Skin and Soft Tissue Coverage of the Upper Extremity -,erein discon sidera,~lt in prothat such consider-

The Cross-FingerFlap

,iess as do

An Established Reconstructive Procedure

David A. Kappel, M.D., F.A.C.S.,* and Joanne 6. Burech, O.T.R./L., A.S.H.T.~

L., et al.: .,-rtip with a ¯ g., 52A:698, ’ aente hand ~..constructive 7,/. B. Saun,phia, \V. B. T. S,, et al.: mlt of thilure 7:176, 1967. lbr fingertip :,tbr of tissue Bone Joint ,,ertip repair. :~tens, J. H.: 1982. .constrtlctive Join.t Surg., :dvancelnent land Surg.,

Since its introduction in the literature 30 years ago, v the cross-finger flap has in the experience of many authors < ~’ u become the single best reconstructive methodfor resurfaeing fingers with significant loss of the soft tissue of the tip. Reportss’ ~ have steadily accumulated testifying to its superiority in terms of sensibility, reliability, durability, and effleaey in returning the injured patient to his or her previous occupation. In spite of the weight of the data, the cross-finger flap has still not achieved wide popularity amongmany hand surgeons, as evidenced by the discussion (or lack thereof) finger tip reconstruction in the most current texts of handsurgery.< a, ~0, o_~Severallarge series ~. ~9. of finger tip injuries also reflect infrequent application of the procedure. The reasons behind this limited acceptance are not easily identified.

.lsions with Surg., 8:49,

INDICATIONS

the fingertip mar pedicle

The indications for the use of the cross-finger flap have been clearly listed by several authors. ~’ r’ s The procedureis reliabl6 and effee= tive in providing sensibility, preservifig"the length of the finger, and covering exposed tendons and bones. It eah be used primarily to replace an avulsed finger pad or secondarily to release a sear or to replace a hyperesthetie sear e~ or an inadequate skin graft. Other indications include the need for tactile gnostic ability, preservation of length, and restoration of bulk and cosmetic appearance (Fig. 1). The crossfinger flap also provides a source for stable and resilient hand skin. In fingertip loss, its chief competitors are VY flaps, either volar or lateral; shortening of the

)r repair of ~rg., 40:163, ;e of a small instr. Surg., y Associates 30th Street York 10016

bone and primary closure; healing by secondary intention; split- or full-thickness skin grafts; pahnar flaps; or distal pedicle flaps, e’ a In reviewing 235 patients, Sturman and Duran found the cross-finger flap to be equal or superior to these other methodsin terms of lack of tenderness, less cold sensitivity, better touch sensation, and better size and texture discrimination. Patients with cross-flnger flaps also had less subjective disability and tended to avoid their areas of repair less. PATIENT SELECTION In terms of patient selection, several I~etors have comeunder consideration. Use of this flap in the pediatric age group is controversial because of the relative immobilization required to protect the attachment of the flap. Certain authors u have recommendedthat children aged

Figure 1. Restoration of bulk, contour, and cosmetic appearance was excellent in a musician whorecovered a 4 ram, two-point discrimination in the cross-finger flaps.

*Clinical Professor of Surgery, West Virginia University School of Medicine, Wheeling, West Virginia ~’Ohio Valley Ivledical Center and Wheeling Hospital, Wheeling, West Virginia Hand Clinics--Vol.

