Large and complex defects of the hand, including both bone and soft tissues, occur predominantly in patients with gunshot, explosion and crush injuries. Wound defects after debridement quite often involve all essential anatomical structures, and their closure and restoration are extremely important for the functional recovery of the upper extremity. Traditional methods of defect restoration are not so effective because of the existing insufficiency of reserve tissues available to cover defects completely. The utilization of non-vascular bone grafts in order to substitute for bone defects leads to protracted wound healing as a result of delayed re-osteogenesis. It is often complicated with full or partial resorbtion of graft. The method of vascularized tissue transfer allows covering defects of diverse type and size through the utilization of various grafts in one stage. It provides an opportunity for the much earlier hand defect restoration. 131 patients had been operated in the period of 1986 - 1996 with various hand complex trauma at the Center of Plastic and Reconstructive Surgery & Microsurgery. Both pedicle (island) and free flaps had been used to fit the defects. Patients undergone reconstruction were distributed as follows: A. Pedicle flap: radial - 38 (17 with bone and soft tissue defects), ulnar - 20 (2), dorsal interosseus flap - 11 (5), groin flap - 69 (24), B. Free flap: dorsal interosseus - 23 (9), dorsalis pedis - 25 (19), groin - 14 (7), scapular - 62 (35).
Forearm is considered to be the best donor region for the complex hand defects. It contains sufficient tissue for reconstructive means, and its vascular pattern is quite favorable for flap harvesting. Pedicle forearm flaps were based on the ulnar, radial and dorsal interosseous artery, including vascularized radial and ulnar bone grafts whenever it was necessary. Since vascularized tendon and nerve grafts could be also used, multi-component tissue transferring in one stage, has become readily available. Dorsal interosseus flap harvesting spares the principal forearm arteries, so that the priority had been given to the utilization of the dorsal interosseus flap in the compromized blood supply of the hand. Free flap transplantation had been performed in those cases when: (i) there was forearm tissue damage and possibility of blood circulation impairment development; (ii) there was more than one bone defect; (iii) nerve and tendon defects needed to be restored as well as the adequate blood flow in nutrient vessels. Bone and soft tissue transplants were primarily harvested from groin and scapular regions, including vascularized fragments of scapula or iliac crest. For the tendon defect restoration we used dorsal interosseus flap in combination with the vascularized fragments of the foot extensors. In several cases hand complex defects were covered immediately after primary debridement. Though this approach is sometimes related with further complications (such as tissue necrosis etc.), it prevented hand deformation as a result of scar formation. We performed two-stage vascularized flap transplantation to avoid such deleterious outcomes. Soft tissue mass was transplanted followed by the vascularized bone fragment transplantation.