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The Posterior Interosseous Flap

The Posterior Interosseous Flap

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Published by vaikunthan
post interosseous flap
post interosseous flap

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Published by: vaikunthan on Jun 03, 2009
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10/28/2012

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The Posterior Interosseous Flap
B Youssef 
1
, A Dancey,
1
V P Sumathi
2
, F C Peart
1
.1.Regional Department of Burns and Plastic Surgery, University HospitalBirmingham, Selly Oak Hospital, Birmingham, United Kingdom.2.Department of Musculoskeletal Pathology, The Royal Orthopaedic Hospital,Birmingham, United Kingdom.Case reportA 57 year-old gentleman presented to his General Practitioner with a swelling on thedorsal aspect of his left hand. The swelling had gradually increased in size over thelast 12 months. It was not painful, associated with any neurological symptoms orfunctional loss. There was no history of trauma or infection.There was no significant past medical history of note and he does not take any regularmedication. He works in a slaughterhouse, he does not smoke and drinks socially.On examination he had a five by seven cm swelling on the dorsal aspect of his lefthand. It was soft, smooth, mobile and it did not appear to involve the extensortendons. The patient was able to make a composite fist, he had full extension at themetacarpal-phalangeal joint and at the proximal and distal inter-phalangeal joints.There was no associated lymphadenopathy or neurovascular deficit.
 
 An MRI (Figure 1 and 2) and incision biopsy were performed. Histology confirmedthe presence of a desmoplastic fibroblastoma (collagenous fibroma). This is a rarebenign soft tissue tumour of fibroblastic origin. In keeping with the current literatureon collagenous fibroma they present as firm, well-circumscribed subcutaneous, orintramuscular, painless masses typically long standing in duration. Complete surgicalexcision is the recommended course of action (1). And this was the proposed planwith immediate reconstruction of the defect after discussion at the soft tissue tumourmulti-disciplinary meeting.Figure 1: transverse section throughthe hand revealing the soft tissuetumour above the 4
th
and 5
th
 metacarpals.Figure 2: Coronal section throughthe left hand, demonstrating the softtissue mass.
 
ProcedureA doppler examination of the vessel and the perforating branches of the interosseousvessels was performed.The surface marking of the posterior interosseous artery was drawn along a line joining the lateral epicondyle of the humerus and the ulnar styloid. A point nine cmdistal to the lateral epicondyle of the humerus marks the centre of the fasciocutaneouselement of the flap (Figure 3).A tourniquet was inflated to 230mmHg prior to dissection to create a bloodless field.The tumour extended down to the periosteum of the metacarpals, it involved extensordigiti minimi (EDM), extensor digitorum communis (EDC) to the ring finger and theparatenon from EDC to the middle finger. The skin and tumour was excised takingthese structures en bloc with the underlying periosteum and the fascia from theinterosseous muscles (Figure 4,5).Extensor indicis proprius was harvested and split into two tails and transferred toEDC at the level of the MCPJ via a 90
0
weave through the tendon using a 3.0 braidedpolyester suture (
Ticron, Tycon
) (Figure 6).The vessels lie orientated in the sagital plane in the fascial septum between extensorcarpi ulnaris and extensor digiti minimi muscles. The artery is superficial in the distalhalf and in the proximal half it lies underneath extensor digiti minimi. Therefore theflap was raised distal to proximal. The pivot point is 2 cm distal to the radio-carpal joint, it is at this point that the posterior interosseous artery anastomoses with theanterior interosseous artery. The flap was then tunnelled to the dorsum of the handfrom its pivot point. The superficial veins were preserved and haemostasis wasachieved (Figure 7,8,9).The flap was inset and the donor site covered with meshed SSG. The skin bridge wasdivided and a split skin graft was placed over the pedicle. One 10 French suction drainwas placed under the flap (Figure 10). The tourniquet was released and excellentblood flow was observed to the flap.

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