ABSTRACT
The objective of treatment is to maintain or create durable soft tissue coverage, allowing optimal function and sensibility. A thorough debridement of avascular or bruised tissue is essential. After this, a wound can be closed taking the following into account:
A wound can be primarily closed if there is no tension on the wound edges while doing so. In all other cases, a consultation by a hand surgeon is required.
In the event of a skin shortage and a well vascularized wound surface, the defect can be closed with a full or partial thickness skin graft.
Donor sites for a partial thickness graft in order of preference are: medial side of the leg, buttock, abdomen, medial side upper arm and skull. For small defects the hypothenar skin graft is very suitable. Donor sites for full thickness grafts in order of preference are: groin, medial side upper arm, retro- or pre-auricular, supraclavicular and, if possible, upper eyelid.
In case of skin shortage and visible ‘white structures’ (i.e. bone, tendon, ligament, nerve), closure of the defect with a skin graft is no longer possible.
The defect should be closed with a local transposition flap or a free vascularized flap. The exception being extensor tendons – if they are still covered with paratenon (the areolar tissue which allows gliding of the tendon), they can be covered with a skin graft.
In case of avulsion injuries, the tissue’s vascularization is often overestimated. In most cases it is wise to obtain a skin graft from the avulsed flap and use that as coverage.
In case of a deficit of the fingers it is important whether there is loss of pulp, exposed extensor or flexor tendons and/or a defect in a functional area. If a skin graft is applied, it should be full thickness to prevent contracture and supply a more durable surface.
If closure of a small defect is not possible with a skin graft many local transposition flaps are available. For larger skin defects, particularly on the back of the hand, it is possible to use a pedicled flap or a free vascularized lap.
