Introduction

High-voltage electric burns, especially in the upper ex-tremity, are usually very aggressive injuries, and troublesomefor both patient and surgeon. The surgical operation should,if possible, be performed immediately after the accident,when the patient’s general condition is stable. Treatment con-sists of immediate fasciotomy and early necrectomy as soonas the extent of the injury is established by MRI scan.

The parameters to be considered in selecting the mostappropriate surgical method for reconstruction of the thumbare: patient’s age and sex, extent of neurovascular dam-age, the patient’s dominant side, and the patient’s expect-ed co-operation. This last aspect requires thorough dis-cussion with the patient and his or her family - often thereis insistence on saving the hand and fingers, no matterwhat the expected outcome may be. This reality is oftenexplained by the fact that in our culture such patients arepsychologically much more willing to accept a contractedand useless finger than an amputated one, in the hope ofpossible surgical reconstruction in the future.

Case report

At the age of 24 this female patient suffered an acci-dent to her left hand (1st, 3rd, and 4th fingers) due to el-evated electric current. She suffered fourth-degree burnsthat also involved the neurovascular bundles, the tendons,and the distal part of the distal phalanges. On first exam-ination, three weeks after the trauma, she showed com-plete necrosis of the volar skin covering the distal pha-langes (Figs. 1-4). After amputation of two-thirds of the

Annals of Burns and Fire Disasters - vol. XVIII - n. 3 - September 2005

161

CASE PRESENTATION - RECONSTRUCTION OF THUMBDEFECT WITH NEUROVASCULAR CROSS-FINGER FLAPAFTER ELECTRICAL BURNS

Terziqi H., Krysander L.

CUC, Surgery Clinic, Reconstructive and Plastic Surgery Department, Pristina, Kosova

SUMMARY. The advantages are underlined of the use of the neurovascular flap, as seen in a patient with injuries in all anatom-ical structures after electrical burns, with defect in the soft tissue together with tendon, vessel, and nerve injuries and necrosis of

CASE REPORT

Fig. 1 - Necrosis of 1st, 3rd, and 4th ngers three weeks after elec-trical burns (volar side).

Fig. 2 - Necrosis of thumb after electrical burns (volar side).

distal phalanges of the 3rd and 4th ngers,the wounds were left for secondary healing.The reconstruction of the volar defect of thethumb was then planned and performed witha ap from the dorsal side of the proximalpart of the index nger, a ap described byAdams. Through a zigzag incision and agradual dissection of the radial nerve to sup-ply the thumb with sensation (Fig. 5), theap was raised and rotated 180° in its longaxis and transferred to the thumb defect, likea crossnger ap but with preserved sensa-tion. The secondary defect of the index n-ger was covered with a full-thickness graftfrom the left inguinal area (Figs. 6,7). The1st and 2nd ngers were then immobilizedfor three weeks, whereupon separation ofthe ngers was performed.

Annals of Burns and Fire Disasters - vol. XVIII - n. 3 - September 2005

162

Fig. 5 - Thumb re-construction withneurovascular cross-nger ap after am-putation of two-thirds of phalanges(left hand).

Fig. 3 - Necrosis of thumb after electrical burns (dorsal side). Fig. 4 - Necrosis of thumb - distal part of phalanx after electrical burns.

Fig. 7 - Thumb reconstruction with neurovascular cross nger ap,full-thickness graft of index nger, and zigzag incision for radial sen-sation (dorsal side).

Fig. 6 - Thumb reconstruction with neurovascular cross-nger ap(volar side).

Discussion

Electrical burns causing loss of sensation in the pinchgrip areas of the ngertips are difficult to treat. In this casereport we present the successful reconstruction of the pulpof the thumb with a radial nerve sensory-supplied cross-nger ap from the index nger.1-4 The incision was plannedto prevent cicatricial contractures. Owing to difficultieswith post-operative care we decided to make the ap re-construction in a two-stage procedure based on both a cu-taneous and a neurovascular bridge instead of solely on anisland ap.5-8 The patient’s history was uncomplicated: shedid not suffer any neurinomas, causalgy, or dystrophy andshe recovered full functionality.9-11 The donor site of theindex nger healed without functional impairment. A full-thickness graft was considered the best way to prevent con-tractures and to give good mechanical strength - some sen-sation was also noted at the follow-up. In this patient thegraft was harvested from the left inguinal area so that the

cicatrix should not be mistaken for an appendectomy scar.

Conclusions

1. Electrical burns of the ngers usually damage thedeep anatomical structures, with severe loss of handfunction, especially when the thumb is affected.

2. Surgical intervention should therefore be planned indetail from case to case. This presentation describesa successful reconstruction of the thumb, the hand’smost vital nger. Although the Adam ap is wellknown, we would stress its importance as a valu-able tool in a hand surgeon’s arsenal.

3. In our culture it is essential not to amputate a n-ger as, psychologically speaking, patients accept de-formed and contracted ngers without function morereadily than having none at all.

Annals of Burns and Fire Disasters - vol. XVIII - n. 3 - September 2005

163

RÉSUMÉ. Les Auteurs soulignent les avantages de l’emploi du lambeau neurovasculaire, comme ils les ont vus chez un patientatteint de lésions dans toutes les structures anatomiques après des brûlures électriques qui présentait un défaut du tissu mou avecen outre des lésions des tendons, des vaisseaux et des nerfs et la nécrose de la phalange distale du pouce. Ils considèrent aussi lavaleur de cette technique aujourd’hui dans le champ de la chirurgie plastique reconstructrice.

BIBLIOGRAPHY

01. Moberg E.: Aspect of sensation in reconstructive surgery of theupper limb. J. Bone Joint Surg., 46A: 817-25, 1964.

02. Keim H.A., Grantham S.A.: Volar-ap advancement for thumband ngertip injuries. Clin. Orthop., 66: 109-12, 1969.

03. Posner M.A., Smith R.J.: The advancement pedicle ap for thumbinjuries. J. Bone Joint Surg., 53A: 1618-21, 1971.

04. Vilain R., Michan J.: “Plastic Surgery of the Hand and Pulp”,Massan, New York, 1979.

05. Litter J.W.: Neurovascular pedicle transfer of tissue in recon-structive surgery of the hand (Abstract). J. Bone Joint Surg., 38A:917, 1956.

06. Hansen D.A.: The island ap in thumb reconstruction. SA Med.J., 47: 1936-38, 1973.

07. Adamson J.E., Horton C.E., Crawford H.N.: Sensory rehabilita-tion of the injured thumb. Plast. Reconstr. Surg., 40: 53-7, 1967.

08. Gaul J.S.: Radial innervated cross-nger aps from index to pro-vide sensory pulp to injured thumb. J. Bone Joint Surg., 51A :1257-63, 1969.

09. Brailliar F., Horner R.L.: Sensory cross-nger pedicle graft. J.Bone Joint Surg., 51A: 1264-68, 1969.

10. Pringle R.G.: Amputation of the thumb. A study of techniques ofrepair and residual disability. Injury, 3: 211-7, 1972.

11. Tubiana R., McCullough J.C., Masqueklet C.A.: “An Atlas of Sur-gical Exposure of the Upper Extremity”, p. 347, Lippincott,Philadelphia, 1991.

This paper was received on 3 November 2004.

Address correspondence to: Dr H. Terziqi, CUC,Surgery Clinic, Reconstructive and Plastic SurgeryDepartment, Pristina, Kosova.E-mail: hasime_te@yahoo.com