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Upper Limb Flaps for Hand Reconstruction

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Upper Limb Flaps for Hand Reconstruction Acta Orthop. Belg., 2004, 70, 98-106 Upper limb flaps for hand reconstruction Konstantin C. XARCHAS, Christos CHATZIPAPAS, Ourania KOUKOU, Konstantin KAZAKOS This article reviews three of the most popular upper MATERIAL AND METHODS limb flaps used in hand surgery, namely the posteri- or interosseous flap, the lateral arm flap and the Sixteen upper extremities (8 fresh cadavers) were dis- radial forearm flap. An anatomic study performed sected to delineate the anatomy, vascular pattern and with the use of eight fresh cadavers (sixteen upper reconstructive potential of the flaps. Six cadavers limbs) is supported by a wide review of the literature. belonged to males and two to females. Mean age was The combined posterior interosseous and lateral arm 51.5 years and mean weight 72 kilograms. Each sub- flap is also discussed. It is concluded that these flaps clavian artery was irrigated with 30 cc normal saline, are easily harvested and dependable and in spite of followed by injection with a silicone rubber compound any disadvantages their combination should be (Microfil). So, we had the determination of all vascular adequate for the treatment of almost any hand branches of each upper extremity. As these flaps are injury. situated in different anatomic areas of the upper limb, we were able to dissect and study each one of them for sixteen consecutive times. Dissections were carried out under loupe magnification. INTRODUCTION Posterior interosseous forearm (dorsal forearm) flap The anatomy of the hand allows cover of small skin defects with a great variety of local pedicle Anatomy. This flap is based on the posterior and island flaps. However, for larger defects it is interosseous artery (PIA). The artery is reported to orig- necessary that flaps from distant donor sites be inate from the common interosseous artery and occa- used, either as free or pedicle flaps. Use of the ipsi- sionally from the ulnar artery. In our specimens it always lateral upper limb as a donor site has many advan- originated from the common interosseous artery. After tages. Both donor and recipient sites are located passing between the chorda obliqua and the interosseous membrane, the posterior interosseous artery runs deep to within the same operative field permitting the entire surgical procedure to be performed with the patient under a single regional block anaesthesia, both flap and recipient sites being prepared syn- chronously in a bloodless field. Also, donor site From the Orthopaedic Department, Democritus University morbidity is restricted to a single extremity. of Thrace, Alexandroupolis, Greece. Orthopaedic surgeons occasionally performing flap Konstantin C. Xarchas, MD, Lecturer. surgery for hand reconstruction, need to be familiar Christos Chatzipapas, MD, Orthopaedic Registrar. Ourania Koukou, MD, Orthopaedic Registrar. with flaps that are dependable and easily harvested. Konstantin Kazakos, MD, Assistant Professor. We therefore present a thorough anatomic and Correspondence : Konstantin C. Xarchas, Democritus bibliographic study of the posterior interosseous, University of Thrace, 6 I. Kaviri Road, 68100 Alexandroupolis, the radial forearm and the lateral arm flap which, as Greece. E-mail : [email protected]. we believe, comprise these qualities. © 2004, Acta Orthopædica Belgica. Acta Orthopædica Belgica, Vol. 70 - 2 - 2004 UPPER LIMB FLAPS FOR HAND RECONSTRUCTION 99 the supinator and enters the deep extensor compartment the ulnar head. The PIA is located in the intermuscular of the forearm at an average distance of 8.0 cm from the septum between the extensor digiti minimi and extensor lateral humeral epicondyle and 14.0 cm from the ulnar carpi ulnaris muscles. head. At the level of the lower border of the supinator As we usually raise the flap with a distal pedicle, a muscle it divides into two branches : the interosseous dorsal skin incision is first made at the level of the dis- recurrent artery that anastomoses with the posterior tal radio-ulnar joint, to ensure presence of the PIA and branch of the profunda brachii artery at the elbow and its anastomosis to the AIA on which the flap will be the main trunk of the PIA that passes distally in the inter- based. The flap is then outlined and the incision extend- muscular septum between the extensor digiti quinti ed to its lower border and circumferentially to its upper (EDQ) and the extensor carpi ulnaris (ECU). Approxi- limit through the radial side. The incision is carried mately 2.0 cm proximal to the distal radioulnar joint, down through the deep fascia enveloping the extensor lateral to the ulnar head and underneath the extensor ten- carpi radialis brevis or extensor digitorum communis dons, the posterior interosseous artery anastomoses with (EDC) and extensor digiti quinti (EDQ) muscles. The the anterior interosseous artery (AIA), the dorsal carpal radial side is raised subfascially, taking the deep fascia arch and the vascular plexus surrounding the ulnar