1. No. 4, November 1985

677

678

David A. Kappel and Joanne G. Burech

7 to 8 years be the youngest patients, whereas others 2~ have shown no reluctance in applying cross-finger flaps in children beginning at age 1. The recommended upper limits of age also vary from 45 to 50 years, I. 16 as persistent postoperative stiffness in the older age group appears to be a significant risk factor. Both sexes have been represented in the reviews.9. ~l. i2. ts. 28. 2t It maybe considered chauvinistic, but in females ~osmetic appearance becomes a significant consideration. Accordingly, if a cross-finger flap is elected, a fullthickness graft is highly recommendedfor reconstruction of the donor finger. Also, a groin donor site provides a less conspicuous donor area than the arm, with favorable characteristics for uncomplicated healing and a satisfactory scar. The donor site graft, unfortunately, may still be hyperpigmented and obvious. As an alternative, a thenar flap in the young female patient may indeed be preferred. ~*, ~9 The darker pigmented dorsal skin in the black patient will also be quite noticeable on the lighter volar surface of the recipient finger; palmar skin, if feasible, will provide a better color match for the volar finger and avoid a hyperpigmented skin graft on the dorsum of the donor finger. SOCIOECONOMIC CON-SIDERATIONS Somecontroversy8, ~9 exists over the rapidity of return to work with the various reconstructive procedures. Obviously, this is usually not a consideration in the pediatric age group,. Distant pedicle flaps from other areas of the body in most series z, ~9 represent the greatest delay in return to work. Cross-finger pedicles generally require longer temporary disability than methods with primary closure but may approximate the same disability period required by secondary healing. If, however, one considers that the cross-finger flap saves subsequent time off for definitive secondary reconstruction, then a significant percentage of unsatisfactory primary methods would be seen to actually contribute to increased lost work time. Wehave," found also that many sedentary occupations or management positions ~ may be conducive to return to work even prior to the definitive division and inset of the flap. Workers’ Com-. pensation benefits represent a cost to business and society but also make it possible to select the best long-term reconstructive procedure without the urgent need to return the patient: to work as quickly as possible. In contrast, a self-employed farmer may decline a multistage

procedure in favor of primary closure, even if it requires shortening of the injured digit. Return to previous occupation in many industrial workers may be enhanced by rec’onstruetion with a cross-finger flap when a com-bination of durability, sensibility, and lack of tenderness is required. This flap has also been quite satisfactory in allowing resumption of skilled manual duties in secretaries, musicians, and others requiring fine manipulative tasks in their vocation or avocation. ’~ CONTRAINDICATIONS Contraindications to the procedure have been well documented.8, is Multiple injuries to the hand, especially if they include the donor finger, mayincrease the risk of stiffness; however, having the shoulder and hand entirely flee, preserving length in multiple amputations (Fig. 2), and covering repaired structures mayoffset that risk. Vasospastie conditions such as Raynaud’sdisease, diabetes mellitus, and Buerger’s disease mayrepresent absolute eontraindieations. Preexisting disabling problems, such as Dupuytren’s eontraeture, rheumatoid arthritis, and advanced age, present an increased hazard to the outcome of a cross-finger flap. Some authors~i also believe that this flap should not be used for the fourth and fifth fingers except in certain selected patients. Wehave, however, not hesitated to use it on any digit.

ADVANTAGES The advantages of hand skin flaps are multiple~ It provides a tough resiliency ~s, 20 un-

Figure2. Multipledistal amputations-subsequent to a lawn mowerinjury weretreated with a cascadeof two cross-fingerflaps anda hypothenar flap.

Cross-FingerFlap ~re, even if digit. many inby redonlen a com~nd lack of also been ~mption of nmsicians, ire tasks in

matched by tissue from other areas of the body. The need for immobilization is limited to the involved fingers and leaves the shoulder free. Sweating in this composite tissue may return, and this will help to avoid the slipperiness of a smooth scar or graft. The abundant vascularity of the hand also makes the properly raised flap quite reliable as well as flexible in terms of flap orientation. TECHNIQUE

have been ties to the donor fin~; however, tirely free, ations (Fig. mayoffset

A well executed cross-finger flap does requir~ a more formal operative setting than the emergency department. It also requires more hand surgical training and expertise than those procedures that could be provided by a physician trained in.emergency medicine. Primary closure, split-thickness skin grafting, orjust simple application of a dressing mayindeed be handled

,naud’s diser’s disease ttions. Preas Dupuyhritis, and l hazard to lap, Some should not ~ers except ¯ , however,

are multi.,ylS,

20 un-

equent

to a

aade of two

Figure 3. A-E, A dorsal defect was treated with a de-epithelialized, "reversed" cross-finger flap. The donor defect and the surface of the flap were covered with a skin graft.

