J_ID: Customer A_ID: MICR30233 Cadmus Art: MICR30233 Ed. Ref. No.: MICR-17-0172.R1 Date: 8-September-17 Stage: Page: 1 Received: 17 May 2017 | Revised: 2 July 2017 | Accepted: 25 August 2017 DOI: 10.1002/micr.30233 RESEARCH ARTICLE Vascularized thumb metacarpal periosteal pedicled flap for scaphoid nonunion: An anatomical study and pediatric case report Sergi Barrera-Ochoa, MD, PhD1,2 | Gerardo Mendez-Sanchez, MD2 | € rr, MD1 | Alfonso Rodriguez-Baeza, MD, PhD3 | Jorge Kno Jayme Augusto Bertelli, MD, PhD4 | Francisco Soldado, MD, PhD1 1 Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat Purpose: Through an anatomical review, the primary aim of this study was to delineate the dorsal de Barcelona, Barcelona, Spain thumb metacarpal (TM) periosteal branches of the radial artery (RA). In addition, we report here 2 Hand and Microsurgery Unit, Hospital the clinical utility of a vascularized TM periosteal pedicled flap (VTMPF), supplied by the first dor- Universitari Quiron-Dexeus, ICATME, sal metacarpal artery (FDMA), in a complex case of scaphoid nonunion. Barcelona, Spain 3 Human Anatomy and Embryology Methods: Ten latex-colored upper limbs from fresh human cadavers were used. Branches of the Department, Faculty of Medicine, RA were dissected under 3x loupe magnification, noting the periosteal branches arising from the noma de Barcelona, Universitat Auto FDMA. The VTMPF was measured for both length (cm) and width (cm). Barcelona, Spain 4 Department of Orthopedic Surgery, Results: The FDMA provided a mean 12 periosteal branches (range 9 to 15), with a mean distance Governador Celso Ramos Hospital, between branches of 0.5 cm (range 0.2–1.1), allowing for the design of a VTMPF which measured polis, Santa Catarina; Center of Florianoo a mean 4 cm in length and 1.2 cm in width. We used a VTMPF to treat recalcitrant scaphoid non- Biological and Health Sciences, Department of Neurosurgery, University of the South of union, with a volar defect of 0.7 cm, in a 16-year-old boy. No bone graft was used. The patient Santa Catarina (Unisul), Tubar~ ao, Brazil experienced no postoperative complications. Successful consolidation was achieved three months after surgery, confirming the flap’s survival. At 14-months of postoperative follow-up, the patient’s Correspondence VAS pain rating was 0 out of 100, and his DASH questionnaire score was 5. The patient had pain- Sergi Barrera-Ochoa, Passeig Sant Joan de Deu, 2. 08950. Esplugues de Llobregat, less range that was 95% that of the contralateral limb. The patient’s pinch and grip strengths were Barcelona, Spain. 6.5 kg and 28 kg, respectively (95% of unaffected side). Email: Dr.barreraochoa@gmail.com Conclusions: VTMPF may be considered a valuable and reliable surgical option for scaphoid non- Funding information union in complex clinical scenarios. This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors. Confidentiality: The authors declare that patient confidentiality was maintained throughout the duration of this study and afterwards. Vascularized Thumb Metacarpal Periosteal Pedicled Flap for Scaphoid Nonunion: An Anatomical Study and Pediatric Case Report. 1 | INTRODUCTION To whom it may concern: we, the authors of this article, hereby state that no part of the work has either been submitted for publication or published Though most pediatric scaphoid fractures have a good prognosis with elsewhere. We also state that the content of this article has been reviewed and approved by all the authors, in full belief that it has been written conservative management (Weber, Fricker, & Ramseier, 2009), sca- honestly and without plagiarism. phoid nonunion has been reported (Ahmed, Ashton, Tay, & Porter, 62 © 2017 Microsurgery. Wiley Periodicals, Inc. 2017;1–8. wileyonlinelibrary.com/journal/micr wileyonlinelibrary.com/journal/micr V Microsurgery. C 2017 | 2019;39:62–69. Wiley Periodicals, Inc. 1 2 | BARRERA-OCHOA ET AL. BARRERA-OCHOA 63. ET AL T AB LE 1 Anatomical study of dorsal thumb metacarpal periosteal branches based on radial artery Septocutaneous Periosteal Branches Perforator Branches Muscular Branches FDMA RB of FDIA FDMA RB of FDIA FDMA RB of FDIA Number Mean 12 5 3 2 6 6 Range 9–15 4–7 2–4 1–3 5–7 5–8 Distance between Mean 0.6 0.7 1.4 2.4 0.9 0.8 branches (cm) Range 0.2–1.1 0.2–1.2 0.8–1.8 2.1–4.3 0.7–1.2 0.6–0.9 Distribution Radial Mean: 9 Mean: 3 Abductor Pollicis First Dorsal Interosseous (Number) Brevis Muscle Muscle Range: 7–12 Range: 2–4 Ulnar Mean: 3 Mean: 2 Range: 2–5 Range: 1–3 FDMA: First Dorsal Metacarpal Artery. RB of FDIA: Radial Branch of First Dorsal Intercarpal Artery. 