Heterotopic Free Pulp Flap in A Patient with A Multiple-Digit Crush Injury

異指指腹自由皮瓣於多指壓砸傷病患－案例報告

張哲瑋(Che-Wei Chang) ； 楊曙亙(Shu-Gen Yang) ； 陳右昇(Yo-Shen Chen)

《臺灣整形外科醫學會雜誌》 Volume 28 Issue 2 (2019/06) Pp. 153-159

Abstracts

Background: Spare-part surgery is a concept applied to treat multiple-digit injury. Tissues from non-salvageable digits such as vessel, bone, tendon and skin have been used as grafts or even as free flaps for reconstruction. The use of spare parts minimizes the need for donor tissue while restoring as much function as possible. Aim and objectives: We report a patient with a multiple-digit crush injury of the left hand. A free pulp flap from the severely damaged middle finger was transferred to optimize the function of the ring finger. Materials and Methods: A 28 years old male worker with no medical history was sent to the emergency department after sustaining a crush injury to the left hand. The middle finger had the most severe damage and the distal phalanx was non-salvageable. There was segmental thrombosis inside the digital artery and no spurting occurred after it was trimmed back. There was a pulp defect on the ring finger with exposure of the distal phalanx and flexor digitorum profundus. A free pulp flap was harvested and transferred from the middle finger to resurface the defect of the ring finger. Results: The heterotopic pulp transfer to the ring finger achieved good function as measured in long-term follow up. Sensation recovery was demonstrated with two-point discrimination (TPD) of 8mm at the 2.5-month follow up and of 6mm at the 4-month follow up. The active of range of motion (ROM) the distal interphalangeal (DIP) joint of the ring finger was 0-70 degrees and the ring finger also showed good grip function at the 5-month follow up. Conclusion: Tissues from non-salvageable digits can be dissected and harvested for use as free flaps for the digits with the best chance of function. Heterotopic free pulp flap was used to replace like with like, creating a sensitized flap.

Keywords

free pulp flap ； multiple-digit ； crush injury ； spare-part surgery

Parallel abstracts

背景：剩餘組織取自嚴重創傷而無法挽救的指頭，如：血管、神經、肌腱、骨頭及皮膚，可以用於重建其他的指頭。應用上可將多種組織一起取下，分離成為自由皮瓣。剩餘組織的使用，可減少重建時對於完整健康組織的需求，同時幫助其他受傷指頭恢復原本功能。目的及目標：我們報告一個因為壓砸傷導致左手多指損傷的病患。手術中將幾乎分離且無循環的中指遠端指節，部分組織取下成為指腹自由皮瓣，用於重建無名指指腹的缺損，以恢復正常的功能。材料及方法：一位28歲的工人本身沒有特殊疾病。因沖床操作不當，造成左手的食指至小指的壓砸傷。中指有最嚴重的組織缺損，遠端指節已沒有循環，並且與近端指節只剩少數軟組織連接，在此軟組織中，可以看到內有多處血栓的指動脈。無名指則是在遠端指節的指腹有缺損，造成骨頭跟肌腱的暴露。因此我們將中指遠端指節分離成指腹皮瓣，移植到無名指的缺損，並將皮瓣上的指神經指動脈接合到相對應構造。結果：移植於無名的指腹皮瓣，增進了手指功能的復原。我們觀察到了觸覺的恢復，移植到無名指的指腹皮瓣，在約兩個半月的追蹤，對於兩點區辨感覺可達8mm，並且在四個月的追蹤，兩點區辨感覺進步到6mm。由於皮瓣將暴露的指骨跟肌腱完整覆蓋，遠端指關節沒有因此攣縮。在約五個月的追蹤，遠端指關節主動活動範圍可達0到70度，並且無名指保有良好的抓握功能，這是病患能夠重新工作的重要原因。結論：本案例的異指指腹皮瓣，是取自無法拯救指頭的剩餘組織，分離成自由皮瓣來重建其他受傷的指頭。由於指腹皮瓣構造類似缺損的組織，重建後可以讓原本受傷指頭，產生保護性的觸覺，進而恢復手指最大的功能。