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These methods require microsurgical technique and include the wraparound 268 Go´mez-Cıa´ and Ortega-Martınez´ flap cheap 100pills aspirin otc diagnostic pain treatment center tomball texas, the great toe pulpfree flap aspirin 100 pills on line hip pain treatment without surgery, the sensate medial plantar free flap, and the free palmaris brevis musculocutaneous flap, among others. To provide coverage for injuries to the palmar surface of the proximal phalanges, we use tissues that provide stability. When possible, while performing reconstruction, we preserve functional units and keep in mind the main arterial supplies of each digit (the collateral cubital artery for the first three digits, and the radial for the fourth and fifth). For deep burns that are small, the advancement–rotation quadrangular flap may be used. For larger burns of the long digits, the injury can be covered with a laterodig- ital island flap or with a cross-finger flap. For coverage of the proximal phalanx of the thumb, the flap of choice is the first dorsal metacarpal artery island flap (Fig. It is also possible to use the second dorsal metacarpal artery island flap or a pulp finger heterodigital island flap, usually from the fourth finger, when the two previous ones are not available. For injuries of the dorsal surface of the digits of limited size, we can use the advancement–rotation quadrangular flap or the bipedicle strap flap (lon- gitudinal or transverse). If the injury is distal to the proximal interphalangeal (PIP) joint, we can also use the adipofascial turnover flap [35a]. When we do not have healthy tissue located proximally on the same digit to cut this flap, we must use skin from the dorsal surface of an adjacent digit by means of a heterodigi- FIGURE 3 The Hand 269 tal reverse-flow neurovascular island flap, a so-called boomerang flap, or a de- epithelialized cross-finger flap. For injuries distal to the PIP joint, the available options are the reverse dorsal digital flap [36,37] and the de-epithelialized cross-finger flap. If the injury is very large, we must mobilize healthy tissue from the skin on the dorsal surface of the hand. The existence of communicating arteries between the palmar and dorsal vascular systems of the hand at the level of the commissures or near the ends of the metacarpal bones allows us to cut reverse-flow flaps in the dorsum of the hand and cover cutaneous injuries of the dorsal surface of the digits. These are the commisural perforators flap and the dorsal metacarpal reverse-flow flaps. These flaps are indicated for proximal injuries since their coverage area does not reach beyond the PIP joint. For injuries distal to the PIP joint that cannot be covered with an adipofascial turnover flap due to the size of the injury, we can use the dorsal digitometacarpal flap, based on the proximal dorsal cutaneous branches of the digital collateral arteries through the anastomotic arte- rial network of the webspace. For large injuries covering nearly the entire dorsal surface of a digit, we can use a U-I flap. This flap uses skin from the dorsal surface of the hand and is based on the existing communicating branches between the second dorsal intermetacarpal artery and the palmar system. Its vascular axis is the second dorsal intermetacarpal artery, the dorsal arch of the carpus, the dorsal branch of the radial artery, and the first dorsal intermetacarpal artery. To cover injuries on the dorsal surface of the thumb, we use the first dorsal metacarpal artery island flap, although we can also use the second dorsal metacar- pal artery island flap when the second digit is also burned. The lack of mobility allowed by the skin of the palm of the hand makes it impossible to cut local flaps from this area. This changes in the case of the dorsal surface of the hand due to the elasticity of the skin in this area. Random flaps, such as the rotation flap, the bipedicle flap, or the rhomboidal flap, can be used to close small and moderately sized injuries. If none of these flaps will work for the injury being treated, we use an axial flap. The most frequently used in this area are those based on anastomoses be- tween the dorsal and palmar intermetacarpal systems [38,39], the commisural perforator flap and the dorsal metacarpal flaps, and the first dorsal metacarpal artery island flap. For more extensive full-thickness burns where a cutaneous graft is not indicated, we use distant flaps. Burns occasionally cause so much tissue destruction that burn coverage using local flaps is not a viable option. The groin flap, as described by McGregor and Jackson in 1972, based on the pedicle of the superficial circumflex iliac artery, has frequently been used to treat soft tissue injuries of the dorsum of the hand and digits. Syndactylization usually results, which necessitates a subsequent surgical procedure to separate 270 Go´mez-Cıa´ and Ortega-Martınez´ the reconstructed digits. The lateral thoracic wall, and even the contralateral arm, have also been used as donor areas for this type of flap. The need to wait at least 3 weeks until the second surgery and the separation of the flap from its donor tissue make it very difficult to care for the burned limbs and prevent proper mobilization therapy and splinting.

