Objective : The objective of this study was to evaluate the clinical features and treatment outcomes of tumors of the finger treated by surgery. Materials and Methods : We retrospectively analyzed cases of digital tumors that were treated with surgery between 2003 and 2012 at our hospital. Results : The patient cohort included 24 women and 11 men. The mean age at diagnosis was 46.1 years, and the average diagnostic delay was 13 years. The most common symptoms were pain (97%), which intensified upon exposure to cold in 23% of patients, and nail deformities (17%). The tumors were subungual in 27 cases, were located in the pulp in 7 cases and extended from the subungual area to the volar aspect of the distal phalanx in 1 case. The tumors varied between 0.1 and 10 mm (mean 4.2 mm) in size. All surgical procedures were performed under microscopic guidance and all patients experienced pain relief after surgery. Conclusion : Glomus tumors can be difficult to diagnose because of non-specific and obscure clinical signs and their small size. Therefore, preoperative imaging might help determine the extent of the lesion, and microsurgery might be a suitable treatment option.
Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. However, joint contracture and extensor tendon adhesions are common complications in the treatment of extensor tendon injury of the hand and digit, so the effect of extensor tenolysis was limited. For these disorders, we have applied adipofascial flap following extensor tendon surgery. According to this concept, adipofascial flap was applied in five cases. The average follow-up period of this series of patients was 11 months (8-11 months). The flaps were used for reconstruction of the tendon gliding surface in three patients, and for prevention of adhesion following tenolysis in two patients. The average %TAM was 75% (44-100%) at the final follow-up. Protracted wound healing was observed in two patients. The adipofascial flap for extensor tendon surgery is locally available, vascularrich, thin and soft, easily elevated, and good for a tendon gliding surface. On the basis of our experience, we recommend the use of an adipofascial flap for the prevention of tendon adhesion in extensor tendon surgery.
In breast reconstruction with deep inferior epigastric perforator (DIEP) flap, preoperative multi-slice CT (MSCT group ; 32 cases, 34 sides) and preoperative MSCT together with intraoperative indocyanine green fluorescent angiography (+ICG group ; 19 cases, 19 sides) evaluations were compared. The perforator was selected in MSCT to emphasize the diameter, the intramuscular course, and the venous anastomosis. In the+ICG group, angiography was used to decide the flap territory in the selected perforator. Two cases were re-operated in each group. There was no significant difference in terms of the complication rate between the groups. One perforator and no midline scar cases in the+ICG group (n=13) were evaluated in terms of the flap territory. The perforator was located 2.8 cm lateral and 1.1 cm caudal from the umbilicus, and its diameter was 1.7 mm on average in MSCT. The average territory of the fluorescent study was 16.7 cm on the pedicle side and 6.3 cm on the contralateral side, and 210 cm2 in area. The more laterally the perforator was located, the more laterally the territory was spread on the pedicle side. There was no such correlation on the contralateral side. Preoperative MSCT and intraoperative ICG angiography for DIEP flap breast reconstruction were thought to be reasonable and instructive, especially for inexperienced surgeons.
We retrospectively evaluated 242 fingers of 221 patients who received surgical treatment other than replantation and amputation stump plasty for fingertip amputation resulting from industrial accidents. They were 110 patients with amputation, 85 patients with crushing injury, and 26 patients with defect. The initial surgical procedures for each patient were skin flap coverage for 60 fingers, free complex flap graft for 14 fingers, and composite graft for 21 fingers. For 95 fingers excluding those treated with amputation, procedures were stump plasty (18 patients), replantation (57 patients) and other (72 patients). The levels of injury by Ishikawa's classification were subzone 1 for 24, subzone 2 for 42, subzones 3 and 4 for 19 fingers, and unknown for 10 patients. The operative procedures for 60 fingers treated with skin flap coverage were oblique triangular flap for 25 fingers, volar advancement flap for 15 fingers, and reverse island flap for 8 fingers. In fingertip amputation with strong crushing, there is no option such as reconstruction from the beginning and amputation stump plasty is likely to be selected; however, treatment strategy should be examined while keeping in mind that an option such as skin flap coverage, which is functionally and cosmetically satisfactory, is available when the patient desires it.
Intraneural hemangioma of a digital nerve is very rare. Only three cases have been reported in the literature. We present a case of a 39-year-old male who had a soft tissue mass in the region of the right palm. The mass had been present for at least 5 years and gradually increased in size, causing him discomfort. MR imaging revealed a subcutaneous lesion that was isointense with the muscle on T1-weighted images and partially hyperintense on T2-weighted images. Morphologically, the lesion demonstrated tubular structures suggesting feeding or draining vessels. Therefore, we diagnosed the tumor as hemangioma and planned to perform resection. In the operation, the mass was found to involve a digital nerve. We performed en bloc resection of the hemangioma with the digital nerve, and reconstructed with sural nerve grafts to bridge the gap in the nerve. At 15 months after this operation, the patient remains free of recurrence. The recovery of sensory perception is very good and he has no pain. In cases of hemangioma around peripheral nerves, we should consider the possibility of peripheral nerves involvement in the differential diagnosis.
We encountered two cases of localized compartment syndrome of the upper arm following prolonged operations, featuring use of a pneumatic tourniquet, to reattach multiple digits. Case 1 : The operative duration was 12 h and the pneumatic tourniquet was inflated for a total of 10h 35 min. A uniform cuff pressure of 280 mmHg was applied. Thirty minutes after surgery, circulatory insufficiency was evident in the reattached digits. The patient complained of severe pain and swelling of the upper arm. Fasciotomy of the arm was immediately performed, using longitudinal skin incisions in the medial and lateral aspects of the arm. The skin color of the reattached digits returned to normal. All digits survived. Case 2 : The operative duration was 9 h 35 min and the pneumatic tourniquet was inflated for a total of 4 h 25 min. The patient complained of increasing pain and swelling in the upper arm. Passive extension and elbow flexion caused severe pain. As no circulatory insufficiency was evident, arm fasciotomy was not performed. The post-operative period was uneventful, thus without any other complication. Compartment syndrome in the upper arm caused by prolonged application of a pneumatic tourniquet can trigger circulatory insufficiency in reattached digits.