Thumb amputation at the carpometacarpal level is very incapacitating. Pollicization may be considered. We describe an alternate technique for thumb reconstruction at the level of the metacarpal base using a trimmed great toe along with a vascularized second metatarsophalangeal joint, including the second metatarsal, all supplied on a single vascular pedicle. Two patients who had a combined soft tissue defect and amputation of the thumb close to the carpometacarpal joint were reconstructed with this method. A transposition of the second toe was performed on top of the remaining proximal phalanx of the great toe to decrease donor site morbidity. This technique provides adequate length to the thumb without compromising another finger by creating a new thumb using a double microsurgical toe transfer on a single vascular pedicle. We minimize donor site morbidity by transposing the second toe onto the great toe.

).Median nerve neurapraxia associated with direct traumatic vascular injury to the brachial artery is extremely low. Brachial pseudoaneurysm could result in compression and elongation of the nerve leading to an ischemic injury. An early diagnosis of these injuries is essential to avoid complications and an improved prognosis could be expected under the correct management.A 46-year-old man, who was initially admitted to a tertiary hospital with a metal splinter penetrating injury at the elbow, was referred to our clinic 2 weeks later with swelling in the elbow and hypoesthesia in the second and third fingers. Electromyography confirmed an incomplete neuropathy of the median nerve and Doppler study revealed a 6 Â 4 cm brachial artery pseudoaneurysm. Operative finding showed a 10 Â 8 mm defect on the posterior medial wall of the brachial artery, which communicated with a large cavity containing a hematoma where the median nerve was clearly compressed (►Fig. 1). The thrombus was evacuated with extraction of the metal fragment and the injured arterial segment resected. Arterial flow was restored through end-to-end anastomosis. Three months after surgery full recovery was noted.The second patient, a 36-year-old man developed tingling sensation and paraesthesias over the thumb and index finger 1 week after suffering a stab wound over the left mid-arm. Electromyography showed a partial axonal injury of the median nerve with denervation of the flexor digitorum profundus of the index finger and the flexor pollicis longus. A 7 Â 5 cm pseudoaneurysm communicating with the distal portion of the brachial artery with displacement of the median nerve was observed by color Doppler. The injured arterial wall was resected and end-to-end anastomosis was

70S HAND 11(1S) 36.9 months (range, 25-49 months postinjury). The range of active motion of joints, grip and pinch strength, cutaneous sensibility, upper-extremity functioning, and subjective satisfaction using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire (MHQ), and psychological sequelae including depression, anxiety, and postraumatic stress disorder (PTSD) were assessed. A correlation analysis among variables was also performed. Results: According to the Strickland criteria, the active motion of digits was excellent in 4 (15%), good in 6 (5%), fair in 9 (35%), and poor in 9 (45%) digits. The mean value of the total grip, pinch strength, and the SemmesWeinstein monofilament testing exceeded 80% of value of the healthy hand. However, the average value of static two point discrimination (s2PD) was less than half value of the healthy hand. The mean score for the DASH and MHQ was 6.9 and 58.9, respectively. The incidence of cold intolerance was 60%. Only 1 patient has showed the symptoms of depression and PTSD after 49 months postinjury as yet. Almost all patients returned to work and half of them did not change their former type of occupations. Conclusions: We concluded that the objective functional results of replanted digits did not affect the daily life and satisfaction of patients. Objective: To describe and present the results of surgical technique with the use of skin flap of second dorsal metacarpal artery retrograde flow to the treatment of patients with retraction of the first web space of the hand and, when necessary, apply longer flaps to cover the palm of the hand. Methods: Sixteen patients were operated with retraction of the first web space. In 6 patients, there was also scar retraction of the palm, in addition to the web space. Before surgery, the angle of opening of the first web space was measured, and the degree of shrinkage was divided into 3 groups: mild, moderate, and severe. Eleven cases were considered serious and 5 moderate. The authors describe in detail the surgical technique. Results: All 16 flaps had survival (100 cases). In 3 cases, there was partial suffering of about 10% of the distal area of the flap with transient ischemia and in 2 cases epidermolysis occurred, all with satisfying results. Retail dimensions ranged on average 10 cm in length and 2.2 cm in width, on average. In 87.5% of the cases there was total closure of the donor area. The opening of the first commissure ranged from 51° to 83° (average of 73.5°). Conclusion: The use of the cutaneous flap of the second metacarpal dorsal artery is reliable and it shows good results for the treatment of retractions of the first web space. It can be considered a good option for cases that present beyond the web space, retraction of the palm. Background: Restoring the aesthetic appearance and sensibility of the fingers, specially the fingertip, after traumatic amputation has an essential role in the functional recovery of the hand. Advances in microsurgery have allo...

PALABRAS CLAVEColgajos libres; Reconstrucción microquirúrgica; Mano; Cobertura cutánea ResumenObjetivo: Revisar los colgajos libres utilizados más frecuentemente en la reconstrucción de la mano y evaluar sus resultados, ventajas y complicaciones. Material y método: Entre el 2011 y el 2014, 49 pacientes fueron intervenidos mediante diferentes transferencias microquirúrgicas, con una edad media de 41 años (25-57). En función de la localización del defecto, se han realizado: a) 29 colgajos libres para los dedos; b) 11 transferencias libres para cobertura de la mano, diferenciando entre zona dorsal de la mano y primera comisura: 5 pacientes; zona volar: 2 pacientes, y cobertura de ambas simultá-neamente: 4 pacientes, y c) 9 transferencias óseas vascularizadas para seudoartosis (7 casos) y reconstrucción de articulaciones (2 casos) en la mano y los dedos.Los resultados fueron evaluados en términos de supervivencia del colgajo, complicaciones, reintervenciones y satisfacción del paciente. Además, en los casos de afectación de los pulpejos de los dedos, también se valoró el índice de discriminación de 2 puntos. Resultados: El porcentaje de supervivencia del colgajo fue del 100%. En 5 casos fue necesaria una tenoartrólisis secundaria y en otro caso (lateral de brazo para cobertura volar de 4 dedos) se intervino al paciente en 2 ocasiones más para la separación completa de los dedos. Se obtuvieron buenos resultados estéticos y funcionales en todos los pacientes, con alto grado de satisfacción. Los pacientes con afectación del pulpejo obtuvieron una media en el índice de discriminación de 2 puntos de 9,1 mm (8-11). Conclusiones: En nuestra opinión, el uso de colgajos libres en cirugía de la mano proporciona un mejor resultado, sin sacrificar ----a diferencia de los colgajos locales----, otras zonas sanas de la mano, consiguiéndose una mínima morbilidad de la zona donante y muy buenos resultados estéticos y funcionales. Document downloaded from http://www.elsevier.es, day 07/07/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Document downloaded from http://www.elsevier.es, day 07/07/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Material and methods: A total of 49 patients, with a mean age of 41 years old (25-57), underwent different microsurgical transfers for hand reconstruction between 2011 and 2014. The type of transfer performed depended on the location of the defects: a) 29 free flaps for finger reconstruction, b) 11 free transfers for hand coverage (dorsal coverage and first web space: 5 patients; volar hand defects: 2 patients; coverage of both regions of the hand at the same time: 4 patients, and c) 9 free vascularised bone transfers for non-unions (7 cases) and joint reconstructions (2 cases) in hand and fingers.The results were evaluated in terms of flap survival, complications, secondary procedures, and patient satisfaction. In addition, when fingertip reconstruction was i...