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Local Hand Flaps. Summer Anatomy Lab July 25, 2013 Jennifer Klok. Reconstructive Ladder. Healing by secondary intention Primary closure Skin graft Local flap Regional flap Free flap. Cross-Finger Flap. Design: Skin and subcutanous tissue

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local hand flaps

Local Hand Flaps

Summer Anatomy Lab

July 25, 2013

Jennifer Klok

reconstructive ladder
Reconstructive Ladder
  • Healing by secondary intention
  • Primary closure
  • Skin graft
  • Local flap
  • Regional flap
  • Free flap
cross finger flap
Cross-Finger Flap
  • Design:
    • Skin and subcutanous tissue
    • Designed over dorsal aspect middle phalynx
  • Vascular supply:
    • Dorsal digital artery
    • Digital perforators
cross finger flap1
Cross-Finger Flap
  • Clinical Applications
    • Coverage of volar aspect of adjacent digits’ middle phalangeal area
    • Distal digital tip coverage
    • Volar oblique fingertip amputations with exposed bone or tendon
anatomy
Anatomy
  • Dorsal Digital Artery (1mm)
    • Dorsal skin distal to the distal proximal phalynx depends on perforating branches from digital arteries
    • Course through Cleland’s ligament
    • Supplies the flap
  • Digital Perforators passing dorsally around finger (0.2-0.3mm)
design and markings
Design and Markings
  • Designed with base adjacent to injured finger
    • Proximal and distal flap marked transversely
    • Connect these with a longitudinal line just dorsal to mid-axis of dorsum of finger
    • 3-sided rectangle
  • Incisions made to encompass whole surface of middle phalynx
dissection
Dissection
  • Incise skin based on markings down to SC fat until loose areolar plane
  • Elevate flap in this plane, taking care to leave the paratenon behind
  • Dissect to Cleland’s ligament; may need to divide ligament to increase pedicle length
  • Cover donor site with skin graft
  • Inset flap
  • Divide flap 2-3 weeks later
reverse cross finger flap
Reverse Cross-Finger Flap
  • For adjacent dorsal digital wound coverage
    • Elevate flap in subdermal plane
    • Adipofascial flap to cover dorsal defect
thenar flap
Thenar Flap
  • To cover defects on the index and long fingers
  • Green’s:
    • “Use where preservation of length is considered important and other techniques that have less potential for complications are not applicable”
thenar flap2
Thenar Flap
  • Donor site found by taking tip of index or ring finger and placing it against thenareminance
  • Draw circle around area of contact
  • Draw H or curved incision at this point
  • Elevate flaps in subcutaneous plane
  • Inset flap
  • Divide in 10-14 days
      • For the H flap, the proximal flap covers the finger defect and distal flap advanced to cover donor
points about the thenar flap
Points about the Thenar Flap
  • To avoid potential for joint stiffness or unsightly scar in donor area:
  • Design flap near the MP crease of the thumb; avoid the midpalmar area
  • Fully flex the MP joint with whatever amount of flexion is required in the IP joints of the recipient finger
  • Detach pedicle 10-14 days post-op and start immediate AROM
first dorsal metacarpal artery flap
First Dorsal Metacarpal Artery Flap
  • Classification:
    • Type A fasciocutaneous flap
    • From dorsal skin over proximal phalynx (FDMA)
  • Clinical Applications:
    • For defects in the thumb
slide17
FDMA
  • Dominant Pedicle:
    • First dorsal metacarpal artery (FDMA)
  • Minor Pedicle:
    • Cutaneous perforators of the FDMA
  • Nerve Supply:
    • Dorsal sensory branches of the radial and ulnar nerves
anatomy1
Anatomy
  • Dorsal metacarpal arteries
    • From dorsal carpal arch formed from dorsal carpal arteries
    • Gives rise to 4 dorsal metacarpal arteries
      • These course over dorsal interosseous muscles
      • Communicates with deep palmar arch
    • Proximal to web space divides into 2 dorsal digital branches
    • Then divide into terminal branches midway along proximal phalynx
anatomy2
Anatomy
  • The first dorsal metacarpal artery (FDMA) tends to be a discrete terminal branch of the radial artery rather than arising directly from that dorsal carpal arch
    • Found in the first intermetacarpal space, just distal to the extensor pollicislongus tendon
  • Supplies the dorsum of the thumb and radial side of the index finger
flap markings
Flap Markings
  • From MCP joint to the PIP joint of index
  • Radial & ulnar borders 1st the midlateral lines on either side of digit
flap dissection
Flap Dissection
  • Incision in 1st dorsal web space, down to FDMA
  • Elevate flap distal to proximal, just above paratenon
  • Fascia and fat adjacent to 2nd metacarpal kept intact to protect vessels
  • Transfer and inset flap
  • Cover donor with skin graft
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