-,erein dis-con sidera-

,~lt in pro-that suchconsider-

,iess as do

L., et al.:.,-rtip with a¯ g., 52A: 698,

’ aente hand~..constructive7,/. B. Saun-

,phia, \V. B.

T. S,, et al.:mlt of thilure7:176, 1967.lbr fingertip

:,tbr of tissueBone Joint

,,ertip repair.

:~tens, J. H.:1982..constrtlctiveJoin.t Surg.,

:dvancelnentland Surg.,

.lsions withSurg., 8:49,

the fingertipmar pedicle

)r repair of~rg., 40:163,

;e of a smallinstr. Surg.,

y Associates30th StreetYork 10016

Skin and Soft Tissue Coverage of the Upper Extremity

The Cross-Finger FlapAn Established Reconstructive Procedure

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

Since its introduction in the literature 30years ago,v the cross-finger flap has in theexperience of many authors< ~’ u become thesingle best reconstructive method for resurfae-ing fingers with significant loss of the soft tissueof the tip. Reportss’ ~ have steadily accumulatedtestifying to its superiority in terms of sensibil-ity, reliability, durability, and effleaey in re-turning the injured patient to his or her pre-vious occupation. In spite of the weight of thedata, the cross-finger flap has still not achievedwide popularity among many hand surgeons, asevidenced by the discussion (or lack thereof) finger tip reconstruction in the most currenttexts of hand surgery.< ~0, o_~ Several large seriesa,~. ~9. of finger tip injuries also reflect infrequent

application of the procedure. The reasons be-hind this limited acceptance are not easily iden-tified.

INDICATIONS

The indications for the use of the cross-fingerflap have been clearly listed by several au-thors. ~’ r’ s The procedure is reliabl6 and effee=tive in providing sensibility, preservifig"thelength of the finger, and covering exposed ten-dons and bones. It eah be used primarily toreplace an avulsed finger pad or secondarily torelease a sear or to replace a hyperesthetie searor an inadequate skin graft. Other indicationse~

include the need for tactile gnostic ability,preservation of length, and restoration of bulkand cosmetic appearance (Fig. 1). The cross-finger flap also provides a source for stable andresilient hand skin.

In fingertip loss, its chief competitors are V-Y flaps, either volar or lateral; shortening of the

bone and primary closure; healing by secondaryintention; split- or full-thickness skin grafts;pahnar flaps; or distal pedicle flaps,e’ a In re-viewing 235 patients, Sturman and Duran foundthe cross-finger flap to be equal or superior tothese other methods in terms of lack of tender-ness, less cold sensitivity, better touch sensa-tion, and better size and texture discrimination.Patients with cross-flnger flaps also had lesssubjective disability and tended to avoid theirareas of repair less.

PATIENT SELECTION

In terms of patient selection, several I~etorshave come under consideration. Use of this flapin the pediatric age group is controversial be-cause of the relative immobilization required toprotect the attachment of the flap. Certainauthorsu have recommended that children aged

Figure 1. Restoration of bulk, contour, and cosmeticappearance was excellent in a musician who recovered a 4ram, 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, whereasothers2~ have shown no reluctance in applyingcross-finger flaps in children beginning at age1. The recommended upper limits of age alsovary from 45 to 50 years,I. 16 as persistentpostoperative stiffness in the older age groupappears to be a significant risk factor.

Both sexes have been represented in thereviews.9. ~l. i2. ts. 28. 2t It may be consideredchauvinistic, but in females ~osmetic appear-ance becomes a significant consideration. Ac-cordingly, if a cross-finger flap is elected, a full-thickness graft is highly recommended for re-construction of the donor finger. Also, a groindonor site provides a less conspicuous donorarea than the arm, with favorable characteristicsfor uncomplicated healing and a satisfactoryscar. The donor site graft, unfortunately, maystill be hyperpigmented and obvious. As analternative, a thenar flap in the young femalepatient may indeed be preferred. ~*, ~9 Thedarker pigmented dorsal skin in the black pa-tient will also be quite noticeable on the lightervolar surface of the recipient finger; palmarskin, if feasible, will provide a better colormatch for the volar finger and avoid a hyperpig-mented skin graft on the dorsum of the donorfinger.

SOCIOECONOMIC CON-SIDERATIONS

Some controversy8, ~9 exists over the rapidityof return to work with the various reconstruc-tive procedures. Obviously, this is usually nota consideration in the pediatric age group,.Distant pedicle flaps from other areas of thebody in most seriesz, ~9 represent the greatestdelay in return to work. Cross-finger pediclesgenerally require longer temporary disabilitythan methods with primary closure but mayapproximate the same disability period requiredby secondary healing. If, however, one consid-ers that the cross-finger flap saves subsequenttime off for definitive secondary reconstruction,then a significant percentage of unsatisfactoryprimary methods would be seen to actuallycontribute to increased lost work time. We have,"found also that many sedentary occupations ormanagement positions ~ may be conducive toreturn to work even prior to the definitivedivision and inset of the flap. Workers’ Com-.pensation benefits represent a cost to businessand society but also make it possible to selectthe best long-term reconstructive procedurewithout the urgent need to return the patient:to work as quickly as possible. In contrast, aself-employed farmer may decline a multistage

procedure in favor of primary closure, even ifit requires shortening of the injured digit.

