope. The wound is cleaned and the skin is sutured, and then the operation is completed (Figs. 15.16, 15.17, and 15.18).

he Finger Pulp Defect T (a) Anesthesia: It is performed under general anesthesia or combined brachial plexus epidural anesthesia. (b) The recipient site: The preparation of the wound is basically the same as the surgical preparation of the recipient site for the thumb defect, and the preparation of the blood vessels in the recipient site is determined according to the different fingers. In the case of the index finger pulp defect, the dorsal digital vein can choose the radial side, and the artery should be the ulnar side. On the ring finger, the opposite choice is true. While the middle finger is in the middle, the choice of arteries and veins is not special. (c) The donor site: The method of dissociation and transplantation of toe flaps is the same as above.

15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition Fig. 15.16 Flap design

Fig. 15.17 Defects of the finger

Fig. 15.18 Reconstruction of finger pulp defect by great toe pulp flap transposition

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15.6.3 Operation Characteristics (a) The length and sensory function of the finger can be retained while it is reconstructed by the great toe flap. The skin on the palm of the finger is dense, and the finger pulp is plump and wear resistant after the operation. (b) The operation is complicated and good small vessel anastomosis technique is needed. (c) It will increase the trauma to the foot.

15.6.4 Announcements (a) This operation is to reconstruct the finger pulp defect by anastomosis of the digital artery and vein to rebuild blood circulation. High microsurgical technique is required. (b) In the case of elective repair, since the proximal digital artery in the finger pulp has been contracted, in order to select the normal artery, a prolonged incision should be made proximally to expose the normal artery for anastomosis under microscope. (c) The key to the success of toe flap transplantation is to cut the donor vein. The best choice is to cut the vein pedicle that extends between the plantar side of the toe and the dorsum of the toe to facilitate anastomosis on the dorsum of the finger. To ensure continuity and quality, it is necessary to cut under the microscope. (d) The feeling of the reconstructed finger pulp can be recovered normally with ribbed and satisfactory appearance. (e) Vascular and nerve repair is key operation. (f) The thicker digital artery should be chosen in the recipient site, the thumb should choose the ulnar or the main artery, the index finger should choose the ulnar digital artery, and the middle and ring fingers should choose the radial digital artery. (g) Too long vascular pedicle through the subcutaneous tunnel of the finger body is easy to lead to the occurrence of postoperative crisis. (h) Postoperative environment of patients should pay attention to heat preservation, keep quiet, strictly smoke-free environment, patients absolutely lie in bed for a week.

15 Reconstruction of Finger Pulp Defects

given, and surgical contraindications were excluded. The thumb was performed complete debridement and repaired by avulsed flap replantation under brachial plexus anesthesia in emergency. The operation was successful, but the thumb pulp was gradually black and necrotic after the operation. After the patient’s condition is stable, the right hand debridement and free fibular great toe flap transplantation of the right foot were performed at a selected time. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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 with plaster external fixation. Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed finger survived successfully. Regular follow- up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 15.19).

15.6.5 Case Description

Case 2 A 26-year-old male patient was admitted to hospital in emergency for 2 h due to pain, bleeding, and movement limitation of the right index finger caused by the machine. Physical examination: Traumatic loss of the radial half side of the middle and distal segment of the right index finger, irregular skin of the stump, exposed bone and tendons, active bleeding, moderate pollution, movement limitation, and the blood supply for the ulnar side was normal. Complete debridement of the right index finger was performed in emergency. Antibiotics, change dressing, and relieve pain were performed after the operation. One week after the operation, the wound was fresh and there was no infection. The right index finger was reconstructed by free great toe nail flap transplantation of the left foot, and the donor foot was repaired by anterolateral thigh flap at a selected time. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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 with plaster external fixation. Routine reconstruction treatment was given after the operation. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory. The donor site healed in the first stage, and the patient was satisfied with the appearance and function (Fig. 15.20).

Case 1 A 26-year-old male patient was admitted to hospital due to reversed avulsion of the right thumb. After admission, routine preoperative preparation for reconstruction was

Case 3 A 27-year-old male patient was admitted to hospital in emergency for 1 h due to pain, bleeding, and bone exposure of the left index finger caused by planer injury.

15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition

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Fig. 15.19 Reconstruction of the right thumb pulp defect by free fibular great toe flap transplantation. (a) Preoperative dorsal view of the finger defect. (b) Preoperative palmar view of the finger defect. (c) The dorsal view of the replanted thumb 10 days after the operation. (d) The dorsal view of the replanted thumb 10 days after the operation. (e) Preoperative design (dorsal side). (f) Preoperative design (plantar side).

(g) Dissociation of the flap. (h) The palmar view of the reconstructed finger 10 days after the operation. (i) The dorsal view of the reconstructed finger 10 days after the operation. (j) The dorsal view of the reconstructed finger 3 weeks after the operation. (k) The palmar view of the reconstructed finger 3 weeks after the operation. (l) The view of the donor foot

Physical examination: He was in good general condition, with stable vital signs, traumatic loss of finger pulp, irregular wound, exposed bone, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The finger pulp was reconstructed by fibular great toe flap transplantation of the right foot under general anesthesia in emergency, and the donor site was covered by

free full-thickness skin graft. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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, and the reconstructed finger survived successfully. The efficacy was satisfactory (Fig. 15.21).

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15 Reconstruction of Finger Pulp Defects

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Fig. 15.20 Reconstruction of the right index finger defect by free left great toe flap transplantation. (a) Preoperative dorsal condition of finger defect. (b) Preoperative palmar condition of finger defect. (c) The condition of finger defect after debridement. (d) Preoperative X-ray. (e) Preoperative design of great toe nail flap. (f) Dissociation of the flap. (g) Dissociation of the flap. (h) The dissociated great toe nail flap. (i) Preoperative design of anterolateral thigh flap. (j) The dissociated anterolateral thigh flap. (k) Thinning of the flap. (l) The situation of the donor site after the operation. (m) The palmar view of the reconstructed

finger after the operation. (n) The dorsal view of the reconstructed finger after the operation. (o) The lateral view of the reconstructed finger after the operation. (p) The local view of the reconstructed finger after the operation. (q) The appearance of the reconstructed finger 6 months after the operation. (r) The function of the reconstructed finger 6 months after the operation. (s) The appearance of the donor foot 6 months after the operation. (t) The function of the donor foot 6 months after the operation

15.6 Reconstruction of Finger Pulp Defect by Great Toe Pulp Flap Transposition

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Fig. 15.20 (continued)

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15 Reconstruction of Finger Pulp Defects

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Fig. 15.21 Reconstruction of the left index finger pulp defect by fibular great toe flap transplantation of the right foot. (a) Preoperative dorsal condition of finger defect. (b) Preoperative palmar condition of finger defect. (c) Preoperative design (dorsal side). (d) Preoperative design (fibular side of great toe). (e) Dissociation of the flap. (f) The blood supply of the flap before cutting. (g) Transplantation of the flap.

(h) The view of the reconstructed finger after the operation. (i) The dorsal view of the reconstructed finger 6 months after the operation. (j) The palmar view of the reconstructed finger 6 months after the operation. (k) The function of the reconstructed finger 6 months after the operation. (l) The appearance of the donor foot 6 months after the operation

Reconstruction of Dorsal Digital Composite Tissue Defects

Abstract

Soft tissue defect of hand is common, when it cannot be treated in time and effectively, they will face finger truncation or late finger body dysfunction, especially composite tissue defect involving the joint. With the development of microsurgical techniques, there are many methods to repair soft tissue defects in hand, but functional recovery in the later stage is still a research topic. Due to the complexity of the anatomical structure and biomechanics of the finger, the tension imbalance after injury, such as the long-course disease, can lead to the occurrence of deformity, such as the buttonhole finger, hammer finger, etc. Emergency repair of the defect and functional reconstruction is of great significance.

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In the treatment of defective wound surface by emergency- free composite tissue flap transplantation combined with 1/2 extensor digital tendon of toe, can not only repair the wound surface in the first stage but also rebuild the function of extensor finger. The advantages are: (a) The application of tendon with blood supply and intact peri-tendon tissue, the suture site of tendon transplantation can heal early and have a certain strength, patients can take the initiative to exercise early to reduce adhesion; (b) The flap contains superficial peroneal nerve and has a good feeling; (c) The skin of the dorsum of the toe is close to that of the finger, and its texture and shape are excellent. However, this method is difficult to operate, there is a certain risk of failure, which requires the operator to have a more in-depth study of the anatomy, functional characteristics, and main uses of various flaps.

Keywords

Finger reconstruction · Dorsal digital composite tissue defect

16.1 Indications Joint is an important functional area of the limb, and its subcutaneous tissue is less, located in the exposed part, so the application of a free skin graft is not only difficult to survive but also easy to form scar, affecting the function of the joint; The application of pedicled chest and abdomen flap can cover a large area, but the patients need to be fixed for 3–4 weeks, which brings great inconvenience and affects the recovery of joint function; The application of a perforator flap for transplantation and repair has also achieved a good effect, but it is limited due to the complicated operation of some flap transplantation, insufficient pedicle length, bloated recipient site, difficult to close the donor site directly, and the phenomenon of different degrees of atrophy of the flap in the later stage;

16.2 Surgical Design After debridement, the flap is designed on the dorsal side of the second foot on the ipsilateral or contralateral side of the injured hand, with the dorsal metatarsal artery as the axis (including 1/2 digitorum tendon longus and cutaneous branch of superficial peroneal nerve). The size and shape of the flap and whether the tendon is removed depend on the recipient site.

16.3 Surgical Method (a) Dissociation of the flap: The flap should be cut according to the preoperative design. The proximal flap incision is made first, and the skin and subcutaneous tissue are cut from proximal to distal to expose the dorsal metatarsal artery and vein. After identifying the course of the dorsal metatarsal artery, a lateral incision is made to separate the cutaneous branch of the superficial pero-

© Springer Nature Singapore Pte Ltd. 2023 J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_16

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neal nerve from the sensory nerve of the flap, and a sharp separation is made medially under the deep fascia. Cut the extensor digitorum longus tendon longitudinally when the flap crosses it, so that the flap carries 1/2 extensor digitorum longus tendon. After crossing the extensor digitorum longus tendon, dissociation should be close to the periosteum, and the dorsal metatarsal artery is dissociated at the toe web, followed retroactively from the distal to the proximal, and the arteries and veins should be carefully protected during the operation. Then cut the skin along the designed line until the flap is completely dissociated, and the blood vessel pedicle should be kept continuously. After the tourniquet is relaxed, the pedicle should be cut off after the flap is ruddy in color. (b) Transposition of the flap: Firstly, according to the defect of the extensor digital tendon, the 1/2 extensor digitorum longus tendon and the extensor digital tendon are sutured. If accompanied by central bundle insertion or extensor digital tendon defect, reconstruction of central bundle or extensor digital tendon insertion should be performed. After the reconstruction, anastomosis of metatarsal-digital artery, dorsal foot vein and dorsal hand vein, cutaneous branch of superficial peroneal nerve, and digital nerve should be performed sequentially. (c) Postoperative treatment: Prevention of infection, vasospasm, thrombosis, bed rest immobilization, and other treatments should be given for 7–10 days. Dressing is changed once every 1–3 days, and functional rehabilitation exercises are guided after suture removal 2 weeks later.

16.4 Operation Characteristics (a) It can avoid the deficiency of previous flap repair and tendon transplantation repair in the second stage. (b) Emergency debridement is easy to clearly identify the anatomical structures of various tissues and their relationships, and understand the injury plane and scope of blood vessels, nerves, tendons, and other tissues. (c) Emergency treatment of the wound can be performed when the tissue has not undergone severe trauma response and secondary pathological changes such as contracture and adhesion from granulation tissue or scar hyperplasia. The complete excision of the deactivated and heavily polluted tissue can avoid excessive or less excision of the tissue and misexcision and create conditions for the repair of the hand-wound and functional recovery. (d) It can not only make patients early functional rehabilitation, but also reduce the pain and medical costs of multiple operations.

16 Reconstruction of Dorsal Digital Composite Tissue Defects

16.5 Announcements (a) At the dorsal side of the proximal segment, the lateral band formed by lumbrical muscle and interosseous muscle should be sutured to reconstruct the insertion point on both sides of the repaired tendon as far as possible. (b) If the wound is located at the central band insertion or distal extensor tendon insertion of the middle dorsal segment of the finger, reconstruction should be needed to restore the continuity of the tendinous anatomical structure of the dorsal finger.

16.6 Case Description Case 1 The 26-year-old male patient was admitted to the hospital for 1.5 h due to pain and bleeding of the left middle finger caused by planer injury. Physical examination: soft tissue defect on the dorsal side of the proximal segment of the left middle finger with exposed bone, flexion deformity, and the defect area was 3.0 × 2.0 cm. X-rays showed no obvious signs of fracture, only a cortical defect on the dorsal side of the third phalanx. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement, the finger was reconstructed by transposition of composite tissue flap on the ipsilateral second toe under brachial plexus epidural anesthesia in emergency, and the donor site was covered by skin graft. The flap area was 3.5 × 2.2 cm. The operation was successful, routine reconstruction treatment was given after the operation. Eight years of regular follow-up were conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 16.1). Case 2 The 29-year-old male patient was admitted to the hospital for 1.5 h due to pain and bleeding of the left thumb caused by a planer injury. Physical examination: Soft tissue defect on the dorsal side of the left thumb with exposed bone, irregular wound, seriously polluted, and the defect area was 7.5 × 2.0 cm. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. After complete emergency debridement, the finger was reconstructed by transposition of the ipsilateral great toe nail flap under brachial plexus epidural anesthesia in emergency, and the donor site was covered by skin graft. The flap area was 8.0 × 2.2 cm. The operation was successful, routine reconstruction treatment was given after the operation. Six months of regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 16.2).

