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Contracture Release and Full-Thickness Skin Graft to Volar Index Finger with K-Wire Insertion

Jonathan Friedstat, MD1; Jonah Poster2

1Shriners Hospitals for Children - Boston
2Icahn School of Medicine at Mount Sinai

Transcription

CHAPTER 1

So today's case involves a kid who had a burn about a year or so ago, and as oftentimes happens, like we try to get them to range and move their fingers, but sometimes the forces of scarring cause the finger to flex volarly, as he has. And so what he's got is kind of a- a flexed- sort of index finger that he can't fully straighten. And what we're gonna do is release the tension on the volar surface of the finger, so that it can be fully straightened. We'll create a defect on the volar surface of the skin and then we'll put a skin graft in that. Because we're going to be releasing it on his finger, and he is not going to keep his finger straight for us, we'll put a metal K-wire down his finger to hold it in position. This will prevent the finger from moving and losing the skin graft to shear. It will also help keep the skin and everything fully straightened so when we sew everything in, we know it will be in a good position functionally for him. Because he's so young, there's certainly a chance that this is going to recur, and since it's a small defect, I think the best option for him would be a small full-thickness graft, where we can take a pinch of skin from his groin. It's not going to be a big defect, if it were a larger defect, then we would use a split-thickness graft. In terms of this operation, I'd say the- I was going to break it down into 3 steps- maybe the- 3 to 4 steps at most. One is release the scar tissue, taking care not to injure the, flexor tendons, and also be mindful of the neurovascular bundles on the radial and ulnar sides of the index finger. Once the finger is fully straightened, then placing the K-wire in place, so that it is stabilized, and that we know the size of the defect. And the third is sewing the skin graft in. And then the fourth, if it's big enough, is to put a bolster or some type of dressing on, and that may be a dressing that as sewn in place, wrapped in place, and/or reinforced with some thermoplast, which is a splinting material to help hold his finger out so that he can't- try to minimize the chance that he can move it while everything is healing.

CHAPTER 2

So you can see like his palmar skin has gotten pulled dorsally, so what we're going to do- do you have a marking pen? What we're going to do is try to release it so that it will go back to where it used to be. So, the scar is sort of tightest along here, so we'll probably… Is that the scar from a prior release or is that from something else? It may be just from how he's healed, because- you can see how it's all pulling- once we do that, then this palmar skin will go back that way, this will go this way, there'll be a space, and we'll put a little skin graft in. So, what we'll do, rather than put like a full tourniquet on, what you can do is do the same thing, so what I'm going to do is I'll get this started wrapping. I may have to wrap a little higher on the forearm. I'll do this for his little fingers. That looks a little more blanched. That's so you can tell it actually is sort of working, it's not perfect, but it's- it's going to slow down the bleeding. Can I see a 15 blade and a epi soak?

CHAPTER 3

All right. So again, I'm holding tension on it here. It'll be similar to what we've done before where it was just very light pressure. Incision. Okay, yes, if you just set that there, i'll probably use it in just a little bit. We'll take the small double hooks. So you can see the start of that release. And now we're going to do the same thing as before. One right there. 1515 would be great. Because everything's all distorted with the scarring, I'm very gentle about how much I'm releasing because I worry about the neurovascular bundles underneath. Because depending on where we're at, sometimes they can get distorted in their location. And so, the last thing you want to do is think that they're not there. Right. And find out in fact they are there, and then you give yourself a real problem. So what you'll see now is like, his finger is pretty straight, and you can probably- we can give the K-wires back because now most of it I can do just by my- you know, now the finger's in a much safer position. So- let's just released this a little bit more. This one you don't get to create as much of a trough, because the finger is so tiny, but you can see now, like the finger is straight. And we can probably get a little bit more of a release over here. So what I'll have you do is I want you to hold the finger like this for me. Put your index finger underneath. I'll take Adson with teeth. So again, I try to grab inside, underneath. One thing that's different with hand and hand surgery is a lot of spreading, very little removing of tissue. Because there's so many important structures in the finger- can I borrow this from you for one sec? Also, the tip is always curved up, so, I can't injure important structures. If the tip is curved down, then I can cause problems. And so, what you can see- like, we're sort of creating a little bit of a trough here, but it's not the same as before. Exactly. And even if I ever do grab on the skin like I do here, it's very gentle and it's very minimal. Sometimes you can just do it all with- spreading alone, but… There we go. So now you can see- the finger is really, really straight. If we go a little bit deeper, you'll start to see the flexor tendon here, and so, that's what I'm trying to avoid, and by leaving this tissue over it, it should protect it, so we don't have to worry about the problems of tendon exposure. But you can see, like significant laxity, now his crease is back where it's supposed to be. And there's extra skin too, the same thing over here. How long do the K-wires need to stay in once they're placed? Usually a couple of weeks- can I see a ruler please? So, now we measure the size of our skin graft, so we need about- a little more than a centimeter by- a little less than 2. Marker?