head. of the extensor digitorum communis and extensor digiti The vascular territory of the PIA is the posterior fore- minimi. Dissection continues from the lateral border of arm skin extending from 2.0 to 4.0 cm below the these muscles towards the ulnar side. Radial retraction interepicondylar line to the wrist. The artery gives off of the EDQ, EIP (extensor indicis proprius) and EDC several fasciocutaneous perforators along its length and exposes the septum and its cutaneous perforators. Here, thus supplies almost the whole width of the skin on the the fascia divides deeply and inserts into the intermus- posterior aspect of the forearm. Along its course, it gives cular septum. It is within this two-leafed fascial enve- several cutaneous branches, two of them being the most lope - the anterior leaf is the extensor carpi radialis bre- substantial : proximal and middle. The proximal cuta- vis with the extensor digitorum communis and the neous branch is a large branch, which courses in the extensor digiti quinti fascia and the posterior leaf is the intermuscular septum, pierces the deep fascia, and dis- extensor carpi ulnaris fascia- that the PIA lies. All mus- tributes in the subcutaneous tissue with two or three ter- cular branches of the PIA are ligated and the dissection minal branches. The middle branch originates in the extends proximally along the septum until a significant middle third of the forearm, where the PIA becomes cutaneous perforator is seen entering the flap and no fur- superficial. It was present in all of our specimens. At the ther than the distal border of the supinator muscle at the distal third of the forearm, the PIA gives the following radial side. The PIA is ligated proximal to this perfora- cutaneous branches : at the level of the wrist the artery tor. The posterior interosseous nerve lies on the lateral anastomoses with the perforating branch of the AIA, the side of the PIA. The nerve is dissected and preserved dorsal carpal arch, and the vascular plexus surrounding carefully. The origins of the interosseous recurrent artery the ulnar head. The posterior interosseous nerve enters and the proximal cutaneous branch are identified. After the dorsal compartment at the proximal third of the fore- localising the major perforator and dividing the PIA, the arm and becomes more superficial as it proceeds distal- ulnar skin incision is made. To harvest the ulnar half of ly. The PIA is accompanied by the posterior interosseous the flap, dissection is carried into the subfascial plane, nerve, which divides into sensory and motor branches. A again taking the extensor carpi ulnaris fascia. The inter- small sensory branch accompanies the artery as far dis- muscular septum and a very thin fascia are raised with tally as the wrist. the flap. The flap is then elevated from proximal to dis- Flap elevation (figs 1, 2 and 3). With the elbow in tal. Ulnar retraction of the ECU exposes the pedicle 90° of flexion, the forearm in full pronation and the within the septum, which should be dissected from the wrist in neutral position, a line is drown from the lateral ulnar shaft. To safeguard the pedicle and its venae comi- humeral epicondyle to the ulnar styloid apophysis. The tantes, a generous cuff of fibrofatty tissue is included entry point of the posterior interosseous vessels into the around the septum. The last motor branches of the pos- posterior compartment of the forearm is marked at the terior interosseous nerve follow the PIA in the septum union of the middle and proximal third of this line. The deep and close to it. The flap is elevated on the reversed center of the flap is designed a little more distally to this, vascular pedicle of the PIA and one additional cutaneous about 8.0 cm distal to the lateral epicondyle. The vascu- vein and then translocated to the hand through a subcu- lar pedicle is located there. The pivot point of the taneous tunnel, or superficially. If needed (cases with reversed vascular pedicle is about 1.0 cm proximal to vein congestion), the vascular anastomosis between the Acta Orthopædica Belgica, Vol. 70 - 2 - 2004 100 K. C. XARCHAS, C. CHATZIPAPAS, O. KOUKOU, K. KAZAKOS Fig. 1. — Posterior interosseous flap. Initial dissection. EDC : Fig. 3. — Posterior interosseous flap elevated and reversed on extensor digitorum communis, ECU : extensor carpi ulnaris, its pedicle to reach metacarpo-phalangeal joints. US : ulnar EDQ : extensor digiti quinti, S : septum where the PIA runs, styloid. An : anastomosis between PIA-AIA and dorsal carpal arch. proximity of the radial nerve, which runs in the groove between brachioradialis and brachialis muscle. The pos- terior radial collateral artery runs downwards between brachialis and triceps. Two nerves should be considered in the flap : A small nerve, arising directly from the radi- al nerve, which supplies the territory of the flap (poste- rior cutaneous nerve of the arm) and the posterior cuta- neous nerve of the forearm that passes through the deep fascia proximal to the lateral epicondyle and supplies the skin over the posterior aspect of the forearm.
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