16.6 Case Description

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Fig. 16.1 Reconstruction of composite tissue defect of the left middle finger by transposition of composite tissue flap of the ipsilateral second toe. (a) Preoperative condition of the finger defect. (b) The condition of the finger defect after debridement. (c) Preoperative design. (d) Dissociation of the flap. (e) Dissociation of the vascualr pedicle. (f)

Transposition of the flap. (g) The dorsal view of the reconstructed finger 8 years after the operation. (h) The palmar view of the reconstructed finger 8 years after the operation. (i) The function of the reconstructed finger 8 years after the operation. (j) The situation of the donor site 8 years after the operation

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Fig. 16.2 Reconstruction of composite tissue defect of the left thumb by transposition of the ipsilateral great toe nail flap. (a) Preoperative condition of the finger defect. (b) Preoperative design. (c) Dissociation of the flap. (d) Transposition of the flap. (e) The appearance of the

reconstructed finger 4 months after the operation. (f) The function of the reconstructed finger 4 months after the operation. (g) The situation of the donor site 4 months after the operation

Special Types of Finger Reconstruction

Abstract

In the history of finger reconstruction, there are many key figures and landmark surgical methods, which have had a decisive impact on the later generations. In recent years, some scholars have made a lot of explorations in the reconstruction methods, especially in the aspect of aesthetics and shape, and put forward the methods and concepts of “aesthetic reconstruction” and “comprehensive reconstruction,” so that the thumb and finger reconstruction is transformed from a simple “moving” and “transplantation” to a reconstruction mode aiming at restoring the appearance and function of the original finger as far as possible. But no matter what method is used to reconstruct the thumb or finger, free-toe transplantation is still the most widely used method in the clinic. With the rapid development of microsurgery technology and the concept of “super microsurgery,” finger reconstruction has been improved continuously depending on the specific situation of the defect tissue, and is getting closer to the ideal perfect level. Keywords

Finger reconstruction · Special types

17.1 Aesthetic Reconstruction (Comprehensive Reconstruction) Aesthetic finger reconstruction is a surgical procedure to repair and reconstruct the thumb or finger defect for aesthetic purposes which belong to the category of partial reconstruction. Compared with the thumb and finger, the shape and function of the second toe are quite different. Fingers are relatively thick and long, the size is symmetrical, the fingertip is a natural cone, the nail is large, the metacarpophalangeal joint has not too much fat accumulation, the rest position of the interphalangeal joint, metacarpophalangeal joint is slightly flexed, etc. While the toes are thin and short, the distal toe pulp is enlarged and clubbed, the neck is small, the subcutaneous fat accumulation

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of the metatarsophalangeal joint is bloated, the metatarsophalangeal joint is hyperextension in the resting state, and the position of the bone and joint moves forward. Therefore, many patients are not satisfied with the appearance and function of the reconstructed finger after the second toe transplantation. For this reason, Cheng et al. put forward the concept of decorative reconstruction to improve the appearance of the reconstructed fingers which mainly focuses on the following three aspects: nail elongation, correction of the plantar isthmus, and removal of the enlarged part of the toe pulp.

17.1.1 Indications (a) Same as various finger reconstruction; (b) Patients with high requirements for finger appearance.

17.1.2 Surgical Design The second toe is removed as before and the shape of the toe is reshaped as needed which includes three aspects: nail elongation, correction of the plantar isthmus, and removal of the enlarged part of the toe pulp.

17.1.3 Surgical Method reparation for the Recipient Site P Same as the second toe transplantation. he Cutting of the Toe T Same as the second toe transplantation. The method of remodeling the second toe is as follows: (a) The nail body should be lengthened and enlarged. A transverse incision of the dorsal distal interphalangeal joint is performed to make a rectangular piece of skin, dissociation is between the nail fold and the nail bed. Then the incision is drawn and sutured to make the nail fold backward.

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(a) If it is the distal segment defect, and the narrow part of the middle segment of the second toe is not obvious, at the same time the circumference is similar to that of the affected finger, while the two sides of the toe pulp are symmetrically enlarged, the “eight” word incision on both sides of the toe pulp should be performed to remove the enlarged part on both sides and directly suture the incision. (b) If the distal segment of the second toe is not significantly enlarged but the plantar stenosis is obvious, the fibular island flap of the great toe is transposition and inserted into the plantar stenosis of the middle segment for thickening. Before the flap is inserted, a longitudinal incision is made on the plantar side of the middle segment of the second toe, and the skin on both sides is dissociated on the surface of the tendon sheath. The flap should be designed with the fibular plantar digital artery of great toe as the axis. The width of the flap should be the difference between the circumferential diameter of the narrow part of the middle segment of the second toe at the donor site and the circumferential diameter of the thumb and finger at the corresponding position of the recipient site. The length should be the distance between the base of the distal segment of the plantar side of the second toe and the toe web. (c) If the distal segment of the second toe is only fibular enlargement and the stenosis of the middle segment is light, the pedicled flap of the fibular side of the second toe pulp is used to improve the fibular enlargement of the second toe and correct the plantar stenosis deformity of the middle segment. (d) If the second toe is simply enlarged in the middle of the toe pulp and the stenosis is obvious, longitudinal fusiform direct incision of the skin in the middle of the toe pulp is used. The width of resection was the difference between the circumferential diameter of the most enlarged part of the second toe and that of the distal segment of the adjacent finger of the recipient’s finger. At the same time, the fibular island flap of great toe is transferred to reconstruct the plantar stenosis of the middle segment.

Transplantation The second toe is dissociated according to the routine, the fractures are fixed with Kirschner wires vertically or across, and the tendons are sutured by adjusting the tension. IV type or above defect of thumb and finger, the reconstructed digital artery and nerve are anastomosed with the radial artery of snuff box and superficial branch of radial nerve, while the accompanying vein or subcutaneous vein is anastomosed. Below IV type defect, the reconstructed digital artery and nerve are anastomosed with proper digital artery and nerve of the recipient site, while the subcutaneous dorsal digital vein is anastomosed. Postoperative Treatment (a) Postoperative nursing, heat preservation, and close observation of blood circulation; (b) Use of antibiotics, anticoagu-

17 Special Types of Finger Reconstruction

lant, and antispasmodic drugs; (c) Protective passive function exercise is performed at 3 weeks after the operation, and systematic active and passive function exercise is performed at 4 weeks after the operation while plaster removal and internal fixation are removed.

17.1.4 Operation Characteristics (a) This operation is a modification of the second toe transplantation with the aim of improving the postoperative appearance. (b) The operation needs to solve the main problems affecting the appearance according to the specific conditions of the toes. There are many specific methods, which need to be mastered flexibly. (c) Familiarity with finger and toe blood supply and flap transposition is required.

17.1.5 Announcements (a) The shape of the second toe and the corresponding contralateral finger should be carefully measured before the operation, and the operation plan is designed according to the principle of “reducing fat and replenishing weight.” (b) The main purpose of this operation is to improve the appearance, which requires careful design of the incision in the donor and recipient sites. (c) The dilatation of the narrow segment of the second toe is only applicable to the finger defect above type III and the adjacent fingers are thicker.

17.1.6 Case Description Case 1 The 23-year-old female patient was admitted to the hospital for 8 weeks due to the right defect. Physical examination: She was in good general condition, with stable vital signs, and distal segment defect of the right thumb. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by the great toe nail flap combined with an Iliac bone graft under general anesthesia, and the donor's foot was repaired by a reverse medial plantar island flap. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Twenty-four months of regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.1).

17.1 Aesthetic Reconstruction (Comprehensive Reconstruction)

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Fig. 17.1 Aesthetic reconstruction of type II defect of the right thumb. (a) Preoperative condition of thumb defect. (b) Preoperative design of the recipient site. (c) Preoperative X-ray. (d) Preoperative design of the donor site. (e) Preoperative design of the flap. (f) Preoperative design of the iliac bone graft. (g) Phalanx formation. (h) Dissociation of the flap. (i) Transposition of the flap. (j) The great toe was repaired by the flap. (k) The flap donor site is covered by skin graft. (l) The reconstructed

thumb survived 7 days after the operation. (m) The X-ray of the reconstructed thumb 15 months after the operation. (n) The palmar view of the reconstructed thumb 24 months after the operation. (o) The dorsal view of the reconstructed thumb 24 months after the operation. (p) The function of the reconstructed thumb 24 months after the operation. (q) The situation of the donor great toe 24 months after the operation. (r) The situation of the donor flap site 24 months after the operation

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Fig. 17.1 (continued)

17.2 Finger Reconstruction in Children Finger reconstruction in children is one of the serious treatment methods for the important finger loss, which seriously affects the function and appearance of the hand. In particular, the second toe is transplanted to reconstruct the missing finger to reconstruct function and appearance. Compared with adult finger reconstruction, finger reconstruction in children still has its particularity: (a) The blood vessels in children are tiny, which are difficult to be anastomosed; (b) The children’s mental development is not complete, that they cannot fully cooperate with the treatment after the operation; (c) Limitations of medication, etc. Until the 1970s, the development of hardware such as surgical microscopes, fine m icroscopic instruments, and microstructures laid the foundation for finger reconstruction in children. Of course, finger reconstruction in children is not only difficult and time-consuming but also has a relatively high risk of success rate. This is a problem that must be considered in practical work.

17.2.1 Indications Incomplete fingers in children seriously affect their physiological and psychological development and have high requirements for appearance and function after reconstruction. Therefore, reconstruction should be performed as long as the physical condition of the child permits, the proximal vascular condition of the finger is good, and the function of the reconstructed finger can be predicted.

17.2.2 Surgical Design Because children are active and do not cooperate with treatment, so anesthesia needs to be safe and reliable. The operation time is long and needs to make full preparation before the operation. The blood circulation of the fingers should be observed closely after the operation. When necessary, an

appropriate amount of sedative drugs can be used. The proper plantar digital artery of toe is selected, which is constant, not affected by the variation of dorsal foot artery, and has the advantages of little injury to children that quick postoperative recovery and satisfactory function are possible.

17.2.3 Surgical Method reparation for the Recipient Site P The size, scope, and characteristics of the defect should be measured before operation. Complete debridement is performed during the operation, the visible blood vessels and nerves are exposed and protected under the microscope which should not be easily ligated but marked for anastomosis. he Cutting of the Toe T (a) Reconstruction of type I finger defect: First, the dorsal digital vein of the great toe is dissociated on the dorsum of the great toe and dissociated proximally to an appropriate length before being cut off, and then dissociated along the vein branch to the fibular end of the great toe to the tip. The dorsal metatarsal artery and plantar metatarsal artery as well as the fibular plantar digital artery of the great toe emitted after anastomosis are dissociated at the toe web. After dissociating the artery and nerve of the fibular plantar of the great toe, the transverse artery is cut and ligated, and the nerve bundle of the artery and nerve bundle is further dissociated distally to the proximal end of the flap. The skin is cut along the design line in the toe pulp, and several superficial toe veins are carefully dissociated proximally for 1–2 cm before being cut off for use. The subcutaneous tissue of the toe pulp is further cut deep to the fibular side of the bone. Cut the toenail on the tibial side and proximal side to the periosteum according to the design line. With a fine milling drill cutting the dorsal side and tibial side of bone, a bone knife separates bone cortex of the fibular and tibial

17.2 Finger Reconstruction in Children

sides, together with part of the toenail and the flap. The plantar digital artery and nerve of the great toe should be cut off at the appropriate length. (b) Reconstruction of types II and III finger defect: The dorsal digital vein of great toe is dissociated on the dorsum of the great toe and dissociated proximally to an appropriate length before being cut off, and then dissociated along the vein branch to the fibular end of the great toe to the tip. The dorsal metatarsal artery and plantar metatarsal artery as well as the fibular plantar digital artery of great toe emitted after anastomosis are dissociated at the toe web. After dissociating the artery and nerve of the fibular plantar of the great toe, the transverse artery is cut and ligated. The skin is cut along the design line in the toe pulp, and the flap is dissociated subcutaneously to the fibular side of the bone. According to the design line, the tibial side of the toenail is cut to the periosteum, and the dorsal bone cortex of the phalanx is cut with a milling cutter. The dorsal toe flap is lifted distally from the surface of the periapendoneum to the insertion point of the extensor digitorum longus tendon. A fine milling cutter is used to cut the dorsal phalangeal cortex and tibial cortex far from the extensor longus tendon. The dorsal phalangeal cortex is separated from the tibial plantar cortex with a bone knife, and part of the toenails and the flap are dissociated together. The fibular plantar artery and nerve of the great toe should be cut off at the appropriate place. The phalanges in the composite tissue flap are trimmed, and the length is measured. If the length could not reach the required length of the reconstructed finger, the iliac bone or allograft bone should be taken for reserve. For those requiring repair of the distal interphalangeal joint, the second interphalangeal joint is grafted. (c) Reconstruction of Type IV finger defect: The flap should be removed through the designed incision at the great toe and the second toe as the donor site. The dorsal metatarsal flap is cut open to expose the superficial dorsal metatarsal vein and dissociated distally to the dorsum of the great toe and second toe to find the main superficial veins as the return veins. Dissociate the deep peroneal nerve, the first dorsal metatarsal artery, the first plantar metatarsal artery, the fibular proper plantar digital artery and nerve of the great toe and the tibial proper plantar digital artery and nerve of the second toe. If the first dorsal metatatsal artery is absent or thin, the longer plantar metatarsal artery can be cut as tissue flap artery. The incision is extended to the dorsal side and the plantar side, respectively, and the extensor longus tendon, deep and superficial flexor tendons of the second toe are dissociated. The length of the tendon is determined according to the condition of the recipient site. The toenail flap is cut according to the designed width of the nail and

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osteotomy is performed on the proximal end of the toenail root of the terminal tarsal toe, so that the phalanx of the terminal toe can be attached to the toenail flap. Then carefully dissociate and cut the composite tissue flap of the proximal interphalangeal joint of the second toe with the middle segment and the proximal phalangeal bone. A suitability length iliac bone strip is cut behind the anterior superior iliac spine 2cm from the iliac crest. Before suturing the skin, according to the condition of the skin defect of the donor foot, cut the appropriate size of spindle-shaped strip along the incision, and then pull it together to suture the wound. If a free inguinal flap is required to repair a foot wound, dissociation of the flap should be performed before the iliac crest is removed. (d) Reconstruction of type V finger defect: The proximal phalanx body is missing in type V finger defect. It is necessary to take one more ilium bone and place it in the position of the proximal phalanx to solve the problem of the proximal phalanx defect. (e) Reconstruction of type VI finger defect: On the basis of type IV defect, the ipsilateral or contralateral second metatarsophalangeal joint is transplanted to reconstruct the metacarpophalangeal joint. (f) Treatment of donor foot: For the case with four toes retained, the residual toenail flap of the second toe can be combined with the great toe stump and internal fixation with Kirschner wire, and the skin is sutured. The dorsal metatarsal wound could be covered by free flaps or free skin graft. The donor site of the toe joint can be filled with an iliac bone of the same size through Kirschner wire fixation. In the case of keeping 5 toes, foot flap or groin flap transplantation can be used to repair the donor wound.

Transplantation The great toenail skin is rolled into a tube and the proximal interphalangeal joint of the second toe should be placed in an appropriate position. The defect between the phalangeal bone in the joint and the great toenail flap is filled with iliac bone strips. A 1.0mm diameter Kirschner wire is used to string the three together to form a new finger, which would be transplanted to the stump of the finger to be reconstructed. The great toenail flap can be transplanted with the second toe joint in the same pedicle, or the tibial plantar digital artery of the second toe can be cut off from the proximal starting point, and then the plantar artery of the second toe and the artery of the toenail flap can be anastomosed with the corresponding proximal proper digital artery respectively after being wrapped. Suture the extensor and flexor tendons with tendon threads. If the great toenail flap is successfully wrapped around the phalangeal artery without disconnection, the dorsal metatarsal artery (or plantar metatarsal

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artery) can be anastomosed with the ipsilateral proper digital artery or palmar digital artery of the reconstructed finger. If the artery is disconnected, the fibular plantar artery of the great toe and the tibial plantar artery of the second great toe can be anastomosed with the ipsilateral proper digital artery of the reconstructed finger, respectively. Then the veins of the great toenail flap and the second toe are anastomosed with the superficial subcutaneous veins of the dorsal hand. Finally, the fibular plantar nerve of the great toe and the tibial plantar nerve of the second great toe are anastomosed with corresponding proper digital nerves of the reconstructed finger.

