Hand & Microsurgery
Case Report
Original
Article
Hand
Microsurg
2016;5:88-91
Hand Microsurg 2014;X:X-X
doi:10.5455/handmicrosurg.193633
doi:10.5455/handmicrosurg.163944
Enhancement of Palmar Advancement Flap:
A Simple Modification
Oguz Kayiran1, Ercan Cihandide2
Flexor pollicis longus repair inABSTRACT
a patient with Linburg-Comstock
Background: Distal fingertip amputations
with exposed A
bone
is challenging
for the surgeon to manage. In order to reanomaly:
case
report
construct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar
1
3
Mehmet
Unal
, comprises
Eren Cansu
, Hakan
advancement flap, first described by
Moberg in
1964,
one2of
the mostCift
popular
options.
Methods: Thirteen patients (11 male, 3 female) with fingertip injuries were operated. Following the elevation of Moberg
flap, proposed modifications were carried out. Joint mobility and pulp sensitivity were recorded as well and advancement
ABSTRACT
scores were noted before and after the modification. These
scores were assessed statistically.
Background:
We present a patient
with this
whonosustained
saw cut injury
to his
hand resulting
in severance
of
Results: No complications
were noted
andanomaly
there was
need foraadditional
surgery.
Excellent
joint mobility
and pulp
the
FPL
and
bilateral
digital
nerves
of
the
thumb.
sensitivity were maintained. This modification showed a statistically significant improvement in the advancement (p<0.05).
Methods:
A 36-year
oldflap
male
who sustained
a sawofcut
injury defects.
to his dominant
right hand
presented
the emer-in
Conclusions:
Moberg
is alaborer
good option
for the closure
fingertip
Some simple
modifications,
astodescribed
gency
department.
wound extended
from
the skin
of advantages
the first weboftothe
theflap.
base of first metacarpal in the palm at
here, can
enhanceThe
the advancement
while
securing
theedge
entire
Urbaniak zone 3. The FPL tendon and both digital nerves were cut. In the operating room, the wound was enlarged with
Key words: Enhancement, Moberg flap, modification
Z incisions and a dissection deep into the wound was conducted. The cut end of the FPL tendon was found and secured
using a different technique. Bilateral digital nerve repair was performed with interpositional grafting of the lateral antecubital
cutaneous nerve bundles.
Results: At the end of the rehabilitation program, the thumb recovered full range of motion, and physical examination
ment flap proximally based on an intact skin pedicle
Introduction
revealed synchronous flexion movement (synkinesis) of the thumb and index finger.
The hand is a unique part in the body in and plays including both neurovascular bundles. This technique
Conclusion: Flexor pollicis longus tendon lacerations are common in the clinical practice of hand surgeons. Making
a successful
of the
pulp with
important
often wrist
irreplaceable
In technique
the in- toestablishes
a separateand
proximal
incision isfunctions.
a very useful
reach a proximal
tendonneurosensation
stump. Otherwise,
aggressive
maneuvers world,
may cause
additional damage
to the tendons
and result
in unpredicted
outcomes.
Theaattempts
to
a limited
advancement
as well.
However,
simple moddustrialized
occupational
hand injuries
need toinvolved
retrieve
the
tendon
at
the
injury
site
resulted
in
failure
and
gave
a
tethering
sensation
to
the
surgeon
who
recalled
the
be healed as soon as possible. Meanwhile, several heal- ification as described here, and never been reported
Linburg-Comstock anomaly.
ing techniques with various options are being applied elsewhere, can enhance additional advancement.
Key words: Flexor pollicis longus laceration, Linburg-Comstock anomaly
Patients and Methods
to hundreds of thousands of patients by experienced
The study was performed with informed consents
practitioners.
obtained
from
Unlike other hand injuries, fingertip amputations the
Introduction
anomaly
[1].allInparticipants.
this case, we present a patient with
Technique
needAnomalous
additional attention
in
order
to
establish
a
normal
connections between flexor pollicis this anomaly who sustained a saw cut injury to his hand
Thirteen
patientsof(11
3 females)
withdigifinpulp
sensibility
maximum
range
of motion,
and resulting
longus (FPL) andand
flexor
digitorum
profundus
(FDP)
in severance
themales,
FPL and
the bilateral
gertip
injuries
operated
under regional
anaeslike others
maintain
the upmost flexion
level of movement
hand func- tal
tendons
maytoresult
in synchronous
nerves
of thewere
thumb.
The attempts
to retrieve
the
thesia.
Palmar
advancement
flap
was
raised
over
tioning.
of index finger and thumb. This anomaly was first de- tendon to injury site resulted with failure and gavethe
a
parathenon
(1)
(Figure
1a).
