PMC5828937_01
Dorsal (a) and palmar views (b) of the left hand on admission. The burned skin was already accompanied by tissue degeneration. A prick test was performed to the middle phalanx with a 23-G needle, but no bleeding was observed beyond the PIP joint; even exudation was not noted (c). In an early blood flow scintigraphy image using Tc 99m HMDP, blood flow absence was shown (d). In a bone metabolism image, bones beyond the PIP joints were not circulatory supplied (e). PIP indicates proximal interphalangeal.
eplasty18e11_fig1.jpg
PMC5828937_01_eplasty18e11_fig1.jpg
F1
On admission, deeper (extending to the tendons, ie, fourth-degree) digital burns of the distal ends of the proximal interphalangeal (PIP) joints were shown (Figs 1a and 1b). A pin prick test was performed to the middle phalanx bone with a 23-G needle, but no bleeding, nor even exudation, was observed beyond the PIP joint (Fig 1c). Scintigraphy showed blood flow absence in the distal phalanx of the index to ring fingers, and a bone metabolism image showed osteonecrosis pattern of these parts (Figs 1d and 1e).
Intraoperative dorsal (a) and palmar views (b) just after debridement of tissues except the bones and tendons. A 6 x 6-cm abdominal flap was harvested (c). Frontal (d) and lateral views (e) of the harvested flap covering the bones and tendons.
eplasty18e11_fig2.jpg
PMC5828937_01_eplasty18e11_fig2.jpg
F2
Thereafter, the bones and tendons were exposed without the surrounding soft tissue (Figs 2a and 2b). A conventional abdominal flap of 6 x 6 cm including superficial fascia was raised in the left lower quadrant to cover the naked tendons and bones of the fingers in a block (Figs 2c-2e).
Dorsal (a) and palmar views (b) of the left hand 2 weeks postoperatively. Dorsal (c) and palmar views (d) of the left hand 9 months postoperatively. Active flexion after 9 months of training (e).
eplasty18e11_fig3.jpg
PMC5828937_01_eplasty18e11_fig3.jpg
F3
The pedicle of the flap was cut and detached from the abdomen 2 weeks later, following an eventual course to produce provisional syndactyly between the index to ring fingers (Figs 3a and 3b). In a state of provisional syndactyly, range of motion (ROM) exercise of the metacarpophalangeal (MCP) and PIP joints was performed for 9 months (Figs 3c-3e).
Dorsal (a) and palmar views (b) of the left hand 1 year and 5 months postoperatively. Active flexion after 1 year and 5 months of training (c). Intraoperative dorsal (d) and palmar views (e) of middle-ring finger separation with grafting. Dorsal (f) and palmar views (g) of the left hand 2 years postoperatively. Active flexion after 2 years of training (h). Functional restoration of digits with an acceptable length. The range of motion of the metacarpophalangeal joint was fully restored and that of the proximal interphalangeal joint was 0  to 75 .
eplasty18e11_fig4.jpg
PMC5828937_01_eplasty18e11_fig4.jpg
F4
Since resurfacing of the burned tendons and bones with the flap was successfully performed, separation of the syndactyly was performed between the index and middle fingers (Figs 4a-4c). Separation of the middle and ring fingers was performed with skin grafting 1 year and 5 months later (Figs 4d and 4e). After rehabilitation for 2 years, all fingers showed complete ROM, restoration of the MCP joint, and a high range (0 -75 ) of PIP joint mobility with an acceptable digital length (Figs 4f-4h).