title: Secondary restoration of fingertip sensation with Littler's heterodigital neurovascular island flap after ring avulsion injury: report of two cases.
abstract: Treatment of ring avulsion injuries is technically challenging. Surgical success depends not only on revascularization and anatomic restoration but also on functional recovery. A functional finger is mobile and sensible. We report two cases of secondary restoration of the finger pulp's sensibility with Littler's heterodigital neurovascular island flap after a ring avulsion injury. Two patients (47-year-old physiotherapist and 21-year-old student) suffered a degloving injury of the 4th finger on the left hand, classified in Urbaniak class III and Kay-Adani class IVd. The emergency treatment consisted in replantation with suture repair of the ulnar proper palmar digital artery; the nerve was not repaired due to its avulsion from the pulp. Four months later, once the vascularization was stable, restoration of the fingertip's sensibility was done using Littler's heterodigital neurovascular island flap. The 3rd finger's ulnar palmar digital pedicle was dissected using a hemi-Bruner incision. The pedicled flap was brought to the host site after being tunneled through the 4th finger's base. A split skin graft was performed at the donor site. After three years of follow-up, two-point discrimination on the 4th finger's radial pulp was 5mm and cortical integration was satisfactory. The donor site had only tactile sensitivity. The DASH (Disabilities of the Arm, Shoulder and Hand) score was 13.3 and 11.7, and the total arc of motion was 90° and 180°, respectively. Littler's flap seems to be appropriate for restoring sensation at fingertip after ring avulsion injuries. Donor site complications seem acceptable.
authors.affiliation: Orthopaedic and hand surgery unit, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France. Electronic address: emmanuella.peraut@live.fr.
authors.forename: E
authors.initials: E
authors.lastname: Peraut
authors.affiliation: Orthopaedic and hand surgery unit, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
authors.forename: M-P
authors.initials: MP
authors.lastname: Mirous
authors.affiliation: Orthopaedic and hand surgery unit, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France. Electronic address: m-chammas@chu-montpellier.fr.
authors.forename: M
authors.initials: M
authors.lastname: Chammas
mesh_terms: D005383:Finger Injuries / Q000150:complications* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020127:Recovery of Function; D012678:Sensation Disorders / Q000209:etiology* / Q000601:surgery*; D013524:Surgical Flaps / Q000098:blood supply* / Q000294:innervation*; D055815:Young Adult
keywords: Degloved digit; Doigt long; Heterodigital neurovascular island flap; Lambeau de Littler; Lambeau neurovasculaire hétérodigital; Littler's flap; Resensibilisation pulpaire; Restoration of sensibility; Ring avulsion injury (class III); Ring finger