Postoperative Treatment (a) After the operation, intensive nursing and close observation of the reconstructed finger should be carried out. (b) Routine treatment of “three antitherapy” after the operation.

17.2.4 Announcements (a) The infant finger (toe) body is small and the blood vessels and nerves are tiny which are usually anastomosed under the microscope 18–24 times to ensure the quality of the anastomosed blood vessels that can increase the reflux and reduce the venous crisis; (b) Cross Kirschner wires are used for bone fixation and the epiphysis and nail bed should be protected as much as possible; (c) Long arm plaster support is an auxiliary condition that cannot be ignored after the operation; (d) Infant compliance is poor, that can be combined with early “hibernation therapy” to reduce vascular crisis caused by the postoperative limb movement and pain.

17.2.5 Case Description Case 1 A 10-year-old male patient was admitted to the hospital for 7 days after stump repair due to the right thumb defect caused by a machine injury. Physical examination: He was in good general condition, with stable vital signs, fingertip defect, scabbed wound, and blood supply of the other fingers was normal. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by a half great toe tip composite flap under general anesthesia in a selective time, and the donor site was performed stump repair. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and

17 Special Types of Finger Reconstruction

stuffed with the broken cotton gauze around, and he returned to the ward safely. Routine reconstruction treatment was given after the operation. Eight months after the operation, the reconstructed finger survived successfully. Regular follow- up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.2). Case 2 The 12-year-old male patient was admitted to the hospital for 10 days after finger replantation due to necrosis of the distal segment of the right index finger caused by punch injury. Physical examination: he was in good general condition, with stable vital signs, the distal segment of the right index finger was necrotic with a clear boundary. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The index finger was reconstructed by the left second toe transplantation under general anesthesia in a selective time, and the donor site was performed stump repair. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. Seven months after the operation, the reconstructed finger survived successfully. Regular followup was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.3). Case 3 The 9-year-old female patient was admitted to the hospital for 1.5 h in an emergency due to pain and bleeding of the left second to fifth fingers caused by modeling injury. Physical examination: she was in good general condition, with stable vital signs, type V defect of the left second to fifth fingers, exposed bones, irregular wound, and seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The fingers were reconstructed by the bilateral second and third toes transplantation under general anesthesia in an emergency, and the donor site was performed stump repair. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Ten months after the operation, the reconstructed fingers survived successfully. Regular followup was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.4).

17.2 Finger Reconstruction in Children

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Fig. 17.2 Reconstruction of type I defect of the right thumb in a child by the left great toenail flap. (a) Preoperative dorsal condition of thumb defect. (b) Preoperative palmar condition of thumb defect. (c) Preoperative X-ray. (d) The condition of thumb defect after debridement. (e) Preoperative design. (f) Dissociation of the flap. (g) The dissociated flap. (h) The palmar view of the reconstructed thumb after the operation. (i) The dorsal view of the reconstructed thumb after the

operation. (j) X-ray after the operation. (k) The situation of the donor site and recipient site 2 weeks after the operation. (l) Appearance contrast of the reconstructed thumb 8 months after the operation. (m) The flexor function of the reconstructed finger 8 months after the operation. (n) The holding function of the reconstructed finger 8 months after the operation. (o) The situation of the donor site 8 months after the operation

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17 Special Types of Finger Reconstruction

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Fig. 17.3 Reconstruction of type IV defect of the right index finger in a child by the free left second toe transplantation. (a) Preoperative palmar condition of the finger defect. (b) Preoperative dorsal condition of the finger defect. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) Dissociation of the second toe. (f) The dissociated toe. (g) The palmar view of the reconstructed finger after the operation. (h) The dorsal view of the reconstructed finger after the operation.

(i) The situation of the donor site after the operation. (j) The dorsal view of the reconstructed finger 7 months after the operation. (k) The palmar view of the reconstructed finger 7 months after the operation. (l) Extensor function of the reconstructed finger 7 months after the operation. (m) Opponens function of the reconstructed finger 7 months after the operation. (n) The dorsal view of the donor site 7 months after the operation. (o) The plantar view of the donor site 7 months after the operation

17.3 Reconstruction of Congenital Deformity of Fingers

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Fig. 17.4 Reconstruction of type V defect of the left second to fifth fingers in a child by free bilateral second and third toes transplantation. (a) Preoperative palmar condition of the fingers defect. (b) Preoperative dorsal condition of the fingers defect. (c) Preoperative design (dorsal side). (d) Preoperative design (plantar side). (e) The palmar view of the

reconstructed fingers 10 months after the operation. (f) The dorsal view of the reconstructed fingers 10 months after the operation. (g) Clamping function of the reconstructed fingers 10 months after the operation. (h) Opponens function of the reconstructed fingers 10 months after the operation. (i) Life situation 10 months after the operation

17.3 Reconstruction of Congenital Deformity of Fingers

method to restore the appearance and function of the finger. In addition, the acquired traumatic absence of the finger is very common, and the technique of finger reconstruction with toe transplantation has been applied quite maturely. The congenital digital deformity is relatively rare and has characteristics different from acquired traumatic digital malformation. Only by mastering the characteristics of congenital digital deformity, the best surgical treatment effect can be obtained.

Finger dysplasia is a kind of congenital disease characterized by short fingers. It is often accompanied by a shallower finger web and usually only involves the hands without obvious heredity. The incidence rate is about 1: 32,000 to 1:40,000. Blauth and Gekele classified the dysplasia of the finger into four types: type I, brachydactylia; type II, split-hand/foot malformation; type III, ectrodactyly; type IV, acheiria. Type I and II hands retain most of their functions, while type III loses most of their functions, and type IV loses all their functions. As long as at least two functional fingers are reconstructed for type III most of the lost function can be restored. Therefore, the surgical treatment of type III is very necessary, and also very meaningful. Toe is the organ most similar to the finger in appearance and function, so it is the best

17.3.1 Indications (a) The patient is young and physically able to endure a long operation; (b) For patients with higher requirements for finger aesthetics; (c) The appearance and function of the donor’s toe are normal.

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17.3.2 Surgical Design (a) For congenital finger defect deformity, reconstruction of the index and middle finger is the first choice; (b) The nerves, blood vessels, tendons, and internal muscles of the affected hand are all dysplasia (the interosseous and lumbrical muscles are often deficient); (c) The branches of the median nerve and ulnar nerve in the palm are abnormal or even defective, so the cutaneous branch of the dorsal radial nerve of hand is needed to suture with the digital nerve of the toe. Vessels are mainly artery malformation, dysplasia of the wall, easy to spasm, vascular crisis after anastomosis, thrombosis; (d) Flexor muscle flexibility is poor, the flexor tendon is flat and thin and its insertion point is wide which often stops in the subcutaneous tissue of the distal palm, while the extensor tendon is often well developed; (e) The defect of the finger is usually manifested as a small skin tag with sufficient skin and soft tissue; (f) There is no need to carry too much skin or dorsal foot flap when taking the toe, which is conducive to the closure of the wound surface of the foot and has little damage to the appearance and function of the foot.

17.3.3 Operation Characteristics (a) The second to fifth fingers, only the proximal part of the proximal phalanx has partial development and the base of the articular surface is abnormal, while some even do not have any phalanx existence, the remaining so-called fingers have no functional role. The abnormal proximal phalanx is often removed during the operation, but the capsule should be retained; (b) The second to fifth metacarpal head dysplasia is serially severe, while the first finger web is often normal. A good metacarpophalangeal joint is the best guarantee of good finger function.

17.3.4 Announcements (a) The reconstruction of the distal interphalangeal joint of types II and III finger defect is of limited effect which should be careful; (b) The diameter of the finger phalanx is small. When cutting the toe, the dorsal part of the phalanx should be cut according to the size of the finger phalanx, and the plantar part could be kept intact to reduce the damage to the function and appearance of the toe. In order to prevent the shrinkage of the reconstructed finger from becoming small, the design of the reconstructed finger should be about 1 cm longer than the circumference of the healthy finger; (c) The grafted joint should be nerved and anastomosed with the sensory nerve of the recipient site to reduce the occurrence of postoperative osteoarthritis; (d)

17 Special Types of Finger Reconstruction

The range of motion of the dorsal extension of the second metatarsophalangeal joint is obviously larger than the range of motion of the plantar-flexion. When the thumb and metacarpophalangeal joint are reconstructed, the range of motion should be adjusted appropriately according to the healthy side. If you want to increase the metatarsophalangeal range of motion, first extend the second metatarsophalangeal joint and then cross the string of Kirschner wires longitudinally, fix the metatarsophalangeal joint with the metacarpophalangeal joint as an extension position, and repair the joint shape appropriately.

17.3.5 Case Description Case 1 The 22-year-old male patient was admitted to the hospital for 10 years due to deformity and function limitation of the right index and middle fingers caused by trauma. Physical examination: He was in good general condition, with stable vital signs, the index and middle fingers are deformed with limited extension and flexion. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The fingers were reconstructed by the left second toe combined with second metatarsophalangeal joint transplantation under general anesthesia at a selected time, and the donor site was performed stump repair. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Nine months after the operation, the reconstructed fingers survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.5). Case 2 The 25-year-old female patient was admitted to the hospital for more than 25 years due to a congenital deformity of the right thumb. Physical examination: She was in good general condition, with stable vital signs, short and deformed thumb, limitation of extension and flexion, and reduced finger web. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The finger and first finger web were reconstructed by the right great toenail flap combined with second toe composite tissue flap transplantation under general anesthesia at a selected time, and the donor site was covered by residual tissue complementary repair. The operation was successful, after the tourniquet relaxed, the reconstructed finger was ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine

17.3 Reconstruction of Congenital Deformity of Fingers

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Fig. 17.5 Reconstruction of the right index and middle fingers defect deformity by free left second toe combined with second metatarsophalangeal joint transplantation. (a) Preoperative palmar view. (b) Preoperative dorsal view. (c) Preoperative X-ray. (d) Preoperative design (the recipient site). (e) Preoperative design (the donor site). (f) The palmar view of the reconstructed fingers after the operation. (g) The donor site covered by direct suture. (h) Postoperative X-ray. (i) The

palmar view of the reconstructed fingers 9 months after the operation. (j) The dorsal view of the reconstructed fingers 9 months after the operation. (k) Holding function of the reconstructed fingers 9 months after the operation. (l) Opponens function of the reconstructed fingers 9 months after the operation. (m) The dorsal view of the donor site 9 months after the operation. (n) The plantar view of the donor site 9 months after the operation

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Fig. 17.6 Reconstruction of congenital deformity of the right thumb by the right great toenail flap combined with second toe composite tissue flap transplantation. (a) Preoperative dorsal view. (b) Preoperative palmar view. (c) Preoperative design. (d) Preoperative design. (e) The dorsal view of the reconstructed finger and first finger web after the operation. (f) The palmar view of the reconstructed finger and first finger web after the operation. (g) The palmar view of the reconstructed

finger 2 months after the operation. (h) The dorsal view of the reconstructed finger 2 months after the operation. (i) The dorsal of the donor site 2 months after the operation. (j) The plantar of the donor site 2 months after the operation. (k) The function of the reconstructed finger 18 months after the operation. (l) The function of the reconstructed finger 18 months after the operation

reconstruction treatment was given after the operation. Eighteen months after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.6).

Case 3 The 19-year-old female patient was admitted to the hospital for more than 19 years due to a congenital deformity of the right middle and ring fingers. Physical examination: She was in good general condition, with stable vital signs. The middle and distal segments of the middle finger were

17.3 Reconstruction of Congenital Deformity of Fingers

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Fig. 17.7 Reconstruction of congenital deformity of the right middle and ring fingers by the distal segment of the right second toe combined with joint composite tissue flap transplantation. (a) Preoperative dorsal view. (b) Dissociation of the flap. (c) The palmar view of the reconstructed fingers after the operation. (d) The palmar view of the reconstructed fingers 2 years after the operation. (e) Holding function of the

reconstructed fingers 2 years after the operation. (f) Extensor function of the reconstructed fingers 2 years after the operation. (g) Postoperative X-ray. (h) The situation of the donor site 2 years after the operation. (i) Working condition of the reconstructed fingers 2 years after the operation

short, with contraction band deformity and limited extension and flexion function. The ring finger was short and deformed with limited function. The fingers were reconstructed by the distal segment of the right second toe combined with joint composite tissue flap transplantation under general anesthesia at a selected time, and the donor site was covered by residual tissue complementary repair. The operation was successful, after the tourniquet relaxed, the reconstructed finger was

ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Twenty-four months after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.7).

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17.4 Reconstruction of Degloving Defects of Fingers Degloving defect of finger is a kind of severe avulsion injury of skin and soft tissue that is unconditional in situ repair. This kind of injury is often accompanied by skin and soft tissue degloving, tendon avulsion from muscle belly, the plane of vein disjunction is mostly near the skin section, and the artery and god are often extracted from the proximal end of a certain length, especially the nerve is longer than the artery, and the artery is often with a long segment of intima injury in microscopic exploration. The injury mechanism refers to the worker wearing gloves to operate the fast- moving machine or the ring wearer’s ring being violently torn. When the finger is involved in the fast-moving machine, the injured person tries to violently pull back, and the soft tissue of the whole finger, including skin, subcutaneous tissue, blood vessels, and nerves, is torn off like a glove. Only phalanges, joints, and extensor and flexor tendons are left in the residual finger, while in severe cases, distal phalanges and extensor and flexor tendons are torn off. Pedicle flap, free flap or toenail flap, and free second toe transplantation are often used to restore the function and appearance of fingers.

17.4.1 Indications (a) The patient is young and physically able to endure a long operation; (b) For patients with higher requirements for finger aesthetics; (c) The appearance and function of the donor’s toe are normal; (d) type I to type VI finger defect.

17.4.2 Surgical Design The toenail flap of the first toe with enough skin, the second toe joint and its tendon system, and the free iliac bone fragment are cut and reassembled to reconstruct a finger with a similar appearance to a normal finger. The distal interphalangeal joint is fused at an angle of about 30°. The toenail flap of the first toe and the joint tendon system of the second toe is co-pedicled, and the blood supply is nourished by the first dorsal metatarsal vessels. For the foot donor site, a free graft of iliac bone is taken to repair the bone defect, and a free graft of groin flap is taken to repair the skin and soft tissue defect.

