Mobile soft tissue cover

A stable, well vascularized, supple soft tissue cover is a prerequisite to functional recovery. This requires adequate debridement and, if needed, flap cover. If a flap is required, and particularly if a free flap is required, timing is critical. The risk of osteomyelitis, wound healing problems, as well as the length and cost of hospital care are directly related to the interval of time between injury and flap cover. Definitive wound closure with a free flap has the lowest complication rate if performed within three days of injury, and the highest complication rate if performed during the "subacute" phase, after granulation tissue has formed (Godina). This timing relationship goes against traditional teachings of delayed primary closure, possibly because of differences arising from the use or from the need for a flap. As elsewhere, the "reconstructive ladder" of wound closure is as follows, and the surgeon should begin at the bottom and consider each rung before advancing to the next:

Most Involved
free flap
distant flap
regional flap
local flap
skin graft
delayed primary closure
primary closure
spontaneous healing
Least Involved
Local and regional flaps from the hand and adjacent fingers are commonly used for finger and thumb tip amputations, and are discussed below. Commonly used larger regional flaps from the forearm include to the radial forearm flap and the posterior interosseous (dorsal forearm) flap. These and other available flaps make free flap reconstruction less frequently indicated for upper extremity reconstruction than for lower extremity reconstruction. When available, single stage flap reconstruction is preferred. Compared to staged reconstruction such as that involving a pedicled groin flap, single stage flaps require less immobilization and allow better elevation of the hand. Every effort should be made to achieve healing as soon as possible. In the hand, stiffness, difficulty with use and ultimate disability is directly related to the length of time required for wound healing.
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