A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center.

INTRODUCTION: The aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol. MATERIALS AND METHODS: Patients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3). RESULTS: Rupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30-175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90-195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group. CONCLUSION: The gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients.

Neurotized lateral gastrocnemius muscle transfer for persistent traumatic peroneal nerve palsy: Surgical technique.

INTRODUCTION: Persistent traumatic peroneal nerve palsy, following nerve surgery failure, is usually treated by tendon transfer or more recently by tibial nerve transfer. However, when there is destruction of the tibial anterior muscle, an isolated nerve transfer is not possible. In this article, we present the key steps and surgical tips for the Ninkovic procedure including transposition of the neurotized lateral gastrocnemius muscle with the aim of restoring active voluntary dorsiflexion. SURGICAL TECHNIQUE: The transposition of the lateral head of the gastrocnemius muscle to the tendons of the anterior tibial muscle group, with simultaneous transposition of the intact proximal end of the deep peroneal nerve to the tibial nerve of the gastrocnemius muscle by microsurgical neurorrhaphy is performed in one stage. It includes 10 key steps which are described in this article. Since 1994, three clinical series have highlighted the advantages of this technique. Functional and subjective results are discussed. We review the indications and limitations of the technique. CONCLUSION: Early clinical results after neurotized lateral gastrocnemius muscle transfer appear excellent; however, they still need to be compared with conventional tendon transfer procedures. Clinical studies are likely to be conducted in this area largely due to the frequency of persistant peroneal nerve palsy and the limitations of functional options in cases of longstanding peripheral nerve palsy, anterior tibial muscle atrophy or destruction.

Endoscopically assisted proximal radial nerve decompression: surgical technique.

STATE OF THE ART: The proximal radial nerve compression syndrome includes supinator syndrome and proximal radial nerve constrictions. This article presents a new endoscopic assisted radial nerve decompression surgical technique described for the first time by Leclère et al. in 2013. SURGICAL TECHNIQUE: Endoscopic scissor decompression of the proximal radial nerve is always performed under plexus anaesthesia. It includes 8 key steps documented in this article. We review the indications and limitations of the surgical technique. CONCLUSION: Early clinical results after endoscopic assisted decompression of the radial nerve appear excellent. However, they still need to be compared with conventional techniques. Clinical studies are likely to widely develop because of the mini-invasive nature of this new surgical technique.

[Return to work after traumatic hand injuries: medical, personal and work-related factors]. / Wiederaufnahme der Arbeit nach traumatischen Handverletzungen: medizinische, persönliche und arbeitsplatzbezogene Faktoren.

PURPOSE: This study aimed to examine the work-related impact of open hand injuries, specifically, the amount of lost work days subsequent to the injury and factors associated with work-related rehabilitation. PATIENTS AND METHODS: We retrospectivley included consecutive patients with acute hand injuries who were operated between 2008 and 2009 in the Division of Hand Surgery (n=435) at the Department of Orthopaedic, Plastic and Hand Surgery. Information was obtained from the medical records and via a self-reported questionnaire sent out in 2011. Patients younger than 18 or older than 65 years, as well as the unemployed were excluded from the study. Descriptive group analysis was used to establish statistical relationships between time off work (TOW) and possible influencing variables. Multiple linear regression was applied to analyse the impact of injury, personal and/or work-related factors on TOW. RESULTS: The sample included 290 patients with a mean age of 38.9 (SD 13.2) years of whom 98.6% returned to work after a median absence of 45.5 days. Univariate analysis demonstrated an association of length of absence from work with socio-demographic, clinical and work-related factors. Multiple regression analysis indicated that the location of injury, the number of injured regions, the need for secondary surgery, age, and the type of occupation were independently associated with TOW. CONCLUSION: Most factors associated with TOW after traumatic hand injuries could not be influenced. Possible interventions should probably target improved injury prevention, optimal clinical treatment and rehabilitation starting early after injury. Whether improvements in communication and enhancement of cooperation between the treatment teams, the workplace and the insurance carrier may support a staged and earlier return to work remains to be investigated.