CHAPTER 4

So, if we did like a little- so that's 2.5. So we said we need a little more than… Did you say we place it right in the crease? Mm Hmm. So if we need like something like… Like that should be plenty. So then what we'll do is we just taper. That'll give us plenty of skin, might even be able to make it smaller, and do something like this. Because this skin is going to stretch a little. Okay.

This will just help us with some hemostasis. No, full. We need one more Kerlix. Heavy scissors. And then you can peek- it bleeds, finger's pink- that's what you want to make sure of. Right. And then we can just- that there.

So, a lot of this is also feel. Do you have a SNaP? What we can then do is- substitute this here. Perfect. And once you've sort of released these edges a bit… I'm really gentle with this when I do it over my finger, I'd rather have there be a little fat like there is here. Are full-thicknesses always harvested in this fashion, or can you do it with- like a thicker setting on the dermatome? Some people have tried it with a thicker setting on the dermatome, I don't think that works as- like, you're basically taking a really thick split most of the time, But you can do it.

Some curved- another SNaP. So what you can see here is we got a good amount of the fat off, not all of it, And then I put another SNaP on the other side, and it acts as a weight, so it kind of sets it over my finger nicely. Now what we do is trim off the fat. The one nice thing about little grafts is there's not much fat. Do you have another SNaP? Mm hmm, yes, these are good. And what you should see is a mostly white surface because that's all that what we're looking at right now is the dermis. Got rid of almost all of the fat. Sometimes it's really hard to get it all. His came off nice and easy, which is… All right, here's the skin. We can just wrap that in a- some- in a moist- let's see how this looks.

We'll need the 3-0 Monochryl in a sec. And then, can I take the local? Okay. So we'll put some in here. Do we close this primarily? Do you have more? Then we'll close this primarily, exactly. Do you do 3-0 interrupted, and then? Yes, 3-0 dermal, and then a 4-0 sub-Q. I'll take the 3-0 Monocryl please. You can cut those right on the knot, perfect. Sometimes you get a little dog ear, we'll fix that. You can try to hide it in the groin crease as best you can. No, Dermabond, and that's it. We'll fix this. That looks better, we'll fit that with the- with the Monocryl because- you saw how it was pulling in? Sometimes you can get it with a stitch, but when it's dimpling like that, and he grows, like he's gonna want his skin crease to be able to move with him. Yes. Plus the 4-0 will have a- you can put them in deep, and get it to fix it sometimes for you, so… Let's see, like- that should heal in a way where he's really not going to notice it too much. And the morbidity much- is much lower from this, like- even if we tried to take a tiny split-thickness skin graft, like- The machine, even at its smallest setting, would harvest way more skin than what we need. And so… If we needed that much skin it'd be a different story. Then what we'll do is- dunk this so the knot goes deep. Since the Dermabond takes a little while to dry, and you almost always want to do it at the very end, when you want to just be done. I just put it on now so it'll- by the time we're done sewing, and K-wiring, and doing all our stuff… This is a really good dressing for kids, because you put it under their diaper, and they can get it wet, and nothing happens because the Dermabond protects it. Let me just make sure his… If I put extra, I just want to make sure that it sits in the skin crease open. Because if we glue him with his skin crease closed, he won't be so happy when he tries to move, and he won't be able to tell his mom and dad that. So what I'll have you do with your left hand is just hold his skin open like this for a little bit- oh sorry, with your right hand- other left. These are a little harder to make those little darts because it's just so tiny. Let's see, I think this will work. I don't mind bleeding from the skin edges too much, it's actually- a good sign. All right, K-wire.