Both
neurovascular
bunIn
1964,
the
volar
advancement
flap
was
first
described in 1979 by authors Linburg and Comstock, tethering sensation to the surgeon who recalls the Lindles were included
in the flap so that neurosensible
scribednames
by Moberg
for the reconstruction
of describe
pulp de- burg-Comstock
whose
have subsequently
been used to
anomaly.
fects of the thumb (1). This flap is a pedicled advance- coverage is accomplished (Figure 1b). To increase the
Author affiliations
: Department of Orthopaedics and Traumatology, 1Medical Park Göztepe Hospital, Istanbul, Turkey 2Marmara University Hospital, Istanbul,
Turkey 3Medipol University, Istanbul, Turkey
Correspondence
: Mehmet Unal, MD, Department of Orthopaedics and Traumatology,
Medical Park Göztepe Hospital, Istanbul, Turkey
Author affiliations : Department of Plastic, Reconstructive and Aesthetic Surgery,1 Izmir University, Izmir/Turkey, 2 Bahcesehir University, Istanbul/Turkey
e-mail: [email protected]
Correspondence
: Oguz Kayiran, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Izmir University, Izmir/Turkey. E-mail: [email protected]
Received / Accepted : July 05, 2015 / July 21, 2015
Received / Accepted : July 08, 2014 / August 12, 2014
© 2016 Turkish Society for Surgery of the Hand and Upper Exremity
© 2014 Turkish Society for Surgery of the Hand and Upper Exremity
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www.handmicrosurgeryjournal.com
Unal M et al.
Case Report
A 36-year old male laborer who sustained a saw
cut injury to his dominant right hand presented to the
emergency department. The wound extended from the
skin edge of the first web to the base of the first metacarpal in the palm at Urbaniak zone 3 (Figure 1). Physical examination revealed loss of active flexion at the IP
joint and anesthesia at both digital nerve distributions,
suggesting severance of the FPL tendon and both digital nerves. The capillary refilling time was adequate.
The patient was taken to the operating room and
the surgery was performed under axillary block anesthesia and tourniquet control. After irrigation of the
wound with saline under loop magnification, both digital nerve ends were explored and prepared for repair
with meticulous dissection. In the next step, the distal
stump of the FPL tendon was explored with ease, and
catching the proximal cut end through the wound was
attempted unsuccessfully; it was thought to be retracted proximally into the wrist level. Therefore, a separate
incision at the wrist, between the radial artery and the
flexor carpi radialis tendon was made, and the proximal
stump of the FPL tendon was explored. The FPL tendon was left in situ in the sheath, and a small pediatric
feeding tube was passed retrograde through the tendon
sheath at wound level and taken out through the proximal incision. The tendon was tied to the tube, and the
tube pulled distally to deliver the tendon stump into
the wound. This attempt failed to retrieve the tendon
end, and produced a tethering sensation. Next, although this is not recommended, the proximal tendon
stump was pulled back to remove the tendon’s cut end
the from wrist incision. However, the efforts to take the
proximal stump out of the proximal incision also failed
Figure 1. Preoperative appearance of injury.
Figure 3. Lateral antecubital cutaneous nerve graft prior to interposition.
Figure 2. FPL tendon was anchored with 22-gauge needle during
tendon repair process.
Figure 4. Completed repair of FPL tendon and bilateral digital nerves
with nerve graft.
89
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Hand and Microsurgery
Year 2016 | Volume 5 | Issue 2 | 88-91
FPL tendon repair in Linbung anomaly
while anchoring sensation of the tendon was felt. During these maneuvers, we realized that pulling the proximal stump of the FPL tendon was causing flexion in the
index finger. We did not perform any further maneuvers in order not to damage the tendon. Eventually, we
enlarged the wound with Z incisions and carried out a
dissection deep into the wound. The cut end of the FPL
tendon was found and secured with a needle (Figure
2). The tendon repair was performed using a modified
Figure 5. Postoperative flexion range of motion with persistent Linburg-Comstock anomaly.
Figure 6. Postoperative extension range of motion with persistent
Linburg-Comstock anomaly.
Kessler core suture with 4/0 PDS and a running epitendinous 6-0 nylon suture. Because the case was a saw
cut injury, the digital nerve stumps beyond the cut ends
were also damaged. Therefore, the degenerated nerve
stumps were removed by cutting them into slices until
healthy nerve fascicules appeared. The remaining gaps
were reconstructed with interpositional grafting of the
lateral antecubital cutaneous nerve bundles (Figures 3
and 4).
A dorsal splint was used to immobilize the wrist,
and thumb metacarpophalangeal and interphalangeal
joints at 45, 60 and 30 degrees, respectively. At postoperative period passive and active assisted rehabilitation program was applied for eight weeks. At the end
of the rehabilitation program, the thumb recovered a
full range of motion, and physical examination revealed
synchronous flexion movement (synkinesis) of the
thumb and index finger (Figures 5 and 6).