17 Special Types of Finger Reconstruction

17.4.3 Surgical Method reparation for the Recipient Site P The size, scope, and characteristics of the defect should be measured before operation. Complete debridement is performed during the operation, the visible blood vessels and nerves are exposed and protected under the microscope which should not be easily ligated but marked for anastomosis. he Cutting of the Toe T (a) Reconstruction of Type I finger defect: First, the dorsal digital vein of the great toe is dissociated on the dorsum of the great toe and dissociated proximally to an appropriate length before being cut off, and then dissociated along the vein branch to the fibular end of the great toe to the tip. The dorsal metatarsal artery and plantar metatarsal artery as well as the fibular plantar digital artery of the great toe emitted after anastomosis are dissociated at the toe web. After dissociating the artery and nerve of the fibular plantar of the great toe, the transverse artery is cut and ligated, and the nerve bundle of the artery and nerve bundle is further dissociated distally to the proximal end of the flap. The skin is cut along the design line in the toe pulp, and several superficial toe veins are carefully dissociated proximally for 1–2 cm before being cut off for use. The subcutaneous tissue of the toe pulp is further cut deep to the fibular side of the bone. Cut the toenail on the tibial side and proximal side to the periosteum according to the design line. With a fine milling drill cutting the dorsal side and tibial side of the bone, a bone knife separates the bone cortex of the fibular and tibial sides, together with part of the toenail and the flap. The plantar digital artery and nerve of the great toe should be cut off at the appropriate length. (b) Reconstruction of types II and III finger defect: The dorsal digital vein of the great toe is dissociated on the dorsum of the great toe and dissociated proximally to an appropriate length before being cut off, and then dissociated along the vein branch to the fibular end of the great toe to the tip. The dorsal metatarsal artery and plantar metatarsal artery as well as the fibular plantar digital artery of the great toe emitted after anastomosis are dissociated at the toe web. After dissociating the artery and nerve of the fibular plantar of the great toe, the transverse artery is cut and ligated. The skin is cut along the design line in the toe pulp, and the flap is dissociated

17.4 Reconstruction of Degloving Defects of Fingers

subcutaneously to the fibular side of the bone. According to the design line, the tibial side of the toenail is cut to the periosteum, and the dorsal bone cortex of the phalanx is cut with a milling cutter. The dorsal toe flap is lifted distally from the surface of the periapendoneum to the insertion point of the extensor digitorum longus tendon. A fine milling cutter is used to cut the dorsal phalangeal cortex and tibial cortex far from the extensor longus tendon. The dorsal phalangeal cortex is separated from the tibial plantar cortex with a bone knife, and part of the toenails and the flap are dissociated together. The fibular plantar artery and nerve of the great toe should be cut off at the appropriate place. The phalanges in the composite tissue flap are trimmed, and the length is measured. If the length could not reach the required length of the reconstructed finger, the iliac bone or allograft bone should be taken for reserve. For those requiring repair of the distal interphalangeal joint, the second interphalangeal joint is grafted. (c) Reconstruction of type IV finger defect: The flap should be removed through the designed incision at the great toe and the second toe as the donor site. The dorsal metatarsal flap is cut open to expose the superficial dorsal metatarsal vein and dissociated distally to the dorsum of the great toe and second toe to find the main superficial veins as the return veins. Dissociate the deep peroneal nerve, the first dorsal metatarsal artery, the first plantar metatarsal artery, the fibular proper plantar digital artery and nerve of the great toe, and the tibial proper plantar digital artery and nerve of the second toe. If the first dorsal metatarsal artery is absent or thin, the longer plantar metatarsal artery can be cut as a tissue flap artery. The incision is extended to the dorsal side and the plantar side, respectively, and the extensor longus tendon, deep and superficial flexor tendons of the second toe are dissociated. The length of the tendon is determined according to the condition of the recipient site. The toenail flap is cut according to the designed width of the nail and osteotomy is performed on the proximal end of the toenail root of the terminal tarsal toe, so that the phalanx of the terminal toe can be attached to the toenail flap. Then carefully dissociate and cut the composite tissue flap of the proximal interphalangeal joint of the second toe with the middle segment and the proximal phalangeal bone. A suitability length iliac bone strip is cut behind the anterior superior iliac spine 2 cm from the iliac crest. Before suturing the skin, according to the condition of the

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skin defect of the donor's foot, cut the appropriate size of spindle-shaped strip along the incision, and then pull it together to suture the wound. If a free inguinal flap is required to repair a foot wound, dissociation of the flap should be performed before the iliac crest is removed. (d) Reconstruction of type V finger defect: The proximal phalanx body is missing in type V finger defect. It is necessary to take one more ilium bone and place it in the position of the proximal phalanx to solve the problem of the proximal phalanx defect. (e) Reconstruction of type VI finger defect: On the basis of the type IV defect, the ipsilateral or contralateral second metatarsophalangeal joint is transplanted to reconstruct the metacarpophalangeal joint. (f) Treatment of donor's foot: For the case with four toes retained, the residual toenail flap of the second toe can be combined with the great toe stump and internal fixation with Kirschner wire, and the skin is sutured. The dorsal metatarsal wound could be covered by free flaps or a free skin graft. The donor site of the toe joint can be filled with an iliac bone of the same size through Kirschner wire fixation. In the case of keeping five toes, foot flap or groin flap transplantation can be used to repair the donor wound.

Transplantation The great toenail skin is rolled into a tube and the proximal interphalangeal joint of the second toe should be placed in an appropriate position. The defect between the phalangeal bone in the joint and the great toenail flap is filled with iliac bone strips. A 1.0 mm diameter Kirschner wire is used to string the three together to form a new finger, which would be transplanted to the stump of the finger to be reconstructed. The great toenail flap can be transplanted with the second toe joint in the same pedicle, or the tibial plantar digital artery of the second toe can be cut off from the proximal starting point, and then the plantar artery of the second toe and the artery of the toenail flap can be anastomosed with the corresponding proximal proper digital artery respectively after being wrapped. Suture the extensor and flexor tendons with tendon threads. If the great toenail flap is successfully wrapped around the phalangeal artery without disconnection, the dorsal metatarsal artery (or plantar metatarsal artery) can be anastomosed with the ipsilateral proper digital artery or palmar digital artery of the reconstructed finger. If the artery is disconnected, the fibular plantar artery of the great toe and the tibial plantar artery of the second great toe

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can be anastomosed with the ipsilateral proper digital artery of the reconstructed finger, respectively. Then the veins of great toenail flap and the second toe are anastomosed with the superficial subcutaneous veins of the dorsal hand. Finally, the fibular plantar nerve of great toe and the tibial plantar nerve of the second great toe are anastomosed with corresponding proper digital nerves of the reconstructed finger.

Postoperative Treatment (a) After the operation, intensive nursing and close observation of the reconstructed finger should be carried out. (b) Routine treatment of "three antitherapy" after the operation.

17.4.4 Operation Characteristics (a) Repair skin soft tissue defect; (b) Repair nail bed defect and rebuild nail function; (c) Rebuilt the good appearance.

17.4.5 Announcements (a) Type II or Type III finger defects can be reconstructed by transplantation of the bone, toenail, and skin composite tissue of the fibular dorsal side of the great toe. The skin and toenail are sufficient, but the length of the toe bone is limited. It is better to bridge a segment of the ilium if it is not long enough. (b) The effect of reconstruction of the distal interphalangeal joint of type II or type III finger defect is limited we should be careful. (c) When cutting the toenail flap, do not separate the toenail and nail bed, try not to separate the bone and nail bed, so as not to affect the appearance of the reconstructed nail. (d) The diameter of the finger phalanx is small. When cutting the toe, the dorsal part of the phalanx should be cut according to the size of the finger phalanx, and the plantar part could be kept intact to reduce the damage to the function and appearance of the toe. The smaller toenail flap can be wrapped by matching the phalangeal of the finger with the smaller toe bone, reducing the design area of the flap and reducing the impact on the donor's toe. (e) In order to prevent the shrinkage of the reconstructed finger from becoming small, the design of the recon-

17 Special Types of Finger Reconstruction

structed finger should be about 1 cm longer than the circumference of the healthy finger, especially in the reconstruction of the thumb. (f) The grafted joint should be nerved and anastomosed with the sensory nerve of the recipient site to reduce the occurrence of postoperative osteoarthritis (g) The range of motion of the dorsal extension of the second metatarsophalangeal joint is obviously larger than the range of motion of the plantar-flexion. When the thumb and metacarpophalangeal joint are reconstructed, the range of motion should be adjusted appropriately according to the healthy side. If you want to increase the metatarsophalangeal range of motion, first extend the second metatarsophalangeal joint and then cross the string of Kirschner wires longitudinally, fix the metatarsophalangeal joint with the metacarpophalangeal joint as an extension position, and repair the joint shape appropriately.

17.4.6 Case Description Case 1 The 41-year-old male patient was admitted to the hospital for 2.5 h due to pain and bleeding of the right thumb caused by a bench drill injury. Physical examination: He was in good general condition, with stable vital signs. Large area of avulsed skin defect of the right thumb, avulsed skin was fragmentary, no replanting condition, a nail bed was present and function was limited. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. The thumb was reconstructed by a Siamese flap of the right great toe pulp, fibular dorsal flap of the proximal segment and dorsal flap of the proximal segment of the second toe transplantation under general anesthesia in an emergency, and the donor site was covered by a free skin graft. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. Twenty-four months after the operation, the reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.8).

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Fig. 17.8 Reconstruction of degloving defect of the right thumb by Siamese flap transplantation. (a) Preoperative condition of finger defect. (b) Preoperative design of the donor site (dorsal side). (c) Preoperative design of the donor site (plantar side). (d) Preoperative design of the fibular flap of the great toe. (e) Dissociation of the flap. (f)

The dissociated flap. (g) Blood vessels distribution of the flap. (h) The wound of the donor foot. (i) The dorsal view of the reconstructed thumb after the operation. (j) The radial view of the reconstructed thumb after the operation. (k) The palmar view of the reconstructed thumb after the operation. (l) The donor site covered by free skin graft

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17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger Transpositional replantation is also known as heterotopic replantation and transpositional reconstruction. When the hand is severely traumatized, the severed finger is partially damaged and partially intact, but it is unconditionally for orthotopic replantation. In order to restore the partial function of the hand as much as possible, the relatively intact finger body will be retained for waste reuse and replanted in the required site according to the functional needs. In order to maximize the reconstruction of the function and utility of the hand, the secondary operation can be avoided and the pain and burden of the patient can be relieved through replanting the less functional severed fingers to reconstruct the more functional important fingers or reconstructing at the proximal limb.

17.5.1 Indications (a) The patient is young and physically able to endure a long operation; (b) for patients with higher requirements for finger aesthetics; (c) the damaged fingers, such as the palm and finger body, are partially damaged, and some of them retain relatively complete organizational structure, which has certain survival conditions.

17.5.2 Surgical Design Doctors through agile clinical thinking and accurate microvascular anastomosis technology, after an accurate assessment of the damage situation, make full use of the hand injury mechanism of complex and serious multi-finger amputation, or distal limb damage. As a result, orthotopic replantation cannot be performed, or even after orthotopic replantation, the main functions of fingers such as pinching, clamping, grasping, and holding cannot be well restored. Transpositional replantation of the relatively intact residual fingers, and finally the relatively satisfactory appearance and function can be achieved.

17.5.3 Surgical Method (a) For patients with severed thumbs and unable to orthotopic replantation, transpositional replantation of thumb should be given priority, followed by the order of index finger, middle finger, ring finger, and little finger.

17 Special Types of Finger Reconstruction

(b) When selecting the replantation of the severed body, focus on the nearby part of the joint, and the complete joint is better. Phalangeal diameter is different, which is correspondingly larger than the thumb. In the use of Kirschner wire fixation should pay attention to the dorsum which should be flat while the dorsal digital vein anastomosis will have a good vascular bed. (c) When performing debridement, the tissue should be preserved as much as possible, so that the amputated body would not be too short due to debridement. The dissociation of the blood vessels and nerves of the broken end should not be too long to avoid pulling and extraction while the length of the phalanx should be more than 0.5 cm shorter than the soft tissue such as tendons, blood vessels, nerves, and skin. (d) Bone fixation can be performed by longitudinal Kirschner wire, “8” shaped steel wire, and screw fixation. In practice, Kirschner wire longitudinal fixation is simple and reliable that can save operation time, although it may affect postoperative joint movement. (e) The first choice is to suture the extensor or flexor tendon that is less injured than the tendon of the amputated finger. Attention should be paid to the appropriate tension, do not angle and discount, 3-0 noninvasive needle suture is used. A deep fascia could be lined in the tendon repair bed to separate the tendon from the bone junction to avoid adhesion at the bone fixation site. (f) Proximal veins are easy to be found, mostly dorsal while the veins of the severed finger are also on the dorsum of the hand or finger. During the anastomosis, 10–12 stitches can be performed end-to-end anastomosis with the distal vein with the appropriate diameter. The radial or ulnar artery is selected to anastomosed with the common digital artery or digital artery of the ectopic replantation finger. However, in the arterial anastomosis, no matter with the common digital artery or digital artery anastomosis, there are difficulties in diameter disparity, which can use the end-to-side method, vascular insertion method and other suture methods to be solved. In addition, if the vessels cannot be directly anastomosed d uring the operation, the arteriovenous reconstruction should be performed by grafting the residual vein or bridging the forearm vein. (g) Special attention should be paid to nerve repair, as it is important for a finger to be successfully replanted to restore satisfactory function. The nerves on both sides should be anastomosed as far as possible, and early recovery is conducive to the recovery of pinching function and early functional exercise. If the nerve defect cannot be directly anastomosed, the healthy residual

17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger

nerve or sural nerve can be transplanted to reconstruct the sensory function of the finger. (h) Skin suture should not be too tight, and an indwelling rubber tablet should be placed for drainage to avoid local bleeding or hematoma forming pressure on venous return which can be removed 48 h after the operation. When dressing, attention should be paid to maintaining an opponens position and braking with the front and back plaster braces.

17.5.4 Postoperative Treatment (a) After the operation, intensive nursing and close observation of the reconstructed finger should be carried out. (b) Routine treatment of “three antitherapy” after the operation.

17.5.5 Operation Characteristics After the hand suffered from severe trauma, the severed finger, such as the palm and finger, is partially damaged, and some remaining is relatively intact, which is unconditionally for orthotopic replantation. In order to restore the partial function of the hand as much as possible, the relatively intact finger body will be retained for waste reuse and replanted in the required area according to the functional needs. The function and utility of the hand can be reconstructed to the greatest extent by replanting the inferior severed fingers in the position of the relatively important fingers, or by reconstructing part of the hand appearance at the proximal limb.

17.5.6 Announcements (a) The mechanism of injury and the condition of the wound must be understood, and the prognosis of replantation surgery should be determined by an experienced physician. (b) For such patients with severe finger body compression and pollution, it is very important to completely remove the inactive tissue and not to remove too much normal tissue during emergency debridement, which is very important to prevent infection and ensure the success of the surgery. (c) In the operation of heterotopic explanation, when the amputated fingers are not separated, it should be noted that there are thick veins near the dorsal web when dividing the fingers.