CHAPTER 5

Can you go up on the gas? Can you please- yes. Keep going. A little more. All right, well, it should work. So now… I choke up on the K-wire initially, so that I have good control over it. And it's a lot of visualization because- it goes in right under the nail, that's where the… And then I aim straight down the shaft of the finger. And once I kind of get it started… Now we're going to try to line this up so it's in a good plane this way, running along the axis, and then also in a good position the other way. Sometimes you have to stand to do this. Move these things out. So again, a good position there, and then always check both… And you'll feel it as it goes through bone, it will slow down. Now let's see where we're at. And then push to show… It was that a little too shallow there, could see it coming towards the finger, so then… So, I'll angle a little bit more volar this time. That's better. So now you'll see his finger doesn't really move, but it's still, again, it's a little- it keeps moving- you can see how it's lined up. It's still coming a little bit dorsal there, so- I would change my angle a little bit more. He's withdrawing just a little bit. The dry Raytech. It's in a good plane laterally, sometimes there's just one position, just- works better. Scissors. A little further, and then hopefully it should immobilize at the MCP joint. That's MCP. That should make it. There we go. Yes. Now, that he can- almost- almost there. That'll hold him, yes, see now how the whole thing- it doesn't move, it's- he can't bend that finger, that's the key. Sometimes they're a little easier to place than others. Do you drill it through all the bones of the finger? Do you drill it into the bottom part? Yes, you get it right in the distal phalanx at the- right under the nail bed. And then you try to run it straight down the shaft, and you kind- you can do it with a C-arm or you can do it with visualization, just visualizing like where your fingers are and then imagining the trajectory of the wire passing through everything. But you don't drill it into like the hand or anything? You go to- for him, in order to stop him from moving his index finger, I'll go through into his metacarpal, so he won't be able to bend anything. You could stop it probably right here, but because his release is close to his metacarpal head, I'll take it further so that the whole thing moves as one piece. He needs anesthesia for a K-wire removal, right? You at least would want to mask him probably, I think. Yes, we have the Jurgan's balls? The 2/8? Yes. Do you have 2/8's? Yeah. Because otherwise I can cut it and bend it back. Yeah, we have it. Okay. So then, let's do- we'll do a Jurgan's ball so you can see. So I'll have you just hold that there. Wire cutters. We'll need a 2/8 Jurgan's ball too. If we were doing more complicated stuff, you'd use a C-arm to look, but you can feel, like clinically, you can see this finger does not bend. It's all one, it all moves as one piece, so I know that I got in the bones. If it's- K-wires are good if you need to have it be like really perfect, but you can also tell clinically. And because this is a short-term, you don't need- it doesn't need to be as perfectly precise, it just has to stop him from moving, that's its function. It protects the tip. so that- all right. Can we see our skin graft?

CHAPTER 6

Are you using a 4-0 Chromic for that? Yes. Unfurl it. Let's start here, we'll get the corner tacked in, and then… I don't think we're going to be able to sew a dressing in on him, so we'll take some Xeroform and we'll fold it, to compress it, and then we'll wrap it with one of those little baby clings. The smallest ones you got, the little tiny like, the- if they're smaller than a one, I would do the smallest, the little, little baby ones is what we'll… Now it's just the same thing. An important thing to always make sure- when you release these finger, is sometimes the neurovascular bundles can get- like can spasm, or sometimes if they've been really badly scarred, you might lose some of that blood supply. Plus when you straighten the finger out before you put the K-wire in, you want to make sure there's good blood supply, which we did, but then also even when you put your K-wire in, like if for some reason you accidentally got into one of the neurovascular bundles, you would want to make sure that the finger has good- still has good perfusion, which in this case you can see it's nice and pink and healthy looking. And then you do the same thing when we put the- when we go to put the dressing on. Because if you make it too tight, baby is not going to be able to tell you that this is too tight, it hurts. They'll cry, but how do you distinguish one type of crying from another? And the last thing you want to have is the finger loses blood supply from doing a good operation, but putting a bad dressing on. Now let's see what- so there's extra. All right. So now we're just going to trim the extra, so, one trick if you're not a hundred percent sure of where to cut to, is you can just make a vertical slit. So what you can do is you make your vertical cut down, until you're at basically the level where you want it to be, or where the sort of, the groove of that is, so probably a little bit more. And then when that lines up, flushed with the edge, then you know that- you can sew it in place. This is a technique plastic surgeons use a lot. Where it works really, really well is like face lifts, when you're trimming off the extra skin there, but- it's good when you're like- you want to make sure that you don't cut off too much extra skin. And all you're doing is another sort of principle of like making something progressively smaller and simpler. So you bisect it and split it into 2 smaller little wounds. And now you can sort of see where those two edges of extra skin are even more clearly because now that piece is tacked in. So then… You come back, you can see there's a suture here, suture here, so all you have to do is just cut between. Oh, perfect. And then we can do the same thing here. That'll fit perfectly. We may have to trim that one out. Sometimes you tack them in, if it's not quite perfect, you may have to adjust it a little bit, but we'll see here in a sec. And borrow these scissors, so… So, another thing is never be so happy with your stitch that you're not willing to take it out and redo it if it doesn't look right. Let me borrow this for a sec. You want rehab to come in too? Yes. And then what we can do is block his finger too. Sometimes you can get the knot to sit on the inside here, like this. We'll take a sloppy wet and a dry. Yes.

