R. Burda 1; M. Kitka 1,2
Department of Trauma Surgery, Faculty Hospital of Louis Pasteur, Košice, and
1; Medical Faculty, University of P. J. Šafárik, Košice, Slovak Republic
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 49, 1, 2007, pp. 13-17
of degloving injury of the fingers and mutilation of other fingers
with skin defects may be treated urgently with a combination of
arterialised pedicle flaps from the forearm and distant axial pattern
engine driver sustained a right hand injury during his work as
the driver of locomotive. His right hand was injured by the front
wheel of the engine (Fig. 1, 2). He was admitted to our department 30
minutes after the injury. Considering the extent of the injury and
the fact that there was no other associate injury, we performed
urgent primary revision. During revision we realized debridement of
all necrotic tissues (Fig. 3). The thumb was intact. The index finger
was almost completely degloved from the level of the proximal third
of the proximal phalanx. Its flexor and extensor tendon was intact,
and inside there was open proximal interphalangeal joint dislocation.
Complete loss of arteries and veins from the level of degloving and
digital nerves was pulled out to the more proximal level.
third and fourth digits were mutilated with no possibility of
reconstruction; simultaneously there were skin defects on both
digits, dorsal and volar from the level of the metacarpophalangeal
joint. The little finger was also crushed, with an unreconstructible
middle and distal phalanx.
shaft fracture of the fifth metacarpal was stabilised with a screw.
The stump of the proximal phalanx of the little finger was covered
with local skin flap without tension.
extent of injury to the third and the fourth finger was assessed, and
subsequently wound debridement was performed; finally only the stumps
of the proximal phalanges remained. The residual skin defect,
covering the degloving index finger and the stumps of the third and
fourth finger, could not be covered with one flap. We decided on
a flap combination.
we created a posterior interosseous artery flap from the
ipsilateral forearm; we took a fasciocutaneous flap 12 x 6 cm
in size on an arterial pedicle, and we utilized this flap to cover
the stumps of the third and fourth fingers (Fig. 4). The length of
the pedicle was 12 cm. From the place of anastomosis
a. interossea anterior and posterior we made an incision
directly to the skin defect. We prefer not to place an arterial
pedicle of the flap in a previously made subcutaneous tunnel,
due to the increased risk of flap necrosis (Fig. 5). The defect on
the fingers was fully covered. The donor defect was covered with
split thickness skin graft from left thigh.
open dislocation of the proximal interphalangeal joint of the index
finger was reduced and stabilized with Kirschner wire.
best solution for covering the index finger seemed to be
a hypogastric (superficial epigastric) flap. A flap 12 cm
long was used. The donor site was first closed by mobilizing the skin
margins. The flap was tubularised, and the index finger was inserted
into the tubularised flap, fixed with sparse sutures (Fig. 6). The
upper extremity was fixed with orthesis. Both flaps were vital and
healed primarily (Fig. 7).
the time of operation we noticed weak bleeding from the wound on the
left thigh after taking the split thickness graft. Bleeding continued
despite the application of local haemostyptics and the patient’s
normal coagulation status. We supposed that the patient suffered from
an undiagnosed coagulation disorder, but this was not confirmed.
Finally we had to stop the bleeding with coagulation. No bleeding was
later registered, and the wound healed without further complications.
The patient was discharged after 10 days and treated on an outpatient
basis. After 3 weeks we separated the hypogastric flap from the
abdominal wall. The donor defect was closed with suture and healed
spontaneously. The wound on the tip of the index finger healed more
slowly, after repeated revision. The Kirschner wire was removed from
stab incision after 6 weeks. Subsequently the patient began to
rehabilitate. After 4 weeks of rehabilitation he could grasp an
object between the index finger and thumb. He was capable of basic
functional use of the hand (including grasping large and small
objects, though the power of grasp was decreased). The extent of
movement in the PIP joint of index finger is limited to 70 degrees of
flexion, while there is virtually no active movement in the DIP
joint. After rehabilitation the patient underwent defatting procedure
twice; despite this, he is not satisfied with the cosmetic appearance
of the hand (Fig. 8, 9). He has repeatedly refused any further
first mention of Posterior Interosseous Artery (PIA) Flap was made by
Zancolli in 1985, but he only published this almost 3 years later, in
and Masquelet were the first authors who published their experience
with PIA flaps, in 1986 and 1987 (8, 10).
