RU2748122C1 - Method of skin grafting in case of circular defect of soft tissues of the finger of the hand - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to reconstructive and plastic surgery, as well as hand surgery, and can be used for dermal plastics in the treatment of a circular defect in the soft tissues of the finger. The method includes circular closure of the soft tissue defect with a reversible, cross, heterodigital flap on the retrograde blood flow of the own digital artery from the surface of the adjacent finger and the dorsum of the hand. Mark and cut out a flap from the contralateral side on the finger of the same name, intact, adjacent to the injured one, along its dorsal-lateral surface, in the projection of its own digital artery and its dorsal branch, with the transition to the dorsum of the hand, in the projection of the dorsal metacarpal artery. The resulting flap with the saphenous vein oriented along the flap is moved to the recipient area, the soft tissue defect is circularly covered with it and sutured. The donor area along the dorsum of the hand is sutured primarily, along the dorsal-lateral surface of the donor finger - the floor is covered with a layer-by-layer skin graft. The donor and recipient fingers are immobilized for 7 days, after the removal of the immobilization, active flexion-extension movements with the operated fingers begin. Three weeks later, the blood supply to the flap is monitored, the feeding leg of the cross-flap is cut off.

EFFECT: ensures the closure of the soft tissue defect of the injured finger with less trauma to the healthy tissues of the patient, early mobilization, obtaining a good functional and aesthetic result due to the use of a flap with main blood supply, from one recipient finger and the back of the hand.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, specifically to reconstructive plastic surgery, hand surgery, and is used for circular soft tissue defect of the finger of the hand, with its traction injury by the ring.

Despite the relative rarity of circular finger defects, their treatment presents difficulties, both in obtaining a functional result and aesthetic one. Up to half of cases of circular trauma result in finger amputation [1].

The known method of skin grafting with a tubular non-free inguinal flap [2], in which at the level of the inguinal fold, a skin-fascial flap is raised on a temporary feeding leg, the length and width of which is sufficient to form a tube, followed by covering the defect of the soft tissues of the finger. The blood supply to the flap is carried out by the superficial artery that bends around the ilium. After three weeks, the feeding leg is cut off. The disadvantage of this method is an excess of soft tissues, lack of early mobilization, impaired grip function.

The closest, in terms of its technical solution, to the proposed invention is adopted by us as a prototype method of combined skin grafting with two cross flaps from adjacent fingers [3]. In this method, a longer flap is used to close the defect of the palmar surface of the injured finger, and the shorter one is de-epithelized and used to close the dorsal defect. Donor wounds are covered with full-thickness skin grafts taken from the anterior surface of the forearm. After three weeks, the feeding legs are cut off. The disadvantage of this method is the lack of early mobilization, violation of the anatomical integrity of two healthy adjacent fingers, the duration of the operation, due to the need for de-epithelialization of one of the flaps, suturing of wounds on 2 fingers.

The essence of the invention is expressed by a set of essential features sufficient to achieve the desired technical result, which consists in closing the soft tissue defect of the injured finger, with less trauma to the healthy tissues of the patient, a flap with main blood supply from one recipient finger and the back of the hand, early mobilization, obtaining a good functional and aesthetic result.

The essence of the method of skin grafting for a circular defect of the soft tissues of the finger of the hand includes circular closure of the soft tissue defect with a reversible, cross, heterodigital flap on the retrograde blood flow of the own digital artery from the surface of the adjacent finger and the dorsum of the hand. The area of the skin is measured from the contralateral side on the finger of the same name, intact, and the required flap is marked along the dorsal-lateral surface of the finger adjacent to the injured one, in the projection of its own digital artery, and its dorsal branch, with the transition to the dorsum of the hand, in the projection of the dorsal metacarpal artery. A flap is cut out while preserving the saphenous vein, oriented along the flap, which is moved to the recipient area, the soft tissue defect is circularly covered with it, and sutured. The donor area along the dorsum of the hand is sutured primarily, along the dorsal-lateral surface of the donor finger - covered with a full-thickness skin graft. The donor and recipient fingers are immobilized for 7 days, after removing the immobilization, active flexion-extension movements with the operated fingers begin. After three weeks, the blood supply to the flap is monitored, the feeding leg of the cross-flap is cut off.

Measurement of the area of the skin on the same intact finger of the contralateral side allows you to more accurately estimate the size of the required flap.

Cutting out the flap along the dorsal-lateral surface of the finger adjacent to the injured one, in the projection of its own digital artery, and its dorsal branch, with the transition to the dorsum of the hand, in the projection of the dorsal metacarpal artery, while maintaining the saphenous vein oriented along the flap, provides a sufficient main arterial blood supply to the injured finger. This blood supply is carried out due to the retrograde blood flow of the digital artery with blood flow into the dorsal branch of the digital artery, through anastomoses - into the dorsal digital artery, which is a continuation of the dorsal metacarpal artery, and venous outflow of the flap due to the preservation of the saphenous vein. Intraoperative blood flow monitoring allows assessment of the blood supply to the flap.

Moving the cut out flap to the recipient area, circularly covering the soft tissue defect with it, and suturing the flap, allows you to close the wound of the injured area. The use of tissues similar in anatomical structure ensures adequate thickness of the flap and their resistance to functional loads.

Primary suturing of the wound on the back of the hand is possible due to the elasticity and sufficiency of the skin.

