|Year : 2019 | Volume
| Issue : 1 | Page : 27-30
Modified mid palmar flap for middle finger tip injuries: A review of 12 cases
Ramneesh Garg, Sheerin Shah, Sanjeev Uppal, Rajinder K Mittal, Bhavya Thakur, Soheb Rafique
Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||19-Aug-2019|
Dr. Sheerin Shah
Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
Background: Fingertip is the most commonly injured area of the hand. The two most commonly advocated flaps for fingertip reconstructions are cross finger flap and thenar flap. There is another flap, raised from the middle of the palm, midway between thenar and hypothenar eminence, called the mid palmar flap which never became popular because of inherent drawback of causing extensive joint contractures. To overcome the problem of joint contractures we added extra 5 mm to the length of flap and separated it by 14 days. Aims and Objectives: This study was conducted to review the outcome, in terms of joint contracture and scar aesthetics in middle finger tip injuries covered with modified Mid palmar flap. Material and Methods: The present study was done in the Department of Plastic Surgery, at Dayanand Medical College & Hospital, Ludhiana, Punjab. Various variables analysed were age, sex, mode of injury, hand dominance, associated fractures and exposed bone. All cases were done under local anaesthesia. Time to division ranged from 12- 14 days. Results: A total of 12 patients were included in this study. The mean age of patients was 35 years. The most common mode was accidental machine injury. The dominant hand (right) was injured in 5 patients. There was associated distal phalanx fracture in 5 patients. There was exposed bone in 7 patients. There was no reported case of hypertrophic scarring at donor site. Scar tenderness was there in 3 of the 12 patients and it persisted for maximum of 6 weeks. PIP and DIP joint stiffness was there for initial 10 days. Conclusion: For middle finger tip injuries, mid palmar flap, with modifications as described, could be better than thenar flap.
Keywords: Fingertip, joint contracture, Mid palmar flap
|How to cite this article:|
Garg R, Shah S, Uppal S, Mittal RK, Thakur B, Rafique S. Modified mid palmar flap for middle finger tip injuries: A review of 12 cases. J Orthop Traumatol Rehabil 2019;11:27-30
|How to cite this URL:|
Garg R, Shah S, Uppal S, Mittal RK, Thakur B, Rafique S. Modified mid palmar flap for middle finger tip injuries: A review of 12 cases. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Dec 11];11:27-30. Available from: http://www.jotr.in/text.asp?2019/11/1/27/264736
| Introduction|| |
Fingertip is defined as the portion of the digit distal to the insertion of the flexor and extensor tendons. It is the most commonly injured area of the hand. The injury may be horizontal, dorsal oblique, or volar oblique and may result in an exposed terminal phalanx or extensive loss of soft-tissue bulk; both of which warrant a flap. The two most commonly advocated flaps for fingertip reconstructions are the cross-finger flap and thenar flap. Both these flaps have their own common advantages and disadvantages. Providing a good robust skin cover is the main advantage, and both being two-stage procedures and requiring prolonged dressings makes them disadvantageous. Thenar flap, in contrast to cross-finger flap, provides same skin turgor, is nonhairy and does not need a graft at the donor site. The most common complications reported with both these flaps are joint contracture and scar tenderness. There is another flap (midpalmar flap) with same advantages (skin turgor and no graft at donor site), but it never became popular because of inherent drawback of causing extensive joint contractures. As the name itself implies, this flap is raised from the middle of the palm, midway between thenar and hypothenar eminence, and along the long axis of the middle finger. To overcome the problem of joint contractures, we added extra 5 mm to the length of flap and separated it by 14 days.
The aim of the present study was to assess the incidence of flap necrosis and morbidities such as joint contractures and donor scar tenderness associated with a modified midpalmar flap when used for coverage of the middle fingertip defects.
| Materials and Methods|| |
The present study was conducted in the Department of Plastic Surgery, at Dayanand Medical College and Hospital, Ludhiana, Punjab. Various variables analyzed were age, sex, mode of injury, hand dominance, associated fractures, and exposed bone. The fingertip injury was classified as per Allen classification. The main goals of the surgery were to provide strong and adequate bulk to fingertip.