2014; Behr et al., 2014; Elhassan & Shin, 2006; Reigstad, Thorkildsen, were dissected under 33 loupe magnification, noting the muscular, the Grimsgaard, Reigstad, & Rokkum, 2013). Since this lesion is a rarity, cutaneous and the periosteal branches arising from the radial artery to however—with a nonunion rate of just 0.8% (Elhassan & Shin, 2006)— the dorsal aspect of the thumb metacarpal (TM). Also noted were the management experience is limited and optimal treatment remains con- distance (in centimeters, cm) between the periosteal branches and the troversial (Elhassan & Shin, 2006). Available treatment options include base of TM, and the distribution of the branches (medial/lateral). The cast immobilization, bone grafting with K-wire fixation, bone grafting VTMPF was measured for length (cm) and width (cm). without osteosynthesis, headless compression screw fixation with or without bone grafting, and vascularized bone grafting (Ahmed et al., 3 | RESULTS 2014; Behr et al., 2014; Chloros et al., 2007; Elhassan & Shin, 2006; Hamdi & Khelifi, 2011; Reigstad et al., 2013; Weber et al., 2009). The anatomical findings are summarized in Table 1. The RA was T1 Vascularized periosteal flaps have gained special attention in recon- located running from volar to dorsal in the anatomical snuffbox, proxi- structive surgery, because of how effective they are at promoting healing mal to the trapeziometacarpal joint, under the insertion of the abductor when used to treat complex bone nonunion in pediatric patients, owing pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Two to their high angiogenic and osteogenic potentials (Qi et al., 2008; Sol- arteries were identified in all dissections, stemming from the radial dado et al., 2012, 2015). We anatomically studied how the radial artery artery and reaching the dorsal aspect of the TM. The first of them— (RA) vascularizes the thumb metacarpal (TM) periosteum to assess the named the first dorsal metacarpal artery (FDMA) (Bertelli et al., 2004)— potential for developing a new vascularized periosteal flap to manage emerged a mean 2 mm (range 1–3 mm) ulnar to the APL, traversing selected cases of pediatric scaphoid nonunion. We sought a technique under the APL from the ulnar to radial side at the base of the TM as it that was less technically demanding and associated with less donor-site ran along the radial aspect of the insertion of the APL tendon, over the morbidity than prior techniques. We also sought a procedure that would fascial layer of the abductor pollicis brevis (APB) muscle. The FDMA, be distinct from what has been described previously for scaphoid nonun- which averaged 1 mm in diameter at the base of the TM and a mean ion treated with vascularized TM bone flaps supplied by the FDMA, as length of 0.52 cm (range 0.44 to 0.61 cm), ran along the dorsal aspect previously described by Bertelli, Tacca, and Rost (2004). Afterwards, we of the insertion of the APL tendon. The artery then continued its used this vascularized TM periosteal pedicled flap (VTMPF) successfully course along the volar third of the dorsal side of the TM, in close con- to reconstruct recalcitrant nonunion of the scaphoid in a 16-year-old boy tact with the periosteum. The FDMA reached the radial side of the in the context of avascular necrosis of the proximal pole and nonunion metacarpal head and, at this level, anastomosed with the radial palmar that had persisted for more than four years. collateral artery of the thumb. The FDMA gave off a mean 12 perios- teal branches (range 9 to 15), with a mean distance of 0.6 cm between 2 | MATERIALS AND METHODS these branches (range 0.2 to 1.1 cm) and a mean length of 6 mm (range 4 to 8 mm). Of these periosteal branches, roughly 75% were radial, For this