(A) Descending lateral femoral circumflex
(B) Genicular
(C) Profunda femoris
(D) Superficial femoral

Reproduced with permission of Moore KL, Dalley AF, eds. Clinically Oriented Anatomy. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:574.

The correct response is Option B.

The saphenous artery supplies vascularity to the saphenous flap, a fasciocutaneous flap that provides only limited coverage of small defects in the region of the knee. The saphenous artery is a branch of the descending genicular artery. The genicular artery arises from the superficial femoral artery.

The descending branch of the lateral femoral circumflex artery arises from the profunda femoris and continues distally in the leg as the superior lateral genicular artery. The profunda femoris artery gives off its major branches more proximally in the leg. The superficial femoral artery becomes the popliteal artery at the popliteal fossa.

References
1. Koshima I, Endou T, Soeda S, et al. The free or pedicled saphenous flap. Ann Plast Surg. 1988;21:369.
2. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. Saint Louis, Mo: Quality Medical Publishing, Inc; 1997:1247.
3. Moore KL, Dalley AF, eds. Clinically Oriented Anatomy. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:574.

Which of the following vascular structures supply the secondary vascular pedicle of the gracilis muscle flap?

(A) Lateral femoral circumflex artery and vein
(B) Medial femoral circumflex artery and vein
(C) Obturator artery and vein
(D) Profunda femoris artery and vein
(E) Superficial femoral artery and vein

The correct response is Option E.

The gracilis flap is a type II muscle flap (one dominant pedicle and one secondary pedicle) that is used for pedicled and free tissue reconstructive procedures. This flap is comprised of one primary vascular pedicle, which is supplied by the profunda femoris artery via the ascending branch of the medial femoral circumflex artery and vein, and one secondary vascular pedicle, which is supplied by the superficial femoral artery and vein.
The lateral femoral circumflex artery and vein supply the rectus femoris and vastus lateralis muscle flaps.

The obturator artery is a branch of the internal iliac artery and divides further to give off vascular branches, primarily in the thigh.

References
1. Mathes SJ. Muscle flaps and their blood supply. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:61-72.
2. Mathes SJ, Nahai F, eds. Reconstructive Surgery: Principles, Anatomy, and Technique. Saint Louis, Mo: Quality Medical Publishing, Inc; 1997:1173.

A 28-year-old man has a markedly diminished dorsalis pedis pulse on the right after being stabbed with an ice pick in the right lower leg. In this patient, the most likely finding on physical examination is numbness at which of the following sites?

(A) Dorsal foot
(B) First web space
(C) Lateral foot
(D) Medial foot
(E) Plantar foot

The correct response is Option B.

This 28-year-old man has a markedly diminished dorsalis pedis pulse after sustaining a laceration of the anterior tibial artery when he was stabbed in the leg. Therefore, he is most likely to have numbness of the first web space of the foot on physical examination. The first web space is innervated by the deep peroneal nerve; this nerve courses within the anterior compartment of the leg with the anterior tibial artery, which becomes the dorsalis pedis artery in the foot.

The dorsal aspect of the foot (with the exception of the first web space) is innervated by the superficial peroneal nerve. The lateral foot is innervated by the sural nerve, and the medial foot is innervated by the saphenous nerve. None of these nerves travels with an artery.

The plantar surface of the foot is innervated by the tibial nerve, which courses within the deep posterior compartment of the leg with the posterior tibial artery.

References
1. Kline DG, Hudson AR, Kim DH, eds. Atlas of Peripheral Nerve Surgery. Philadelphia, Pa: WB Saunders Co; 2001:135-144, 145-150.
2. Netter F, ed. Atlas of Human Anatomy. Summit, NJ: CIBA-Geigy Corp.; 1989: 491, 506, 508, 510.

Which of the following is the most common primary arterial blood supply to the great toe flap used in toe-to-thumb transfer?

(A) First dorsal metatarsal artery from the communicating branch between the dorsalis pedis and plantar arteries
(B) First dorsal metatarsal artery from the dorsalis pedis artery
(C) First dorsal metatarsal artery from the plantar arch
(D) Second dorsal metatarsal artery from the dorsalis pedis artery
(E) Second dorsal metatarsal artery from the plantar arch

The correct response is Option B.

