Hand & Microsurgery
Case Report
Original
Article
Hand
Microsurg
2015;4:50-52
Hand Microsurg 2014;X:X-X
doi:10.5455/handmicrosurg.179789
doi:10.5455/handmicrosurg.163944
Enhancement of Palmar Advancement Flap:
A Simple Modification
Oguz Kayiran1, Ercan Cihandide2
ABSTRACT
Background: Distal fingertip amputations with exposed bone is challenging for the surgeon to manage. In order to reconstruct a good sensate pulp with appropriate closure, various flaps are advocated in the literature. Of these, palmar
advancement flap, first described by Moberg in 1964, comprises one of the most 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
scores were noted before and after the modification. These scores were assessed statistically.
1
1
Results: No complications
wereDadaci
noted and
there was
no need
for additional
Mehmet
, Zeynep
Altuntas
, Bilsev
Ince1surgery.
, FatmaExcellent
Bilgen2 joint mobility and pulp
sensitivity were maintained. This modification showed a statistically significant improvement in the advancement (p<0.05).
Conclusions: Moberg flap is a good option for the closure of fingertip defects. Some simple modifications, as described in
ABSTRACT
here, can enhance the advancement while securing the
entire advantages of the flap.
This paper presents a rare case of a mass located on the volar face of the wrist, which translocated to the palmar region
Key words: Enhancement, Moberg flap, modification
under pressure. An examination revealed a 3x3 cm mass on the palmar face of the wrist that was painless and soft on palpation. A region measuring 2x2 cm on the skin of the palmar region whitened when pressure was applied to the mass. The
mass was removed and a pathological examination confirmed the presence of a cystic foreign body reaction secondary to
theIntroduction
presence of wooden foreign bodies.
ment flap proximally based on an intact skin pedicle
A mobile mass in the wrist and palmar regions:
A case presentation
Key words: Mobile mass, hand and wrist mass, cystic foreign body
reaction
including
both
The hand is a unique part in the body in and plays
important and often irreplaceable functions. In the industrialized
world, occupational hand injuries need to
Introduction
be healed
as body
soon as
possible. Meanwhile,
several healForeign
granulomas
are post-traumatic
reing
techniques
with
various
options
are
being
applied
active masses that are among the most frequently ento hundreds
of thousands
of patients
by experienced
countered
lesions
on the palm
of the hand
[1,2]. They
practitioners.
develop as a response of the organism to implanted
Unlike
other
injuries,
fingertip
amputations
foreign
bodies,
andhand
tissue
reactions
may vary
dependneed
additional
attention
in
order
to
establish
a normal
ing on the nature of the foreign body, the anatomical
pulp sensibility
andofmaximum
range
of motion,
and
region,
the duration
exposure, or
the presence
or ablike others
to maintain
upmosttolevel
of handbody.
funcsence
of excessive
tissue the
sensitivity
the foreign
tioning.
In
such cases, upon recognizing the presence of a forIn 1964,
advancement
was first
deeign body,
the the
hostvolar
organism
attempts flap
to isolate
it. The
scribed most
by Moberg
for the
reconstruction
deobjects
commonly
found
at the root of
of pulp
foreign
fects of the thumb (1). This flap is a pedicled advanceAuthor affiliations
neurovascular bundles. This technique
establishes a successful neurosensation of the pulp with
a limited
advancement
as well.glass,
However,
modbody
reaction
masses include
wood,a simple
and metals,
ification
as described
and never
beenorreported
which
generally
presenthere,
as surface
lesions
masses
elsewhere,
can
enhance
additional
advancement.
with little pain or slight sensitivity, although such leMethods
sionsPatients
may alsoand
show
signs of infection. The majority
The
study
was
performed
informed
consents
of such cases have a previous with
history
of penetrating
obtainedand
from
participants.alongside such imaging
injuries
thisallinformation,
Technique
methods
as radiography or ultrasonography, may help
Thirteen
patients
(11body,
males,
3 females)
withlight
finin identifying the
foreign
thereby
throwing
gertip
injuries [1-5].
were operated under regional anaeson
the etiology
thesia.
the
ThisPalmar
paper advancement
presents a rareflap
casewas
of araised
mass over
located
parathenon
(1) of
(Figure
1a).which
Both neurovascular
on
the volar face
the wrist,
translocated tobunthe
dles
were
included
in
the
flap
so
that
neurosensible
palmar region under pressure.
coverage is accomplished (Figure 1b). To increase the
: Department of Plastic Reconstructive and Aesthetic Surgery, 1Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey,
2
Kahramanmaras Necip Fazil State Hospital, Kahramanmaras, Turkey
Correspondence
: Mehmet Dadaci, Department of Plastic Reconstructive and Aesthetic
Surgery, Necmettin Erbakan University, Meram Faculty of Medicine,
Author affiliations : Department of Plastic, Reconstructive and Aesthetic Surgery,1 Izmir University, Izmir/Turkey, 2 Bahcesehir University, Istanbul/Turkey
Konya, 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 : February 10, 2015 / March 22, 2015
Received / Accepted : July 08, 2014 / August 12, 2014
© 2015 Turkish Society for Surgery of the Hand and Upper Exremity
© 2014 Turkish Society for Surgery of the Hand and Upper Exremity
www.handmicrosurgeryjournal.com
www.handmicrosurgeryjournal.com
Dadaci M et al.