flap affords a very durable and aesthetic option for soft-tissue
coverage of the dorsum of the hand. The flap donor site can usually
be closed primarily with little to no morbidity. In comparison to
other local and distally based flaps, such as the radial forearm
flap, major blood vessels are spared. The PIA flap should be
considered a reliable and judicious alternative to free
microvascular transfer procedures for soft-tissue defects of the hand
proximal to the level of the PIP joint (16).
flaps are also a good option for palmar defects or to wrap
around neurolyzed nerves (12).
flap may be easily and safely employed in the coverage of soft tissue
defects of the hand and the wrist due to such advantages as minimal
donor area morbidity, an acceptable cosmetic appearance, and a more
simple dissection than that required for other surgical flaps (5, 6,
is possible to apply a PIA flap urgently in emergencies without
increased risk of complication, and this method of application
shortens hospitalisation time in clinical practice (4).
cutaneous branches of the posterior interosseous artery supply the
skin of the dorsal aspect of the forearm. This vascular anatomy
allows the surgeon to obtain an island flap of the dorsal forearm
based on the distal anastomosis between the two interosseous arteries
at the distal part of the interosseous space (15).
PIA course corresponds to a line drawn from the lateral
epicondyle of the humerus to the head of the ulna, i.e. to the septum
between the extensor carpi ulnaris and extensor digiti minimi
proprius muscles. The artery, which has an average calibre of 1.7 mm,
gives off 7 to 14 cutaneous branches in its course. The PIA
anastomoses the anterior interosseous artery and the dorsal carpal
network in 98.6% of cases. The artery remains closely related to the
deep branch of the radial nerve and is crossed by the branches of
this nerve to the extensor carpi ulnaris muscle. The cutaneous
distribution of the PIA extends from elbow to wrist, centred on the
epicondylar-ulnar line, with an average breadth of 5 cm (8, 10).
PIA flap is based on posterior interosseous artery, which is branch
of the common interosseous artery. The existence of distal
anastomosis between PIA and Anterior Interosseous Artery (AIA)
facilitates the use of this flap as a reversed pedicled flap.
it was observed (2) that there is a choke anastomosis between
the recurrent dorsal branch of the anterior interosseous artery and
the posterior interosseous artery at the level of the middle third of
the posterior forearm, but no anastomosis was found in the proximal
third of the forearm. In the distal third of the posterior forearm
there is a recurrent branch of the anterior interosseous artery
(traditionally called the distal anastomosis of the interosseous
arteries). It was assumed that the blood flow is not reversed when
the so-called posterior interosseous reverse forearm flap is raised.
From this point of view, this flap could be renamed the recurrent
dorsal anterior interosseous direct flap; however, the classical name
is maintained for practical purposes. From the venous standpoint, the
cutaneous area included in this flap belongs to an oscillating type
of venous territory and is connected to the deep system through an
interconnecting venous perforator that accompanies a medial
cutaneous arterial branch located at 1 to 2 cm distal to the
middle point of the forearm.
summarize, the flap advantages are as follows: no impairment of main
forearm arteries; possibility to close donor site with suture unless
the flap size is larger than 4 x 4 cm and use as
osteofasciocutaneous flap; opportunity to raise flap as free flap.
disadvantages are these: in 5% of the population there is no distal
anastomosis between PIA and AIA, which may comprise flap usage;
visible scar; hair growth in recipient area; no sensitivity and
jeopardizing of nervus radialis profundus during dissection.
is not appropriate to use a flap in cases of previous surgery in
dorsal forearm and in cases when the flap required is smaller than
dissections PIA and its anastomosis should be verified with a Doppler
probe, or dissection should begin with verification of distal ramus
communicans (7, 12).
variant was described in 24 per cent of patients, but not all of them
compromise realization of flap dissection (12). Missing PIA in the
middle third of forearm has also been recorded, along with course of
distal perforator artery in musculus extensor digiti minimi and
crossing of ramus superficialis nervus radialis with distal
significant statistical correlation was found between occurrence of
anatomical variants and complications (necrosis of flap). A risk
factor for flap necrosis is enlargement of flap more proximal than
4–5 cm above the proximal perforator vessel.
