The recovery of sensation and function after cross-finger flaps for fingertip injury

Topographical Analysis of Pacinian Corpuscle in the Pulp of Human Cadaver Finger Tip Pulp: A Pilot Cadaver Study

Background: The human hand is a specialised organ for fine motion and sensation and has a relatively large representation in the homunculus. The pathway of sensation starts from information sent by mechanoreceptors in the hand. This study reports the topography of the Pacinian corpuscle in the fingertips of a human cadaver. Methods: All 10 digits from both hands of a fresh-frozen cadaver were examined. Glabrous skin distal to the distal interphalangeal joint was harvested superficial to the periosteum including fat and subcutaneous tissue. The glabrous skin were divided into 10 sections that included five distal and five proximal sections. Modified gold chloride staining was performed. Sectioned specimens were observed under a light microscope and the density of Pacinian corpuscles was determined in each segment. The density of the corpuscles was compared between the radial/ulnar and proximal/distal segments and also between digits from the right hand versus those from the left hand. Results: Pacinian corpuscles were observed only in the subcutaneous tissue. There was no significant difference in density of the corpuscles between the distal and proximal segments or between the right and left hands. There was a statistically significant greater density of Pacinian corpuscles on the radial segments of all digits except the thumb. Conclusions: There is a greater density of Pacinian corpuscles on the radial side of the human fingertip in all digits except the thumb.

Donor Finger Morbidity in Cross-Finger Flap: A Systematic Review and Meta-Analysis

Background The morbidity of donor finger in a cross-finger flap has not received as much importance as the outcomes of the flap itself. The sensory, functional, and aesthetic morbidity of donor fingers, reported by various authors, are often contradictory to each other. In this study, objective parameters for the sensory recovery, stiffness, cold intolerance, cosmetic outcome, and other complications in the donor fingers, reported in the previous studies, are systematically evaluated.

Methods This systematic review is reported using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol and was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42020213721). Literature search was done using “cross-finger,” “heterodigital,” “donor finger,” and “transdigital” words. Data regarding demography, patients' number and age, follow-up duration and outcomes of donor finger, including 2-point discrimination, range of motion (ROM), cold intolerance, questionnaires, etc. were extracted from included studies. Meta-analysis was performed using MetaXL and risk of bias was evaluated using Cochrane risk of bias tool.

Results Out of the total 16 included studies, 279 patients were objectively evaluated for donor finger morbidity. Middle finger was most frequently used as donor. Static two-point discrimination seemed to be impaired in donor finger in comparison to contralateral finger. Meta-analysis of ROM suggested that statistically there is no significant difference in ROM of interphalangeal joints in donor and control fingers (pooled weighted mean difference: −12.10; 95% confidence interval: −28.59, 4.39; I2 = 81%, n = 6 studies). One-third of donor fingers had cold intolerance.

Conclusion There is no significant effect on ROM of donor finger. However, the impairment that seems to be in sensory recovery and aesthetic outcomes needs to be further evaluated objectively.

A Systematic Review of the Sensory Outcomes of a Standard Cross-Finger Flap Reconstruction for Fingertip Defects

Background: The standard (dorsal) cross-finger flap (CFF) is one of the common flaps used for fingertip reconstruction. There is little consensus regarding the sensory outcomes associated with this flap. In this systematic review, we evaluated objective sensory outcome parameters of patients who underwent CFF reconstruction. Methods: This systematic review is reported using the PRISMA protocol and was registered with the International Prospective Register of Systematic Reviews. Literature search was done using the terms 'cross-finger flap', 'heterodigital', 'finger-tip' and 'transdigital'. Data regarding the number of patients, follow-up duration and sensory outcomes, including 2-point discrimination (2-PD) were extracted from included studies. The analysis was performed using Microsoft Excel with MetaXL add-in software. Certainty assessment and summary of findings table was created using GRADEpro GDT. Results: This review includes 14 studies with 301 patients. We found a statistically significant difference in static 2-PD of recipient and control fingers (pooled weighted mean difference [WMD]: 1.66; 95%CI: 0.03, 3.29; p = 0.00; I²=92%, n = 7 studies). Conclusions: Dorsal CFF reconstruction for fingertip defect does not provide adequate sensory recovery. Level of Evidence: Level III (Therapeutic).

