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Non-microvascular alternatives for treatment of pediatric hand conditions: Sometimes a better option

David T. Netscher¹, Gina Cruz², Carolyn Berg³
¹Division of Plastic Surgery, Department of Orthopedic Surgery, Baylor College of Medicine
²Division of Plastic Surgery, Baylor College of Medicine
³Michael E. DeBakey Department of Surgery, Baylor College of Medicine,
Houston, Texas, USA

 

 

Correspondence

David T. Netscher, M.D.,
Clinical Professor, Division of Plastic Surgery
Professor, Department of Orthopedic Surgery
Baylor College of Medicine, Houston, Tx, USA
6624 Fannin, #2730, Houston, TX 77030
Tel: 713-799-8090
Fax: 713-795-5006
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Purpose: Non-microvascular options exist for pediatric hand reconstruction. The aim is evaluate the indications and outcomes for these reconstructions.

Methods: Evaluate results of different types of reconstruction as supported by the evidence in the literature and from personal experience.

Results: Case studies show the value of local pedicle flaps from the hand and forearm, the specific role for the groin flap, distraction lengthening, non-vascularized toe phalanageal transfers, non-vascularized toe joint transfer, and prosthesis fitting.

Conclusions: Non-microvascular options do not require special equipment needs and in certain congenital and traumatic situations may actually be a better treatment option than the microvascular alternatives.

Key words: intrinsic hand flaps, forearm flaps, groin flap, toe phalangeal transfer, distraction lengthening, toe joint transfer

 

 

Introduction

There are a number of congenital and pediatric trauma conditions of the hand that are traditionally treated by microvascular reconstruction. However, under certain circumstances, non-microvascular solutions may provide an equally successful, if not better alternative form of treatment. These non-microvascular alternatives include pedicle and retrograde vascular flaps, full-thickness nail bed grafting, distraction lengthening, non-vascularized toe phalangeal and toe joint transfers, and prosthetics. All of these alternatives need thorough discussion with patient and parents and establishment of realistic goals and expectations.

Method

1. Soft Tissue Reconstruction of the Hand

a. Groin Flap

The groin flap was one of the first described pedicle axial pattern1 and free flaps[2]. At one time, the groin pedicle flap served as the workhorse for hand reconstruction[3]. Recent developments have however dictated the more frequent use of free flaps which have the advantage of singlestage reconstruction, enhanced vascularity, more durable coverage of orthopedic hardware, and ability to keep the extremity elevated and reduce hand swelling and facilitate hand therapy.

However, under certain circumstances, the groin flap may still be indicated. In the trauma situation, one may use a groin flap for initial soft tissue coverage, sparing available recipient vessels for later microvascular toe transfer. This teenager shown in the figure sustained a mutilating hand injury while bailing hay. A preliminary groin flap provided the necessary soft tissue coverage and bulk to maintain the first webspace. Microvascular toe transfer subsequently reconstructed the thumb ( fig. 1a, 1b).

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Fig. 1a. Groin flap provides preliminary hand soft tissue coverage Fig. 1b. Subsequent microvascular toe to hand transfer is done

In congenital hand anomalies, when there are longitudinal deficiencies, suspect major vascular anomalies to be present. This infant had syndactyly and deficiencies on the radial side of the hand ( fig. 2a, 2b). After syndactyly release, the thumb was transposed, and the index finger ray was recreated with a free iliac bone graft to the second digit metacarpal. Soft tissue bulk was required for the first webspace. Total absence of the radial artery in the forearm precluded both a turnover retrograde radial forearm pedicle flap or a free flap. A groin pedicle flap served this function well.

