The Posterior Interosseous Flap

B Youssef1, A Dancey, 1 V P Sumathi2, F C Peart1.

1.Regional Department of Burns and Plastic Surgery, University Hospital

Birmingham, Selly Oak Hospital, Birmingham, United Kingdom.
2.Department of Musculoskeletal Pathology, The Royal Orthopaedic Hospital,
Birmingham, United Kingdom.

Case report

A 57 year-old gentleman presented to his General Practitioner with a swelling on the

dorsal aspect of his left hand. The swelling had gradually increased in size over the
last 12 months. It was not painful, associated with any neurological symptoms or
functional loss. There was no history of trauma or infection.

There was no significant past medical history of note and he does not take any regular
medication. 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 left
hand. It was soft, smooth, mobile and it did not appear to involve the extensor
tendons. The patient was able to make a composite fist, he had full extension at the
metacarpal-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 confirmed
the presence of a desmoplastic fibroblastoma (collagenous fibroma). This is a rare
benign soft tissue tumour of fibroblastic origin. In keeping with the current literature
on collagenous fibroma they present as firm, well-circumscribed subcutaneous, or
intramuscular, painless masses typically long standing in duration. Complete surgical
excision is the recommended course of action (1). And this was the proposed plan
with immediate reconstruction of the defect after discussion at the soft tissue tumour
multi-disciplinary meeting.

Figure 1: transverse section through

the hand revealing the soft tissue
tumour above the 4th and 5th
metacarpals.

Figure 2: Coronal section through

the left hand, demonstrating the soft
tissue mass.
Procedure

A doppler examination of the vessel and the perforating branches of the interosseous
vessels 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 cm
distal to the lateral epicondyle of the humerus marks the centre of the fasciocutaneous
element 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 extensor
digiti minimi (EDM), extensor digitorum communis (EDC) to the ring finger and the
paratenon from EDC to the middle finger. The skin and tumour was excised taking
these structures en bloc with the underlying periosteum and the fascia from the
interosseous muscles (Figure 4,5).

Extensor indicis proprius was harvested and split into two tails and transferred to
EDC at the level of the MCPJ via a 900 weave through the tendon using a 3.0 braided
polyester suture (Ticron, Tycon) (Figure 6).

The vessels lie orientated in the sagital plane in the fascial septum between extensor
carpi ulnaris and extensor digiti minimi muscles. The artery is superficial in the distal
half and in the proximal half it lies underneath extensor digiti minimi. Therefore the
flap 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 the
anterior interosseous artery. The flap was then tunnelled to the dorsum of the hand
from its pivot point. The superficial veins were preserved and haemostasis was
achieved (Figure 7,8,9).

The flap was inset and the donor site covered with meshed SSG. The skin bridge was
divided and a split skin graft was placed over the pedicle. One 10 French suction drain
was placed under the flap (Figure 10). The tourniquet was released and excellent
blood flow was observed to the flap.
 Figure 3: pre-operative marking. Flap
designed according to the size of the
tumour. Length and position of the
pedicle marked.

Figure 4: Initial dissection of the soft

tissue tumour on the dorsum of left hand.
 Figure 5: The excised
soft tissue tumour.
excised

Figure 6: Extensor Digitorum Communis

(EDC) to the small and ring finger was
excised en bloc with the tumour and an
Extensor Indicis Proprius transfer to EDC
performed.

Figure 7: Elevation of the flap

the posterior interosseous
artery and its venae
commitantes are displayed.
Figure 8 & 9: Fascio-cutaneous
flap and pedicle completely
elevated.
 Figure 10:Image of the flap in its final
position and the donor site covered with a
split skin graft.

Figure 11:Two weeks post operatively,

the flap and skin graft have taken well.
Pathology

The results of the histo-pathological examination of the specimen were discussed at

the multi-disciplinary meeting, which confirmed that this was a desmoplastic
fibroblastoma.

Figure 12: Macroscopic picture: cut

surface shows a well circumscribed,
greyish white tumour measuring 5x4x2.7
cm.

Figure 13: Microscopic image (x40):

shows a paucicellular lesion composed of
spindled and stellate shaped fibroblasts set
in a collagenous stroma.

The excision margins were clear of tumour and no further treatment is required at this
stage. He will be followed up at regular intervals as an outpatient.
Anatomy of the posterior interosseous flap

The posterior interosseous flap is a type B fascio-cutaneous flap. The flap is

developed in a plane between the fascia and muscle. Here exists a layer of loose
connective tissue and fat containing cutaneous veins, nerves and a rich network of
arteries.

The perforating vessels of the posterior interosseous artery penetrate the fascia to run
longitudinally with numerous transverse anastomoses in the subcutaneous tissue. The
fascia envelops the muscle tissue and thickens to form a septum between individual
muscle bellies. The posterior interosseous artery arises from the common interosseous
artery, passes posteriorly above the interosseous membrane and then runs between
supinator superficially and abductor polllicis longus deeply with the posterior
interosseous nerve to descend and supply the extensors muscles of the forearm. It
forms an anastomosis with the distal branches of the anterior interosseous artery and
the dorsal carpal arch. The artery gives of perforators along its entire length. The
septocutaneous perforators anastomose in the superficial layer of the deep fascia and
form rich vascular arcades. Near the wrist joint, three types of anastomoses have been
identified. The first one with the anterior interosseous artery is located just proximal
to the distal radio-ulnar joint. The second one with the dorsal carpal arch, and the
third includes several branches that surround the ulnar head on both sides and
anastomoses with the ulnar artery. This rich vascular supply means that the flap can
be raised even when one of the anastomoses is injured.
.
 Course and distribution of the Cross section through the
posterior interosseous artery middle third of the forearm.

