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J Orthop Surg Res
J Orthop Surg Res
Journal of Orthopaedic Surgery and Research
1749-799X
BioMed Central London

5041
10.1186/s13018-024-05041-y
Research Article
Clinical application of the free superficial palmar branch of radial artery flap for soft-tissue reconstruction of distal digital injury
Zhao Wei 1216405335@qq.com

Song Kun-xiu
Ma Bing-dong
Liu Yong-tao
https://ror.org/008w1vb37 grid.440653.0 0000 0000 9588 091X Department of Hand (micro) Surgery, Binzhou Medical University Hospital, Binzhou, Shandong China
9 9 2024
9 9 2024
2024
19 55311 6 2024
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Purpose

The purpose of this study is to retrospect and summarize clinical efficiency and experience of the free superficial palmar branch of radial artery (SPBRA) flap for soft-tissue reconstruction in distal digital injury.

Method

13 patients with soft-tissue defect of finger, reconstructed by the free superficial palmar branch of radial artery (SPBRA) flap in our department from January 2020 to January 2022, were reviewed. After 6–12 months of follow-up, evaluated the treatment effect of the fingers reconstructed by SPBRA flap.

Results

All the flaps in our series application were survival uneventful, and all the donor sites were closed primarily without complications or obvious scarring. The flaps were soft in texture and satisfactory in appearance and function. The flaps with the median nerve palmar cutaneous branch had a good sensation recovery. Measurement of two-point discrimination (TPD) ranged from 6 to 10 mm. All patients were satisfied with the aesthetic appearance. According to the Evaluation Trial Standards of Upper Limb Partial Function of Hand Surgery of Chinese Medical Association, the results were graded as excellent in 11 cases and good in 2 cases.

Conclusion

The SPBRA perforator flap has the advantages of simple operation, soft texture, good appearance and function, and is credible and useful for reconstructing various finger injuries.

Keywords

Free superficial palmar branch of radial artery flap
Soft-tissue reconstruction
Distal digital injury
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

The hands are an important organ of the body, which play a significant role of aesthetic and function in life quality and societal action [1]. There are many factors for finger injuries, including trauma, infection, burn, ischemia and neoplasms [2]. Among these, injuries caused by trauma are the most common, especially in the distal finger, accompanying with tendon, nerve, or artery defect, which should be reconstructed by composite tissue flap to cover the defect and reconstruct the function and appearance. Various flaps were reported in literatures, including advancement flaps [3, 4], cross-finger flaps [5], local island flaps [6–8] and free flaps [9–11]. With the development of perforator flap theory and microsurgical technique, physiological reconstruction and esthetic efficacy is the goal of the hand surgeons, and minimizing donor site injury is worthy of consideration. Kamei et al. first reported the thenar flap, based on the superficial branch of the radial artery for hand soft-tissue reconstruction in 1993 [12]. The purpose of this paper is to review and summarize our clinical experience.

Patients and methods

We conducted a retrospective review of patients who underwent SPBRA flap transfer reconstruction for distal digital injuries between January 2020 and January 2022. The mean age of the patients was 37 years (range 23–56), 8 men and 5 women. The mechanism of injuries was as follows: crush injury (5 cases), chainsaw injury (3 cases), cut injury (5 cases). The injured digits were: index finger 5, middle finger 5, ring finger 2 and little finger 1. Finger wound area: 1.7cmx2.1 cm to 2.7cmx3.8 cm. All patients were treated with debridement and anti-infection treatment on time. After the wound was stable, SPBRA flap was performed for reconstruction. Full written consent was obtained from all patients prior to each procedure.

Operative technique and post-operative management

Preoperative preparation

The patients improved the preoperative examination and eliminated the operative contraindications. The SPBRA flap originates from the radial artery and tends to the tubercle of scaphoid bone, then enters the thenar area, at the superficial of the thenar muscles. A handheld Doppler probe is used to trace and mark the course of the superficial branch of the radial artery, in order to design flap.

Wound debridement

Thorough wound debridement under arm tourniquet controls performed in all cases. Following wound debridement, the artery and vein of the donor side were dissected and marked with a single stitch.

Flap design and incise

The flap was designed along the route of the SPBRA flap with an elliptical shape to facilitate donor site closure (Fig. 1). According to the design, the proximal radial edge of the flap slitted first to expose the radial artery and find the superficial palmar branch of the radial artery under microscope. Attention should be paid during the harvest to protect the perforators of superficial palmar branch of radial artery and its accompanying vein and also subcutaneous veins. After confirmed the perforating artery and vein included in the flap, the flap was excised. During the operation, either the palmar cutaneous branch of the median nerve (PCBMN) or the branches of the superficial radial nerve or the lateral antebrachial cutaneous nerve can be included in the flap and coapted to the proximal cutting end of the digital nerve. To dissect the flap edge, with only vascular pedicle attached, the blood circulation was observed before the pedicle was broken. The flap was transferred to the injured finger, and the SPBRA flap and the accompanying vein or superficial cutaneous vein were anastomosed with the proper digital artery and dorsal or volar superficial cutaneous vein under microscope respectively. The donor sites were closed directly. The patients remained in hospital on complete bed rest for 7 days. They underwent rehabilitation for digit movement starting 2 weeks post-operatively.

Fig. 1 The design of flap in donor site was simplified before surgery

Assessment item and standard

After 3, 6, and 12 months of follow-up, all follow-ups were completed by the same group of attending physicians. Referring to selection and late efficacy of fingertip skin grafting [13] and the Evaluation Trial Standards of Upper Limb Partial Function of Hand Surgery of Chinese Medical Association [14], a standard for evaluating the late-term functional efficacy of flap and finger function was established (Table 1), including postoperative survival of the flap, long-term recovery of the flap, recovery of the donor site, and total active movement (TAM) of the fingers.