Reactivated Moraxella osteitis presenting as granulomatous disease.

Granulomatous infections are commonly associated with mycobacteria, brucellosis, actinomycosis, nocardiosis, spirochetes, and fungi. Rarely, granuloma formation is a host response to other bacterial infection. Osteomyelitis and osteitis that reactivate many years after the primary episode is a known phenomenon. A reactivation that presents as a granulomatous disease is rare. We present a case of reactivated osteitis due to Moraxella osloensis with consecutive granuloma formation.

[Endoscopically assisted decompression of the median nerve in the pronator and Kiloh-Nevin syndrome: Surgical technique]. / Décompression du nerf médian assistée par endoscopie dans le syndrome pronateur et le syndrome de Kiloh-Nevin : technique chirurgicale.

STATE OF THE ART: The proximal median nerve compression syndrome includes the pronator teres and the Kiloh-Nevin syndrome. This article presents a new surgical technique of endoscopic assisted median nerve decompression. MATERIAL AND SURGICAL TECHNIQUE: Endoscopic scissor decompression of the median nerve is always performed under plexus anaesthesia. It includes 6 key steps documented in this article. We review the indications and limitations of the surgical technique. RESULTS: Since 2011, three clinical series have highlighted the advantages of this technique. Functional and subjective results are discussed. We also review the limitations of the technique and its potential for future development. CONCLUSION: Although clinical results after endoscopic assisted decompression of the median nerve appear excellent they still need to be compared with conventional techniques. Clinical studies are likely to develop primarily due to the mini-invasive nature of this new surgical technique.

[Collagenase injection in Dupuytren's disease, evaluation of the ultrasound assisted technique]. / Traitement de la maladie de Dupuytren par collagénase injectable, évaluation de l'échographie assistée.

Since October 2011, the enzymatic lysis of Dupuytren's cord was introduced in Switzerland (Xiapex(®), Auxilium Pharmaceuticals, Pfizer). Here we present our first university experience and underline the major role of ultrasound during the injection. Between December 2011 and February 2013, 52 injections were performed to eliminate 43 Dupuytren's cords in 33 patients. The mean age of the patients was 64.4 ± 8.5 years. Complications were documented for each patient. Before, directly after and after a minimum of 6 months post-injection, the contracture of the treated joint was measured with use of a goniometer. The DASH score was evaluated after a minimum of 6 months and the patients were asked to subjectively evaluate the outcome of the treatment (very good, good, mild, poor) and whether they would reiterate it if necessary. Four skin defects, one lymphangitis, and one CRPS were responsible for a complication rate of 18%. There was no infection and no tendon rupture in the series. The mean MCP joint contracture was respectively 36.8 ± 27.4°, 3.5 ± 7.8° (gain of mobility compared to the preoperative situation 33.3°, P<0.001), and 8.4 ± 13.9° (gain 28.4°, P<0.001) respectively before, just after and at the long-term clinical control. The mean PIP joint contracture was respectively 36.5 ± 29.1°, 5.9 ± 6.7° (gain 30.6°, P<0.001), and 15.1 ± 13.8° (gain 21.4°, P<0.001) respectively before injection, just after and at the long-term clinical control. The DASH score decreased from 24 ± 14 to 7 ± 9 (P<0.001). Eighty-one per cent of the patients were satisfied or very satisfied of the treatment. All but two would reiterate the treatment if necessary. Ultrasound is able to target the injection of collagenase in order to reduce complications. The short-term results of this non-invasive therapy are very promising however comparison with conventional procedures is difficult as the long-term results are lacking.

Aseptic tissue necrosis and chronic inflammation after irrigation of penetrating hand wounds using Octenisept®.