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Fig. 2a. Infant with syndactyly and deficient thumb

 

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 Fig. 2b. Multistage reconstruction with index finger metacarpal reconstruction and webspace creation with groin flap

 

b. Reverse Radial Forearm Pedicle Flap

This flap has now become commonly used for soft tissue reconstruction to the first webspace and the dorsum of the hand[4]. It can be performed more quickly than a free flap. It can be raised as a fascial flap or as a fasciocutaneous flap. An example is shown in this child who had excision of an infantile fibrous hamartoma from the dorsum of the thumb ( fig. 3). This is a locally aggressive tumor that required wide excision that included the extensor mechanism. Single-stage reconstruction was done with a free tendon graft and turnover retrograde radial forearm pedicle flap.

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Fig. 3. Reverse radial forearm fasciocutaneous flap reconstruction to dorsum of thumb after tumor resection 

c. Intrinsic Hand Flaps

With improved understanding of the hand and finger vascular anatomy[5], a variety of antegrade and retrograde pedicle flaps of the hand have been described[6]. An example is seen in this child who had a large avulsing injury to the volar little finger when his hand was dragged along the ground from a fast moving go-cart ( fig 4a, 4b). An intrinsic hand flap enables reconstruction with tissue of similar quality and texture. Microvascular techniques are utilized to dissect these tiny vessels, without necessitating an actual microvascular anastomosis. Because of the substantial finger length differences between the ring and little fingers, an arterialized pedicle flap taken from the ulnar side of the ring finger can resurface the little finger, without violating the critical distal volar pulp pad of the ring finger and the ulnar digital nerve to the ring finger is left intact. A full-thickness skin graft is used for the flap donor site. Final functional and aesthetic outcome is good.

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Fig. 4a. Avulsing little finger volar defect reconstructed with ulnar digital artery island flap from adjacent ring finger Fig. 4b. Final result  after skin grafting  donor site on ring finger

 

2. Fingertip Injuries

Distal fingertip amputations may be treated by composite grafting, but even in children there is up to 30% total necrosis and failure rate[7]. Distal finger amputations may also be replanted by microvascular reconstruction, but establishing venous outflow is a problem, often needing blood transfusion, great technical expertise is required, and there is potential failure rate of 30-50%[8-11]. In the face of failure of reattachment, one is committed to more proximal revision amputation, and irritating and dysfunctional nail deformities. Recognizing that preservation of the perionychial tissues is vital to functional and aesthetic reconstruction, we have found that removing these tissues from the amputated part as a full-thickness skin graft, and provision of volar bulkiness by means of a cross finger or volar advancement flap, enables excellent outcome (fig. 5a). Provided a minimal amount of eponychial fold and the germinal matrix remain, new nail growth is ensured across the support and scaffold provided by the bulk of the local flap and the overlying perionychial graft. The success rate is high and aesthetic outcome is very good using this technique in children and has been reported in consecutive cases[12] (fig. 5b).

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Fig. 5a. Child with amputated fingertip undergoes cross-finger flap and full-thickness grafting of perionychial tissues Fig. 5b. Long-term results of similarly reconstructed digits with local flaps and grafting

 

3. Distraction Lengthening

Distraction lengthening has been used in the hand for a long time[13-14]. In children, it has served us well for multiple digit traumatic amputations and also in congenital hypoplasias. Provided sufficient length of proximal phalanx remains, digits can be lengthened to enable fingertip to thumb tip prehension[15]. If multiple digits are involved, microvascular toe transfers become impractical. Even in the ideal situation for which microvascular toe transfer is best suited, namely constriction band amputation of the thumb, distraction lengthening is a plausible solution ( fig. 6). The parents may decline sacrifice of the toe or, as is sometimes the case, multiple toes may also be involved by constriction bands, and so may not be available for transfer. Bone may form within the distracted space (always try to retain a periosteal sleeve) but on occasion, interposition bone grafting may be required.