- Patients with middle fingertip injury with exposed bone or excessive pulp loss
- Patients willing to keep their involved hand immobilized and dressed for at least 2 weeks were included in the study.
The exclusion criteria were as follows:
- Patients who are unable to flex Proximal Interphalangeal joint/Distal Interphalangeal joint (PIP/DIP)
- Patients with known history of joint contractures
- Patients with a history of arthritis
- Patients with the history previous injury over-involved finger.
All cases were done under local anesthesia. Time to division ranged from 12 to 14 days.
All cases were done under local anesthesia/digital block. After thorough cleaning of the wound, the flap was planned in reverse over midpalmar area with base lying along the oblique skin crease of palm, positioning the middle finger in 90° flexion at metacarpophalangeal (MP) joint, 90–100° flexion at PIP joint, and 5–10° flexion at DIP joint. A proximally-based flap was marked, with ulnar margin of the flap lying along the oblique palmar crease and an extra 5-mm length was added that would allow some degree of mobilization at both PIP and DIP joint [Figure 1]. After infiltration of plain 2% lignocaine solution, the incision was made and the flap was raised in subcutaneous plane taking underlying fat along with. Hemostasis was maintained with bipolar cautery. Donor site was closed primarily. The flap was inset using 5-0 nylon [Figure 2]. The sutures along the upper margin were taken through the nail plate. The finger was positioned and dressed in a way so that there is a gap between the palm and finger. The patient was discharged on the same day. The first dressing was changed after 48 h and subsequently on day 5, 8, and 10. In all cases, flap separation and inset were done, under local anesthesia, maximum by day 14. Physiotherapy was started immediately after flap separation. The patient was then assessed at weekly intervals for the 1st month and then monthly for the next 6 months, for PIP joint mobility and donor scar characteristics.
| Results|| |
A total of 12 patients were included in this study. The mean age of patients was 35 years. The most common mode was accidental machine injury. The dominant hand (right) was injured in five patients. There was associated distal phalanx fracture in five patients. There was exposed bone in seven patients. As per Allen classification, seven patients were in Class 2 and five patients were in Class 3. Reconstructive goals were achieved in all cases. There was no case of flap necrosis or wound infection. The tissue match was excellent, and the pulp tissue bulk was achieved satisfactorily in all cases [Figure 3]. There was no reported case of hypertrophic scarring at donor site. Scar tenderness was there in three of the 12 patients and it persisted for maximum of 6 weeks. In all except one patient, the initial PIP and DIP joint stiffness, resolved fully with physiotherapy within 6 weeks of surgery [Table 1].
| Discussion|| |
“Replace like with like” is the time-proven dictum given by Sir Harold Gillies. Fingertip has a special keratinized skin character, nearest to the match of which is palmar skin. As compared to skin graft or standard cross-finger flap, palmar flap provides three-dimensional reconstructions, which is more esthetic and functional. Gatewood introduced the concept of using palmar skin for covering finger defects in 1926., Although he described it as medially based flap from thenar area for a palmar defect over middle phalanx of the index finger, it was later modified and used for fingertip injury. Various modifications of flaps from palms have come up since then. Flatt, in 1950, modified it to being a more proximally based flap. Beasley, described a laterally based thenar flap, with its distal border positioned in the MP flexion crease of the thumb. Fusco described midpalmar flap for fingertip defect in 1954. Zancolli described the possibility of using different flaps from midpalm skin, but he did not comment on the size of the flap. The use of palmar flaps was initially criticized because of the complications of proximal joint contracture and donor scar tenderness. Beasley. and Sturman and Duran demonstrated that joint contracture occurred with flaps which are harvested more medially as palmar flaps not as thenar flaps.