A Prospective Trial Comparing Outcomes at 11 Months of a Standard Cross-Finger Flap versus a Laterally Based Thenar Flap for Fingertip Reconstruction

Background: The standard cross-finger flap (CFF) and laterally based thenar flap (LTF) are the time-tested modalities of fingertip reconstruction. We were unable to find any studies that have compared these two flaps for fingertip reconstruction. The aim of this study is compare the outcomes of these two flaps at 11 months after fingertip reconstruction. Methods: This is a prospective study of 40 patients with fingertip amputation who underwent reconstruction with either a standard CFF or an LTF. Data with regards to the patient, the injury, treatment and complications were recorded. Patients were followed up weekly for the first 6 weeks and at 3, 6, 9 and 12 months thereafter. Outcome measures assessed at final follow-up included passive range of motion, two-point discrimination, cold intolerance, patient aesthetic satisfaction with the flap, assessment of donor scar and psychosocial benefit. Results: Fingertip reconstruction was done with 23 CFFs and 17 thenar flaps. Partial necrosis was noted in three thenar flaps. The mean follow-up period was 11 months. The sensory recovery and aesthetic satisfaction with the flap were greater in thenar flap group. There were no differences between the two flaps in the other outcome measures. Conclusions: Sensory recovery and aesthetic outcomes were better in thenar flaps compared to a CFF. However, thenar flap were associated with a greater incidence of partial flap loss. Level of Evidence: Level III (Therapeutic).

Locoregional Options for Acute Volar Pulp Fingertip Defects

The volar fingertip is a unique anatomic structure, delicate yet durable, that allows us to navigate the world, acquire information from our surroundings, and express ourselves. Injuries to the volar finger can cause permanent dysfunction and should be taken seriously. In treating injuries of the volar fingertip, the surgeon has an opportunity to choose from a host of reconstructive options and provide the patient with an outcome suitable to their needs. In doing so, the hand surgeon is well-positioned to aim for the reconstructive ideal of restoring both structure and function.

Is the cross-finger flap a good option at the extensor zone defect?

Objectives

This study aims to evaluate the surgical and clinical outcomes of reversed cross-finger subcutaneous flaps applied to patients with dorsal digital defects.

Patients and methods

Between January 2015 and September 2018, 25 (22 males, 3 females; mean age 35.6±11.6 years; range, 19 to 65 years) out of 27 patients under prospective follow-up with finger dorsal digital defect were retrospectively screened and included in the study. The data, obtained by the same two surgeons at six months postoperatively in patients who had undergone reversed cross-finger subcutaneous flaps surgery, concerned cold intolerance, a static two-point separation test, and functional results using range of motion (ROM) and Quick Disabilities of the Arm, Shoulder and Hand (DASH) scoring.

Results

The majority of the patients presented with occupational injury (64%), most commonly to the dominant hand (76%) and the fourth finger (36%) most frequently. Seven patients with extensor tendon defects underwent reconstruction with a palmaris longus autograft. At the six-week postoperative follow-up, all flaps were live, the donor site had no morbidity, and no additional intervention was performed. There was no statistically significant difference in finger joint ROM (p>0.05). Cold intolerance was observed in 14 patients (56%). The mean dynamic two-point distinction was 6.0±0.7 mm and the QuickDASH score was 22.3±5.0.

Conclusion

Due to reasons such as minimal donor site morbidity, satisfactory functional finger outcomes, and easy applicability, reversed cross-finger subcutaneous flap is a good option for reconstruction of defects in the dorsal aspect of the finger with or without extensor mechanism defects.

VY Advancement, Thenar Flap, and Cross-finger Flaps

The VY advancement, thenar flaps, and cross-finger flaps are workhorse flaps used in reconstruction of fingertip defects. They are reliable and simple to raise without need for microvascular dissection. In addition, they usually provide good results in terms of sensibility and range of motion. This article reviews the history, anatomy, and surgical technique of these flaps with a focus on aesthetic refinements with illustrative cases.

Flap Related Complications Requiring Secondary Surgery in a Series of 851 Local Flaps Used for Fingertip Reconstruction

BACKGROUND

Local flaps are widely used to cover fingertip defects. Errors in design or technical execution of the flap may lead to morbidity and additional surgical procedure. The purpose of this study was to review flap related complications requiring unplanned secondary surgery to characterize preventable issues.