Penetrating hand wounds are common and these are managed by thorough debridement. However, stab wounds without evidence of divided structures are often treated with irrigation using antiseptic substances, antibiotic therapy, and immobilization. Octenisept® (Schülke & Mayr Ltd) is a widely used antiseptic agent for disinfection of acute or chronic wounds. It has a broad spectrum of antiseptic efficacy and has become an antiseptic of first choice in many hospitals. Within a few months, four patients presented to us with chronic inflammation and severe tissue necrosis after irrigation of penetrating hand wounds with Octenisept®. Repeated surgery and debridement was required in all patients. Wound healing was prolonged and patients had persisting oedema. Penetrating hand wounds must not be irrigated with Octenisept®.

[Hand and wrist surgery]. / Operative Eingriffe an Hand und Handgelenk.

Despite improved medical treatment of rheumatoid arthritis, carpal tunnel compression, caput ulnae syndrome and palmar and dorsal tenosynovitis with potential tendon rupture represent urgent surgical indications. While diagnostic and therapeutic synovectomy may guide medical treatment, it should be performed before joint instability and destructive arthritis are established. Swan-neck and Boutonniere deformities as well as ulnar or radial drift of metacarpophalangeal (MCP) joints or the wrist can only be corrected when the involved joints are supple and intact. In the presence of destructive arthritis, partial and total wrist fusion, arthroplasties of the MCP joints and arthrodeses of the distal interphalangeal joints are recommended.

[Ultrasonic and radiographic quantification of palmar angulation in metacarpal IV and V neck fractures]. / Sonografische und röntgenologische Quantifizierung der Palmarabkippung von subkapitalen Frakturen der Metakarpalia IV und V.

PURPOSE/BACKGROUND: Therapy of metacarpal neck fractures depending on radiographically measured palmar angulation is discussed controversially in the literature. Some authors describe normal hand function of malunited metacarpal neck fractures with a palmar angulation up to 70°; others define 30° as the uppermost limit to maintain normal hand function. However, the methods of measuring palmar angulation are not clearly defined. Here, we present a new method to measure palmar angulation using ultrasound. The aim of this prospective study is to compare the radiographic methods of measuring palmar angulation with the ultrasound method. PATIENTS/MATERIAL AND METHOD: 20 patients with a neck fracture of the metacarpals IV or V were treated either conservatively or operatively. 2 weeks after trauma or operation, an x-ray was performed. 2 examiners measured the palmar angulation on the oblique and lateral projections using 2 different methods (medullary canal and dorsal cortex methods). At the same time, the 2 examiners performed measurements of palmar angulation using ultrasound. The measurements obtained with the different methods as well as by the 2 examiners at 2 different terms were compared. Intra- and interobserver reliability of each method was calculated, and for the ultrasound method a test for accuracy of the measured angles was performed. RESULTS: Depending on the method of radiographic measurement and different x-ray projections, an average of up to 20.3° higher angles were determined as compared with the ultrasound method. The average deviation in angles measured within and between the 2 examiners was lower for the ultrasound method than for the radiographic methods, corresponding to a higher degree of intra- and interobserver reliability. CONCLUSION: The ultrasound method for measuring palmar angulation in metacarpal neck fractures is simple, and appears to be more precise in comparison to radiographic methods. An exactly lateral projection of the fractured metacarpal bone can be imaged without superposition and exposure to radiation. The question arises whether previous studies that suggested normal hand function with palmar angulation up to 70° might have been based on too high angle-readings due to the use of radiographic methods.

Inter- and intraobserver reliability of predefined diagnostic levels in high-resolution sonography of the carpal tunnel syndrome - a validation study on healthy volunteers.