Venous drainage is from both the superficial and the deep systems, and there are
multiple anastomoses between these venous channels. There is venous drainage
through the superficial veins and the venae commitantes within pedicle to ensure flap
survival (2).
Discussion

Reconstruction of the soft tissue on the dorsum of the hand can be a challenging
problem. Free flaps can be time consuming, require specialised equipment and labour
intensive post-operative care. Distant flaps may require multiple stage reconstruction
and prolonged periods of immobilisation.

Local fascio-cutaneous flaps, although limited in mobility and quantity, offer simple
and effective wound coverage. The donor sites do not often require reconstruction and
can be closed directly or using a split skin graft.

Fasciocutaneous flaps

Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue, and the
underlying fascia.

When moving skin alone, the distance it can travel is limited by its length to breadth
ratio. Including the deep fascia with its prefascial and subfascial plexuses enhances
the circulation of these flaps, but also frees these limb flaps from the length and
breadth limitations they were previously subjected to. They are simple to elevate,
quick, and fairly reliable in healthy patients. They provide ideal resurfacing where a
thin flap of tissue is required. No functional loss results from the area they are raised
as no muscle is taken.

Fasciocutaneous flaps can be used to provide cover over areas of bare tendon and
bone. The procedure can be pre-planned, as described in our case report, based on the
direction and orientation of the fascial plexus or fasciocutaneous perforators. These
flaps provide a donor sites in areas where random axial flaps are not feasable. There
are disadvantages; they are not as resistant to infection as muscle flaps and predicting
failure can be difficult (2,3).
Cormack and Lamberty classification of fasciocutaneous flaps (4,5).

 Type A has multiple fascio-cutaneous perforators. They enter at the base of the
flap and extend through the full length of the flap. The flap can be based
proximally, distally, or as an island.

 Type B has a single moderately sized fasciocutaneous perforator. This can be

used as a free flap or as an island.

 Type C has multiple small perforators running along the fascial septum. The
supplying artery is included with the flap. It can be based proximally, distally,
or as a free flap.

 Type D is an osteomyocutaneous flap. It has multiple small perforators

running along the fascial septum, the supplying artery is included in the flap. It
can be based proximally or distally on a pedicle or used as a free flap.
Forearm flaps
Flaps originating from the volar aspect of the forearm

The axial pattern reverse forearm flap: the axial-pattern reverse radial forearm
fasciocutaneous flap has become one of the primary flaps for reconstruction of soft-
tissue defects of the hand. This pedicled flap provides a good amount of malleable
and relatively hairless tissue with a durable blood supply. Its diadvantages include
sacrificing a major artery, this may jeopardize the hand’s viability and affect the
morbidity and appearance of the donor site (6).

The axial pattern reverse forearm fascial flap: involves a fascial flap and split skin
grafting to cover the wound. Only the fascia is taken with this flap and therefore there
is less donor site morbidity. As with the previous flap this does involve sacrificing a
major vessel (7).

The distally based radial forearm fascio-cutaneous flap: This type of flap was
proposed to avoid the disadvantages caused by axial-pattern reverse radial forearm
fasciocutaneous flaps. It is based on the septocutaneous perforators of the distal radial
artery and therefore does not involve sacrificing a major artery (8).
Flaps originating from the dorsal aspect of the forearm

The de-epithelialized turnover flap: This is a reversed dermis flap. The pedicle of the
flap remains intact. The mobile upper part of the flap is turned over the defect and the
pedicle itself. A mesh graft covers both, the flap and the donor site.

Local adipo-fascial turnover flap: This flap is reliant on the amount of soft tissue that
is available this limits the extent to which this flap can be raised. This is, however, a
reliable and straightforward way to resurface a defect on the dorsal aspect of the hand
(9).

Radial forearm flap: The radial forearm flap was described in China in 1978. It is
supplied by the septocutaneous perforating branches of the radial artery in the
forearm. Generally, the skin is thin, pliable, and usually hairless while the vascular
pedicle may be up to 18 cm in length and the vessel diameters are usually large (2 - 4
mm). The superficial radial nerve and the medial and lateral antebrachial cutaneous
nerves can also be made part of this flap to add sensation to the tissue. Patency of the
ulnar artery and superficial palmar arch should be confirmed prior to elevating this
flap. It does leave a conspicuous donor site. An osteofasciocutaneous version of this
flap has been described with a segment of radius to create a vascularized bone graft.
Ulnar artery forearm flap: The ulnar artery forearm flap, located on the ulnar aspect
of the forearm, is based on the septocutaneous perforators of the ulnar artery, which
has a diameter of 2.5-3.0 cm. It is similar to the radial forearm flap and can be
dissected to include bone, nerve, or a musculotendinous unit. This flap is used as free
flap or as a pedicled flap for coverage of the upper extremity. In addition, it may be
used as a vascular conduit or fascia-only flap.

The posterior interosseous artery flap: Type B fasciocutaneous flap based over the
dorsal aspect of the forearm between the radius and ulna. It is based on the posterior
interosseous artery branch of the common interosseous artery. Its main advantage is
that it avoids sacrificing the two main arteries of the forearm. Dissection of the
pedicle can be difficult and complicated. It can also be raised as an
osteofasciocutaneous falp, creating a vascularised piece of ulna. It is used to
reconstruct defects on the dorsum of the hand, wrist and first web space (10).

Conclusion
The case report has demonstrated that the posterior interosseous artery flap offers
excellent tissue for reconstruction of the dorsum of the hand. In addition it does not
compromise any major vessels and avoids the dissection of lymphatic and venous
systems on the volar aspect of the forearm. This gentleman has had a good functional
and cosmetic result following resection of the tumour on the dorsum of the hand.
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