CHAPTER 7

And then we'll give him a little block here, because we like him. And then a little bit more right here. That should make him happy. Well, I went above it into the scar because the skin from the crease had been displaced distally, so I tried to look where the skin wanted to go back to and then I made the- the contracture release incision there, so that he would have more glabrous palm skin. And then leave a rim of scar like you've seen. And for these little ones, I find it's very difficult to- to make a- like to sew a dressing on, like- a tie-over bolster just doesn't really make sense to me, so, I just roll the Xeroform up. Small, full, big ones, split, I mean, that finger is so tiny- honestly, like the chance of him needing another release is high, but- like that's your donor site versus trying to take a shave of skin, which will be much harder. So, that's why. This is one of those times where I hear what Donelan says, but I- I'm not sure I would do a- a split-thickness I think will be a- you'd be more morbid from the donor site. All right, now, this is the baby..., see I told you it's like a- it's like a really big Mentos. All right, so now, if you hold the hand up here. All right. And then once you get it here, you can slide your hand- right hand down to the forearm. Come down around the rest, because there's no way he's going to just leave that thing alone. So, I want you to just hold his fingers out here, yes, perfect. Well I think we're probably good at this point. This will be for their splint. They can protect it with the splint. And if they want to wrap over it, I'm fine with that.

CHAPTER 8

So, you know, overall the operation I think went really well. We were able to get the finger fully out in extension, without any tension, and get a small little graft in there from his groin, which should allow him to heal and have good- full mobility of his finger. The K-wire was a little harder to place, but what you do is, sometimes when you have difficulties with it, you look to see what you're doing wrong and then you keep adjusting until you get it in the right position. By the end, we had at where he couldn't move his finger at all, which was exactly the way we wanted it to be. In terms of recovery, again, in similar principle of like if you leave the dressing on for a little bit longer, the graft will be more healed and certainly with full-thickness grafts, because they have more- they're are all of the epidermis and dermis as opposed to a split where you only have a portion. It takes longer for those grafts to really heal in, so leaving the dressing on here for a couple of weeks is nice because if there is any epidermolysis and the epidermis on the- on the full-thickness graft sloughs off, it's all going to happen under the dressing, and then most likely be healed by the time you take it off in 2 weeks. And you know, for- for this kid, could you try to do it at the bedside, and have him come in quickly and pull the K-wire? Yes. It's much easier when he's not moving around, and if there's any stitches you have to trim out, you can. But all the stitches were absorbable on purpose, so that- if for whatever reason the dressing came undone, or he couldn't have the stitches come out, there would be little harm to him. The biggest complication you watch for with this operation is that the scarring can displace the neurovascular bundles. Usually they get displaced volarly and centralize, so as you're releasing it, the biggest thing to watch out for is that you don't injure those neurovascular bundles as you're performing the contractual release. His was not a very deep scar, so we didn't have to get past much to the sub-Q fat, which then protects both the neurovascular bundle to some degree and also the flexors. If you do find yourself looking over them and you need to see them to do the release, then you want to make sure you fully visualize them. In his case, we didn't get to a depth or a width in those areas where it was necessary to go looking for them. When you release the finger, you also want to then make sure that it's reperfused, and he had good perfusion to the tip of his finger, both after the release and then also with the K-wire placement. The last thing you always want to watch out for is as you're wrapping the dressing on, like you don't want to make the finger dressing too tight, and you make sure that you test that by looking at the cap refill of the- either the nail bed or the finger pad, and in this case it looked good. So you know, I would expect him to do well. Really important thing is rehab and their splint that they put on him, so they put on a plastic splint that will protect over not only the tip of the wire that's got a rubber stopper on it, but also around all his fingers, so that he doesn't chew on it and do things that kids that are, you know, 2 years old roughly will do. And the splinting and the K-wire, all these things are designed to basically prevent the graft from moving, so that it heals well. Those are the really- the important things, and the splinting in kids, in particular in burns, is really, really critical to getting good results. If you don't have a tourniquet, you can always use an Esmark, like we did there, and you can do it on- if you're doing just a finger, whether it's a release and a graft on the tip of the finger, if you don't want to- if you don't have it an Esmark, you can get a glove, cut a hole in the glove, and then roll it into almost like a ring, and it creates a band that creates a tourniquet on the finger, so that you can then do whatever work you need to on the finger, and make sure you cut the band. So those are ways to help minimize bleeding, so you're able to work on small fingers easily and see what you're doing.