679

by the emergency physician, but this "convenience" should not influence the choice of the most appropriate procedure for each individual patient. Most often, these procedures can be performed in adults under a regional anesthetic as outpatient surgery. This represents a significant finprovement in hospital bed utilization since Barelay’s~ report in 1955 of an average hospital stay of 13 days. The pediatric patient will usually require a general anesthetic, and patients with other associated injuries may need a short stay in the hospital. The technique has been often described in the literature msince the initial report by Gurdin and Pangman.~ Our series, which includes more than 200 patients, led us to certain opinions that deserve to be shared. Wehave selected the donor finger on the basis of the ease of transposing the flap rather than whether it is radial or ulnar. Several authors ~, s. ~, ~ have

680

David A. Kappel and Joanne G. Burech

advocated plaster immobilization, whereas others 5. lo, n have used K-wiresfor fixation during the period between stages. Except in the occasional uncooperative (young) pediatric patient, we have found a light dressing with cotton gauze, Kling bandage, and tape an adequate dressing and sufficient immobilization. Attention to detail in positioning the fingers with gauze between them and rolled or flu.fled gauze under them to support their gentle curve is important for comfort in the period between stages. The excellent vascularity of the dorsal skin allows great flexibility in the design of the flap, r. 5, 2o although in our experience the classic lateral based flap is nearly always applicable. The flap mayalso be de-epithelialized to cover a dorsal defect in an adjacent finger (Fig. and both the flap and the donor defect gralq~.ed. Whenan adjacent finger tip is resurfaced, nearly all of the dorsal skin over the middle phalanx is raised (Fig. 4), the surgeon being quite careful to preserve the vascular epitenon over the extensor tendon.5. ~2 This insures the take of the graft over this donor site. This larger donor site, which blends into the skin creases adjacent to the PIP and DIP joints and those

extending from each midlateral line, results in a better cosmetic appearance~ than a small gr~fft perched in the middle of the dorsal skin. Fullthickness skin grat}s are significantly superior in appearancethan are split graftss, ,a (Fig. 5). the procedure is being done under a regional anesthetic, additional local anesthesia can be used to obtain a full-thickness graft from the groin. The groin would be our donor site of choice in females and children and the recommendedsite in the adult male as well. The tieover bolster ~°-12 is advocated by manyauthors, but in the convex dorsum of the finger, this may actually create sulci at the margins and a potential space for hematomato collect. Tacking sutures around the periphery of the graft, attention to hemostasis, and compression of the graft with the dressing material usually result in excellent take of the graft without the need for a bolster. The uncommoncomplication of flap loss (in our series) is usually related to poor patient selection, for example, an uncooperative patient or a diabetic. (The remaining instances of flap loss in our series are seeminglyinexplicable and maybe related to technique.) One flap was lost in a patient, who, during readmission 4 months

Figure 4. A-E, A standard cross-finger flap was raised with care taken to preserve the epitenon. The donor defect was covered with a full-thickness skin graft.

681

Cross-FingerFlap METHODS

¯ ,:sults in .:,all graft .m. Full:mperior ~g. 5). If regional can be !;ore the :: site of , recomThe tieauthors, :.,,er, this ,is and a Tacking .’-,yaft,atm of the i y result ~he need , loss (in patient - patient 7s of flap :able and . waslost t months Figure5. "Small"flaps andhyperpigmented split-thicknessskin grafts.resultedin a less thansatisfactoryappearaneeof donorsites.