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(d) During vascular anastomosis, the needle distance and edge distance must be uniform and accurate, and the knot should be lifted gently to prevent the anastomosis from turning inside. The operation should be steady, light, and fast. (e) The problem of the different sizes of the finger and the diameter of the blood vessel will appear in the proximal and distal ends. It should be adjusted and matched appropriately according to its anatomical characteristics, and a variety of vascular anastomosis methods should be adopted. (f) Survival after replantation is not the only indicator of successful replantation. “success” should be defined as a return to the good appearance and function of the affected hand. Therefore, after the replanted finger is survived, functional exercise should begin. (g) Postoperative nursing is the most important, must let the patient actively cooperate with the treatment, in order to obtain the best effect. Careful treatment of drugs, avoiding multi-drug combinations.

17.5.7 Case Description Case 1 The 38-year-old female patient was admitted to the hospital for 1 h due to pain and bleeding of the left hand caused by an injection molding machine in hurty. Physical examination: She was in good general condition, with stable vital signs. The left wrist joint was severely defective, only the thumb and the body structure from the distal to the proximal segment of the ring and little fingers remained intact, skin and soft tissue avulsion defect of the left wrist, palm, and second to third fingers, multiple fractures, irregular edges of the tendons, blood vessels, nerves, bleeding, and the residual fingers were without blood supply. After debridement under anesthesia, the remained thumb, ring finger, and little finger were trimmed and then transpositionally replanted to the metacarpus and radius, and fixed with ø1.0 mm Kirschner wire. The tendons, blood vessels, and nerves were anastomosed for repair. The operation was successful, after the tourniquet relaxed, the reconstructed fingers were ruddy with moderate tension, wrapped with the sterile cotton, bulked, and stuffed with the broken cotton gauze around, and she returned to the ward safely. Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed fingers survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.9).

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Fig. 17.9 Reconstruction of the left wrist defect by transpositional replantation of the residual thumb, ring finger, and little finger. (a) Preoperative lateral view of hand defect. (b) Preoperative palmar view of hand defect. (c) The palmar view of the reconstructed hand after the operation. (d) The radial view of the reconstructed hand after the opera-

tion. (e) Preoperative X-ray. (f) Postoperative X-ray. (g) The reconstructed fingers survived 2 weeks after the operation. (h) The extensor function of the reconstructed fingers 15 months after the operation. (i) The holding function of the reconstructed fingers 15 months after the operation

Case 2 The 20-year-old male patient was admitted to the hospital for 1.5 h due to pain and bleeding in the right hand caused by a chainsaw injury. Physical examination: He was in good general condition, with stable vital signs. Longitudinal oblique wound on the right hand, fingertip defect of the index finger, the middle finger was defected from distal to middle plane of the proximal segment, the ring and little fingers were amputated, and only partial of the skin of the ulnar side of the palm connected, and the amputated finger bodies were complete without blood supply. Irregular ends of fractures, tendons, blood vessels, and nerves could be seen in the wound surface that was bleeding, and the residual fingers had no blood supply. After debridement under anesthesia, the remained ring finger and little finger were trimmed and then transpositionally reconstructed the

middle and ring fingers, and fixed with ø1.0mm Kirschner wire. The tendons, blood vessels, and nerves were anastomosed for repair. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.10). Case 3 The 46-year-old male patient was admitted to the hospital for 1 h due to pain and bleeding of the right hand caused by hot stamping of mold. Physical examination: He

17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger

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Fig. 17.10 Reconstruction of the right middle and ring fingers by transpositional replantation of the residual ring finger and little finger. (a) Preoperative palmar condition of hand defect. (b) Preoperative dorsal condition of hand defect. (c) Preoperative X-ray. (d) Postoperative X-ray. (e) The palmar view of the reconstructed hand after the opera-

tion. (f) The dorsal view of the reconstructed hand after the operation. (g) The palmar view of the reconstructed hand 12 months after the operation. (h) The dorsal view of the reconstructed hand 12 months after the operation. (i) The flexor function of the reconstructed hand 12 months after the operation

was in good general condition, with stable vital signs. A longitudinal wound on the right palm (from the second finger web to the ulnar rasceta), about 7 × 2 cm, with avulsions of skin and soft tissue from the proximal segment of thumb with traces of hot pressure, proximal segment defect of the index finger (severe destruction of metacarpophalangeal joint), and complete from distal part of proximal segment of the ring finger without blood circulation. Fracture masses, tendons, blood vessels, and broken ends of nerves can be seen in the wound, with irregular wound margins, bleeding, and poor blood supply of third to fifth fingers. After debridement under anesthesia, the remained middle segment of the index finger was trimmed and then transpositionally reconstructed the thumb, and fixed with ø1.0 mm Kirschner wires. The tendons, blood vessels, and nerves were anastomosed

for repair. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.11). Case 4 The 53-year-old male patient was admitted to the hospital for 3 h due to pain and bleeding in the right hand caused by a Lathe injury. Physical examination: He was in good general condition, with stable vital signs. The proximal segment of the index finger is destructively severed from the transverse palmar stria of the right hand. The structure of the

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17 Special Types of Finger Reconstruction

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Fig. 17.11 Reconstruction of the right thumb by transpositional replantation of the residual index finger. (a) Preoperative palmar condition of hand defect. (b) Preoperative palmar condition of hand defect. (c) Preoperative dorsal condition of hand defect. (d) The palmar view of the reconstructed hand after the operation. (e) The dorsal view of the

reconstructed hand after the operation. (f) The palmar view of the reconstructed hand 3 months after the operation. (g) The dorsal view of the reconstructed hand 3 months after the operation. (h) Preoperative X-ray. (i) Postoperative X-ray

severed middle and little fingers was relatively intact and connected by the tendons, blood vessels, and nerves torn from the proximal end. Multiple skin contusions, tendon, blood vessel, and the nerve torn seriously of the ring finger. Most of the ulnar side of the palm was defective, and serious defects from the wrist. The thumb and first finger web were intact. Fracture masses, tendons, blood vessels, and broken ends of nerves can be seen in the wound, with irregular wound margins, and bleeding. The residual fingers were without blood supply. After debridement under anesthesia, the remained ring finger and little finger were trimmed and

then transpositionally reconstructed the middle and ring fingers, and fixed with ø1.0mm Kirschner wire. The tendons, blood vessels, and nerves were anastomosed for repair. The operation was successful, after the tourniquet relaxed, the reconstructed fingers 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. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed fingers were satisfactory (Fig. 17.12).

17.5 Reconstruction of Finger Defects by Transpositional Replantation of Ampuated Finger

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Fig. 17.12 Reconstruction of the right-hand function by transpositional replantation of the residual middle finger and little finger. (a) Preoperative palmar condition of hand defect. (b) Preoperative dorsal condition of hand defect. (c) Preoperative X-ray. (d) Postoperative X-ray. (e) The palmar view of the reconstructed hand 2 weeks after the

operation. (f) The dorsal view of the reconstructed hand 2 weeks after the operation. (g) The palmar view of the reconstructed hand 18 months after the operation. (h) The dorsal view of the reconstructed hand 18 months after the operation. (i) The flexor function of the reconstructed hand 18 months after the operation

Case 5 The 26-year-old male patient was admitted to the hospital in emergency due to pain and bleeding of the right hand caused by a punch injury. Physical examination: He was in good general condition, with stable vital signs. In the right hand, the thumb was missing, the index finger was amputated, and the first and second metacarpal bones and their skin and soft tissue were defective. After debridement under anesthesia, the remained index finger was trimmed and then transpositionally reconstructed the thumb, and fixed with ø1.0 mm Kirschner wire. The first finger web was

repaired by distal radial artery perforator flap of the ipsilateral foreare, and the donor site was covered by a free skin graft. The operation was successful, after the tourniquet relaxed, the reconstructed finger was 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. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.13).

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Fig. 17.13 Reconstruction of the right thumb by transpositional replantation of the residual index finger. (a) Preoperative palmar condition of hand defect. (b) Preoperative dorsal condition of hand defect. (c) Preoperative condition of the index finger. (d) The palmar view of the reconstructed thumb after the operation. (e) Design of the flap. (f)

Dissociation of the flap. (g) The palmar view of the reconstructed hand 15 days after the operation. (h) The dorsal view of the reconstructed hand and donor site 15 days after the operation. (i) The dorsal view of the reconstructed hand and donor site 6 months after the operation. (j) The function of the reconstructed hand 6 months after the operation

17.6 Temporary Heterotopic Replantation (Reconstruction) of Severed Fingers

17.6 Temporary Heterotopic Replantation (Reconstruction) of Severed Fingers When the finger is amputated, the integrity of the distal part of the finger is good while the proximal part is unconditionally replanted due to serious injury or poor general condition, the distal part of the finger can be temporarily heterotopic replanted in other parts of the body. The healthy arteries and veins in this part provide a stable blood supply and nutrition for the severed finger body temporarily. After the general condition and the proximal injury, the wound improves, the heterotopic replanted finger body will be transplanted back to the original position, and the purpose of recovering the appearance and function of the finger body would be achieved by repairing the blood vessels, nerves, bones, tendon and other tissues of the finger body. This method of replantation is called temporary heterotopic replantation. In 1986, Godina et al. (1986) proposed that the chest wall could be the accepting site for severed limbs when the proximal limbs were not in a good condition, which made microsurgery feasible for ectopic implantation. Chernofsky and Sauer (1990) ectopically transplanted a severed limb forearm to the abdomen and successfully replanted it to the in-situ position after 11 weeks in 1990. Hallock (1992) suggested that the upper abdominal blood vessels could be used to keep a single severed finger alive. Miao Kaixi successfully hetertopically implanted the second to fifth fingers with finger webs to the foot back in 1992. Gao Weiyang carried out the successful hetertopically implantation of a severed finger to the groin in 1996. This method, of course, expands the indications for the replantation of severed fingers, which can save the functions of the hand as far as possible.

17.6.1 Indications (a) The patient is young; (b) Be physically able to endure a long operation; (c) For patients with higher requirements for finger aesthetics; (d) The injured hand or fingers are partially damaged, which means partial tissue structure is relatively complete, and there are blood vessels, nerves and other survival conditions for anastomosis.

17.6.2 Surgical Design First of all, doctors should judge the damaged situation and make an accurate assessment based on their own quick thinking and exquisite micro-vascular anastomosis technology. Due to serious hand injury and pollution, it leads to unconditional emergency orthotopic replantation, or even if pinch-

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ing, clamping, grasping, and grasping cannot be ensured successfully after orthotopic replantation. Emergency heterotopic replantation of the residual limb. Temporary blood circulation and other supplies were obtained to ensure the effective survival of the residual finger. After 2 weeks, the body was restored to a stable state, and the surviving residual limb was transplanted back to its original position again. In severe cases, tissue transplantation was required to cooperate with repair and reconstruction, so as to achieve the reconstruction of relatively satisfactory limb morphology and function.

17.6.3 Surgical Method (a) The operation should be carried out in groups, one group to take the debridement for the proximal and distal parts of the severed finger, the other group to design the accepting site, flap, repair the ectopic finger, etc. (b) The diameter of the accepting vessel and the heterotopic finger vessel should be the same and the anastomosis should be performed under a ×8 microscope. (c) The nerves can be matched in the second phase. (d) Depending on the soft-tissue defect, the finger could be ectopically replanted with some soft tissue. If the soft- tissue defect is to be repaired with an adjacent tissue flap, pedicle amputation should be carried out. (e) Design the incision at the accepting site and separate the vessels that should be anastomosed under a microscope according to the principle of an arteriovenous ratio of 1:2. The vascular defect can be solved by vessel transplantation. (f) Find the nerve end in the severed finger and anastomose it with the nerve at the accepting site. (g) Repair the soft-tissue defect with the flap of the ectopic implantation site.

17.6.4 Postoperative Treatment (a) After the operation, intensive nursing and close observation of the reconstructed finger should be carried out. (b) Routine treatment of “three antitherapy” after the operation.

17.6.5 Operation Characteristics After severe trauma, part of the severed hand, finger, and other parts are damaged and relatively intact. Such injury and pollution lead to unconditional direct in-situ reconstruction in an emergency.

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In order to restore the function of the injured hand as much as possible, the residual limbs should be selected for temporary heterotopic replantation where is convenient.

17.6.6 Announcements 1. In the case of completely severed fingers combined with a serious compound injury that cannot tolerate long-term replantation surgery, the fingers can be hetertopically implanted after debridement and replanted in a second phase. 2. Ectopic implantation should be considered when the important finger is completely severed, whose distal part is complete, and the proximal is seriously damaged. Replantation in situ or transposition is not permitted; otherwise, the function will not be good. 3. The principle for the choice of accepting site is: (a) The location is concealed and the effect is small. (b) It is easy to fix the severed finger. The diameter of the accepting vessel and the heterotopic finger vessel should be the same, constant, easily separated, and obtained. There should be a nerve for anastomosis that does not affect body function. (c) There should be a flap to repair the soft tissue defect. (d) The most commonly used sites are the abdomen, the thigh, the calf, etc.