METHODS

851 local flaps were used to reconstruct fingertip defects during a 9-year period. Patients requiring unplanned secondary surgery to address flap related complications were subjected to analysis.

RESULTS

31 of 851 flaps (3.6%) required unplanned secondary surgery because of flap related complications. The most reliable flap was VY advancement flap with only one (0.3%) re-operation. The reverse vascular island flap, cross finger flap, and neurovascular island flap were associated with the comparable number of complications (8.0%; 6.3%; and 3.8% respectively). Total or partial necrosis was the cause for re-operation in 6 patients (0.7%). The typical reason for secondary surgery was inadequate soft tissue cover of the tip with homodigital neurovascular island flap and flexion contracture with reverse vascular island flap. Cross finger flaps were revised because of poor graft take at the donor site, bulky flap or flap necrosis.

CONCLUSIONS

Local flaps are reliable operations to cover fingertip defects. Each flap has potential pitfalls, which may be avoided if the surgeon is aware of them.

Thenar Flap for Severe Finger Tip Injuries in Children

Twelve children aged between 18 months and 11 years old who had sustained a severe fingertip amputation with total or subtotal pulp loss were treated with a distal-based thenar flap. The injuries were palmar oblique amputations or avulsion injuries involving the pulp and the nail bed. The pedicles of the thenar flaps were divided after 18 to 25 days and none suffered any necrosis. At the final follow-up, no interphalangeal joint contractures were found, the average two point discrimination was 5 mm, the thenar scar was asymptomatic and the subcutaneous tissue of the thenar flap was providing sufficient bulk to produce a rounded contour, like a normal fingertip. The thenar flap is a useful technique for use with severe fingertip injuries when local flaps cannot provide enough soft tissue and replantation is not possible.

Cross-finger flap for reconstruction of fingertip amputations: Long-term results

Fingertip amputations are severe hand injuries. Their treatment must restore the sensation and metabolic activity needed for pain-free finger function. The cross-finger flap (CFF) can be used for this purpose. The goal of this study was to assess the long-term clinical outcome following use of this flap.

METHODS

This was a retrospective analysis of 28 patients operated because of fingertip amputation: 16 type 3, 8 type 2 and 4 type 4. The CFF was harvested from an adjacent finger on the dorsal side of the middle phalanx down to the epitenon. A dorsopalmar hinge was preserved to ensure vascularisation. The CFF was divided an average of 18.7 days later. The following parameters were evaluated: pulp volume (injured compared to contralateral finger), presence of neuroma, occurrence of complications (necrosis, infection, and donor site morbidity), cold discomfort, static and tactile discrimination, and patient satisfaction (0 to 10 on VAS).

RESULTS

The average follow-up was 19.7 years; 22 patients (78.6%) were re-examined in person or contacted by telephone. The average healthy pulp to reconstructed pulp ratio was 1.03. No postoperative complications such as neuroma were found. Cold sensitivity was present in 7 patients. The flap was re-sensitised in all the patients. There was no donor site morbidity. The average patient satisfaction score was 9 (range 8-10).

CONCLUSIONS

Over the long-term, use of the CFF results in nearly normal fingertip metabolism, no complications and good distal sensitivity without pain or neuromas. This is a simple, reliable, long-lasting reconstruction technique.

LEVEL OF EVIDENCE

IV.

Reconstruction of the transverse and dorsal-oblique amputations of the distal thumb with volar cross-finger flap using the index finger

We performed a retrospective review of 12 patients with dorsal oblique and transverse amputations of the distal thumb who were treated with a volar cross-finger flap from the index finger. The mean patient follow-up period was 28 months postoperatively (range: 19-43 months). There were no instances of flap loss, infection, or donor site complication in our series. The mean Semmes-Weinstein monofilament testing scores on the injured thumb and the donor site were 0.65 g (range: 0.16-2 g) and 0.51 g (range: 0.16-1 g), respectively. The mean 2-point discrimination testing scores on the injured thumb and the donor site were 4.5 mm (range: 3-8 mm) and 4.3 mm (range: 3-7 mm), respectively. This study suggests that the volar cross-finger flap using the index finger is a reliable technique in repairing dorsal oblique and transverse amputations of the distal thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Soft-tissue coverage of the hand: a case-based approach

Adequate soft-tissue coverage of the hand is paramount to achieve optimal aesthetic and functional results in patients with complex hand defects. In this article, the authors present four illustrative clinical cases and discuss potential reconstructive modalities. For each scenario, two surgical options are discussed: one established and one nontraditional method of reconstruction. The authors' preferred method and technical pearls for execution are presented.