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Fig. 6. Distraction lengthening of thumb proximal phalanx in a child with constriction ring amputation 

 

4. Reconstruction of Multiple Absent Digits

Symbrachydactyly, especially in the face of a normal or relatively normal thumb, is an excellent opportunity for multistage reconstructions using non-microvascular techniques. This plan involves non-vascularized proximal toe phalanx transfer, followed by syndactyly release and deepening of the webspaces and finally distraction lengthening. Provided metacarpals are present and if digital distraction of the small digits by the examiner shows retractile recoil (indicating presence of tendon mechanisms) then toe phalangeal transfer can be undertaken. Multiple digits can be reconstructed (whereas microvascular toe transfers would be impractical). Additionally, one does not have to be concerned with proximal abnormal neurovascular structures that are invariably the case with symbrachydactyly (unlike constriction band syndrome) that would complicate microvascular reconstruction[16].

One will encounter a natural bursa over the end of the metacarpal which has a pristine articular cartilage surface. This bursa can be incised saggitally and serves as attachment for collateral ligaments. Extensor tendons are also reattached. The toe phalanx is harvested from the second or third toe, keeping a corona of attached periosteum and collateral ligaments at the bone base[17,18]. The goal is to restore phalanges to each of these finger nubbin skin envelopes and so maintain the ultimate breadth of hand span for a stronger grip than can be achieved with one or two microvascular toe transfers. Mobility and function is obtained at the reconstructed MP joints. Finally, the toe phalanx will grow with a patent physis remaining, especially if done before 18 months of age. While the growth capacity is less than for a normal finger, at least the stage is set for subsequent staged reconstruction with webspace deepening and distraction lengthening[16]( fig.7a, 7b, 7c).

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Fig. 7a. Patient with symbrachydactyly and subsequent proximal toe phalangeal transfer.

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Fig. 7b. At an older age distraction lengthening is performed.

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Fig. 7c. Final functional result

5. Non-vascularized Toe Joint Transfer

While vascularized joint transfer has proven successful for metacarpophalangeal joint reconstruction, the range of motion achieved at the proximal interaphalangeal joint is often disappointing[19,20]. Vascularized joint transfer in children has the possible advantage of retaining epiphyseal growth potential as well. However, in a few cases, we have found that nonvascularized proximal interphalangeal toe joint transfer performed as well. The synovial space of the transferred joint is retained by preserving collateral ligaments, volar plate, and dorsal capsule. Additionally, the central slip is retained. The recipient site is prepared by an extensor tendon splitting approach and the damaged joint is excised. Bone fixation is accomplished by longitudinal Kirschner wires and the central slip mechanism is simply sutured in place. Range of motion of the reconstructed joint has proved excellent and the epiphysis has stayed open ( fig. 8a, 8b). Perichondrial arthroplasty has been used for resurfacing with some success, but has no role when there is significant bone destruction and loss[21]. We have not used this technique in adults, favoring arthrodesis or implant arthroplasties for proximal interphalangeal joint reconstruction.

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Fig. 8a. Child with PIP joint destruction following infection. Toe PIP joint non-vascularized transfer is perform

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Fig. 8b. Functional outcome; also showing radiographic preservation of the epiphysis 

6. Prostheses.

Even in juveniles, where contrary to conventional wisdom that microvascular toe transfers may be the best reconstructive option, the patient may decline further reconstruction. I had a patient who had failure of a thumb replantation following avulsion from his dominant right hand. He was a talented high school basketball player and declined toe transfer since it would diminish his jumping athletic prowess. He continued the basketball season, learned to shoot at baskets with his left hand, and used a small stubby prosthesis on the thumb. He achieved a basketball scholarship and continued a successful basketball career at college. Another patient with multidigit amputations, was wellserved with prosthetic digits to fill in the gaps between missing fingers ( fig. 9).

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Fig. 9. Patient with multiple amputated digits has prosthesis that helps function by filling in the gaps between missing fingers 

 

Conclusions

Familiarity with a variety of reconstructive techniques is important when treating pediatric hand problems. Recourse to non-microvascular techniques where there may also be microvascular alternatives may be dictated by patient preference, lack of microvascular expertise or equipment, especially for the very small structures involved with children, but more especially the non-microvascular methods may actually sometimes be the better choice[22].

 

 

 

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