1. Open Fractures of the Hand with Soft Tissue Loss
David Ruta, MD, Kagan Ozer, MD 
Hand Clinics 
Volume 29, Issue 4, Pages (November 2013)
DOI: /j.hcl
Copyright © 2013 Elsevier Inc. Terms and Conditions

2. Fig. 1
A 35-year-old patient presented to an outside hospital with a gunshot injury to his left long finger sustaining an open comminuted fracture of the proximal phalanx with bone and soft tissue loss along with laceration of flexor digitorum superficialis and common extensor tendon. He was transferred to our facility following an initial irrigation and temporary K-wire fixation.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

3. Fig. 2
The patient underwent single-stage bone (iliac crest) and soft tissue reconstruction using second dorsal intermetacarpal artery flap. We routinely use Doppler ultrasound to locate the perforator. This flap can be extended more proximally to the dorsal aspect of the wrist joint based on the same pedicle.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

4. Fig. 3
Nine months after his initial surgery, he underwent hardware removal and a tenolysis procedure. These photographs show his final follow-up at 18 months.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

5. Fig. 4
A 29-year-old patient presented with a gunshot injury sustaining open fracture/dislocations of the third and fourth carpometacarpal (CMC) joints with a dorsal soft tissue defect. Bone loss included the base of the third metacarpal and capitellum.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

6. Fig. 5
Following extensive irrigation and debridement, the patient underwent primary bone and soft tissue reconstruction in a single stage. The iliac crest corticocancellous bone graft measuring 1.5 × 3 cm, placed at the CMC joints of the third and fourth digits, can be seen in the left lower corner (arrow). Coverage was performed with an ulnar artery perforator flap harvested along the ulnar border of the forearm and rotated 120°. Common extensor tendons of the third and fourth digits were then repaired.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

7. Fig. 6
The patient shows near-complete range of motion and incorporation of the bone graft 6 months after the surgery. Further remodeling and flattening of the flap is expected up to 12 months after the surgery.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

8. Fig. 7
A 65-year-old gun safety instructor accidentally shot himself, sustaining open fractures of the third and fourth metacarpals with bone and soft tissue loss. Following extensive irrigation and debridement, he underwent iliac crest corticocancellous bone grafting and soft tissue coverage with posterior interosseous flap. Doppler ultrasound is routinely used to locate the perforator, usually at the floor of the fifth dorsal compartment, as marked in the upper left picture.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions

9. Fig. 8
Radiographs show complete healing of the bone graft 3 months after the injury. Plate-screw fixation was placed across the CMC joints of the third and fourth digits on the hamate and capitate, which did not result in any motion limitation at the wrist.
Hand Clinics  , DOI: ( /j.hcl )
Copyright © 2013 Elsevier Inc. Terms and Conditions