study, 10 upper limbs (5 right and 5 left) from fresh adult human while 25% were ulnar. Both of the more distal branches ran in a radial cadavers were used (mean age 72 years). In all specimens, we performed direction in 100% of the dissections. The FDMA primarily provided a anterograde arterial injection of colored natural latex through the brach- mean six muscular branches (range 5 to 7) to the APB muscle. There ial artery at the level of the elbow. The branches of the radial artery was a mean of three cutaneous branches (range 2 to 4). One of these BARRERA-OCHOA 64 ET AL. | BARRERA-OCHOA ET AL3. The second artery, named the radial branch (RB) of the first dorsal intermetacarpal artery (FDIA) (Bertelli et al., 2004), arose from the RA a mean 13 mm (range 11 to 16 mm) distal to the FDMA. The RB of the FDIA, which averaged 0.8 mm in diameter and a mean length of 0.41 cm (range 0.36 to 0.48 cm), traversed under the EPL at the base of the TM as it ran along the ulnar aspect of the dorsal side of the TM. The artery then continued its course along the ulnar third of the dorsal side of the TM. The RB of the FDIA reached the ulnar side of the meta- COLOR carpal head and ended as an axial vessel, which continued as the ulnar collateral dorsal artery. There were a mean five periosteal branches (range 4 to 7), with a mean distance of 0.7 cm between branches (range 0.2 to 1.1 cm) and a mean length of 5 mm (range 4 to 6 mm). Of these five, three generally were radial (60%) and two ulnar (40%). In all FIGURE 1 Dissection of the posterior compartment of thumb of the dissections, the more proximal periosteal branch had a radial metacarpal (TM). Periosteal branches originating in the radial artery direction, running over the insertion of the APL tendon until it anasto- (#) between the APL (^) and ECRL (^) muscles were found running mosed with the first dorsal metacarpal artery (FDMA)—proximally at transversely across the periosteum of the dorsal aspect of the TM the base of TM, and distally at the head of the TM to form a vascular (*). Detail of the periosteal branches arising from the FDMA (white arrow) and RB of the FDIA (black arrow) to the TM (*). (**) Second arch (Figure 1). There were a mean six muscular branches from the RB F1 metacarpal. (<>) First dorsal interosseous muscle of the FDIA (range 4 to 9) to the first dorsal interosseous muscle (range 5 to 8). In five of the dissections, cutaneous perforating branches were three arose at the level of the base of the TM (proximal or distal to the located near the head of the TM and the junction of the proximal and EPB tendon); another at the level of the middle third of the TM (2 to middle thirds of the TM. 3 cm from the metacarpophalangeal joint), and a third at the level of Each of these arteries was accompanied by a vein along its entire the distal third of the TM. course. The periosteal branches from the FDMA and the RB of the COLOR FIGURE 2 A: Before harvesting, showing the vascularized TM periosteal pedicled flap (VTMPF) (black oval) supplied by the FDMA (white arrow) and the RB of the FDIA (black arrow). B: After harvesting the VTMPF (<>) from the TM (*), it was designed to be a pedicled flap in an anterograde fashion. (#) Radial artery 4 | BARRERA-OCHOA ET AL. BARRERA-OCHOA 65. ET AL FIGURE 3 (A) Anteroposterior and (B) lateral radiographs and (C) a coronal MR image at four years of follow-up, showing recalcitrant non- union and avascular necrosis of the scaphoid FDIA anastomosed in the superficial layer of the dorsal periosteum, proximal pole (Figure 3). On a 10 cm visual analog scale (VAS), the F3 forming a vascular network. patient rated his pain as 8, and had a quick DASH (Disabilities of the The proposed periosteal graft was harvested from the complete Arm, Shoulder and Hand) score of 68. The patient’s range of movement dorsal aspect of the TM, producing a pedicle that had a minimum length included 308 and 408 of wrist flexion and extension, 20 and 108 of pro- of approximately 15 mm (range 12 to 17 mm). Alternatively, the graft nation and supination, and 108 and 58 of radial and ulnar deviation, could be harvested partially at the distal side of the thumb; in this latter respectively. Grip strength was 30% that of the opposite hand. case, the pedicle was larger, up to a length of approximately 40 mm Nonunion was exposed using a volar approach. Sclerotic bone was (range 36 to 44 mm). Before harvesting, the mean size of the flap was debrided and excised at the nonunion site. A maneuver in accordance 12 cm2 (range 10.8 to 14 cm2). The periosteal flap measured a mean with that described by Lynch and Linscheid (1997) was performed. 