er flap was epitenon. l-thickness

later for finger tip revision, was found to have metastatic carcinoma. Timing of division is most often 12 to 14 days,~, s. ~ but early as 7 days has been referred to in the literature. Delaying division until 3 o~;eeks or longer~’ ~s is seldomindicated and may contribute to stiffness of the fingers. Inset of the flap t= requires reconstituting the original defect by elevating the raw edge of the defect under the pedicle of the flap prior to suturing this last edge into the recipient finger. This results in a flatter, smootherflap. The flap is also divided at its origin near the midlateral line and the excess is discarded, n again for optimal appearance of the donor site. Anysubsequent tendency to form hypertrophic sear 9!ong the edge of the donor site is treated with ~: 1-inch Coban pressure wrap for several months. Occasionally, after inset of the flap in an asymmetric defect, the Coban wrap also proves to be helpful in "shaping the stump." Followingfinal inset of the flap, an intensive program is begun to regain any lost motion and eliminate stiffness. This facilitates a rapid return to work and minimizes any residual disability.

Our material consists of 205 patients seen over a period of 11 years. A questionnaire ~vas mailed to all patients requesting historical data regarding the nature of the accident, the injury, and work status at the time of the injury and subsequent to it. Information was also requested about lost work time, requirements for therapy, and eventual disability awards, if any. Twelve questions were also included to be answered with the description of excellent, good, fair, or poor as the patient’s perception of his or her result. These questions specifically addressed motion, task performance, pain, durability, sensibility, and appearance. Those patients responding to the questionnaire were subsequently seen for objective measurements in our hand rehabilitation unit. Individual and cumulative motion was recorded for the joints of all digits in the injured hand. Pinch and grip strengths were quantitared. Sensibility was compared using pressure monofilaments, and two-point discrimination of the flap, the contralateral fingertip, and the donor site on the dorsum of the finger was assessed. A timed dexterity test was also performed.~4 In addition, a Ninhydrin (triketohy~4. ,:lrindene hydrate) test as described by Moberg was carried out On each patient. RESULTS In the initial phase of the study, 23 patients responded to the questionnaire and were avail.able for objective testing. Thirty-eight charts were available for review of the clinical course and operative notes. It was at least 6 months postinjury for all patients. Males outnumbered females more than 4 to 1. The patients’ ages ranged from 1V~ to 76 years. As would be expected, the majority of the patients belonged to the labor portion of the work force. Crushing predominated as a cause of injury. Lost work time averaged 67 days. Management level patients, however, often returned to work during the period between stages. Nearly half of the patients received hand therapy, which we believe is, in large part, responsible for the minimalloss of range of motion. Of 23 job-related injuries, there was only one financial disability settlement in a patient without associated injuries or amputations, and it was sixteen hundred dollars. All patients returned to their job, except one whohad suffered multiple other injuries and partial amputations.

