Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Prochain SlideShare
What to Upload to SlideShare
Suivant

Partager

Thumb reconstruction

from neligan

Livres associés

Gratuit avec un essai de 30 jours de Scribd

Tout voir

Livres audio associés

Gratuit avec un essai de 30 jours de Scribd

Tout voir

Thumb reconstruction

  1. 1. By Dr Akasha Amber PGR P&R.S
  2. 2.  Loss of thumb: trauma  Best ideal way: replantation  Next option: reconstruction  Level of loss  rehabilitation
  3. 3.  Trauma; most common  Working age males  Mechanism:  Sharp cuts  Avulsion  Crush  Mixed (saw or lawn motor injuries)  Infections  Neoplasm  Congenital absence
  4. 4.  History  Complete examination of thumb  Every component  Integrity of skin, tendons and skeleton, neurovascular evaluation, feasibility of arterial & venous anastomosis  Examination of entire hand  Examination in infections/tumors of thumb  Particular note to peri-operative & intra-operative procedures  Radiographic evaluation
  5. 5.  Patient’s expectation (personal & professional needs)  Patient’s own decision  Informed consent  End goals : stability, motion & sensibility with adequate length  Adherence with the choice of reconstructive method type, adherence with the rehabilitation  Medically optimized (DM & CVD control, tobacco cessation  Infection control prior to reconstruction
  6. 6.  Proximal  From CMCJ to metacarpal neck  Middle  From metacarpal neck till IPJ  Distal  IPJ to thumb-tip
  7. 7.  Distal 3rd  Middle 3rd  Proximal 3rd
  8. 8.  Functional  Rarely requires lengthening  Chief goals: soft tissue coverage, maintenance of length, sensory perception  OPTIONS:  When no bony exposure:  Secondary healing:  upto 1.5cm,  daily dressings( petroleum/bismuth impregnated gauze)  Stable scar, two point discrimination,sensate,easy,preferred  Skin grafts:  Large defects, less sensate  Split or full thickness  Hypothenar eminence, volar wrist crease, groin crease
  9. 9.  When bone exposed:  Size & location  Vascularised flap coverage  ASTOY’s V-Y advancement flap  Neurovascular volar advancement flap(Moberg Flap)  Cross finger flap from index  Littler neurovascular island flap  1st dorsal metacarpal artery flap
  10. 10.  Thumb tip closure via volar V-Y advancement flap, perfused by small vessels traversing the subcutaneous tissues  Small areas  Limited advancement  Moberg thumb (neurovascular) volar advancement flap  sensate flap  Midlateral line incision to prox phalanx  IPJ flexed and fixed  Defects of 1–2 cm sq.  Island flap,variation  Flap elevated,only attachment is NVB
  11. 11.  CROSS-FINGER FLAP TO THE THUMB  Defects of 2-3 cm sq.  Disadvantage: thumb cooptation with index for 2-3 weeks need of skin graft on index defect  Cleland’s ligament of the index radial neurovascular bundle can kink the flap, needs release
  12. 12. Neurovascular island flap (Littler's flap) Rarely as primary coverage Commonly for sensation restoration to thumb pulp Ulnar NVB of middle or ring finger minimum impact on pinching & grip function Thick cough of fatty tissue around NVB, vasa vasorum of artery, only venous outflow At webspace, radial br of corresponding common digital artery divided, nerve fascicles split Flap transposition to thumb via tunnel or direct incision Donor site; grafting
  13. 13. First Dorsal Metacarpal Artery Flap (“kite flap”) Dorsal thumb defects Anatomical snuffbox: princeps pollices artery(radially) & FDMA(ulnarly)  from index-finger dorsum, Must include subcutaneous fat and interosseous muscle fascia with the pedicle thick fatty tissue with venae comitantes of artery (venous outflow) Flap transpositioned via tunneling or direct incision Donor site; grafting
  14. 14.  Functionally limiting  Soft tissue coverage, function & lengthening  Acute phase:  Revise Amputation Primary Closure Later Reconstruction  Length restoration  Absolute or relative  Relative lengthening: (phalangization)  Allows thumb excursion( opposition;palmar & radial abduction)  Small webspace deepening:  Z-plasties & skin grafting  Large webspace deepening:  Dorsal hand flap, radial forearm flap, posterior interosseous flap
  15. 15. four-flap Z-plasty used for deepening of the first webspace and/or releasing a first webspace contracture First webspace , full-thickness skin graft
