History

Early soft tissue coverage was first proposed by Byrd and colleagues [15]. Lister and Scheker [5] coined the term emergency free flap in a 1983 presentation at the Post Congress Meeting of the

Fig. 7. Radius and ulna were exposed, with much of the distal ulna lost. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 8. After radical debridement, osteosynthesis of the radius is obtained with a 3.5 plate. Tightening of the flexor and extensor tendons provides the right tension for the muscle. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

Fig. 8. After radical debridement, osteosynthesis of the radius is obtained with a 3.5 plate. Tightening of the flexor and extensor tendons provides the right tension for the muscle. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

International Federation of Societies for Surgery of the Hand in Bloomington, Indiana and published a review of their work in the Journal of Hand Surgery, American Volume in 1988. The authors evaluated all the cases at their unit requiring free flap coverage over a 4-year period and found the common denominators for the best results obtained in these patients. Those cases that were closed within the first 24 hours from the time of injury did the best in terms of postoperative course, including number of days in the hospital, a lower complication rate, a lower infection rate, higher flap survival, and a better functional recovery. A possible factor to explain the differences, however, is that the group that underwent later coverage may have had more

Fig. 9. Because of the thickness of the subcutaneous tissue, a muscle flap was necessary. (Courtesy of The Christine M. Kleinert Institute for Hand and Microsurgery, Inc., Louisville, KY; used with permission.)

severe injuries than the group undergoing free flap coverage within the first 24 hours. Similar cases with similar trauma that were delayed did not attain the same degree of function as those receiving earlier coverage, however.

Hand surgeons have attempted to close wounds primarily, particularly when bone is exposed. For that reason, Tranquilli-Leali [16], Moberg [17], and Atasoy and colleagues [18] created advancement flaps that would cover such wounds to the tip of the finger and thumb primarily. In reconstructive surgery, the rotation flap and the transposition flap have been developed to allow primary closure. The authors cover wounds with cross-finger flaps and even with pedicled flaps from distant areas. By performing an emergency free flap, they are just removing one of the steps in reconstruction, dividing a ped-icled flap that might have been applied to the wound. For some surgeons, performing micro-vascular anastomoses may be troublesome in some emergency circumstances; yet, those same people readily perform a lengthy microvascular procedure as an elective scheduled operation. Re-establishing circulation to the wounded area also allows it to benefit from the use of systemic antibiotics and permits the healing process to start immediately.

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