Emmanuella Peraut

Secondary restoration of fingertip sensation with Littler's heterodigital neurovascular island flap after ring avulsion injury: Report of two cases

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 pulps sensibility with Littlers 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 fingertips sensibility was done using Littlers heterodigital neurovascular island flap. The 3rd fingers 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 fingers base. A split skin graft was performed at the donor site. After three years of follow-up, two-point discrimination on the 4th fingers 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. Littlers flap seems to be appropriate for restoring sensation at fingertip after ring avulsion injuries. Donor site complications seem acceptable.