D. The joint with its island of skin has been set into the defect
created by opening up the scarred, contracted recipient area. Proximal
vascular structures have been repaired. The flap could have been innervated
by a branch from the superficial peroneal anatomosed to a branch of the
superficial radial. One should almost always carry such a skin island
to facilitate closure of the recipient area, to protect branches of the
vascular pedicle entering the joint, provide venous drainage, and serve
as an island for monitoring circulation to the joint transplant.
A 14-year-old boy sustained a segmental loss of the proximal interphalangeal joint to his left ring finger in a bizarre bicycle accident.
4-01. Circulation to the distal tissues was preserved through the
intact ulnar skin bridge containing the neurovascular bundle.
FIG. 4-02. X ray revealed the clean bone and joint loss.
FIG. 4-03. Wound closure was achieved by shortening the digit, permitting the ulnar bridge to bulge out like an "inchworm."
|| FIG. 4-04. Bony stability was achieved with a small K-wire inserted retro-gradely. The parents were then counseled on the importance of immediate reconstruction to prevent scar tissue from shortening and binding of all structures.
FIG. 4-05. The operative plan was accepted by the family and the wound was recreated 3 days after injury. The proximal and distal radial neurovascular structures were dissected out.
FIG. 4-06. Simultaneously, a second team mobilized the ipsilateral second toe, disarticulating it at the metatarsal joint and the distal interphalangeal joint. The neurovascular pedicle on the medial (radial) side of the toe was carefully preserved at
FIG. 4-07. The tubular toe transplant containing the joint was interposed into the traumatic defect in the finger, splitting the lateral-ulnar side to permit the insertion of the intact skin bridge, which fortunately increased the circumference of the transplant perfectly.
FIG. 4-08. Full flexion and extension were finally achieved after a secondary flexor tenolysis. Extension is shown.
FIG. 4-09. Flexion is shown.