PURPOSE: High-resolution ultrasound is becoming increasingly important in the diagnosis of carpal tunnel syndrome (CTS). Most studies define cut-off values of the cross-sectional area (CSA) of the median nerve in different locations. The individual range of nerve swelling, the size of the nerve, and its CSA are not addressed. The aim of the study is to define the intra- and interobserver reliability of diagnostic ultrasound using two different cross-sectional areas of the median nerve at the carpal tunnel in predefined locations. MATERIALS AND METHODS: Two observers using high-resolution ultrasound examined 50 wrists of healthy volunteers independently. The CSA of the median nerve was measured at the entrance of the carpal tunnel and 2 cm proximal to the palmar wrist crease. The height and width of the carpal tunnel were determined using anatomical landmarks. The intra- and interobserver reliability was determined using Cronbach's alpha. RESULTS: Depending on the observer, the mean width of the carpal tunnel ranged from 3.37 to 3.43 cm with the height ranging from 1.18 and 1.19 cm. The CSA of the nerve was measured with values of 8.43 and 9.05 mm (2) on the pisiform level and 9.37 and 9.68 mm (2) on the proximal level. Cronbach's alpha ranged from 0.754 to 0.940 for the interobserver reliability and from 0.924 to 0.996 for the intraobserver reliability. CONCLUSION: To use high-resolution ultrasound for the diagnosis of carpal tunnel syndrome, the reproducibility of this method has to be evaluated. Our study confirms examiner-independent reproducibility of two predefined diagnostic cross-sectional areas resulting in good alpha values.

Clinical results of flexor tendon repair in zone II using a six-strand double-loop technique compared with a two-strand technique.

The clinical and functional results of 46 patients who underwent zone II flexor tendon repair using the Lim/Tsai technique combined with the Kleinert/Duran early active mobilisation regime and place and hold exercises were assessed. The results were compared with 25 patients who were treated by the modified Kessler technique and the Kleinert/Duran regime alone. After a follow-up of 8 to 17 weeks, the Lim/Tsai group had a better grip strength and a significantly better total active motion of 141 degrees compared with 123 degrees . The rupture rates (Lim/Tsai: 1/51; Kessler: 3/26) and the extension deficits were not statistically different in the two groups. However, the complication rate was significantly lower and the average time of treatment was significantly shorter in the Lim/Tsai group. These results support the use of the Lim/Tsai six-strand repair technique in zone II flexor tendon injuries and early active mobilisation without rubber-band traction.

Bone morphogenetic protein as an adjuvant in the treatment of Kienbock's disease by vascular pedicle implantation.

This case report documents the first use of bone morphogenetic protein (BMP) as an adjuvant to revascularisation with a first dorsal metacarpal arterio-venous pedicle in the treatment of a patient with Stage III Kienbock's disease. The patient had complete relief of her symptoms of wrist pain by 8 months postoperatively, when X-rays showed no further evidence of lunate collapse and an MRI scan demonstrated islands of revascularisation. It is impossible to prove unequivocably that BMP contributed to the result seen in this one patient, but this adjuvant concept is based on experimental evidence demonstrating that optimal bioengineering of vascularised bone is dependent on four factors - a structural matrix, progenitor cells, BMP and a vascular supply, and BMP may play a future role in promoting new bone formation in Kienbock's disease.

[Revision surgery after carpal tunnel release using a posterior interosseous artery island flap]. / Revisionschirurgie des karpaltunnelsyndroms - ergebnisse der behandlung mit der dorsalen vorderarmlappenplastik.

PURPOSE: The aim of this study is to evaluate the results of fasciocutaneous posterior interosseous artery island flaps in the treatment of recurrent or persistent carpal tunnel compression syndrome (CTS). PATIENTS AND METHODS: From 1997 to 2006, 14 patients (8 women, 6 men, ages ranging from 26 to 77 years with a mean age of 55.7 years) have been operated for recurrent or persistent CTS, or for a neuropathic pain syndrome. All patients were treated with a posterior interosseous island flap following neurolysis of the scarred median nerve. The patients were evaluated pre- and postoperatively using a pain visual analogue scale and the DASH score. Sensibility, motor dysfunction, pain and success of the treatment were classified as good, better or bad. RESULTS: Mean follow-up of the patients was 23.8 months (1.7 to 93.5 months). The pain evaluation showed a statistically significant improvement (p < 0.005) decreasing from a mean value of 6.7 to 1.5. The DASH score was also statistically significantly improved postoperatively (p < 0.005). The best results were observed in patients without extensive preliminary median nerve damage. The duration of symptoms before re-operation did not influence the outcome. Seven patients demonstrated good, five improved and two patients maintained poor results. The two patients with poor results suffered from extremely scarred and injured median nerves following previous carpal tunnel surgery. CONCLUSION: Protective coverage of the median nerve by use of a fasciocutaneous island flap after failure of carpal tunnel release provides a good gliding tissue cover and reduces the risk of adhesions between the nerve and the surrounding tissues after previous surgery. While this protection of the nerve can reduce painful symptoms it does not guarantee total pain relief in all patients. Pain relief and functional recovery strongly depend on the preexisting condition of the median nerve.

