The two presented cases are difficult cases, and do not
frequently occur, not even in a large hand trauma unit.
The authors have chosen in these cases for debride-
ment, followed by coverage with a pedicled distant flap
(from the abdomen). Later on two separate free vascular-
ised first web and toe pulp flaps were used to reconstruct
the pulp of the remaining fingers' ends. Both patients
have good end results for which the authors should be
gratulated. One case was presented three days after injury
with compartment injury. The other could be immediately
treated in their own hospital. So, the latter case is the one
which can be discussed better.
First of all it is stated that debridement can not be per-
formed enough initially. Although it can be very difficult,
I still think it is possible. Debridement can also be per-
formed in the first three days in two sessions, after which
a more definite cover can be planned. We have also used
the groin flap (or abdomen) for coverage in such difficult
cases, but nearly always directly after initial debridement.
However, I do feel coverage, for instance with a temporal
fascia flap, is possible in the first days, and should over-
come the often seen stiffer joints following distant pedi-
cled flaps. In these particular cases I agree with the au-
thors that primary first web and pulp flaps of the toes
are not possible directly, because the defect is too large
and the risk of losing the flap is too high.
The authors have established that innervated (partial)
toe flaps can demonstrate a good sensibility with 2 point
discrimination up to 6 mm, although I would urge to use
the filament test in these cases, as this test is more objec-
tive. Sensibility in toe transfers has been reported to be
even better than on the donor site. The donor site of the
dorsum of the foot and of the first web and pulp can re-
main a problem for which I do not have an answer as yet.
In conclusion debridement, even in these cases, can be
completed in one stage. A temporal fascia free flap with
skin grafts in a very early stage can be an alternative to
a pedicled groin (or abdomen) flap. The authors have
demonstrated good results, with toe pulp and 1st web
flaps, which to my mind is the best method of reconstruc-
tion in these particular cases.
Department of Plastic and Reconstructive Surgery
University Hospital Rotterdam,
Dr. Molewaterplein 40, NL-3015 GD Rotterdam,