17.6.7 Case Description Case 1 The 25-year-old male patient was admitted to the hospital for 2 h due to pain and bleeding of destructive avulsion of the skin and soft tissue of the left hand caused by high-speed machine injury. Physical examination: He was in good general condition, with stable vital signs. Large area of skin and soft tissue defect of left forearm and hand, second to fifth fingers defect, skin defect of the thumb, only nail bed remained, bone exposed, seriously polluted. The avulsed skin and soft tissue were fragmentary, and the avulsed blood vessels, nerves, and tendons were like hemp silk, with serious pollution and no conditions for replanting. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. Wound debridement and VSD operation were performed under general anesthesia in emergency. Two weeks after the operation, the wound was expanded under general anesthesia at a selected time. The design of the donor sites of iliac abdomen,

17 Special Types of Finger Reconstruction

bilateral thigh, and foot was performed. The left iliac abdominal flap, the bilateral anterolateral thigh flaps, the great toenail flap combined with dorsal foot flap and the second toe were taken to repair the wound and reconstruct finger function. During the operation, vascular series anastomosis was adopted, and the free tissue of the foot was hetertopically replanted with vascular pedicle to foster and reconstruct the finger. After the foster thumb survived, vascular pedicle amputation of the thumb was performed under general anesthesia in the second stage. Routine reconstruction treatment was given after the operation. The reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.14). Case 2 The 18-year-old male patient was admitted to the hospital for 2 h due to pain and bleeding of destructive avulsion of the skin and soft tissue of the left thumb caused by noodle press. Physical examination: He was in good general condition, with stable vital signs. The left thumb was torn off from the metacarpophalangeal joint, and the digital nerves and digital arteries were pulled out about 3cm from the proximal end. The flexor tendon was continuous; the distal finger body was intact. The skin of the proximal palm was exfoliated and partially missing, and there was no anastomosis condition for the proximal arteries and veins. After admission, the skin with mild proximal contusion was replanted in situ, and the pedicled abdominal flap (6 × 8 cm) was designed to repair the dorsal defect of the hand. At the same time, the distal intact finger body was transferred and anastomosed to the radial side of the proximal segment of the right index finger for temporary heterotopic replantation. Three weeks after the operation, the left thumb was reconstructed by the surviving foster finger under general anesthesia in the second stage. Routine reconstruction treatment was given after the operation. The reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise for 12 months. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.15). Case 3 The 34-year-old female patient was admitted to the hospital for 8 h due to pain and bleeding of the severed left thumb caused by a rapidly working machine. Physical examination: she was in good general condition, with stable vital signs. After the dressing was opened, it was found that the left thumb was missing, the wound surface was seriously polluted and bleeding slowly, and the skin defect of the stump of the thumb was accompanied by bone exposure. The

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Fig. 17.14 Reconstruction of the left forearm and left hand avulsed wound by temporary heterotopic replantation of the second toe. (a) Preoperative condition of the left upper limb. (b) Preoperative design of the donor’s foot. (c) Preoperative design of the left iliac abdominal flap, the bilateral anterolateral thigh flaps. (d) Dissociation of the great toenail flap and the second toe. (e) Dissociation of the left anterolateral thigh flap. (f) Dissociation of the right anterolateral thigh flap. (g)

Temporary heterotopic reconstruction. (h) The appearance of the reconstructed hand 4 weeks after the operation. (i) The appearance of the reconstructed hand 16 months after the operation. (j) The appearance of the reconstructed hand 16 months after the operation. (k) The function of the reconstructed hand 30 months after the operation. (l) Working condition of the affected limb 30 months after the operation

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Fig. 17.15 Reconstruction of the left thumb by temporary heterotopic replantation of the residual finger body in the second stage. (a) Preoperative radial condition of the left thumb. (b) Preoperative palmar condition of the left thumb. (c) Preoperative dorsal condition of the left thumb. (d) Preoperative X-ray. (e) Temporary heterotopic replantation

in emergency. (f) The survived foster finger 3 weeks after the operation. (g) The appearance of the first web space 1 year after the operation. (h) The abduction function of the reconstructed finger 1 year after the operation. (i) The opponens function of the reconstructed finger 1 year after the operation

skin defect area was about 3 × 4 cm. The severed finger was wrapped and preserved with gauze, the finger abdomen and fingernail were black, the skin and soft tissue were avulsed to the interphalangeal joint, and the interphalangeal joint was committed fracture. The flexor pollicis longus tendon and extensor pollicis longus tendon were avulsed about 25 cm, and bilateral digital nerves were avulsed about 8 cm. The avulsion of bilateral digital proper arteries was about 4 cm, and the avulsed vessels, nerves, and tendons were seriously polluted. After admission, routine preoperative preparation for reconstruction was given, and surgical contraindications were excluded. Wound debridement and VSD operation were performed under general anesthesia in an emergency. The severed finger was connected to the anterolateral thigh

perforator flap to complete temporary heterotopic replantation. The left thumb was reconstructed by the surviving foster finger combined with the composite anterolateral thigh flap under general anesthesia in the second stage. Routine reconstruction treatment was given after the operation. The reconstructed finger survived successfully. Regular followup was conducted to guide functional exercise for 12 months. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.16). Case 4 The 39-year-old male patient was admitted to the hospital for 8 h due to pain and bleeding of the severed left thumb caused by a machine. Physical examination: He was in good general condition, with stable vital signs. Defect of

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Fig. 17.16 Reconstruction of the left thumb by temporary heterotopic replantation of the residual finger body. (a) Preoperative condition of the left thumb. (b) The situation of the left thumb after debridement. (c) The design of temporary heterotopic replantation. (d) Dissociation of the flap. (e) Soft tissue defect of the thumb repaired by the flap. (f) Blood supply of the foster finger. (g) VSD. (h) The situation of the

foster finger 15 days after the operation. (i) Dissociation of the foster finger. (j) The appearance and flexor function of the reconstructed thumb 1 year after the operation. (k) The function of the reconstructed hand 1 year after the operation. (l) The appearance of the donor site 1 year after the operation

skin and soft tissue from the distal ulnar side of the right forearm to the first finger web space, comminuted fracture of the distal ulna; open fracture of the right thumb, and relatively intact dorsal skin; the right index and middle fingers were torn and severed at the metacarpophalangeal joint. The distal finger bodies were relatively complete and connected with the finger web, and the metacarpophalangeal joints were damaged. The fourth and fifth metacarpal bones were

damaged from the base and the wound surface was seriously polluted. There was no condition for orthotopic replantation. Debridement was performed and the index and middle fingers were transferred to the dorsum of the right foot under brachial plexus epidural anesthesia in an emergency. After a blood transfusion, the foster fingers were ruddy in color. The right forearm and hand were covered by VSD after debridement. A free anterolateral thigh flap was transplanted to

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Fig. 17.17 Reconstruction of the fight hand by temporary heterotopic replantation of the residual finger bodies in the second stage. (a) Preoperative palmar condition of the right hand. (b) The residual part of the thumb. (c) The appearance of the right hand after debridement. (d) Preoperative X-ray. (e) Temporary hetertopic replantation. (f) The sur-

vived foster fingers 3 weeks after the operation. (g) X-ray of the foster fingers. (h) The appearance of the right hand after VSD treatment. (i) The design of the flap. (j) Wound repair by the flap. (k) Temporary heterotopic reconstruction. (l)The appearance of the reconstructed hand 1 month after the operation

repair the wounds of the forearm and hand at an elective time. After the wounds healed, the thumb and index finger were reconstructed by the foster index finger and middle finger, respectively. Routine reconstruction treatment was given after the operation. The reconstructed finger survived successfully. Regular follow-up was conducted to guide functional exercise. The appearance and function of the reconstructed finger were satisfactory (Fig. 17.17).

Further Reading Foucher G, Nagel D. "Custom-made" toe transfer for partial thumb amputation. Tech Hand Up Extrem Surg. 1998. 2(3): 210-20. Upton J, Mutimer K. A modification of the great-toe transfer for thumb reconstruction. Plast Reconstr Surg. 1988. 82(3): 535-8. Lin PY, Sebastin SJ, Ono S, Bellfi LT, Chang KW, Chung KC. A systematic review of outcomes of toe-to-thumb transfers for isolated traumatic thumb amputation. Hand (N Y). 2011. 6(3): 235-43.

Further Reading May JW. Aesthetic and functional thumb reconstruction: great toe to hand transfer. Clin Plast Surg. 1981. 8(2): 357-62. Hirasé Y, Kojima T, Matsui M. Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers. Plast Reconstr Surg. 1997. 99(3): 774-84. Vitkus K. Aesthetic reconstruction of long fingers with toe-to-hand transfer. J Reconstr Microsurg. 1988. 4(5): 369-80. Cheng G, Fang G, Hou S, et al. Aesthetic reconstruction of thumb or finger partial defect with trimmed toe-flap transfer. Microsurgery. 2007. 27(2): 74-83. Wei FC, Chen HC, Chuang DC, Jeng SF, Lin CH. Aesthetic refinements in toe-to-hand transfer surgery. Plast Reconstr Surg. 1996. 98(3): 485-90. de Oña I R, Garcia VA, de Oya A S. An Alternative Thumb Reconstruction by Double Microsurgical Transfer From the Great and Second Toe for a Carpometacarpal Amputation. J Hand Surg Am. 2018. 43(10): 955.e1-955.e9. Zhang G, Ju J, Li L, Tang L, Fu Y, Hou R. Combination free foot flaps for digit reconstruction: A retrospective analysis of 37 cases. J Plast Reconstr Aesthet Surg. 2019. 72(5): 729-736. Wei FC, Colony LH, Chen HC, Chuang CC, Noordhoff MS. Combined second and third toe transfer. Plast Reconstr Surg. 1989. 84(4): 651-61. Strauch RJ, Wei FC, Chen SH. Composite finger metacarpophalangeal joint reconstruction in combined second and third free toe-to-hand transfers. J Hand Surg Am. 1993. 18(6): 972-7. Woo SH, Lee GJ, Kim KC, Ha SH, Kim JS. Cosmetic reconstruction of distal finger absence with partial second toe transfer. J Plast Reconstr Aesthet Surg. 2006. 59(4): 317-24. Kang QL, Chai YM, Chen W, Zeng BF. Digital reconstruction and donor site resurfacing: a two-flap technique. Microsurgery. 2007. 27(5): 470-6. Kim HS, Lee DC, Kim JS, et al. Donor-Site Morbidity after Partial Second Toe Pulp Free Flap for Fingertip Reconstruction. Arch Plast Surg. 2016. 43(1): 66-70. Leung PC. Double toe transfers. J Hand Surg Br. 1987. 12(2): 162-5. Del PF. Extreme Thumb Losses: Reconstructive Strategies. Plast Reconstr Surg. 2019. 144(3): 665-677. Hahn SB, Park HJ, Kang HJ, Kang ES. Finger reconstruction with a free neurovascular wrap-around flap from the big toe. J Reconstr Microsurg. 2001. 17(5): 319-23. Chen HC, Tang YB, Wei FC, Noordhoff MS. Finger reconstruction with triple toe transfer from the same foot for a patient with a special job and previous foot trauma. Ann Plast Surg. 1991. 27(3): 272-7. Koshima I, Kawada S, Etoh H, Saisho H, Moriguchi T. Free combined thin wrap-around flap with a second toe proximal interphalangeal joint transfer for reconstruction of the thumb. Plast Reconstr Surg. 1995. 96(5): 1205-10. Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969. 51(4): 677-9. Rui Y, Mi J, Shi H, Zhang Z, Yan H. Free great toe wrap-around flap combined with second toe medial flap for reconstruction of completely degloved fingers. Microsurgery. 2010. 30(6): 449-56. Schenker M, Kelley SP, Kay SP. Free hand-to-toe transfer: a method to minimise donor-site morbidity in free joint transfers. Br J Plast Surg. 2003. 56(1): 57-9. Zhang J, Xie Z, Lei Y, Song J, Guo Q, Xiao J. Free second toe one- stage- plasty and transfer for thumb or finger reconstruction. Microsurgery. 2008. 28(1): 25-31. Daniel RK, Weiland AJ. Free tissue transfers for upper extremity reconstruction. J Hand Surg Am. 1982. 7(1): 66-76. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toe transfer for thumb and finger reconstruction in 300 cases. Plast Reconstr Surg. 1993. 91(4): 693-700; discussion 701-2.

279 O'Brien B, Gould JS, Morrison WA, Russell RC, MacLeod AM, Pribaz JJ. Free vascularized small joint transfer to the hand. J Hand Surg Am. 1984. 9(5): 634-41. Tsai TM, Lim BH. Free vascularized transfer of the metatarsophalangeal and proximal interphalangeal joints of the second toe for reconstruction of the metacarpophalangeal joints of the thumb and index finger using a single vascular pedicle. Plast Reconstr Surg. 1996. 98(6): 1080-6. Kuzu İM, Kayan RB, Öztürk K, Güneren E. Functional Improvement with Free Vascularized Toe-to-hand Proximal Interphalangeal (PIP) Joint Transfer. Plast Reconstr Surg Glob Open. 2018. 6(7): e1775. Wei FC, Seah CS, Chen HC, Chuang CC. Functional and esthetic reconstruction of a mutilated hand using multiple toe transfers and iliac osteocutaneous flap: a case report. Microsurgery. 1993. 14(6): 388-90. Lin CH, Lin YT, Sassu P, Lin CH, Wei FC. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg. 2007. 120(5): 1315-21. Ayyala HS, Condé-Green A, Datiashvili R. Great Toe-to-Thumb Hemi- Pulp Transfer. Eplasty. 2016. 16: ic33. May JW, Daniel RK. Great toe to hand free tissue transfer. Clin Orthop Relat Res. 1978. (133): 140-53. May JW, Bartlett SP. Great toe-to-hand free tissue transfer for thumb reconstruction. Hand Clin. 1985. 1(2): 271-84. Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases. Plast Reconstr Surg. 2004. 113(3): 882-92. Camporro D, González I, Martín C. Isolated second toe transfer after total amputation of the left fifth finger in a professional guitar player. J Hand Surg Eur Vol. 2014. 39(9): 1003-4. Wei FC, Coskunfirat OK, Lin CH, Lin YT. Isolated third-toe transfer: indications, technique, and reliability. Plast Reconstr Surg. 2005. 115(5): 1314-21; discussion 1322-4. Vitkus K, Vitkus M, Krivulin A. Long-term measurement of innervation density in second toe-to-thumb transfers receiving immediate postoperative sensory reeducation. Microsurgery. 1989. 10(3): 245-7. Hierner R, Berger AK. Long-term results after vascularised joint transfer for finger joint reconstruction. J Plast Reconstr Aesthet Surg. 2008. 61(11): 1338-46. Gu YD, Cheng DS, Zhang GM, Chen XM, Xu JG, Yang XB. Long-term results of toe transfer: retrospective analysis. J Reconstr Microsurg. 1997. 13(6): 405-8. Foucher G, Nagle DJ. Microsurgical reconstruction of fingers and fingertips. Hand Clin. 1999. 15(4): 597-606, viii. Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg. 1994. 93(2): 345-51; discussion 352-7. Adani R, Woo SH. Microsurgical thumb repair and reconstruction. J Hand Surg Eur Vol. 2017. 42(8): 771-788. Xu L, Gu YD, Xu JG, Rui YJ, Shou KS. Microsurgical treatment for bilateral thumb defect: five case reports. Microsurgery. 2003. 23(6): 547-54. Morrison WA. Microvascular nail transfer. Hand Clin. 1990. 6(1): 69-76; discussion 77. el-Gammal TA, Wei FC. Microvascular reconstruction of the distal digits by partial toe transfer. Clin Plast Surg. 1997. 24(1): 49-55. Foucher G, Moss AL. Microvascular second toe to finger transfer: a statistical analysis of 55 transfers. Br J Plast Surg. 1991. 44(2): 87-90. O'Brien B, MacLeod AM, Sykes PJ, Browning FS, Threlfall GN. Microvascular second toe transfer for digital reconstruction. J Hand Surg Am. 1978. 3(2): 123-33. Tsai TM, Falconer D. Modified great toe wrap for thumb reconstruction. Microsurgery. 1986. 7(4): 193-8. Ju JH, Hou RX. One-stage cosmetic finger reconstruction using a second toe island flap containing terminal branches of the toe artery. Orthop Traumatol Surg Res. 2015. 101(3): 345-51.