  16. 16. double-opposing Z-plasty (known as the “jumping man” flap). This Z-plasty
  17. 17. Thumb amputation stump Scar band Dorsal hand flap Skin graft •Based on metacarpal arterial system, more than one metacarpal artery •Can release adductor pollices
  18. 18. Radial artery forearm flap •Major drawback: •compromises future thumb reconstruction •However ,radial artery perforator flap •Fascia alone,suprafascial skin flap ,fsaciocutaneous flap •Allen’s test •Pivot point;midway •BR & FCR
  19. 19. •Posterior interosseous artery flap •Reverse flow via anatomic connection btw AIA & PIA just proximal to DRUJ •Marking btw ulnar head and lat.epicondyle of elbow •Pedicle btw FCU & FDM •Drawback: appearance/color
  20. 20. Groin flap
  21. 21.  Absolute lengthening:  Metacarpal lengthening  MATEV  Osteoplastic reconstruction: bone graft wrapped with a flap  On-top plasty  pollicization
  22. 22.  MATEV  More proximal loss in middle third of thumb injuries  Contraindicated in thumb metacarpal remnant <3cm  Long period of ext.fixation,multiple visits  Osteotomy, proximal and distal pins for distraction device  Distraction: 1 mm /day  Ossification of gap, or bone grafting(iliac crest/radius)  Drawback: 1st webspace contracture
  23. 23.  3 stages:  Skeletal reconstruction with iliac crest bone graft wrapped with a flap(groin flap)  Groin flap division & serial thinning  Pulp reconstruction with NV island flap  Drawback:  Multiple stages  Bone resorption  bulky appearance
  24. 24. Iliac crest bone graft used for osteoplastic reconstruction of a thumb. The fixation of the bone graft is in progress, and will be covered by a groin flap
  25. 25.  Good for more proximal middle 3rd thumb injuries  Pollicization &/or on-top plasty  Pollicization vs on-top plsty  Racket type incision for ontop plasty at base of thumb stump and donor finger  Dorsal vein taken, nerves, arteries taken  Thumb prepared  Bony fixation; internal fixation,screw & plates
  26. 26. Pollicization of the 2nd ray. Preoperative appearance; Postoperative appearance; Opposition between new thumb and the little finger
  27. 27.  Challenging  Loss of thenar musculature  Microsurgical reconstruction  Pollicization with later opponensplasty  On-top plasty  Osseointegrated prosthetic digits & thumb
  28. 28.  Immobilisation (plaster spnit)…..1 week  Removable splint…..2 weeks  Suture removal  Active range of motion exercises….6 week  Late scar modification techniques
  29. 29.  1st webspace contracture  Tendon adhesions  Non-union, malunion  Joint stiffness  neuromas
  30. 30.  Replantation  Toe to hand transfer  Prosthesis  Nonmicrosugrical techniques for minimum optimal function
  31. 31.  Hand with amputation of all fingers proximal to functional level, with or without thumb amputation
  32. 32.  Immediate management  Resuscitation, dealing life threatening injuries, preserving amputated digits  Assessment  Initial operation  Debridement with preserving all viable structures  Avoid shortening of structures  Cauterization and pull & cut method for nerves avoided  Tag all structures
  33. 33.  Function decreases by 50% if amputation is proximal to PIP, 100% loss if proximal to MCPJ  Great toe, trimmed great toe, great toe wrap around flap, pulp flap or second toe flap  Additional bone graft interpositioning between transferred toe and metacarpal or distraction lengthening
  34. 34.  Proximal or distal amputations( related to insertion of FDS)  Partial toe flap(including either DIP or PIP & DIP) for distal amputations  More proximal injury; whole second toe transfer  Adjacent or separate 2 toe transfer  Ulnar 2 fingers: strong hook grip  Radial: tripod pinch
  35. 35.  Type 1A: 2 separate toes or combined 2nd & 3rd or 3rd & 4th toe transfer  type1B: combined 2nd & 3rd toe transfer  Type 1C: same as other two types  Type 2 injuries:  reconstruction of fingers similar as in type 1  If thenar muscles intact(IIA & IIB); one stage reconstrcution of thumb and fingers  If thenar muscles damaged, thumb recon delayed until finger function is achieved, prosthesis for later thumb position
  36. 36.  Retrograde dissection in 1st webspace, identification of dominant pedicle (70% FDMA, 20% FPMA, 10% both)  Identifying venous system, lazy S incision, at least one sizeable vein from venous plexus of intermediate layer  preservation of length of all structures