The midpalmar area has a rich blood supply mainly from superficial palmar branches of the radial artery (SPBRA) which arise at the level of 1–2 cm proximal to distal wrist crease and run superficially in skin and then dip into palmar fascia at a point 0.5–1 cm radial to thenar crease. This is the area, which forms the base of pedicled midpalmar flap and the rich blood supply in this area helps in early flap separation. SPBRA gives a major branch above thenar muscles which anastomosis with superficial palmar arch. The robust vascularity of this area has been used to harvest free palmar and thenar flaps, as illustrated by Orbay et al. We added an extra 5 mm to the pedicle for easy dressing and keeping the finger slightly raised. We believe that this helped minimal motion at all joints and prevented any flexion contracture in the later period. We followed Beasley et al, in separating all flaps between 10 to 14 dyas. None of our patients had any flap failure and the reconstructive goals were achieved in all cases. On a follow-up of 6 months, we did not observe any permanent or functionally disabling joint contractures. Although Barbato et al. observed 25% rate of joint contracture requiring extension splints in his review of 20 patients covered with distally based thenar flap and divided at 3 weeks, Rinker reported no significant flexion contractures in his patients. He attributes a small reduction of flexion in few of his patients to the fact that they already had some previous injury over joints. Reports suggest that one of the main reasons of joint stiffness is delayed separation.,, We advocate separation of palmar flaps at 10–14 days and early mobilization and physiotherapy to prevent such results. Melone et al. and Fusco also emphasized on the need for early division of flap to prevent the joint contractures.
In our study, three of 12 patients complained scar tenderness in the first 3 weeks of follow-up. These patients were put on pregabalin 75 mg twice daily for 3 weeks. The tenderness decreased thereafter. Esthetic result of fingertips in the form of contouring, the shape of the nail, and finger length was very satisfactory to all patients. The donor scar got camouflaged in oblique skin crease and no scar hypertrophy was seen. We do not do free flap for fingertip injuries.
Drawbacks of this study are as follows:
- Small study group
- Not comparative with any control group
- Both static and dynamic 2PPD over flap tip were not studied.
| Conclusion|| |
We believe that for middle fingertip injuries, mid palmar flap, with modifications as described, could be better than thenar flap as the donor tissue (mid palm) is in straight axis of the flexed finger.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fassler PR. Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Allen MJ. Conservative management of finger tip injuries in adults. Hand 1980;12:257-65.
Gillies H, Millard DR. The principles and Art of Plastic surgery. London: Butterworth; 1957.
Rinker B. Fingertip reconstruction with the laterally based thenar flap: Indications and long-term functional results. Hand (N
Gatewood J. A plastic repair of finger defects without hospitalization. JAMA 1926;87:1479.
Meals RA, Brody GS. Gatewood and the first thenar pedicle. Plast Reconstr Surg 1984;73:315-9.
Flatt AE. The thenar flap. J Bone Joint Surg Br 1957;39-B:80-5.
Beasley RW. Reconstruction of amputated fingertips. Plast Reconstr Surg 1969;44:349-52.
Fusco EM. Finger reconstruction with palmar skin flaps. Am J Surg 1954;84:608-11.
Zancolli EA. Colgajo cutaneo en isla del hueco de la palma. Prensa. (Island flap from palm) Med Argent 1990;77:14-20.
Sturman MJ, Duran RJ. Late results of finger tip injuries. J Bone Joint Surg 1963;45:289-98.
Orbay JL, Rosen JG, Khouri RK, Indriago I. The glabrous palmar flap: The new free or reversed pedicled palmar fasciocutaneous flap for volar hand reconstruction. Tech Hand Up Extrem Surg 2009;13:145-50.
Barbato BD, Guelmi K, Romano SJ, Mitz V, Lemerle JP. Thenar flap rehabilitated: A review of 20 cases. Ann Plast Surg 1996;37:135-9.
Melone CP Jr., Beasley RW, Carstens JH Jr. The thenar flap – An analysis of its use in 150 cases. J Hand Surg Am 1982;7:291-7.
[Figure 1], [Figure 2], [Figure 3]