6 cm in length (range 5.5 to 6.4 cm) and 2 cm in width (range 1.8 to Humpback deformity was corrected, and the scapholunate angle and 2.2 cm). After harvesting, the mean two-dimensional area of the flap the scaphoid length were improved from 708 to 558 and from 20 mm F2 was 10.5 cm2 (range 8.5 to 12.6 cm2) due to elastic retraction (Figure 2). to 23 mm (1 mm of difference with contralateral scaphoid), creating a volar defect of 7 mm at the nonunion site. This bone correction was 4 | CASE REPORT stabilized with two retrograde 2 mm headless compression screws (Extremifix Cannulated Screw SystemTM, OsteoMedV C , Dallas, Texas, A 16-year-old, right-handed boy was examined after sustaining a fall USA). As no bone graft was added to the nonunion site and a volar onto his right wrist. Four years prior to presenting to us, due a scaphoid defect was created, the goal of the screw was to maintain and stabilize fracture B2 (as prescribed by Filan & Herbert, 1996), the patient had the reduction, without compression of the nonunion to not collapse or undergone fixation of the scaphoid with a retrograde headless com- flexion the scaphoid. We putted a bone spreader in the nonunion site pression screw. Three years after that first surgery, the patient under- during the insertion of the screws to avoid the flexion of the scaphoid. went corticocancellous bone grafting from the distal radius, fixed with Finally, the VTMPF was harvested through a separate incision over the two 2 mm Kirschner-wires for scaphoid nonunion D312. When the TM. Periosteal flap vascularization was from the FDMA, and was con- patient presented to us, one year after his second surgery, radiographs structed in an anterograde direction (Figure 4). F4 and magnetic resonance imaging (MRI) showed recalcitrant nonunion The harvesting technique we employed for the VTMPF adhered to D412 of the fracture localized in the middle third of the scaphoid, with most of the standard steps used to obtain a TM vascularized bone graft a scapholunate angle of 70 degrees and avascular necrosis of the (Bertelli et al., 2004). This longitudinal skin incision ran from the dorsal COLOR BARRERA-OCHOA 66 ET AL. | BARRERA-OCHOA ET AL5. FIGURE 4 Scaphoid reconstruction. (A): Volar scaphoid approach to expose bone nonunion creating a volar defect. (B): VTMPF (#) after detachment from the TM, with previous transfer to the scaphoid. (Black arrow) FDMA. (C): Correction and fixation of scaphoid nonunion with two headless compression screws, and transversal placement of the flap (#) to bridge the nonunion side of the thumb metacarpophalangeal joint to a point midway postoperatively, after which the patient underwent daily physiotherapy between the extensor pollicis longus (EPL) and EPB within the anatom- to enhance his wrist and thumb range of motion. ical snuffbox. The skin was incised and the EPB tendon sheath opened Periosteal callus ossification was initially observed four weeks after and retracted in an ulnar direction. This exposed the FDMA and the RB surgery. A nonunion junction was achieved at three months, com- of the FDIA and their branches to the TM’s periosteum. Along their pletely filling the volar defect. The patient developed volar and radial respective courses, cutaneous and muscular branches of the FDMA scaphoid exophytic ossification that did not impinge upon either the and the RB of the FDIA were ligated, and the vessels then followed radial styloid or radiocarpal joint (Figure 5). F5 into the metacarpal head. At this location, and in accordance with the Fourteen months postoperatively, the nonunion had united both measures of the slot created in the scaphoid, a rectangular periosteal clinically and radiologically. The