Effects of local continuous release of brain derived neurotrophic factor (BDNF) on peripheral nerve regeneration in a rat model.

The purpose of this study was to evaluate the effect of continuously released BDNF on peripheral nerve regeneration in a rat model. Initial in vitro evaluation of calcium alginate prolonged-release-capsules (PRC) proved a consistent release of BDNF for a minimum of 8 weeks. In vivo, a worst case scenario was created by surgical removal of a 20-mm section of the sciatic nerve of the rat. Twenty-four autologous fascia tubes were filled with calcium alginate spheres and sutured to the epineurium of both nerve ends. The animals were divided into 3 groups. In group 1, the fascial tube contained plain calcium alginate spheres. In groups 2 and 3, the fascial tube contained calcium alginate spheres with BDNF alone or BDNF stabilized with bovine serum albumin, respectively. The autocannibalization of the operated extremity was clinically assessed and documented in 12 additional rats. The regeneration was evaluated histologically at 4 weeks and 10 weeks in a blinded manner. The length of nerve fibers and the numbers of axons formed in the tube was measured. Over a 10-week period, axons have grown significantly faster in groups 2 and 3 with continuously released BDNF compared to the control. The rats treated with BDNF (groups 2 and 3) demonstrated significantly less autocannibalization than the control group (group 1). These results suggest that BDNF may not only stimulate faster peripheral nerve regeneration provided there is an ideal, biodegradable continuous delivery system but that it significantly reduces the neuropathic pain in the rat model.

Healing of a critical-sized defect in the rat femur with use of a vascularized periosteal flap, a biodegradable matrix, and bone morphogenetic protein.

BACKGROUND: The purpose of this study was to evaluate the osseous healing of a critical-sized femoral defect in a rat model with use of recombinant human bone morphogenetic protein-2 (rhBMP-2), a matrix fabricated of D,D-L,L-polylactic and hyaluronan acid (OPLA-HY), and a vascularized periosteal flap. METHODS: The carrier matrix OPLA-HY with or without rhBMP-2 was implanted in a 1-cm-long femoral defect and secured with a plate and screws. In some groups, a vascularized periosteal flap was harvested from the medial surface of the tibia. In group 1, the femoral defects in the animals were filled with the OPLA-HY matrix alone; in group 2, the OPLA-HY matrix was covered by the vascularized periosteal flap; in group 3, 20 mug of rhBMP-2 was added to the OPLA-HY matrix; and in group 4, the femoral defect containing the OPLA-HY matrix and 20 mug of rhBMP-2 was wrapped circumferentially by the vascularized periosteal flap. The presence and density of new bone formation in the femoral defect were evaluated radiographically, histologically, and with histomorphometry at four and eight weeks postoperatively. RESULTS: Groups 1 and 2, which were not treated with rhBMP-2, showed no radiographic or histologic evidence of mature bone formation at four or eight weeks. Both groups 3 and 4, which were treated with rhBMP-2, demonstrated excellent bone formation. However, with the periosteal flap, group 4 demonstrated more bone formation on histomorphometric analysis at eight weeks (43.1%) than did group 3 (28.3%) (p < 0.01). Additionally, heterotopic bone formed outside the boundaries of the defect in eight of the fifteen animals in group 3, which had no periosteal flap. CONCLUSIONS: Bone-tissue engineering with use of the OPLA-HY matrix and rhBMP-2 produced good bone formation in the rat femoral defect model. However, the addition of a vascularized periosteal flap significantly increased bone formation within the boundaries of the defect and prevented heterotopic ossification.