the reverse posterior interosseous flap to be reliable the flap
should include the septocutaneous perforators in the distal third of
the forearm. To cover distant defects reliably by a flap with
a long pedicle, the flap should extend up to the distal third of
the forearm to include a piece of skin with numerous perforators
distant flaps are indicated for coverage of acute hand wounds, it is
advantageous to design the service-able portion of the flap on the
distal area of the vascular territory of the groin flap (hypogastric
or groin flap). Cautious but “radical” defatting can be performed
on the lateral portion of the groin flap territory. When constructed
in this way, the long medial base of the groin flap allows freedom of
movement at the wrist and metacarpophalangeal and interphalangeal
joints, thus decreasing oedema and stiffness. In the management of
soft-tissue defects in the hand requiring distant flap coverage, it
is possible to utilize the conventional groin flap in preference to
the microvascular free flap when both techniques will deliver equal
hypogastric flap (Superficial Epigastric) was first described in 1946
by Shaw and Payne (11). This flap has proved suitable for coverage of
of the hypogastric flap include: 1 – its location in an area with
little hair; 2 – minimal donor site morbidity; 3 – multiple
arteriovenous supply; 4 – potential for incorporating bone with
overlying skin flap even when used as a pedicle flap; and 5 –
potentially large size. Disadvantages include: 1 – problems with
colour matching; 2 – possibility of damage to vessels from previous
inguinal surgery; and 3 – thickness of the flap in obese patients
is possible to find in the literature (14) a reference to
combinations of posterior interosseous and lateral arm flap, which
are appropriate almost for every hand injury. We suppose that the
combination of arterialised pedicle flaps from the forearm and
distant axial pattern flaps is also a suitable alternative for
use in case of serious hand injury.
of Trauma Surgery
Hospital of Louis Pasteur
1. Akinci M., Ay S., Kamiloglu S., Ercetin O. The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases. J. Plast. Reconstr. Aesthet. Surg., 59, 2006, p. 148–152.
2. Angrigiani C., Grilli D., Dominikow D., Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast. Reconstr. Surg., 92, 1993, p. 285–293.
3. Chow JA., Bilos ZJ., Hui P., Hall RF., Seyfer AE., Smith AC. The groin flap in reparative surgery of the hand. Plast. Reconstr. Surg., 77, 1986, p. 421–426.
4. Ege A., Tuncay I., Ercetin O. Posterior interosseous artery flap in traumatic hand injuries. Arch. Orthop. Trauma Surg., 123, 2003, p. 323–326.
5. Koch H., Kursumovic A., Hubmer M., Seibert FJ., Haas F., Scharnagl E. Defects on the dorsum of the hand – the posterior interosseous flap and its alternatives. Hand Surg., 8, 2003, p. 205–212.
6. Lu LJ., Gong X., Liu ZG., Zhang ZX. Antebrachial reverse island flap with pedicle of posterior interosseous artery: a report of 90 cases. Br. J. Plast. Surg., 57, 2004, p. 645–652.
7. Masquelet AC. Le lambeaux interosseaux postérieur. Le lambeaux artériels pediculés du member supérieur Monographies du Groupe d’Etudes de la Main, 17, 1990, p. 86–93.
8. Masquelet AC., Penteado CV. The posterior interosseous flap. Ann. Chir. Main, 6, 1987, p. 131–139.
9. Ozdemir O., Coskunol E., Alpaydin S. An appropriate alternative for the reconstruction of soft tissue defects in the hand and the wrist: the distally-based island posterior interosseous flap. Acta Orthop. Traumatol. Turc., 37, 2003, p. 233–236.
10. Penteado CV., Masquelet AC., Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg. Radiol. Anat., 8, 1986, p. 209–215.
11. Shaw DT., Payne RL. One-staged tubed abdominal flaps: single, pedicle tubes. Surg. Gynecol. Obstet., 83, 1946, p. 205.
12. Vogelin E., Langer M., Buchler U. How reliable is the posterior interosseous artery island flap? A review of 88 patients. Handchir. Mikrochir. Plast. Chir., 34, 2002, p. 190–194.
13. Wright PE. II., Acute Hand Injuries – Grafts and Flaps. In Canale, TS (Ed.) Campbell’s Operative Orthopaedics. Mosby, 2003, chapter 62.
14. Xarchas KC., Chatzipapas C., Koukou O., Kazakos K. Upper limb flaps for hand reconstruction. Acta Orthop. Belg., 70, 2004, p. 98–106.
15. Zancolli EA., Angrigiani C. Posterior interosseous island forearm flap. J. Hand. Surg. [Br.], 13, 1988, p. 130–135.
16. Zwick C., Schmidt G., Rennekampff HO., Schaller HE. Soft-tissue coverage of the hand using the posterior interosseous artery flap. Handchir. Mikrochir. Plast. Chir., 37, 2005, p. 179–185.