patient’s VAS pain rating was 0, and his graft was designed that was centered on the FDMA. The lateral border quick DASH score was 5. The patient also had painless range of motion of the flap overlying the APB was then incised and the pedicle within that was 95% that of the contralateral limb. The limits of active wrist the periosteal dissected from the dorsal side of the TM, in a rectangular range of motion were 808 flexion, 708 extension, 158 radial deviation, shape, to the level of the first metacarpal neck. The periosteal flap was and 308 ulnar deviation. The patient’s pinch and grip strength were elevated from distal to proximal using a periosteal elevator. Finally, 6.5 kg and 28 kg, respectively, which equaled 95% of the strength of proximal release of the periosteum at the level of the metacarpal mid- unaffected hand. The patient had resumed all his usual daily activities. shaft was performed. The proximal vascular pedicle was then released from the base of the TM to the trapeziometacarpal joint capsule. Then 5 | DISCUSSION an intraoperative assessment to ensure the blood supply of the perios- teal flap was performed. A tunnel down to the tendons of the first dor- In this paper, we have described the anatomy of dorsal TM periosteal sal compartment was created. The VTMPF then was pushed in a branches of the RA, allowing to designed a novel pedicled periosteal palmar direction toward the scaphoid nonunion. The vascular pedicle flap, harvested from the dorsum of the TM using the first dorsal meta- lay radial, while the VTMPF was placed transversally over the nonunion carpal vessels’ axis. The VTMPF was successful at achieving bone con- and sutured to adjacent soft tissues. The vascular pedicle then was solidation in a patient with recalcitrant scaphoid nonunion. inspected to detect any kinking, compression, or tension. The capsular The vascular blood supply of the dorsal side of the thumb was flaps were approximated loosely and the subcutaneous layer and skin constant in all our dissections, in agreement with previous anatomic sutured. The length and width of the flap before detachment were studies (Bertelli, Pagliei, & Lassau, 1992; Brunelli, Brunelli, & Nanfito, 2.5 cm and 1.8 cm, respectively, and 2 cm and 1.4 cm after harvesting. 1991; Pistre, Pelissier, Martin, & Baudet, 2001). However, limited infor- A below the elbow plaster cast was applied, but removed three weeks mation exists regarding the dorsal TM periosteal branches. The FDMA 6 | BARRERA-OCHOA ET AL. BARRERA-OCHOA 67. ET AL FIGURE 5 Radiographic evolution after the VTMPF. (A) Anteroposterior, (B) contralateral wrist and (C) lateral radiographs; and (D) coronal and (E) sagittal computed tomography (CT) images at at 6-months of follow-up, revealing a nonunion junction and volar and radial scaphoid exophytic ossification (white arrows) axis has been described as a means by which to obtain TM bone flaps and around the wrist, is their fragility and susceptibility to trauma during (Bertelli et al., 1992; Brunelli et al., 1991; Pistre et al., 2001). Our pro- tailoring and manipulation (Steinmann & Bishop, 2001; Straw, Davis, & cedure is similar to what has been described previously for adult Dias, 2002). However, this may be avoided because the VTMPF allows patients in whom scaphoid nonunion was treated with vascularized TM for the inclusion of a different vascular axis (FDMA and RB of the bone flaps supplied by the FDMA (Bertelli et al., 1992; Yuceturk, Isiklar, FDIA), increasing the reliability of the periosteal flap. Furthermore, Tuncay, & Tandogan, 1997). Our technique might be considered a because of its versatility, the VTMPF can be transferred in either a pal- modification of the previous one that has been adapted for the pediat- mar or dorsal direction, whichever is required by the surgeon (Bertelli ric population, focusing solely on periosteum rather than bone. The et al., 2004). In addition, according to results reported previously (Pistre rationale for this change is that a vascularized periosteal flap yields et al., 2001), with regard to the number and distribution of cutaneous faster consolidation than a vascularized bone flap (Yuceturk