Palmar arch reconstruction using dorsal venous arch of foot for revascularisation of multiple digits

Abstract

A case of trauma causing total loss of superficial and deep palmar arches of hand with ischemia of all the digits was managed using dorsal venous arch of the foot to reconstruct the palmar arch. The ends of the venous arch were anastomosed to radial and ulnar arteries and the tributaries to the arch were coapted to the cut ends of the common digital vessels and princeps pollicis. The surgery yielded gratifying results, successfully revascularising all the digits.

INTRODUCTION

With road traffic accidents taking epidemic scales in many parts of the world, hand trauma can come in a protean presentation and pose difficult challenges. Hence, hand surgeon needs to be abreast with every possible option to make a wise decision in an emergency situation. We present one such difficult case and the innovative method we employed successfully.

CASE REPORT

The present case report is about a 14-year boy who met with a road traffic accident in which a metal bar impaction across the palm through first web resulted in avulsion the thumb and palmar soft-tissues [Figures 1 and 2]. All the digits including thumb were ischemic. Except the first carpometacarpal (CMC) joint fracture-dislocation, the bony skeleton was remarkably uninjured. There were no other life-threatening injuries, no co-morbidities.

Figure 1.

At presentation

Figure 2.

At presentation

On exploration under anaesthesia, it was found that the palmar arches were crushed and torn away from the ulnar and radial arteries proximally and the common digital arteries and princes pollicis distally [Figures 3 and 4]. A gap of about 6 cm existed between ulnar and radial arteries and the cut ends of the digital vessels with the loss of palmar arches.

Figure 3.

The palmar arch defect

Figure 4.

The palmar arch defect illustrated

Digital nerves and long digital flexors were intact while the extensor pollicis longus was avulsed.

Considering the need to perfuse four digital vessels-three common digital vessels and princeps pollicis-using ulnar and radial artery afferents, it was decided to use the dorsal venous arch of the foot as the intervening vessel graft and to reconstruct the palmar arch. Ipsilateral foot was chosen. Under tourniquet without emptying the veins, dorsal venous arch was surface marked. A T-shaped incision made and skin flaps raised to expose the venous arch [Figure 5]. The same was carefully dissected and harvested including sufficient length of the proximal extensions of the arch, the tributaries from the web spaces and a longer tributary from the medial aspect of the great toe [Figure 6]. The donor site was closed primarily.

Figure 5.

Dorsal venous arch exposed

Figure 6.

Venous arc harvested

The hand was thoroughly debrided. First CMC joint was fixed with axial K wire. The vein graft was placed in-situ and the lengths of the limbs (tributaries) were shortened and laid as per the defect. Unfavourably directed valves were ruled out by flushing saline. The vessel ends were prepared for anastomoses. The proximal open-ends of the venous arch were anastomosed to the ulnar and radial arteries on either side. The most proximal tributary arriving from the medial aspect of the great toe was anastomosed to the princeps pollicis. The other three tributaries were anastomosed to the three common digital arteries. Vascular anastomoses were performed using 8-0 nylon interrupted sutures. Clamps were released after all the anastomoses were completed. Flow across all the anastomoses was confirmed [Figure 7]. Each of the fingers showed 100% oxygen saturation with triphasic wave-forms. One dorsal vein was also anastomosed. Post-operative recovery was uneventful [Figures 8–10].

Figure 7.

Anastomosis

Figure 8.

Post-operative healing

Figure 10.

Post-operative recovery

Figure 9.

Post-operative recovery

DISCUSSION

Destruction of the palmar arch without mangling the rest of the hand being a rare coincidence, there is little experience reported with the reconstruction of palmar arch. However, palmar arch destruction due to chronic diseases such as hypothenar hammer syndrome and their microsurgical reconstruction with or without vein graft have been reported.[1,2,3] Marques replaced a thrombosed palmar arch with a saphenous vein graft anastomosing common digital arteries end-to-side to the vein graft.[3] Zhuang and Wang reported in 1999 their experience in which they used dorsal venous arch of the foot to perfuse common digital arteries from ulnar artery.[4] However, it was not a complete arch. As far as we could ascertain from our literature search there has been no instance of total palmar arch and all common digital arteries reconstruction ever reported in the literature.

The inception of the choice of this unusual venous conduit in our case was a result of a schematic visualisation of the missing arterial segment [Figure 6]. As imagined, we could successfully anastomose afferent ulnar and radial arteries to the main trunk of the venous arch and provide efferent to the common digital vessels and princeps pollicis. Although it involved six microsurgical anastomoses, each of the fingers including the thumb was salvaged.

One potential problem that can be predicted to arise in this technique is the venous valves. However, it is fairly conclusively recorded that valves are scarce in foot and even when present, are meant to direct blood flow from plantar to dorsal venous arcs.[5] However, in the event of utilising longer marginal veins, if a valve is encountered, it is far more advisable to excise the venous segment containing the valve and reanastomosing than to forcefully over distend the vein so as to render the valve incompetent. The latter technique is more likely to start a thrombus and cause a catastrophy.

Our case illustrates a unique clinical scenario, which can nonetheless present in any emergency department, any day. The case demonstrates that reconstructing palmar arch using dorsal venous arch of the foot is a viable option and a gratifying one at that.

The authors acknowledge the contribution of Mr. Vinod Kumar and Ms. Shamna in their assistance with the photo archives.