Dorsally extended digital island flap for repairing soft tissue injury of the fingertip

BACKGROUND

The digital triangular island flap is one of the most useful types of flap for repairing soft-tissue loss at the fingertip, because it is sensate and has glabrous skin. However, this type of flap has several disadvantages, including limited length of advancement and limited flap size.

METHODS

We have developed a new type of dorsally extended digital island flap to extend the reach of the digital triangular island flap. This dorsally extended portion, 15 mm in width and 20 mm in length, is based on the dorsal branch of the digital artery at the distal phalanx level. This island flap has a longer reach than the conventional digital island flap and can transfer larger amounts of soft tissue to the injured fingertip. Sixteen patients with fingertip amputation were treated using this flap.

RESULTS

All of the flaps survived. The dorsally extended digital island flap could repair pulp tissue losses up to 30 mm in length in oblique volar injury. In transverse injury, a new fingertip could be produced with this flap in a single stage. We successfully covered the exposed bone without shortening the digital bone of the fingertip using our extended flap. No claw nail deformity occurred and no flexion contracture remained in any of the cases.

CONCLUSION

Use of a dorsally extended digital island flap is recommended for repairing fingertip injury in cases with defect sizes ranging from 10 to 30 mm in length and also in both oblique volar and transverse injuries. This flap is more versatile for repair of fingertip injury than the conventional digital island flap.

Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the anatomy of the fingertip. 2. Describe the methods of evaluating fingertip injuries. 3. Discuss reconstructive options for various tip injuries.

SUMMARY

The fingertip is the most commonly injured part of the hand, and therefore fingertip injuries are among the most frequent injuries that plastic surgeons are asked to treat. Although microsurgical techniques have enabled replantation of even very distal tip amputations, it is relatively uncommon that a distal tip injury will be appropriate for replantation. In the event that replantation is not pursued, options for distal tip soft-tissue reconstruction must be considered. This review presents a straightforward method for evaluating fingertip injuries and provides an algorithm for fingertip reconstruction.

Reconstruction of the distal finger with partial second toe transfers by means of an exteriorised pedicle

This study reports the outcome of a series of ten microsurgical fingertip reconstructions with partial toe transfers in which the vascular pedicle was exteriorised and subsequently excised after the transfer had become established. The aim of this technique was to provide better aesthetic and functional outcomes. The technique was successful and without complication in nine of the ten patients who had excellent functional and aesthetic outcomes. Arterial thrombosis resulted in partial necrosis of the fingertip in the other case.

Fingertip reconstruction with the laterally based thenar flap: indications and long-term functional results

The thenar flap is a time-tested method of fingertip reconstruction, but functional outcome data are scarce in the literature. The purpose of this study was to analyze the long-term function following fingertip reconstruction with a laterally based thenar flap and to compare these results with other established methods. Nineteen patients underwent a thenar flap between 2001 and 2004. Patients ranged in age from 3 to 48 years. The mean angle of proximal interphalangeal immobilization was 66 degrees (range 30-85 degrees ) and was greater for radial digits. Time to division ranged from 11 to 15 days. Seventeen patients underwent follow-up evaluation of range of motion, two-point discrimination, and sensory threshold (Semmes-Weinstein). A questionnaire measured patient satisfaction in three areas: sensibility, function, and appearance. The mean follow-up was 20 months. Reconstructive goals were met in all cases. The mean metacarpalphalangeal and proximal interphalangeal motion in the reconstructed fingers was not significantly reduced, compared to the unaffected side. The distal interphalangeal motion was 42 degrees , compared to 55 degrees in the contralateral side (p < 0.01). The mean static two-point discrimination in the flap was 6.8 mm, compared to 3.8 mm in the contralateral side. Fourteen of 17 patients exhibited monofilament thresholds of 33.1 g/mm(2) or less. There were no hypertrophic or tender donor scars. This study does not support the contention that thenar flaps are associated with problematic donor scars and flexion contractures, even for adults or ulnar digits. Sensory recovery compared favorably to published results of cross-finger and homodigital flaps. When sound technical principles are followed, excellent outcomes can be expected.

