Operative First Web Contracture Management: Current Strategies

Abstract

» First web contractures can be due to nonthermal trauma, burns, congenital differences, and Dupuytren contracture.» Mild cases are managed with contracture release and full-thickness skin graft or when surrounding skin is pliable, Z-plasty.» Release of severe contractures creates a tetrahedral void that may require local or distant flap coverage. Reconstructive options include dorsal transposition flaps, regional rotation flaps, free tissue transfer, first metacarpal distraction osteogenesis with web deepening, or pollicization.

Fig. 1

The Z-plasty exists in multiple variations. The traditional 2-flap 60° Z-plasty increases length 75%. The 4-flap Z-plasty exists as the 45° and 60° Z-plasties. Fraulin and Thompson reported that a 4-flap 60° Z-plasty results in a 167% increase. In addition, the 4-flap 45° Z-plasty increases length 132% and the 5-flap increases length 84%.

Fig. 2

The first web space is tetrahedral in shape. Resurfacing of the released first web should fill the tetrahedral space. D = dorsal, R = radial, U = ulnar, and V = volar.

Fig. 3

Demonstration of the dorsal transposition flap whereby full-thickness skin overlying the index metacarpal is mobilized to cover the first web. The donor site is covered by skin grafting.

Fig. 4

Pedicled rotation flap coverage of the first web may be accomplished with either a reversed radial forearm flap (RRFF) or a posterior interosseous artery (PIA) flap. The RRFF is perfused by ulnar arterial flow through the palmar arch retrograde to the radial artery (Fig. 4-A). Alternatively, the PIA flap pedicle is perfused by retrograde flow from distal communication with the anterior interosseous artery (Fig. 4-B). The PIA flap does not require a functioning radial artery or intact palmar arch.

Fig. 5-A

Fig. 5-B

Fig. 6

Third and fourth degree burns resulted in severe first web contracture and amputations. The radiograph demonstrates recreation of the cleft by second metacarpal excision and thumb lengthening by pollicization of the remaining distal index finger.

Fig. 7-A

Fig. 7-B

Fig. 8

Figs. 8-A and 8-B A contracted first web in Dupuytren contracture may be lengthened following fasciectomy with a large Z-plasty. Fig. 8-A Incorrect positioning of the palmar limb leads to a longitudinal wound in the axis of the thumb, which can later lead to thenar contracture. Fig. 8-B The palmar limb should be based proximally. With palmar and digital disease requiring fasciectomy, the flap may be extended ulnar and the wound left open.