Introduction: Hand injuries continue to be a major occupational hazard and a frequently associated injury in road traffic accidents requiring flap cover for soft tissue defects. Various local flaps, regional flaps, distant flaps, and free flaps are used for covering hand defects. Posterior Interosseous Artery (PIA) Flap is a reliable regional flap for such defects. It is a reverse pedicled fasciocutaneous flap, based on the anastomosis between Posterior and Anterior Interosseous arteries near distal Radio Ulnar Joint. In our present study, we have documented a consistent branch from the ulnar artery, running around the neck of the ulna and anastomosing with the PIA which enhances flap vascularity when carefully retained. We have designed the flap based on mid-forearm perforator from PIA which avoids encountering PIN branches present proximally. The perforator is eccentrically placed in the flap design, thus allowing the proximal forearm skin to be raised in the flap without compromising the reach of the flap

Aim: To study the technical refinements in PIA flap and to recapitulate the versatility of PIA flap for various defects of distal forearm and hand.

Methodology: A prospective study was conducted over a period of 15 months to include 15 cases of distal forearm and hand defects that could be covered with PIA flap. The patients were observed for outcomes.

Results: Fifteen cases were included in this study over a span of 15 months. The average age was 41.9 years. Post-traumatic defects in the dorsum of hand, fingers, thumb, and volar aspect of the distal forearm; Post burn contractures in the palm (camphor burns), 1st web space, and thumb; and post excisional defect of tumor in hand were included. None of the flaps had any partial or total necrosis. One patient had flap edema (6.67%) and another patient had venous congestion (6.67%) of the flap which subsided by conservative management.

Conclusion: PIA is a versatile and reliable flap for the defects in the distal forearm and hand. Mid-forearm perforator can be chosen whenever feasible with appropriate flap design to avoid encountering PIN branches. Vascularity can be enhanced by maintaining the communicating vessels from the ulnar artery around the neck of the ulna.

Keywords:  dorsal interosseous artery flap, distally based island flap, distally based fasciocutaneous flap, hand reconstruction, distal forearm reconstruction, post-burns reconstruction of hand.

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Dr Jaganmohan Janardhanam

Rajiv Gandhi Government General Hospital & Madras Medical College, Chennai