280 Cheema TA, Miller S. One-stage osteoplastic reconstruction of the thumb. Tech Hand Up Extrem Surg. 2009. 13(3): 130-3. Cong HB, Chang SM, Qiao YP, Wang CL, Sui HM, Cong L. One-stage reconstruction of complicated thumb injury with combination of microsurgical transplantations. Microsurgery. 2007. 27(3): 181-6. del PF, García-Bernal FJ, Delgado J, Regalado J, Sanmartín M, García- Fernández D. Overcoming soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis fasciosubcutaneous toe free flap: Surgical technique. J Hand Surg Am. 2005. 30(1): 111-9. Dautel G, Gouzou S, Vialaneix J, Faivre S. PIP reconstruction with vascularized PIP joint from the second toe: minimizing the morbidity with the "dorsal approach and short-pedicle technique". Tech Hand Up Extrem Surg. 2004. 8(3): 173-80. Lee DC, Kim JS, Ki SH, Roh SY, Yang JW, Chung KC. Partial second toe pulp free flap for fingertip reconstruction. Plast Reconstr Surg. 2008. 121(3): 899-907. Tsai TY, Fries CA, Hsiao JC, et al. Patient-Reported Outcome Measures for Toe-to-Hand Transfer: A Prospective Longitudinal Study. Plast Reconstr Surg. 2019. 143(4): 1122-1132. Salon A, Journeau P, Drape JL. Post-traumatic distal interphalangeal finger joint reconstruction using a free hemi-joint transfer from the fifth toe middle phalanx. J Pediatr Orthop B. 2005. 14(2): 116-9. Rose EH, Hendel P. Primary toe-to-thumb transfer in the acutely avulsed thumb. Plast Reconstr Surg. 1981. 67(2): 214-8. Leung PC. Problems in toe-to-hand transfers. Ann Acad Med Singapore. 1983. 12(2 Suppl): 377-81. Chi Z, Song DJ, Tian L, Hu FH, Shen XF, Chim H. Reconstruction of combined thumb amputation at the metacarpal base level and index amputation at the metacarpal level with pollicization and bilateral double toe composite transfer. J Plast Reconstr Aesthet Surg. 2017. 70(8): 1009-1016. Wong VW, Yousaf IS, Higgins JP, Katz RD. Reconstruction of digit planer injuries using component transfer of double second toes: A case report. Microsurgery. 2019. 39(4): 364-368. Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstr Surg. 1983. 71(3): 372-86. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg. 1988. 82(3): 506-15. Wei JN, Wang SH, Li YN. Reconstruction of the thumb. Clin Orthop Relat Res. 1987. (215): 24-31. Liu C, Liu L, Liu G, et al. Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study. J Orthop Surg Res. 2019. 14(1): 287. Kimata Y, Mukouda M, Mizuo H, Harii K. Second toe plantar flap for partial finger reconstruction. Plast Reconstr Surg. 1998. 101(1): 101-6. Cho BC, Lee DH, Park JW, Byun JS, Baik BS. Second toe to index finger transfer. Br J Plast Surg. 2000. 53(4): 324-30. Mitz V. Second toe to thumb transfer with extensor digitorum brevis opponensplasty. Ann Plast Surg. 1986. 17(3): 259-62. Tsai TM, McCabe S, Beatty ME. Second toe transfer for thumb reconstruction in multiple digit amputations including thumb and basal joint. Microsurgery. 1987. 8(3): 146-53. Yazici I, Cavusoglu T, Karakaya EI, Vural AC, Vargel I. Second toe- to-thumb transfer with transposition of the thumb stump to second finger. Injury. 2013. 44(6): 876-7. Graham D, Bhardwaj P, Sabapathy SR. Secondary Thumb Reconstruction in a Mutilated Hand. Hand Clin. 2016. 32(4): 533-547. Leung PC. Sensory recovery in transplanted toes. Microsurgery. 1989. 10(3): 242-4. Coskunfirat OK, Wei FC, Lin CH, Chen HC, Lin YT. Simultaneous double second toe transfer for reconstruction of adjacent fingers. Plast Reconstr Surg. 2005. 115(4): 1064-9.

17 Special Types of Finger Reconstruction Wei FC, Chen HC, Chuang CC, Noordhoff MS. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg. 1988. 81(3): 366-77. Wei FC, Yim KK. Single third-toe transfer in hand reconstruction. J Hand Surg Am. 1995. 20(3): 388-94; discussion 395-6. Koshima I, Etoh H, Moriguchi T, Soeda S. Sixty cases of partial or total toe transfer for repair of finger losses. Plast Reconstr Surg. 1993. 92(7): 1331-8; discussion 1339-41. Yu Z, Huang Y. Sixty-four cases of thumb and finger reconstruction using transplantation of the big toe skin-nail flap combined with the second toe or the second and third toes. Plast Reconstr Surg. 2000. 106(2): 335-41. Nakazawa H, Nozaki M, Kikuchi Y, Honda T, Isago T, Sasaki K. Successful reconstruction of the ring finger using a twisted toe flap. J Reconstr Microsurg. 2004. 20(8): 615-9; discussion 620. Lin YT. Technical keys in maximizing finger proximal interphalangeal joint motion after vascularized toe joint transfers. J Hand Surg Eur Vol. 2019. 44(7): 667-675. Hsu CC, CYY L, Kao D, Moran SL, Lin YT. The impact of transferred vascularized toe joint length on motion arc of reconstructed finger proximal interphalangeal joints: a cadaveric study. J Hand Surg Eur Vol. 2017. 42(8): 789-793. Valauri FA, Buncke HJ. Thumb and finger reconstruction by toe-to- hand transfer. Hand Clin. 1992. 8(3): 551-74. Foucher G, Binhamer P. Thumb reconstruction by micro-vascular techniques. Int Angiol. 1995. 14(3): 313-8. Leung PC. Thumb reconstruction using second-toe transfer. Hand Clin. 1985. 1(2): 285-95. Leung PC. Thumb reconstruction using second-toe transfer. Hand. 1983. 15(1): 15-21. Henry SL, Wei FC. Thumb reconstruction with toe transfer. J Hand Microsurg. 2010. 2(2): 72-8. Valauri FA, Buncke HJ. Thumb reconstruction--great toe transfer. Clin Plast Surg. 1989. 16(3): 475-89. Friedrich JB, Vedder NB. Thumb reconstruction. Clin Plast Surg. 2011. 38(4): 697-712. Ganske JG. Toe to hand transfer as an option for thumb reconstruction. Iowa Med. 1987. 77(12): 596-9. Demirkan F, Wei FC, Jeng SF, Cheng SL, Lin CH, Chuang DC. Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint. Plast Reconstr Surg. 1999. 103(2): 499-507. Chen H, Jiang C, Xu Y, Sun Y. Toe-to-finger combined with free flap transfer for primary one-stage post-traumatic reconstruction of the complex fingerless hand. J Plast Reconstr Aesthet Surg. 2017. 70(12): 1708-1714. Nishijima N, Yamamuro T, Fujio K. Toe-to-finger transfer combined with wrap-around flap: a new technique for four-finger amputation. J Hand Surg Am. 1995. 20(2): 213-7. Williamson JS, Manktelow RT, Kelly L, Marcuzzi A, Mahabir RC. Toe- to-finger transfer for post-traumatic reconstruction of the fingerless hand. Can J Surg. 2001. 44(4): 275-83. May JW, Smith RJ, Peimer CA. Toe-to-hand free tissue transfer for thumb construction with multiple digit aplasia. Plast Reconstr Surg. 1981. 67(2): 205-13. Raveendran SS, Syed M, Shibu M. Toe-to-hand transfer in a severely burned upper limb: a surgical dilemma. J Plast Reconstr Aesthet Surg. 2009. 62(11): e463-5. Yoshimura M. Toe-to-hand transfer. Plast Reconstr Surg. 1980. 66(1): 74-84. Gu YD, Zhang GM, Chen DS, Yan JG, Chen XM. Toe-to-hand transfer: an analysis of 14 failed cases. J Hand Surg Am. 1993. 18(5): 823-7. Yoshimura M, Nomura S, Yamauchi S, Umeda S, Ueno T, Iwai Y. Toe- to-hand transfer: experience with thirty-eight digits. Aust N Z J Surg. 1980. 50(3): 248-54.

Further Reading Gülgönen A, Gudemez E. Toe-to-hand transfers: more than 20 years follow-up of five post-traumatic cases. J Hand Surg Br. 2006. 31(1): 2-8. Wei FC, Jain V, Chen SH. Toe-to-hand transplantation. Hand Clin. 2003. 19(1): 165-75. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Reconstr Surg. 1991. 88(1): 149-53. Pisarek W. Transfer of the third, fourth and fifth toes for one-stage reconstruction of the thumb and two fingers. Br J Plast Surg. 1990. 43(2): 244-6. Sastre N, Caravantes MI, Mayoral-Garcia C. Two-stage toe-to-thumb reconstruction in pollicized second metacarpal and useless fingers. J Reconstr Microsurg. 1996. 12(7): 431-7. Chen HY, Lin YT, Lo S, Hsu CC, Lin CH, Wei FC. Vascularised toe proximal interphalangeal joint transfer in posttraumatic finger joint reconstruction: the effect of skin paddle design on extensor lag. J Plast Reconstr Aesthet Surg. 2014. 67(1): 56-62. Kim HS, Jeong TW, Park SH, Lee BI. Vascularized Partial Free Toe Tissue Transfer Under Local Anesthesia. Ann Plast Surg. 2015. 75(5): 539-42. Ellis PR, Hanna D, Tsai TM. Vascularized single toe joint transfer to the hand. J Hand Surg Am. 1991. 16(1): 160-8. Cheng G, Fang G, Hou S, et al.Aesthetic reconstruction of thumb or finger partial de'feet with trimmed toe—flap transfer. Mierosurgery 2007; 27: 74-83. Xing S, Shen Z, Jia W, et al. Aesthetic and functional results from nailfold recession following fingertip amputations[J]. J Hand SurgAm, 2015, 40(1): 1-7. https://doi.org/10.1016/j.jhsa.2014.09.010. Yu GR, Yuan F, Chang SM, et al Microsurgical second dorsal metacarpal artery cutaneous and tenOcutaneOus flap for distal finger reconstruction: anatomic study and clinical application. Microsurgery, 2005;25(1):30-35. Salon A, Journeau P, Drape JL Post⋅traumatic distal interphalangeal finger joint reconstruction using a free hemi-joint transfer from the fifth toe middle phalanx J Pediatr Orthop B 2005;14(2):116—119. Morrison WA, Obrim BM, Maeleod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg AM, 1980, 5(6): 575—583. Kimura N, Saitoh M, Hasumi T et al. A “sandwich toe” flap: a new strategy for reconstruction of the distal phalanx of the finger. Plast Reconstr Surg 2005; 1 16(1): 251-257 Yokoyama T, Hosaka Y, Kusano T, et al Finger palmar surface reconstruction using medial plantar venous flap: possibility of sensory restoration without neurorrhaphy. Ann Plast Surg 2006:57(5):552—556 Woo SH, Lee GJ, Kim KC.et al Cosmetic reconstruction of distal finger absence with partial second toe transfer. J Plast Reconstr Aesthet Surg 2006;59(4):317—324 Al Qattan MM.De—epithelialized cross-finger flaps versus adipofascial turnover flaps for the reconstruction of small complex dorsal digital defects:a comparative analysis.J Hand Surg Am 2005:30(3):549-557 Ishida O, Taniguchi Y, Sunagawa T, et al.Pollicization of the index finger for traumatic thumb amputation.Plast Reconstr Surg 2006; 1 17(3):909—914 Takeishi M, Ishida K, Kurihara K.Free dorsal middle phalangeal finger flap.J Reconstr Microsurg 2006;22(7):493-498. Josty IC, Laing JH, Dent C.Reconstruction of disruptions of the deep transverse metacarpal ligament of the ring finger using the A1 pulleys.J Hand Surg 2006;31(4):439-440. Cheng G, Fang G, Hou S, et al, Aesthetic reconstruction of thumb or finger partial defect with trimmed toe-flap transfer.Microsurgery 2007;2f21:74.83. Coskunfirat OK, Wei FC, Lin CH, et al.Simultaneous double second toe transfer for reconstruction of adjacent fingers.Plast Reconstr Surg 2005; 115(41):1084—1069. Slesarenko Y.Minimally invasive technique for finger flexor pulley reconstruction.Hand Surg 2006; 1 1f3):153-157.

281 Adani R,Marcoccio I,Tarallo L. Nail lengthening and Fingertip Amputations Plast[J].Reconstr Surg; 2003 Oct, 112(5):1287-1294. Kleinert HE, Kadsan ML, Romero JL. Small blood vessel anastomosis for salvage of severely injured upper extremity. J Bone Joint Surg [Am]. 1963;45:788. Komatsu S, Tamai S. Successful replantation of a completely cutoff thumb: case report. Plast Reconstr Surg. 1968;42:374–7. Cheng GL, Pan DD, Zhang NP, Fang GR. Digital replantation in children: a long-term follow-up study.J Hand Surg Am. 1998 Jul;23(4):635-46. Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg, 1986,78:295-9. Chernofsky MA, Sauer PF. Temporary ectopic implantation. J Hand Surg [Am], 1990,15:910-4. Hallock GG. Transient single-digit ectopic implantation. J Reconstr Microsurg, 1992,8:309-11. Matloub HS, Yousif NJ, Sanger JR. Temporary ectopic implantation of an amputated penis. Plast Reconstr Surg, 1994,93:408-12. Graf P, Groner R, Horl W, et al. Temporary ectopic implantation for salvage of amputated digits. Br J Plast Surg, 1996,49:174-7. Kayikcioglu A, Agaoglu G, Nasir S, et al. Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation. Plast Reconstr Surg, 2000,106:868-73. Yeatts RP, Hoopes PC Jr, Saunders SS. Eyelid replantation eight months after traumatic avulsion. Ophthal Plast Reconstr Surg, 2004,20:390-2. Bakhach J, Oufqir AA, Baudet J, et al. [Salvage of amputated digits by temporary ectopic implantation]. Ann Chir Plast Esthet, 2005,50:35-42. Bakhach J, Katrana F, Panconi B, et al. Temporary ectopic digital implantation: A clinical series of eight digits. J Hand Surg Eur Vol, 2008. Cavadas PC, Landin L, Navarro-Monzones A, et al. Salvage of impending replant failure by temporary ectopic replantation: a case report. J Hand Surg [Am], 2006,31:463-7. Tomlinson JE, Hassan MS, Kay SP. Temporary ectopic implantation of digits prior to reconstruction of a hand without metacarpals. J Plast Reconstr Aesthet Surg, 2007,60:856-60. Ramdas S, Thomas A, Arun Kumar S. Temporary ectopic testicular replantation, refabrication and orthotopic transfer. J Plast Reconstr Aesthet Surg, 2007,60:700-3. Li J, Ni GH, Guo Z, et al. Salvage of amputated thumbs by temporary ectopic implantation. Microsurgery, 2008,28:559-64. Zhou MW, Song J, Song L, et al. The big toe wrap-around flap combination of the second phalange with the metatarsal to reconstruct the thumb. Chinese Journal of Microsurgery, 2018,41(1):31-34. Wang KL, Xiao CS, Ye ZH, et al. The hallux nail flap combination of the second phalange with the tibia lateral diamond shaped flap, joint, and tendon composite tissue to reconstruct the thumb. Chinese Journal of Microsurgery, 2016,39(3): 241-245. Cao XX, Chen JF, Chang RG, et al. Subemergency reconstruction of grade III and IV thumb defect by great toe wrap-around flap combined with the tissue flap of second toe. Chinese Journal of Microsurgery, 2015. 38(3): 254-257. Li L, Ju JH, Cui LJ, et al. Thumb reconstruction using wrap-around flap from the big toe, dorsalis pedis flap and iliac crest bone graft: a report of 5 cases. Chinese Journal of Hand Surgery, 2016. 32(5): 325-328. Huang YP, Chen Z, Wang X, et al. A method of reconstruction of type II b defect of thumb both and reserving the length of the donor toe. Chinese Journal of Microsurgery, 2014. 37(4): 352-355. Cheng GL, Fang GR, Pan DD, et al. Reconstruction and respiration of thumb and finger defect with various kinds of toe tissue transplantation. Chinese Journal of Hand Surgery, 1995. (04): 200-203.

