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  • A thorough appreciation of anatomy is a prerequisite prior to engaging in any surgery on the hand and foot.

  • Functional considerations play an important role in closure design.

  • Closure options run the gamut from secondary intention healing to cross-finger flaps.

image Beginner Tips

  • Assess laxity and tension by having the patient make a fist and move through a range of motion.

  • The atrophic dermis on the dorsal hand lends itself to percutaneous suturing techniques.

  • Residual edema is possible, particularly if lymphatics are severed.

image Expert Tips

  • Random pattern flaps are most useful on the proximal hand and fingers.

  • Fasciocutaneous flaps such as the keystone flap may help preserve vascular supply, but require a high level of knowledge and comfort with local anatomy to be properly freed and undermined.

image Don’t Forget!

  • Nerve blocks are very useful on the hand and foot, as minimizing local anesthetic infiltration may reduce background edema and mitigate against anatomic distortion.

  • Do not aggressively undermine fasciocutaneous flaps, as this may lead to impaired blood supply.

image Pitfalls and Cautions

  • Both motor and sensory nerve damage may occur with large hand and foot repairs.

  • Grafts should be adequately immobilized to maximize their chance of survival.

image Patient Education Points

  • Minimizing tension across a healing surgical site is critical; splints may help not simply by immobilizing the relevant anatomy, but by reminding the patient of the need to minimize activity. Assess patient compliance and motivation before considering a two-stage flap.

  • For foot reconstruction, the legs should be elevated as much as possible in the postoperative period.

image Billing Pearls

  • Fasciocutaneous flaps should be coded using the adjacent tissue transfer codes (14040–14041).

  • A cross-finger flap is coded as 15574, and division is coded as 15620.

  • When repairing a fingertip defect with a cross-finger flap, both flap and graft CPT codes may be used.


The hand represents a unique challenge for any surgeon, with numerous important vascular, neurologic, and cutaneous structures residing within close proximity. Reconstruction of this area is predicated on a thorough appreciation of local anatomy, as well as an established comfort level with local anesthesia and nerve blocks.


The use of appropriate nomenclature facilitates communication between clinicians. Anterior and posterior surfaces are described as palmar and dorsal, respectively. For laterality, radial and ulnar are preferred over medial and lateral. The fingers are numbered from radial to ulnar, but common names are favored. Each phalanx is numbered from distal to proximal in numerical order. The osseous structure of the hand consists of 8 carpal bones, 5 metacarpals, and 14 phalanges.

Vascular anatomy

The vascular supply to the hand comes from the radial and ulnar arteries. The radial artery enters ...

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