et al., branches arising from the FMDA, a composite periosteocutaneous flap 1997). This can be explained by the abundance of osteogenic stem could be used in the same way. The skin paddle should be located cells located within the cambium layer (Finley, Wood, & Acland, 1979; either on the proximal or the distal part of the TM, because cutaneous Soldado et al., 2012a,b). The cambium layer, in intimate contact with branches are present at this level. Finally, as with any FDMA axis flap both the nonunion focus and the poorly-vascularized surrounding tis- (Bertelli et al., 2004; Yuceturk et al., 1997), the VTMPF can be raised in sues, may induce healing more efficiently than a vascularized bone either an anterograde or retrograde fashion (Pistre et al., 2001). graft (Soldado et al., 2012c,2015,2017). Using a FDMA pedicle graft requires separate incisions to accom- Contrary to Bertelli et al. (1992) and Pistre et al. (2001) who plish periosteal harvesting and scaphoid treating. This is inconvenient, reported that small osteoperiosteal branches of the FDMA were pres- relative to a 1,2 intercompartmental supraretinacular artery pedicle ent only at the levels of the proximal and distal thirds of the TM, we graft (Straw et al., 2002), but is of great advantage in multi-surgery found a vascular network formed between the periosteal branches cases like the one reported here. Like our own patient, none of the from the FDTA and the RB of the FDIA, which supplied the complete patients in the Bertelli et al.series expressed any donor site complaints dorsal aspect of the TM. This finding increases the versatility of the (Bertelli et al., 2004). VTMPF, as it facilitates custom sizing and location harvesting. Another Several vascularized periosteal graft techniques have been important consideration concerning vascularized bone grafts raised in reported recently as reliable techniques to enhance bone union in BARRERA-OCHOA 68 ET AL. BARRERA-OCHOA ET AL7.| particularly-unfavorable scenarios in children (Diaz-Gallardo et al., distal radius growth plate was adjacent. We also disregarded the option 2017; Finley et al., 1979; Qi et al., 2008; Soldado et al., 2012a,b, of a vascularized bone graft pedicled on the transverse volar carpal artery, c2012c,2015,2017), with excellent results treating bone nonunion because the patient had previously had an autograft, with the volar (Diaz-Gallardo et al., 2017; Finley et al., 1979; Qi et al., 2008; Soldado aspect of the distal radius used as the donor site. et al., 2012a,b,c,2015,2017; Yuceturk et al., 1997). Vascularized perios- Regardless of the limitations inherent in a single case report, we teal grafts are easy and quick to harvest at this young age, and the feel that the technique we have just described can be used success- flap’s elasticity permits it to readily conform to the recipient’s bed con- fully to manage selected cases of scaphoid nonunion with a bone figuration (Finley et al., 1979; Soldado et al., 2012a,b,2017). Previous gap. The VTMPF we have described is an attractive alternative to vascularized periosteal grafts reported for the treatment of recalcitrant conventional nonvascularized and free vascularized bone/periosteal nonunion did not require nonunion-focused bone grafting, as was true grafting procedures to treat this difficult condition in children and in our case (Finley et al., 1979; Qi et al., 2008; Soldado et al., 2012a, adolescents. b2012b,2015,2017). With stable internal screw fixation, scaphoid waist nonunion with collapse and bone loss can be treated successfully using only a cancellous bone graft (Cohen, Jupiter, Fallahi, & Shukla, 2013). C ONFLICT OF INT E RE ST One potential disadvantage of a VTMPF without a corticocancellous Neither the authors, their immediate family, nor any research foun- bone graft for scaphoid nonunion might be the risk of scaphoid col- dation with which they are affiliated have received any financial lapse. To decrease this risk and provide superior biomechanical stability payments or other benefits from any commercial entity related to of the construct, we performed the fixation with two headless com- the subject of this article. pression