The pulp ring avulsion lesion as a new indication for the free dorsal middle phalangeal finger flap: a case report

An ideal reconstruction of fingertip injuries should provide good sensibility and no pain in the activities of daily life. We report a case of a professional trumpet player who sustained a severe avulsion injury when his right index finger was crushed in a slamming door. The soft tissue of the distal finger was debrided circumferentially. To cover the defect we performed a free dorsal middle phalangeal finger flap from the ipsilateral ring finger. This flap provides excellent sensory recovery and an aesthetic outcome.

Sensory reconstruction of the fingertip using the bilaterally innervated sensory cross-finger flap

The authors present a series of 15 patients with large soft-tissue defects of the fingertips as a prospective, nonrandomized study. In all cases, reconstruction was achieved using a bilaterally innervated sensory cross-finger flap. This sensory fasciocutaneous flap relies on the dorsal branch of the proper digital nerves, which branch off at the level of the head of the proximal phalanx; sensory supply to the dorsal skin of the middle phalanx is thus ensured. The reconstructive procedure consists of two steps. First, the contralateral dorsal branch of the proper digital nerve is elevated with the flap at proximal interphalangeal joint level. Microsurgical coaptation is performed to the proximal nerve stump of the injured fingertip. After 3 weeks, when the pedicle is dissected, the second nerve is dissected and coapted. Clinical results were evaluated after 12 months. Because the regenerative distance is only 1.5 to 2.5 cm, good sensory regeneration should be expected. In nine of 16 flaps, sensory quality of S2+ (Highet) was present in the flap after 3 weeks. After 12 months, two-point discrimination was present in all patients, the values ranging between 2 and 6 mm (for two-point discrimination), with an average of 3.6 mm. The rate of complications was low. With acceptable additional operative action, a good functional result can be achieved. The indications of this method are discussed in comparison with other methods of fingertip reconstruction.

Arterialized venous dorsal digital island flap for fingertip reconstruction

Fingertip resurfacing is a challenging reconstructive problem; despite the existence of many different surgical methods, enthusiasm on developing versatile flap techniques has been continuing. In this report, we describe an arterialized venous dorsal digital island flap for fingertip reconstruction. The vascularity of the reverse dorsal digital island flap is augmented by performing an arteriovenous anastomosis between a dorsal vein in the flap and one of the proper digital arteries at the fingertip. Eight flaps were used in eight patients for the reconstruction of their fingertip defects. The ages of the patients ranged from 19 to 41 years, with an average of 28.4 years. In two cases, the flap was used as a neurosensorial flap by coapting the dorsal digital radial nerve to the digital nerve. The mean follow-up was 11 months, and all but one flap totally survived. The operative technique is easy except for the necessity of performing standard microvascular surgery. The flap may be a good alternative for repairing fingertip defects in selected cases.

The modified cross finger flap for finger pulp and nail bed reconstruction

We describe a modification of the cross finger flap procedure. The modification enhances the amount of soft tissue under the flap, permitting reconstruction of the nail bed where necessary. We present two clinical cases.

Fingertip Injuries: Evaluation and Treatment

The primary goal of treatment of an injury to the fingertip is a painless fingertip with durable and sensate skin. Knowledge of fingertip anatomy and the available techniques of treatment is essential. For injuries with soft-tissue loss and no exposed bone, healing by secondary intention or skin grafting is the method of choice. When bone is exposed and sufficient nail matrix remains to provide a stable and adherent nail plate, coverage with a local advancement flap should be considered. If the angle of amputation does not permit local flap coverage, a regional flap (cross-finger or thenar) may be indicated. If the amputation is more proximal or if the patient is not a candidate for a regional flap because of advanced age, osteoarthritis, or other systemic condition, shortening with primary closure is preferred. Composite reattachment of the amputated tip may be successful in young children. The outcome of nail-bed injuries is most dependent on the severity of injury to the germinal matrix.