David A. Kappeland Joanne G. Burech 6higher than the 6.0 mmreported by Gellis. Of the 23 returning the questionnaire, all but 3 listed their motion as good or excellent. Two- Kleinert has stated that a two-point discrmination level of less than 8 mmis functional. thirds of the patients felt they performed fine Thirteen of the 24 patients had results of 7 mm motor tasks well. A similar number were relaor less and 5 had a discrimination level of tively free from pain. Cold intolerance, howgreater than 10 mm.Interestingly, 17 patients ever, was a complaint in nearly half of tl~e demonstrated a two-point discrimination level group. Subjective evaluation of sensation was in the flap that was actually better than the disappointing, as only 9 described their sensidonor site on the contralateral hand. This was bility as good or excellent. However, only a also observed by Sturman and Duran, ~9 who third felt that durability of the flap was a probnoted that the flap can take on the sensory lem or described strength as fair to poor. Over characteristics of the recipient finger tip. 80 per cent were able to perform work tasks Dexterity testing, as described by Moberg, well. The appearance of the flap and the donor in 8 patients with injuries to thumb, index, or site was described as good or excellent in twolong fingers revealed that the tasks were perthirds of the patients; there was a slight preformed, on the average, just 17 per cent more ponderanceof full-thickness grafts in this group. slowly. In performing these tests, four patients Whenasked if they could use their injured avoided using the injured finger, in each case hand normally, again, 80 per cent responded an index finger. positively, and only 2 patients listed their overGrip strength correlated more closely with all satisfaction as fair or pooli. hand dominancethan ~vith the hand of injury. Right and left hands were equally injured. Pinch strength, measuredas lateral pinch, pulp Index fingers were most commonlyinjured. Six to pulp, and "g-jaw chuck," showed mild dimthumbs and 5 little fingers received flap coverage. The long finger was the most common inution in the aforementioned 8 patients. Lab ~ral pinch was 88 per cent of normal; pulp to donor finger, as would be expected fi’om its pulp, 80 per cent; and 3-jaw chuck, 91 per cent. central location in the hand. Assessment of sudomotor function ~vas atDivision of the flap was performed as early tempted with the Ninhydrin test, but the reas 11 days and as late as 24 days after the initial sults were gehel~dly unreliable and difficult to procedure. The average period between stages reproduce. was i5.9 days. Objective measurement of range of motion in patients under 50 years of age was uniformly good. A close scrutiny of the five patients older SUMMARY than 50 years revealed a minimal decrease in motion, except in two patients (Table 1). Patient Cross-finger flaps have been performed by M.R., the oldest patient at age 76, had a our group in more than 200 patients. Subjective previous injury to a PIP joint, with pre-existing questioning and objective testing in a random stiffness. Patient G.SI required an intramedgroup of 23 of these patients confirms the value ullary K-wire across the DIPjoint for a fracture of this procedure for reconstruction of the inin the injured digit. The results in this group jured finger. It is reliable and flexible in its are in contrast to results in patients older than application. The patients usually report their 50 years in other series)’ 12 flaps to be functional, durable, and free of pain. Pressure monofilament testing consistently Cold intolerance, as with other methods of showeda slight decrease in sensitivity in tlhe reconstruction, remains a problem. Sensibility flaps, but all of the fingers fell within the range in the flaps proved to be functional in the of "normal results," which were established by majority of patients. The preservation of length testing the contralateral fingertips in the group. and range of motion is reflected in the fact that Two-point discrimination averaged 8.25 rum in the cross-finger flaps, which is somewhat disability settlement was a rare occurrence. 682

Table i. Rangeof Motionin Injured andDonorFingers of Patients Older than 50 Years P~NGEOF MOTION(DEGREE~) PATIENT

C.C. W.C. M.R. C.S.

AGE 58 69 58 76 54

INJURED DIGIT Thumb Long Little Ring Long

MP

PIP

DIP

24/66 0/80 0/81 0/90 0/95

0/45 0/92 0/107 0/84 9/99

0/64 5/61 40/70 0/11

Total 87 2.36 244 204 196

DONOR DIGIT Long Ring Ring Little Ring

IZ~NGEOF MOTION (DEGREES) alp

PIP

DIP

Total

0/90 0/82 0/83 0/84 0/100

0/100 0/91 0/100 0/75 9/91

0/60 5/60 0/59 10/41 10/35

260 228 242 190 207

Cross-Finger Flap 6:1 by Gellis. it discrminas fl~nctional. mlts of 7 mm tion level of ,, 17 patients dnation level ter than the nd. This was )uran,19 who the sensory .~er tip, by Moberg, nb, index, or ;ks were per~er cent more four patients in each case closely with and of injury. al pinch, pulp ,ed mild dimpatients. Lab ,rmal; pulp to ~, .91 per cent. ction was att, but the rend difficult to

performed by ~ts. Subjective ,~ in a random irms the value :ion of the inflexible in its ~, report their ~d flee of pain. r ~nethods of m. Sensibility ~tional in the ation of length n the fact that ,ccurrence. ~ar8 ~TION{DEGREES) DIP