screws (Garcia, Leversedge, Aldridge, Richard, & Ruch, 2014). This rigid fixation allowed the patient to initiate rehabilitation after only three weeks of immobilization, so that the patient attained 90% of OR CID the contralateral wrist’s range of movement within two months of sur- Sergi Barrera-Ochoa MD, PhD http://orcid.org/0000-0001-6820- gery. Advantages include the marked simplification of surgical carpen- 3494 try and the rapid periosteal callus than can fill the bone gap that Jayme Augusto Bertelli MD, PhD http://orcid.org/0000-0002-9890- eventually evolves into a cortical union without compromising scaphoid 5080 reduction or carpal alignment. Francisco Soldado MD, PhD http://orcid.org/0000-0003-1759-9868 We disregarded nonbiological surgical techniques (Reigstad et al., 2013) and opted for a vascularized procedure, owing to our patient’s R EF ER E NCE S grave clinical scenario (nonunion D412), which was characterized by Ahmed, I., Ashton, F., Tay, W. K., & Porter, D. (2014). The pediatric frac- both avascular necrosis of the proximal pole and nonunion that had ture of the scaphoid in patients aged 13 years and under: An epide- persisted beyond four years, both significant predictors of a poor func- miological study. Journal of Pediatric Orthopaedics, 34, 150–154. tional outcome (Bae, Gholson, Zurakowski, & Waters, 2016; Moon, Dy, Bae, D. S., Gholson, J. J., Zurakowski, D., & Waters, P. M. (2016). Func- Derman, Vance, & Carlson, 2013. This condition required both angio- tional outcomes after treatment of scaphoid fractures in children and adolescents. Journal of Pediatric Orthopaedics, 36, 13–18. genic and vascular resources (Bae et al., 2016; Moon et al., 2013; Suna- Behr, B., Heffinger, C., Hirche, C., Daigeler, A., Lehnhardt, M., & Bickert, gawa, Bishop, & Muramatsu, 2000). B. (2014). Scaphoid nonunions in skeletally immature adolescents. Alternative biological procedures might include a free vascularized Journal of Hand Surgery (European Volume), 39, 662–665. € rger, Windhofer, Gaggl, & Higgins, 2013). periosteal or bone graft (Bu Bertelli, J. A., Pagliei, A., & Lassau, J. -P. (1992). Role of the first dorsal However, a local pedicled vascularized periosteal flap offers several metacarpal artery in the construction of pedicled bone grafts. Surgical advantages over a free flap for complex scaphoid nonunion. These and Radiologic Anatomy, 14, 275–277. advantages include less donor-site morbidity; an operative field that is Bertelli, J. A., Tacca, C. P., & Rost, J. R. (2004). Thumb metacarpal vascu- limited to one upper extremity; there being no need to sacrifice either of larized bone graft in long-standing scaphoid nonunion–a useful graft via dorsal or palmar approach: A cohort study of 24 patients. Journal the main vascular axes (Bertelli et al., 2004; Brunelli et al., 1991; Pistre of Hand Surgery American Volume, 29, 1089–1097. et al., 2001; Straw et al., 2002; Steinmann & Bishop, 2001; Yuceturk Brunelli, F., Brunelli, G., & Nanfito, F. (1991). An anatomical study of the et al., 1997); and, finally, being a technically less demanding and shorter vascularization of the first dorsal interosseous space of the hand, and procedure. Other local reconstructive options include a pedicled dorsal description of a bony pedicle graft arising from the second metacar- distal radius bone graft supplied by the dorsal vasculature of the wrist, pal bone. 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How to cite this article: Barrera-Ochoa S, Mendez-Sanchez G, Reigstad, O., Thorkildsen, R., Grimsgaard, C., Reigstad, A., & Rokkum, M. €rr J, Bertelli JA, Soldado F. Vascularized Rodriguez-Baeza A, Kno (2013). Excellent results after bone grafting and K-wire fixation for thumb metacarpal periosteal pedicled flap for scaphoid nonun- scaphoid nonunion surgery in skeletally immature patients: A mid- An anatomical ion: An anatomicalstudy studyand and pediatric pediatric case case report. report. Microsur- Microsurgery. term follow-up study of 11 adolescents after 6.9 years. Journal of Orthopaedic Trauma, 27, 285–289. gery. 2019;39:62–69. 2017;00:000–000. https://doi.org/10.1002/micr.30233 https://doi.org/10.1002/micr.30233