Table 1 Items and standard in SPBRA flap postoperative assessment

Results

All the 13 patients were reviewed. All patients had an uneventful post-operative course and returned to work within four weeks. There was no contour deformity, and no complaints about cold intolerance or post-operative pain with average follow up of 9 (6–12) months. The scar of the donor site varied in size and texture, however, no complications were reported from the patient. There were no issues with wrist function. The two-point static discrimination test demonstrated flap sensitivity with a range of 6–10 mm. According to the Evaluation Trial Standards of Upper Limb Partial Function of Hand Surgery of Chinese Medical Association, the results were graded as excellent in 11 cases and good in 2 cases.

Cases presentations

Case 1

A 41-year-old male sustained a crush injury to the right ring finger from a agricultural machine, resulting in loss of soft-tissue of distal digital. The patient refused a toe free flap, therefore a free innervated perforator flap of the SPBRA flap was elevated from the right wrist. The SPBRA was anastomosed to the radial digital artery, venous outflow re-established through a dorsal venous anastomosis, and the PCBMN coapted to the radial digital nerve. The donor site was directly closed. The flap survived completely, with no complications. No secondary debulking procedure was necessary. The patient was followed up for 12 months achieving a static two-point discrimination of 9 mm at the fingertip (Fig. 2).

Fig. 2 (a) crush injuries of the right ring finger .(b-c) wound debridement was performed; the connected digital arteries and veins were examined; a 4 × 2-cm flap was elevated and transferred. (d) the donor sites were closed directly and outcome at 12 months

Case 2

A 52-year-old male sustained a strangulation injury to the right middle finger from a completely resulting in loss of soft-tissue of the volar aspect. A free innervated perforator flap of the SPBRA was elevated from the right wrist. The SPBRA flap was anastomosed to the radial digital artery, venous outflow re-established through a dorsal venous anastomosis, but the nerve was not anastomosed. The donor site was directly closed. The flap survived completely, with no complications. No secondary debulking procedure was necessary. The patient was followed up for 12 months (Fig. 3).

Fig. 3 (a) a strangulation injury to the right middle finger; a 3 × 2-cm flap was elevated and transferred (b) the artery and vein of the donor side were dissected and marked. (c) anastomotic vessel and outcome at 12 months

Discussion

When the reconstruction of complex soft-tissue defects of the digits is required, important considerations depend upon the nature, location, size and shape of the post-debridement wound defect and the patient’s age, gender and general health [15]. Skin grafts, local flaps, and homo-or hetero-digital flaps can achieve adequate coverage in most cases with small size defects [16–20]. However, the mechanism of injury may lead to avulsed or crushed tissues, with or without concomitant distal vascular compromise and resultant additional tissue loss, which may widen the zone of injury beyond the remit of local reconstructive modalities [21–23].

A like-for-like reconstruction offers optimal functional and aesthetic outcomes, so the aim where necessary must be to import similarly composite tissue to that deficient in the wound [24–26]. To achieve this, a complex defect involving bone, tendon, nerve and vessel may require an osteotendinous vascularized free tissue transfer.

Local and loco-regional solutions may require multi-staged procedures and engender donor site morbidity, while not always providing sensate outcomes. Free flap transfers have disadvantages, including the need for microsurgical techniques and relatively long operating times and involve the use of flaps from other parts of the body. But they also have advantages, such as high cosmetic satisfaction and few restrictions of surgical options, considering the injury location and intensity.

Based on our experience and clinical advantages, we think that the following are the best indication for SPBRA flap transfer: soft-tissue reconstruction of distal digital injuries; fingertip amputation stumps; extensive soft-tissue defects on the palmar side of a finger; and injury to the middle part of the finger that cannot be reconstructed with local or distal flaps. SPBRA flap advantages [27]: the anatomy of superficial palmar branch of radial artery is relatively fixed; the texture and thickness of the flap were close to the skin of the hand, with good appearance and no need to secondary thinning; without compound anesthesia; the vascular caliber of the flap was matched, which was convenient for anastomosis; the flap can carry tendon and nerve at the same time. The disadvantages of the flap are as follows: the vascular pedicle of the flap is short; the flap is not suitable for large wound repair of the hand due to its limited area; the operator should have microsurgical skills [27]. A main limitation of our study is that it is retrospective. We did not use a validated subjective scoring system, not least for functional and cosmetic outcomes.

Conclusion

In conclusion, we believe that the SPBRA flap transfer is a good free flap for a range of finger injuries.

Acknowledgements

We thank the reviewers and editors for their helpful comments on this article.

Author contributions

Wei Zhao and Kun-Xiu Song wrote the main manuscript text and Bing-Dong Ma, Yong-Tao Liu prepared Figs. 1, 2 and 3. All authors reviewed the manuscript.

Funding

This work was supported by the Specialty construction foundation: The clinical specialty construction foundation of Shandong Province (2020), Grant umber SLCZDZK-0303.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Approval was granted by the ethics committee of Binzhou Medical University Hospital, China (KYLL-200), with all patients signing the written informed consent. All methods were performed in accordance with the relevant guidelines and regulations approved by the ethics committee of Binzhou Medical University Hospital.

Consent for publication

Written informed consent to publish the clinical details and images of the patient was obtained.

Informed consent

Informed consent was obtained from all participants for using their imaging data and questionnaire scores.

Competing interests

The authors declare no competing interests.

Abbreviations

SPBRA Superficial palmar branch of radial artery

TPD Two-point discrimination

TAM Total active movement

PCBMN Palmar cutaneous branch of the median nerve

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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