Anatomy of the proximal cutaneous perforator vessels of the gracilis muscle.

An anatomic study was performed to analyse the proximal perforator vessels of the gracilis musculocutaneous flap. Twenty-three cadaver legs preserved by the method of Thiel were carefully dissected 24h after the proximal vascular pedicle was injected with a red silicone mass. Nine additional cadaver legs were injected with ink, to visualise the skin area supplied by the proximal perforators, respectively, clarified by a modified Spalteholz technique to demonstrate the anatomic course of the perforators. A considerable variation in numbers and localisation of proximal cutaneous perforators was found. One to four perforators were seen within an area of 6 x 6 cm(2) at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter ranged from 0.5 to 1.0 mm. The ink-injections showed an oval shaped angiosome with a mean surface of 88 cm(2) at the level of the proximal gracilis pedicle. We conclude from this anatomic study, that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by experienced hands bearing in mind the unpredictable perforator-anatomy.

The secreted brain-derived neurotrophic factor precursor pro-BDNF binds to TrkB and p75NTR but not to TrkA or TrkC.

The neurotrophin brain-derived neurotrophic factor (BDNF) binds to two cell surface receptors: TrkB receptors that promote neuronal survival and differentiation and p75NTR that induces apoptosis or survival. BDNF, as well as the other members of the neurotrophin family, is synthesized as a larger precursor, pro-BDNF, which undergoes posttranslational modifications and proteolytic processing by furin or related proteases. Both mature neurotrophins and uncleaved proneurotrophins are secreted from cells. The bioactivities of proneurotrophins could differ from those of mature, cleaved neurotrophins; therefore, we wanted to test whether pro-BDNF would differ from mature BDNF in its neurotrophin receptor binding and activation. A furin-resistant pro-BDNF, secreted from COS-7 cells, bound to TrkB-Fc and p75NTR-Fc, but not to TrkA-Fc or TrkC-Fc. Likewise, pro-BDNF elicited prototypical TrkB responses in biological assays, such as TrkB tyrosine phosphorylation, activation of ERK1/2, and neurite outgrowth. Moreover, mutation of the R103 residue of pro-BDNF abrogated its binding to TrkB-Fc but not to p75NTR-Fc. Taken together, these data indicate that pro-BDNF binds to and activates TrkB and could be involved in TrkB-mediated neurotrophic activity in vivo.

[How reliable is the posterior interosseous artery island flap? A review of 88 patients]. / Wie zuverlässig ist die distal gestielte A. interossea posterior-Lappenplastik? Eine retrospektive Analyse von 88 Patienten*

The distally-based, reverse posterior interosseous flap can be used to reconstruct soft-tissue defects in the region of the hand, provided there is an intact anastomotic network of the posterior and anterior interosseous system at the wrist. Between 1986 and 2000, 88 flap procedures were planned. Anatomical variations were recorded in 21 patients (24 %), in five of which the flap could not be harvested. In the remaining 16 patients, flap dissection was more difficult due to anatomical variations. There was a complication rate of 23 %, including haematoma, congestion, infection or technical errors, which resulted in flap necrosis of variable degrees in 11 patients (13 %). In case of haematoma, flap loss could be reduced by early revision surgery. There was no statistical correlation between anatomical variations and complications or flap loss. Secondary flap corrections, including defatting and remodelling, were commonly performed in due course. Knowing the limitations of the posterior interosseous flap, fasciocutaneous flaps are considered ideal to reconstruct soft-tissue defects or contractures of the thumb web and the dorsal hand because of good tissue matching. Fascial flaps are a good option for palmar defects or to wrap around neurolyzed nerves.