The first dorsal metatarsal artery (FDMA), arising from the dorsalis pedis artery, is the most common primary arterial blood supply to the great toe flap, which is used in toe-to-thumb transfer. Although the vascular anatomy that supplies the great toe flap is somewhat variable, the FDMA typically arises from the dorsalis pedis artery and travels in a relatively dorsal plane. It may travel dorsal or plantar to the interosseous muscle or through the muscle itself.

The FDMA is less likely to arise from the communicating branch between the dorsalis pedis and plantar arteries or from the plantar arch.

The second dorsal metatarsal artery does not contribute to the great toe flap.

References
1. Gordon L. Toe-to-thumb transplantation. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone, Inc; 1999;2:1299-1326.
2. May JW Jr, Savage RC. Micro neurovascular free transfer of the big toe. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia of Flaps. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998:1013-1018.

A 77-year-old man has a 4 ( 3-cm defect of skin and soft tissue over the distal third of the tibia after he had a stroke and fell. He has a history of myocardial infarction and chronic obstructive pulmonary disease. Physical examination of the lower leg shows exposed bone and desiccated periosteum; there is no fracture.

Which of the following is most appropriate for reconstruction of the defect?

(A) Full-thickness skin graft
(B) Cross-leg flap
(C) Fasciocutaneous flap
(D) Gastrocnemius flap
(E) Free tissue transfer

The correct response is Option C.

The most appropriate management is coverage of the defect with a fasciocutaneous flap. This flap is ideal for reconstruction of lower extremity wounds in patients with severe illness or multiple trauma, or in patients with small wounds that cannot be covered with a skin graft alone. The fasciocutaneous flap can be based either proximally or distally on various septocutaneous perforators, including those of the medial leg (which lie approximately 3 cm posterior to the tibia), the posterolateral septum, and the anterolateral leg.

Skin grafting should not be performed over bone that is exposed and lacks periosteum. Some surgeons have recently described a technique for grafting over exposed bone, in which holes are drilled into the bone to allow for granulation and grafting is then performed. However, this process is not the best option in an elderly patient with multiple medical problems.

The gastrocnemius flap is appropriate for defects of the upper and sometimes middle third of the leg, but lacks the adequate reach for defects of the distal leg.

Cross-leg flaps are rarely used now because of the availability of free tissue transfer. This flap is more appropriate in children than elderly patients, in whom stiffness is a factor.

Free tissue transfer is not an option in a patient who has had serious medical conditions, including stroke, myocardial infarction, and pulmonary disease.

References
1. Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg. 1991;18:571-582.
2. Sherman R, Law M. Lower extremity reconstruction. In: Achauer BM, Eriksson E, Guyuron B, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Saint Louis, Mo: Mosby - Year Book, Inc; 2000;1:475-496.

A 50-year-old man has noninfected wound dehiscence with exposure of the hardware two weeks after undergoing open reduction and internal fixation of an ankle fracture. A photograph and radiograph are shown above. Following debridement of the wound, which of the following is the most appropriate management?

(A) Skin grafting
(B) Coverage with a free flap
(C) Application of an external fixator and skin grafting
(D) Removal of the hardware and skin grafting
(E) Removal of the hardware and coverage with a free flap

The correct response is Option B.

This patient has early wound dehiscence after undergoing open reduction and internal fixation of a lateral malleolus fracture. Appropriate management involves early coverage of the exposed bone and hardware to promote bony union while preventing bacterial colonization of the hardware, which may lead to the development of osteomyelitis. Because this patient underwent open reduction and internal fixation only two weeks ago, fixation is still required to maintain rigid fracture stabilization. Instead, coverage with a free flap is recommended to provide stability and vascularity and to enhance function once bony union is obtained.

Skin grafting will not provide stable, well vascularized coverage in this patient. External fixation is problematic because of the location of the fracture. Removal of the hardware two weeks after fracture is indicated only for established hardware failure.

References
1. Attinger C, Cooper P. Soft tissue reconstruction for calcaneal fractures or osteomyelitis. Ortho Clin North Am. 2001;32:135-170.
2. Sherman R, Law M. Lower extremity reconstruction. In: Achauer BM, et al, eds. Plastic Surgery: Indications, Operations and Outcomes. Saint Louis, Mo: Mosby Year-Book, Inc; 2000:475-496.