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A New Flap for the Treatment of Postburn Contractures of the Hand

Sevin, Asuman M.D.; Sevin, Kutlu M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 225e-226e
doi: 10.1097/01.prs.0000305386.55161.be
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Sir:

Postburn contractures are still a challenging problem. Various local and distant flaps have been used to reconstruct hand contractures. However, distant flaps are more complicated and are mostly not suitable for the thin skin of the hand. We have used dorsolateral proximally pedicled ulnar skin flaps to cover a patient’s flexion contracture defects.

A 7-year-old boy sustained a burn on the right hand that caused severe flexion scar contractures on the metacarpophalangeal joints of fingers 3, 4, and 5. First, the contractures were released and scar tissues were excised to obtain complete extension of the metacarpophalangeal joints. The flexor tendons were exposed after release of the contractures. Dorsolateral proximally pedicled local flaps were raised from the ulnar sides of fingers 3, 4, and 5 (Fig. 1). The flaps were rotated to cover the flexion defects. The donor sites were closed primarily. The hand was splinted for 2 weeks. Passive motion was started after 1 week. After 3 weeks, physical therapy was started to move the metacarpophalangeal joints.

Fig. 1.
Fig. 1.:
Preoperative view of the patient’s hand. Dorsolateral flaps were planned on the ulnar sides of fingers 3, 4, and 5.

In postburn contractures of the hand, surgical treatment is often necessary when splinting has failed to improve the functional or aesthetic outcome. In our experience, there are several major types of postburn contracture involving the volar and dorsal sides of the hand: flexion contracture of the metacarpophalangeal joint, flexion contracture of the proximal interphalangeal joint, adduction contracture of the thumb, and extension dorsal contracture.1

Postburn contractures of the hand require appropriate surgical treatment whenever conservative approaches have failed. Kalliainen and Schubert1 stated that multiple reconstructive options exist for the web space contracture: skin grafts, local flaps, and distant flaps have all been used to release the contracture and resurface the resultant defect. Local flaps, however, are frequently more suited to web contractures between the fingers.1 Katsaros used free flaps in selected cases and stated that it is a modern reminder that there are many ways to treat defects of the upper limb and that the responsibility of the surgeon is to be both imaginative and wise in securing the best possible result for the patient.2 However, microsurgery is a more complex and expensive method, so free flaps may be indicated in selected cases. Innocenti and Felli reported some distant flaps for reconstruction of the first interdigital commissure,3 but distant flaps require multiple sessions, so they are not superior to local flaps. Furnas used Z-plasties to treat hand contractures.4 Z-plasties are especially useful in treating the web contractures, but they may be insufficient to cover large flexion defects. Our new flap has a secure blood supply that is very suitable for the palmar defect because it is thin. Cross-finger flaps have been used to cover palmar defects, but donor-site morbidity is one of the major drawbacks of this method.5 Our flap is prepared from the ulnar sides of the finger, which are not involved in opposition, so donor-site morbidity is minimal (Fig. 2).

Fig. 2.
Fig. 2.:
At 1 year postoperatively, the fingers have full extension and no recurrence is seen.

Asuman Sevin, M.D.

Plastic Surgery Department

Ankara Numune Research and Training Hospital

Ankara, Turkey

Kutlu Sevin, M.D.

Plastic and Reconstructive Surgery Department

Ankara University Ankara Medical Faculty

Ankara, Turkey

REFERENCES

1. Kalliainen, L. K., and Schubert, W. The management of web space contractures. Clin. Plast. Surg. 32: 503, 2005.
2. Katsaros, J. Indications for free soft-tissue flap transfer to the upper limb and the role of alternative procedures. Hand Clin. 8: 479, 1992.
3. Innocenti, M., and Felli, L. Reconstruction of the first interdigital commissure with distal flaps. Chir. Organi. Mov. 74: 69, 1989.
4. Furnas, D. W. Z-plasties and related procedures for the hand and upper limb. Hand Clin. 1: 649, 1985.
5. Koch, H., Kielnhofer, A., Hubmer, M., and Scharnagl, E. Donor-site morbidity in cross-finger flaps. Br. J. Plast. Surg. 58: 1131, 2005.

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