Covering the dorsal-lateral surface of the donor finger with a full-thickness skin graft is necessary due to a lack of skin after the donor graft has been taken.

The immobilization period of 7 days creates sufficient conditions for the beginning of the germination of blood vessels into the flaps, and active flexion-extension movements with the operated fingers contribute to the restoration of the function of the fingers of the hand.

Cutting off the leg after 3 weeks ensures reliable restoration of the flap blood supply due to neovascularization from the recipient finger, and control of the blood flow of the engrafted flap allows us to assess the sufficiency of its blood supply.

The method is explained by the attached illustrations, where:

in fig. 1 shows a photo of the hand after treating the wound of damage to 4 fingers;

in fig. 2 - view after necrectomy, and flap marking;

in fig. 3 - selected flap;

in fig. 4. - an engrafted flap before cutting off the feeding pedicle for a period of 3 weeks.

FIG. 5. and FIG. 6. - result two weeks after cutting off the feeding leg.

The method is carried out as follows.

Measurement of the area of the skin from the contralateral side on the same name, intact, finger for more accurate planning of the size of the required flap. After anesthesia, under aseptic conditions, along the dorsal-lateral surface of the finger adjacent to the injured one, in the projection of its own digital artery, and its dorsal branch, with the transition to the dorsum of the hand, in the projection of the dorsal metacarpal artery, a flap is cut out while preserving the saphenous vein, oriented along the flap. The latter is moved to the recipient area, circularly covered with a soft tissue defect, sutured. The donor area along the dorsum of the hand is sutured primarily, along the dorsal-lateral surface of the donor finger - covered with a full-thickness skin graft. Immobilization of the donor and recipient fingers is carried out for 7 days, after which active flexor-extension movements with the operated fingers begin. After three weeks, the blood supply to the flap is monitored, the feeding leg of the cross-flap is cut off.

Clinical example

Patient K., 25 years old, 06/20/2019, climbing over the fence, caught the ring, received a ring injury to the 4th finger of the right hand, type 3 according to Urbaniak.

Upon admission to GAUZ "RKB MH RT", the patient underwent a wound toilet. On June 22, 2019, after anesthesia, under aseptic conditions, necrectomy was performed. Measured the area of the skin from the contralateral side on the same, intact finger. The skin was marked, a vascularized skin graft of the dorsal-ulnar surface of the third finger and the dorsum of the hand was harvested, in the projection of the 3rd intercarpal space, with the inclusion of the own digital artery with its dorsal branch, dorsal digital artery and dorsal metacarpal artery, preserving the saphenous vein, into the flap. oriented along the flap. The isolated flap was placed on the defect area, wrapped around the finger, blood flow control was performed, which showed a satisfactory blood supply to the flap. The wound on the back of the hand was sutured primarily. A full-thickness skin graft was placed on the finger, taken from the anterior surface of the forearm, and sutured, aseptic bandages, plaster immobilization were applied. In the postoperative period, dressings were performed. On the 7th day, immobilization was stopped, active flexion-extension movements with the operated fingers began. The wound healed initially, the stitches were removed on the 14th day.

The feeding leg of the cross-flap was dissected off after three weeks. The wound healed initially, and after another 2 weeks the stitches were removed, the patient was sent for rehabilitation treatment to the polyclinic. When viewed after 6 months, the range of motion in the fingers is satisfactory, the grip is not disturbed. The patient is satisfied with the achieved result.

Thus, the proposed method of skin grafting in case of a circular defect, annular injury of the soft tissues of the finger of the hand, allows you to restore the circular defect of the skin of the finger with tissues similar in anatomical structure, preserve the function of the hand, and obtain a satisfactory aesthetic result.

Information sources

1. (Pynn B.R., Bartkiw T.R., Clarke H.M. Ring avulsion injuries and the basketball player // Br J Sports Med. - 1997. - Mar. - Vol. 31 (1). - P. 72-74)

2. Karthikeyan, G., & Krishnamoorthy, R. (2011). Degloving injuries of the hand. Indian Journal of Plastic Surgery, 44 (2), 227.

3.m Double Cross-Finger Flaps. A Novel Technique for Management of Ring Avulsion Injuries. Ahmed Abo-hashem Azab Moosa, MD (Ann Plast Surg. 2010 Apr; 64 (4): 409-11. Doi: 10.1097 / SAP.0b013e3181b142d5.

Claims (1)

A method of skin grafting for a circular soft tissue defect of a finger, including circular closure of a soft tissue defect with a reverse crossover, heterodigital flap on the retrograde blood flow of the own digital artery from the surface of the adjacent finger and the back of the hand, characterized in that the area of the skin is measured from the contralateral side to the finger of the same name, intact, and the marking of the required flap on the dorsal-lateral surface of the finger adjacent to the injured one, in the projection of its own digital artery and its dorsal branch, with the transition to the dorsum of the hand, in the projection of the dorsal metacarpal artery, cut out the flap while preserving the saphenous vein, oriented along the flap, which is moved to the recipient area, the soft tissue defect is circularly covered with it and sutured, the donor area along the dorsum of the hand is sutured primarily, along the dorsal-lateral surface of the donor finger - covered with a full-layer skin tract With the graft, the donor and recipient fingers are immobilized for 7 days, after the removal of the immobilization, active flexion and extension movements with the operated fingers begin, after three weeks the blood supply to the flap is monitored, the feeding leg of the cross flap is cut off.

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