Case Report
A 30-year-old male patient was referred to our clinic with a mass on his right wrist, which he had for four
years. An examination revealed a 3x3 cm mass on the
palmar face of the wrist that was painless and soft on
palpation (Figure 1). A region measuring 2x2 cm on the
skin of the palmar region whitened when pressure was
applied to the mass (Figure 2). The patient explained
that a piece of wood had penetrated his hand five years
Figure 1. Appearance of the mobile mass in the wrist.
Figure 2. Skin of the palmar region showing whitening when pressure
was applied to the mass.
Figure 3. Appearance of the mass during the operation.
51
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Hand and Microsurgery
ago, and that he had removed part of the piece himself,
bandaged it and allowed it to heal spontaneously. The
patient had no complaints within the initial year after
the trauma, although he reported the presence of the
painless mass on his hand for the last four years, claiming that it had not grown any further. An ultrasonography revealed a fusiform cystic lesion measuring 3x8 cm
with a foreign body inside, progressing continuously
into the palmar region of the wrist and hand. The patient was operated upon under axillary blockage using
a pneumatic cuff. The mass was explored through an
incision performed on the mass from the ulnar region
of the wrist. The mass, which was found to be cystic,
crossed under the flexor retinaculum and reached the
palmar region over the transverse carpal ligament.
Hence, a total excision was performed (Figure 3). The
removed specimen was opened, revealing cyst fluid, as
well as wooden splinters. A pathological examination
of the mass confirmed the presence of a cystic foreign
body reaction.
Discussion
This case presentation demonstrates that a foreign
body penetrating the palmar region as a result of a penetrating trauma can remain in place for a long period
of time without causing pain, and can subsequently
transform into a mobile mass. Although the patient
suspected the presence of a foreign body in his hand,
he delayed treatment, as the wound had healed without
causing any pain or inflammation. This led him to delay referring to any healthcare institution for a period
of five years. A physical examination showed that the
mass disappeared upon pressure, with the palmar region whitening, indicating that the mass reached the
palmar region and was interconnected. Additionally,
the whitening and plumping in the palmar region suggested that the lesion was cystic and mobile.
Penetrating hand injuries should alert one to the
potential presence of a foreign body; therefore, a complete anamnesis should be obtained from the patient.
The presence of a foreign body should be assessed by
X-ray or ultrasonography prior to operation or surgical exploration, which should not be shied away from
when required. Previous studies have shown that only
0–15 percent of wooden foreign bodies can be detected
Year 2015 | Volume 4 | Issue 2 | 50-52
Mobile mass in wrist and palmar region
through radiographic techniques [6]. In cases where
such techniques are insufficient, an advanced examination can be conducted with computerized tomography
and magnetic resonance imaging. Occasionally, the
foreign body may not be detectable at first sight due
to the smallness of the laceration or the absence of a
radio-opaque material. In such cases, the clinical representation and medical history of the patient will be very
helpful [1,5-8].
Particularly in cases where the patient or the relatives of the patient report no history of trauma, it may
be difficult to identify a foreign body granuloma. Cases
without a known history of previous trauma and the
absence of a foreign body through radiological imaging
may easily lead to a diagnosis of a primary soft tissue
tumor [1-4].
The morphology of a foreign body granuloma may
vary according to the type and size of the foreign body
and the site of the trauma. Foreign bodies that are embedded in soft tissue can result in pain, toxic and allergic reactions, and inflammation and infections, while
those with sharp edges can penetrate tissues, potentially causing tendon and nerve damage. Deep soft-tissue
infections, septic arthritis, periostitis and osteomyelitis
may develop after wood splinter injuries. In some cases,
the problem may remain dormant for years, with no apparent symptoms, but may finally manifest clinically as
a foreign-body granuloma resembling a primary soft
tissue tumor [6-9].
In this reported case, a cystic foreign body reaction had developed around the foreign body. The cystic
mass caused no nerve pressure symptoms, as it was located on the transverse carpal ligament, while the majority of the mass was situated in the forearm region.
Foreign bodies in the hand can result in the development of a mass, which can be easily confused with
soft tissue tumors. In this regard, it is important that the
trauma history be investigated, as foreign body granulomas should be eliminated in cases with such lesions.
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Acknowledgements: None
Conflict of interest: All named authors hereby declare that they have no conflicts of interest to disclose.
Funding statement: This research was not sponsored by an outside organization.
This study conformed to the Helsinki Declaration.
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