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Lateral x-ray of the left knee of a 15-year old girl with a non-ossifying bone fibroma discount aspirin 100pills otc pain medication for dogs with arthritis. The clear demarcation with marginal scle- the metaphyses buy 100pills aspirin amex pain spine treatment center, the chondroblastoma is primarily always rosis and the lobular structure are typical observed in the epiphyseal area. AP x-ray (a) and sagittal MRI (b) of the left knee of a 15-year old girl with chondroblastoma in the lateral femo- ral condyle. Such a finding should not be confused with a case of osteochondrosis a b dissecans ( Chapter 3. AP and lateral x-rays (a) of the left knee of a 16-year ary aneurysmal bone cyst. By comparison with adults, the giant cell tumors and enchondromas in particular are underrepresented in 3 children and adolescents (⊡ Table 3. In contrast with the situation for the proximal femur, solitary bone cysts hardly ever affect this area. In general, the ratio of benign to ma- lignant tumors in the statistical data for our register tends to favor the malignant type, since many benign tumors neither need to be biopsied nor treated and therefore do not appear in the statistics. Proximal tibia and fibula For the most part, the same tumors form on the proximal lower leg as on the distal femur (⊡ Table 3. They can almost always be diagnosed reliably on the basis of a plain x-ray. Non-ossifying bone fibromas are even more frequently encountered in the proximal tibial metaphysis ⊡ Fig. AP and lateral x-rays of the left knee of a 11-year old girl than in the distal femur. Giant cell tumors and fibrous with an aneurysmal bone cyst in the tibial shaft dysplasia are also slightly more common here. This is a particularly typical site for the rare chondromyxoid fibroma. On the other hand, giant cell tumors are rare compared to their frequency of occurrence in adults [24, 29]; this also applies to the enchondroma. Here, too, many more benign tumors occur in this part of the body, in absolute terms, than would be suggested by the statisti- cal records. Tibial shaft Tumors in the tibial shaft are fairly rare (as generally applies for diaphyses). In addition to osteoid osteomas, enchondromas, aneurysmal bone cysts (⊡ Fig. A condition that particularly affects the tibial shaft is osteofibrous dyspla- sia according to Campanacci (⊡ Fig. AP and lateral x-rays of the left knee of a 7-year old girl shaft area [5, 32, 42] ( Chapter 4. This condition with an osteofibrous dysplasia (Campanacci) of the proximal tibia can sometimes be confused with the malignant adaman- tinoma, which also occurs almost exclusively at this site ( Chapter 4. Malignant tumors Patella Distal end of the femur Tumors on the patella are very rare. We have only encoun- The distal femoral metaphysis is the classical site of the tered 11 cases. The literature primarily primary bone tumor can also occur here, they are fairly describes chondroblastomas and giant cell tumors, while rare in children and adolescents. AP x-ray and MRI (a) of a 16-year old girl with an osteosarcoma in the area of the distal femoral metaphysis. The knee is the second most frequent site Tumors that are particularly common in adults include for the latter condition after the finger joints. Although parosteal or periosteal osteosarcoma (in contrast with these involve benign changes they can cause major treat- the classical high-grade osteosarcoma, these are weak- ment problems. Popliteal cysts are very typical and com- ly malignant tumors), chondrosarcoma and malignant mon tumor-like lesions in children. Popliteal The distribution of malignant tumors in the proximal cysts should not be confused with Baker cysts, which lower leg is also similar to that in the distal femur.

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