282 Chen WW, Wei P, Wang YJ, et al. Thumb reconstruction using wrap- around flap from the big toe with the distal phalanx and the skin island of the second toe: a clinical study. Chinese Journal of Hand Surgery, 2013. 29(2): 79-81. Zheng H, Gao XJ, Yang FQ, et al. Reconstruction of grade II and III thumb defect by great toe wrap-around flap with interphalangeal joint. Chinese Journal of Hand Surgery, 2008. 24(4): 237-238. Cheng GL, Liu YP, Chen YQ, et al. Aesthetic digital reconstruction with one stage second toe transfer: clinical research and application. Chinese Journal of Hand Surgery, 2017. 33(4): 275-278. Wang JC, Zhao BX, Liu JW, et al. The first dorsal metacarpal artery fasciocutaneous flap transfer to improve appearance of the thumb reconstructed by second toe transfer. Chinese Journal of Hand Surgery, 2006. 22(5): 299-300. Wang XX, Long DY, Li J, et al. Application of three-dimensional reconstruction images of the first metatarsal dorsal artery CT in thumb reconstruction. Chinese Journal of Microsurgery, 2013. 36(5): 443-446. Li JN, Ju JH, Wang SF, et al. Reconstruction of metacarpal joint plane defects of multiple fingers. Journal of Practical Hand Surgery. 2012. 26(3): 222-225,228. Cai XY, Min JH, He ZJ, et al. Emergency one-stage replantation and reconstruction for multiple digital amputation. CHINESE JOURNAL OF ORTHOPAEDIC TRAUMA, 2007. 9(10): 999-1000. Fang GR, Ding XH, Qu ZG, et al. A modified toe-to-hand transfer: ante-rotation of metatarsophalangeal joint. Chinese Journal of Microsurgery, 2004. 27(4): 241-242. Mou Y, Huang D, Wu WZ, et al. Anatomy of thumb reconstruction by transferring modified great toe skin-nail flap and second toe. CHINESE JOURNAL OF CLINICAL ANATOMY, 2010. 28(2): 131-134. Shao XZ, Yu YD, Ma WS, et al. Capsuloplasty in reconstruction of class II defect of the thumb: observation of clinical outcomes. Chinese Journal of Hand Surgery, 2009. 25(6): 354-355. Liu MW, Feng CC, Yang DY, et al. Emergency reconstruction of the digital tip. Chinese Journal of Hand Surgery, 2002. 18(2): 103-104. Qu ZG, Fang GR, Ding XH, et al. Reconstruction of end section defect of thumb and finger. Chinese Journal of Microsurgery, 2008. 31(4): 267-269. Qu ZG, Fang GR, Cheng GL, et al. Reconstruction of I and II degree defect of thumb and finger. CHINESE JOURNAL OF ORTHOPAEDICS, 2002. 22(7): 386-389. Hou SJ, Cheng GL, Fang GR, et al. Etiology and management of vascular compromise in toe-to-hand transfer(an analysis of 164 cases). Chinese Journal of Microsurgery, 2005. 28(2): 130-132. Liu GY, Cheng YC, Zhu XW, et al. Clinical application of reconstructive surgical procedures of thumb. Chinese Journal of Microsurgery, 2013. 36(3): 241-244. Song JX, Dong RC, Liu GW, et al. Early microsurgical repair and reconstruction of severe thumb injury. Chinese Journal of Hand Surgery, 2003. 19(3): 171-172. Wang K, Ju JH, Jin GZ, et al. Reconstruction of proximal thumb plane defect with iliac bone combined with the same pedicled toenail and dorsum pedis flaps. Chinese Journal of Plastic Surgery, 2019. 35(2): 162-165. Feng P, Hou SJ, Sun LT, et al. Emergency hand reconstruction of five fingers' missing. Journal of Practical Hand Surgery, 2018. 32(03): 276-277 Nie JX, Wu YY, Liang DF, et al. Clinical effect of full reconstruction for distal thumb and finger defect. 2016. 19(4): 444-447. Sun WH, Wang ZT, Qiu SQ. Full reconstruction of IV to VI-degree finger defect. Chinese Journal of Microsurgery, 2011. 34(4): 269-271. Hou SJ, Cheng GL, Fang GR, et al. Aesthetic reconstruction of distal finger or middle-distal finger segment with transplantation of 2nd, 3rd or 4th toe. Chinese Journal of Microsurgery, 2009. 32(2): 110-112.

17 Special Types of Finger Reconstruction Fang YX, Wang SS, Zhang S. Rehabilitation exercise of patients following finger reconstruction. CHINESE JOURNAL OF NURSING, 2008. 43(9): 784-785. Qiu SQ, Wang ZT, Sun WH, et al. Donor site repair of great toe-nail flap in finger reconstruction surgery. Chinese Journal of Microsurgery, 2011. 34(4): 272-275. Zhang JL, Xie ZR, Lei YW, et al. An elaborate operative approach about nali nail unit reconstruction by vascularized composite toe nail tissue transplantation. Chinese Journal of Microsurgery, 2005. (04): 21-22+102. Du D, Zhuang YQ, Jiang HL, et al. The application of double flap transfer in aesthetic reconstruction of the thumb. Chinese Journal of Hand Surgery, 2007. 23(4): 208-210. Zhang QR, Shou KS, Shi HF, et al. Combined implantation of bilateral flaps of toe on reconstruction of thumb and other fingers in the skin degloving injury of the hand at one stage. Chinese Journal of Microsurgery, 2006. (06): 419-421+481. Liu LY, Zhang ZQ, Ma LF, et al. Clinical experience of reconstruction of multiple finger defects with bilateral second toe transfer. Chinese Journal of Hand Surgery, 2014. 30(4): 281-282. Cheng GL. A review and prospect of toe-to-hand transplantation in China. Chinese Journal of Hand Surgery, 2007. 23(02): 65-68. Li MW, Ma LF, Zhang Z, et al. Hallux-nail flap with distal phalanx combined with iliac bone for reconstruction of thumb with III degree defect. Chinese Journal of Microsurgery, 2018. 41(2): 129-132. Shou KS, Zhang QR, Li XR, et al. Subemergent repair and reconstruction of thumb and finger: a report of 358 cases. Chinese Journal of Hand Surgery, 1995. (04): 204-206. Fan CY, Zeng BF, Cai PH, et al. Reconstruction of serious thumb defects with first web space contracture. CHINESE JOURNAL OF ORTHOPAEDIC TRAUMA, 2003. 5(3): 173-175. Huang YP, Ding WQ, Yin SQ, et al. Repairing donor site of foot after improved toe-to-thumb reconstruction utilizing superficial circumflex iliac artery perforator chimeric flap. Chinese Journal of Microsurgery, 2017. 40(3): 229-233. Hu ZH, Duan H, Zhang W, et al. Thumb reconstruction by transplanting of second toe tissue and t shape flap of big-toe fibular side free-graft. CHINESE JOURNAL OF AESTHETIC MEDICINE, 2009. 18(9): 1238-1239. Hou SJ, Cheng GL, Fang GR, et al. Reconstruction and repair of finger defects with free toe transplantation. Chinese Journal of Hand Surgery, 2001. (04): 22-24. Guo A, Zhang GL, Xu ZY, et al. Application of nail lengthening in free second toe transfer for reconstruction of the thumb/finger. Chinese Journal of Hand Surgery, 2006. (06): 362-363. Zhou ZB, Pan D, Tang JY, et al. Propeller flap based on the terminal dorsal perforator of proper palmar digital artery for reconstruction of fingertip defects. Chinese Journal of Microsurgery, 2018. 41(2): 152-155. Ju JH, Jin GZ, Liu YF, et al. Reconstruction of finger joints using the proximal interphalangeal joint of the second toe. Chinese Journal of Microsurgery, 2009. 32(2): 107-109,2. Cheng GL. Goals, surgical planning and techniques of toe-to-hand transfer. Chinese Journal of Hand Surgery, 2006. (01): 6-7. Kang QL, Zhang CC, Xu SG. Evaluation of Clinical Results of Lesser Toe Transplantation for Segmental Finger Reconstruction. THE ORTHOPEDIC JOURNAL OF CHINA, 2003. (01): 19-21. Gu YD, Chen DS, Zhang GM. Thumb and finger reconstruction by toe transplantation: a report of 400 cases. Chinese Journal of Hand Surgery, 1995. (04): 195-199. Huang D, Mao LS, Jiang YH, et al. Clinical analysis of thumb and finger reconstruction with toe transplantation. Chinese Journal of Microsurgery, 2002. (03): 13-14. Cheng GL, Pan DD, Yang ZX, et al. RECONSTRUCTION OF THUMB AND FINGER BY TRANSPLANTATION OF COMPOSITE TOE

17 Further Reading TISSUES: EXPERIENCE IN 208 CASES. CHINESE JOURNAL OF TRAUMA, 1991. (01): 22-24+64. Lin J, Yu YL, Wu C, et al. Emergency reconstruction of the complex dorsal digital defect using the composite flap with extensor tendon graft from the second toe. CHINESE JOURNAL OF PLASTIC SURGERY, 2011,27(2):101-1-3. Kang QL, Zeng BF, Cai YM, et al. A new method for aesthetic refinement in second toe to finger transfer reconstructure surgery. Chinese Journal of Microsurgery, 2008;31(1):9-11. Fang GR, Ding XH, Qu ZG, et al. A modified toe-to-hand transfer: ante-rotation of metatarsophalangeal joint. Chinese Journal of Microsurgery, 2004, 27(4):241-242. Zhang JS, Yang RX, Zhu QF, et al. Analysis of the Causes of Emergency Hand Trauma Postoperative Tendon Adhesion and Early Prevention Strategy. Chinese and Foreign Medical Research, 2015(20):14-16. Ju JH, Jin GZ, Liu YF, et al. Repair of proximal interphalangeal joint (finger) defects using the second toe proximal interphalangeal joint with skin flaps. Chinese Journal of Hand Surgery, 2009;25(4):239-241. Huang MF, Feng XM, Chen J, et al. Systematic rehabilitation nursing after second-toe transplantation and reconstruction of thumb. Modern Hospital, 2017;17(7):1091-1092. Wan SX, Xiao YF, Wang YJ, et al. Replacement of damaged second metacarpophalangeal joint with pedicaled second metatarsophalangeal joint: 11 cases report. Chinese Journal of Microsurgery, 2006;29:252-254. Wang ZT, Ding ZH, Zhou JY, et al. Transplant the big toe tip to reconstruct the finger tip. Chinese Journal of Microsurgery, 2003;26(11):186. Zhou LR, Cai RX, Wang W, et al. Combined transfer of the dorsal flap from the big toe and digital neurovascular island flap for thumb reconstruction. Chinese Journal of Microsurgery, 2001;24(3):165-166. Hou SJ, Cheng GL, Fang GR, et al. Partial distal thumb reconstruction with great toe transfer. Chinese Journal of Microsurgery, 2001;24(1):23-25. Liu Y, Zhang CJ, Fu XM, et al. Repair of thumb and cutaneous deficiency with the second toe taking along dorsum of foot skin flap and footplate skin flap. Journal of Clinical Orthopaedics, 2015,18 (4):469 -471. Wang WD, Zhao FL, Wang YB, et al. Clinical study on postoperative complications of foot after toe transplantation. Journal of Practical Hand Surgery, 2015,29(1):44 -46. Hou SJ, Cheng GL, Fang GR, et al. Repair of compound defect in the hand by compound or combined flap transfer. Chinese Journal of Microsurgery, 2003;26(1):9—11.

283 Wang LG, Huang JH. Clinical observations of nail bed defect reconstruction by autologous dermis grafts. Chinese Journal of Hand Surgery, 2012, 28(1): 39-40. Lv GX, Cheng GL, Pan DD, et al. Treatment of nail bed injury and post-traumatic nail deformity. Chinese Journal of Hand Surgery, 1995,11(S1):17-18. He XQ, Xu YQ. An introduction to supermicrosurgery. Journal of Traumatic Surgery, 2017,19(1):1-4. Yan T, Zhang GL, Chen CH, et al. Repairing nail bed defect of different kinds by corresponding operation methods. Journal of Practical Hand Surgery, 2016,30(3):291-294. Hou SJ, Cheng GL, Fang GR, et al. Repair of traumatic nail loss. Chinese Journal of Hand Surgery, 2002;18(4):209-210. Li MW, Wu G, Luo CH, et al. Decorative repair of nail-bed defect at finger by partial nail-bed flap at second toe with blood-vessel anastomosed. Chinese Journal of Microsurgery, 2017,40(5):445-448. Yu KL, Zhang YZ, Tian DH, et al. Repair of the half soft tissue and nail bed defects of distal part of thumb by using the fibular flaps of hallux with part of nail bed. Chinese Journal of Microsurgery, 2015,38(1):38-40. Lv GX, Cheng GL, Pan DD. Treatment of nail bed injury and post- traumatic nail deformity. Chinese Journal of Hand Surgery, 1995,11(S1):17-18. Liang WQ, Xu YF, Wu MY, et al. Partial toenails flap to reconstruct thumb nail bed defect. Journal of Practical Hand Surgery, 2015,29(2):170-172. Li WQ, Wang L, Gong WX, et al. Coverage of the thumb soft tissue defect by five kinds of flaps. CHINESE JOURNAL OF ORTHOPAEDICS, 2004,24(8):474-477. Lu XY, Zhang YL, Zhao LZ, et al. IMPROVED INDEX FINGER DORSAL ISLAND FLAP FOR PRIMARY REPAIR OF THUMB TIP INJURY. CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY, 2011,(4):412-415. Hao RZ, Men Z, Yang HY, et al. Repair of distal finger degloving injury with homodigital flap based on the dorsal branch of the digital artery and adjacent finger island flap. Chinese Journal of Hand Surgery, 2017,(6):401-403. Li WQ, Wang L, Gong YX, et al. Coverage of the thumb soft tissue defect by five kinds of flaps. CHINESE JOURNAL OF ORTHOPAEDICS, 2004,24(8):474-477. Wang JN, Zhang LB, Wang SY. FOLLOWING-UP STUDY ON RECOVERY OF AMPUTATED FOOT AFTER TEMPORARY ECTOPIC IMPLANTATION. CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY, 2008, 22(5):551-553.