Total

0/60 5/60 0/59 10/41 10/35

260 228 242 190 207

683

10. Ketchum,L. D.: Skin flaps. In Green, D. P. (ed.): Operative HandSurgery, Vol. 2. NewYork, Churchill LivingstoneInc., 1982. 11. Kislov, R., aud Kelly, A. P., Jr.: Cross-fingerflaps in digital injuries, ~vithnotesouKirschnerwirefixation. J. Plast. Reconstr.Surg., 25:312-322,1960. 12. Kleinert, H. E., McAlister, C. G., MacDonald, C. J., eta].: Acritical evahmtion of cross finger flaps. J. Trauma,14:756-763, 1974. 13. Miller, A. M.: Single finger tip injuries treated by thenm"flap. Haud,6:311-319,1974. 14. Moberg,E.: Objective methodsfor determining the functional value of sensibility in the hand. J. Bone REFERENCES Joint Surg., 40B:454-476,1958. 15. Nicolai, J. P. A., and Hentenaar, G.: Sensation in cross-finger flaps. Hand,13:12-16,1981. 1. Barclay,T. L.: Thelate results of finger-tip injuries. ~. Porter, R. W.: Fnnctional assessment of transplanted Brit. J. Plast. Surg., 8:38-42,1955. skinin volar defectsof the digits. J. BoneJoint Surg., 2. Bennett, J. E.: Fingertip avulsion. J. Trauma,6:’249, 50A:955-963,1968. 1966. ~. Brody, G. S., Cloutier, A. M., and Woolhouse,F. M.: 17. Russell, R. C., VanBeek,A. L., Wavak,P., et al.: Alternative hand flaps for amputationsand digital Thefinger tip injury--an assessmentof management. defects. J. HandSurg., 6:399-405,1981. J Plast. Reconstr.Surg., 26:80-90,1960. 4. Buncke,H. J., and Harris, G. D.: Skin coverage for 18. Smith,J. R., and Bom,A. F.: Anevaluation of fingerchallenginghand injuries. In Strickland, J. W., and tip reconstructionby cross-finger and palmarpedicle Steichen, J. B. (eds.): Difficult Problemsin Hand ~/~ flap. J. Plast. Reconstr.Surg., 35:409-418,1965. Surgery. St. Louis, C. V. Mosby,1982. ¯ Sturman, M. J., and Duran, R. J.: Late results of finger-tip injuries. J. BoneJoint Surg., 45A:289-298, 5. Curtis, R. M.: Cross-fingerpedicle’ flap in handsurgery. Ann.Surg., I45:650-655,1957. 1963. 6. Gellis, M., and Pool, R.: Two-pointdiscrilnination 20. Tempest,M.N.: Cross-finger flaps in the treatment of injuries to the fiuger tip. J. Plast. Reconstr.Surg., distances in the normalhand and forearm.J. Plast, Reconstr. Surg., 59:57-63,1977. 9:205-222,1952. 7. Gurdin, M., and Pangman,W.J.: Therepair of surface 2!. Thomson,H. G., and Sorokolit, W.T.: The crossfinger flap in children: A fbllow-upstudy. J. Plast. defects of fingers by trans-digital flaps. J. Plast. Reconstr. Surg., 5:368-371,1950. Reconstr. Surg., 39:482-487,I967. 8. Horn,J. S.: Theuse of full thickness hand skin flaps 22. Winspur,I.: Fingertip injuries. In Boswick,J. A., Jr. in the reconstruction of injured fingers. J. Plast. (ed.): Current Conceptsin HandSurgery. PhiladelReconstr. Surg., 78:463, 1951. phia, Lea and Febiger, 1983. 9. Johnson,R. K., and Iverson, R. E.: Cross-finger ped1300Chapline Street icle flaps in the hand. J. Bone Joint Surg., Wheeling,WestVirginia 26003 53A:913-919,197i.

This flap has been applied in patients of widely varying ages with minimal morbidity. Overall patient satisfaction has been quite rewarding. In the properly selected patient, the carefully performed procedure provides a superior means of reconstruction for the injured finger with loss of significant soft tissue.