At postoperative 8th week, In order to demonstrate the interconnection between the flexor pollicis
longus and the flexor digitorum profundus of the index
finger, an MRI was performed in a 1.5 T MR system
(GE). The patient was in a prone position with the arm
above the head. The wrist was positioned in pronation
with the fingers held in extension. Proper surface coils
were used to minimize motion artifacts with optimal
signal-to-noise ratios. Transverse and coronal plane
fast spin-echo (FSE) sequences were performed. T1W
images were taken with TR 580, TE 15, ETL 3, NEX
2, matrix 384 x 256 and 3 mm slice thickness. T2W
fat-saturated images were performed with TR 3380,
Figure 7. MRI at postoperative eight weeks left: connection between index FDP and FPL middle and right, repaired and healed FPL tendon.
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Hand and Microsurgery
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90
Unal M et al.
TE 36, ETL8, NEX2, matrix 384 x 224 and 3 mm slice
thickness. Transverse Fast spin echo T1W contiguous
images showed a tendinous slip extending proximally
from the flexor digitorum profundus of the index finger
to the flexor pollicis longus distally (Figure 7).
Discussion
The interconnections between FPL and FDS of index fingers, which results in synkinesis of the thumb and
index finger are not uncommon, and the prevalence may
be in the range of 20% - 31% in the population [1, 2].
Anatomically, the connections were reported to be occurring at wrist or proximal forearm level, and running
from FPL to FDP [3, 4]. In this case, the connection was
at wrist level, but the direction was from FDP to FPL.
Most of the individuals who do not engage in jobs
requiring fine motor hand movements may be unaware
of their anomaly. The anomaly mainly affects musicians
and may cause tenosynovitis due to repetitive movement of the fingers, and may be dangerous for security
personnel who carry pistols because the simultaneous
movement of the fingers may cause pulling of the trigger when trying to pull the hammer of the pistol [5, 6].
In FPL tendon lacerations located in zone III, according to Urbaniak, the proximal end frequently retracts back to the wrist level [7]. The proximal end can
usually be found with exploration through the wound,
and retrieved easily with atraumatic grasping of the
tendon end in the sheath. If the tendon end cannot be
found or retrieved easily, blind attempts to catch the
tendon with a Kocher clamp as persistent grasping and
probing should be avoided, and a separate incision at
the wrist, between the radial artery and the flexor carpi
radialis, should be made to locate the proximal stump
of the tendon. At this stage, leaving the tendon in situ in
its sheath is recommended instead of taking the tendon
out of its sheath to find the cut end. This maneuver may
injure peritendinous synovial tissue, and may cause adhesion during the healing period. The tendon can then
be rethreaded through its proper route by inserting a
carrier-like pediatric feeding tube, a suture passer, or a
cerclage wire through the sheath from the distal end to
the proximal wrist incision. The tendon is attached to
the carrier, and pulling the carrier back to wound re91
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Hand and Microsurgery
trieves the tendon from proximal to distal. In our case,
neither these technical maneuvers nor trying to pull
the proximal end back out of proximal wrist incision
failed to reach the tendon end. We encountered resistance that gave a sensation of the anchoring of the tendon. This situation reminded us of the Linburg-Comstock anomaly. Therefore, we enlarged the wound and
performed a dissection of the thenar muscles to reach
the tendon end. After reaching and securing the tendon
end, the rest of the operation was uneventful.
Flexor pollicis longus tendon lacerations are common in the clinical practice of hand surgeons. Making
a separate proximal wrist incision is a very useful technique to reach the proximal tendon stump. If, as in this
case, the surgeon feels resistance during the maneuvers
to reach the proximal stump, the tendon should not be
subjected to forceful pulling, and one should remember the Linburg-Comstock anomaly. Otherwise, aggressive maneuvers may cause additional damage to the
tendons involved and result in unpredicted outcomes.
Conflict of interest statement
The authors have no conflicts of interest to declare.
References
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3. Lombardi RM, Wood MB, Linscheid RL. Symptomatic restrictive thumb-index flexor tenosynovitis:
incidence of musculotendinous anomalies and results of treatment. J Hand Surg 1988;13:325–8.
4. Old O, Rajaratnam V, Allen G. Traumatic correction of Linburg-Comstock anomaly: a case report.
Ann R Coll Surg Engl 2010; 92: W1-3.
5. Karalezli N, Karakose S, Haykir R, et al. LinburgComstock anomaly in musicians. J Plast Reconstr
Aesthet Surg 2006;59:768-71.
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anomalies in musician and nonmusician hands.
Plast Reconstr Surg 2003;112:1815-24.
7. Urbaniak JR. Repair of the flexor pollicis longus.
Hand Clin 1985;1:69-76.
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