  37. 37.  Cruciate incision of recipient site  Webspace incision stay in midline, proximal V incision  Avoid scars in weight-bearing areas  Skin grafts discouraged, primary closure is better
  38. 38.  Parallel intraosseous wires; require 0.5cm of bone, good union, correct post-op malalignment or malrotation  Extensor tendons reconstructed 1st, then flexors  K wire is place in DIP and PIP for fixation in extension position  Nerve repair in next step(dorsal digital with peroneal; superficial with deep branches)  Arterial anastomosis  Keep arteries in back-up when in difficulty  Venous anastomosis  Skeletonization of NVB  Skin closed
  39. 39.  Trimmed great toe
  40. 40. A dorsal S incision on dorsum of foot expose donor veins, extensor mechanism & arterial pedicle retrograde dissection in 1st webspace Plantar dissection begins with midline incision, avoiding the weight-bearing areas of foot expose digital nerves and flexor tendon
  41. 41.  Specially for soft tissue loss but with intact skeleton  Same technique as in trimmed great toe  Disarticulation at IPJ  Flap degloved over the toe skeleton including only distal phalanx
  42. 42. •Markings on lateral aspect of great toe •Rich nerve supply •Includes both branches of DPN and digital nerve proper •Proper digital artery
  43. 43. Surface markings on the donor foot, showing FDMA & suitable vein Harvested toes with artery, veins, nerves, and tendons
  44. 44. Combined second- and third-toe flap harvested as transmetatarsal transfer for reconstruction of a metacarpal hand Reconstructed hand primary closure of all wounds without tension
  45. 45. For adjacent finger defects and larger thumb or palm defects sensate flap
  46. 46.  Microvascular ICU,close monitoring for 5 days  Keep patient warm, pain free and well hydrated  Nursing  Flap monitoring:  Internal implantable Doppler, pulse oximetry, infrared temperature assessment  Clinical observation  Any doubt: rapid action  Slight hand elevation  Non-bulk,non-constricting dressing  Intraoperative dextran, continuous post-op fluid infusion  Oral aspirin: for 2 week post-op
  47. 47.  Collaboration  5 staged rehabilitation program Protective stage(days 1-3)  Pt & hand therapist Early mobilization stage(day 4 to 4week)  Bone-union via immobilization of osteosynthesis site  Prevent joint stiffness by:  Passive movement distal to union site(day4 to 2 weeks)  Passive movement proximal to union site(at 4 weeks)  Any malalignment/malrotation corrected; splinting between exercises
  48. 48. Active motion stage(5-6 weeks)  Active mobilization, scar management  Splint(block or dynamic  Non-weight bearing Activities of daily living training stage (7-8 weeks)  Educate about daily activities, sensory education Prevocational training(8 weeks onwards)  Return to work, Occupational capabilities  Night splint for a year(in extension, prevents clawing)
  49. 49.  Both objective & subjective  Early:  learning light touch,pressure,localization,pin prick, static & moving 2 point discrimination tests  Late:  Delayed retraining of central cortical function  Memory,cncentration,relearning  Touching objects blindly & non-blinded
  50. 50.  Vascular compromise  Arterial spasm,thrombosis  Release sutures, local application of lidocaine,fluid optimization  Re-exploration, additional anastomosis  Repeat transfer of toe to hand  Venous congestion  Wound healing problems  Skin flap necrosis  Neuroma in donor area
  51. 51.  For functional improvement:  Flexor tenolysis  Arthrodesis  Web-space deepening  For aesthetic improvement:  Pulp plasty  Scar revision  Flap thinning
  • ReenaMINZ

    Oct. 4, 2021
  • phongsavathchanthalungsy

    Sep. 8, 2021
  • ssuserfa2e5e

    Jul. 1, 2021
  • brienthomas

    Mar. 18, 2021
  • abuulala

    Sep. 8, 2020
  • akashaamber

    Jul. 15, 2020
  • annahhl

    Mar. 14, 2020
  • kunalsayani

    Nov. 28, 2019
  • drkarthikaithal

    Oct. 29, 2019
  • RezaFahlevi31

    Oct. 8, 2019
  • drmeheraj

    May. 4, 2019
  • asmaaRabie2

    Mar. 14, 2019
  • SeifAhmed

    Jan. 29, 2019

from neligan

Vues

Nombre de vues

850

Sur Slideshare

0

À partir des intégrations

0

Nombre d'intégrations

0

Actions

Téléchargements

0

Partages

0

Commentaires

0

Mentions J'aime

13

×