Return to previous occupation in many in-dustrial workers may be enhanced by rec’on-struetion with a cross-finger flap when a com--bination of durability, sensibility, and lack oftenderness is required. This flap has also beenquite satisfactory in allowing resumption ofskilled manual duties in secretaries, musicians,and others requiring fine manipulative tasks intheir vocation or avocation. ’~

CONTRAINDICATIONS

Contraindications to the procedure have beenwell documented.8, is Multiple injuries to thehand, especially if they include the donor fin-ger, may increase the risk of stiffness; however,having the shoulder and hand entirely flee,preserving length in multiple amputations (Fig.2), and covering repaired structures may offsetthat risk.

Vasospastie conditions such as Raynaud’s dis-ease, diabetes mellitus, and Buerger’s diseasemay represent absolute eontraindieations. Pre-existing disabling problems, such as Dupuy-tren’s eontraeture, rheumatoid arthritis, andadvanced age, present an increased hazard tothe outcome of a cross-finger flap. Someauthors~i also believe that this flap should notbe used for the fourth and fifth fingers exceptin certain selected patients. We have, however,not hesitated to use it on any digit.

ADVANTAGES

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

Figure 2. Multiple distal amputations-subsequent to alawn mower injury were treated with a cascade of twocross-finger flaps and a hypothenar flap.

~re, even ifdigit.many in-

by redon-len a com-~nd lack of

also been~mption ofnmsicians,

ire tasks in

have beenties to thedonor fin-

~; however,tirely free,ations (Fig.may offset

,naud’s dis-er’s diseasettions. Pre-as Dupuy-hritis, andl hazard tolap, Someshould not~ers except¯ , however,

are multi-.,ylS, 20 un-

equent to aaade of two

Cross-Finger Flap

matched by tissue from other areas of the body.The need for immobilization is limited to theinvolved fingers and leaves the shoulder free.Sweating in this composite tissue may return,and this will help to avoid the slipperiness of asmooth scar or graft. The abundant vascularityof the hand also makes the properly raised flapquite reliable as well as flexible in terms of flaporientation.

TECHNIQUE

A well executed cross-finger flap does requir~a more formal operative setting than the emer-gency department. It also requires more handsurgical training and expertise than those pro-cedures that could be provided by a physiciantrained in.emergency medicine. Primary clo-sure, split-thickness skin grafting, orjust simpleapplication of a dressing may indeed be handled

679

by the emergency physician, but this "conven-ience" should not influence the choice of themost appropriate procedure for each individualpatient.

Most often, these procedures can be per-formed in adults under a regional anesthetic asoutpatient surgery. This represents a significantfinprovement in hospital bed utilization sinceBarelay’s~ report in 1955 of an average hospitalstay of 13 days. The pediatric patient will usu-ally require a general anesthetic, and patientswith other associated injuries may need a shortstay in the hospital.

The technique has been often described inthe literature m since the initial report by Gurdinand Pangman.~ Our series, which includes morethan 200 patients, led us to certain opinionsthat deserve to be shared. We have selectedthe donor finger on the basis of the ease oftransposing the flap rather than whether it isradial or ulnar. Several authors~, s. ~, ~ have

Figure 3. A-E, A dorsal defectwas treated with a de-epithelial-ized, "reversed" cross-finger flap.The donor defect and the surfaceof the flap were covered with a skingraft.

680

advocated plaster immobilization, whereasothers5. lo, n have used K-wires for fixation dur-

ing the period between stages. Except in theoccasional uncooperative (young) pediatric pa-tient, we have found a light dressing with cottongauze, Kling bandage, and tape an adequatedressing and sufficient immobilization.

Attention to detail in positioning the fingerswith gauze between them and rolled or flu.fledgauze under them to support their gentle curveis important for comfort in the period betweenstages.

The excellent vascularity of the dorsal skinallows 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 may also be de-epithelialized to covera dorsal defect in an adjacent finger (Fig.and both the flap and the donor defect gralq~.ed.When an adjacent finger tip is resurfaced,nearly all of the dorsal skin over the middlephalanx is raised (Fig. 4), the surgeon beingquite careful to preserve the vascular epitenonover the extensor tendon.5. ~2 This insures thetake of the graft over this donor site. This largerdonor site, which blends into the skin creasesadjacent to the PIP and DIP joints and those

David A. Kappel and Joanne G. Burech

extending from each midlateral line, results ina better cosmetic appearance~ than a small gr~fftperched in the middle of the dorsal skin. Full-thickness skin grat}s are significantly superiorin appearance than are split graftss, ,a (Fig. 5). the procedure is being done under a regionalanesthetic, additional local anesthesia can beused to obtain a full-thickness graft from thegroin. The groin would be our donor site ofchoice in females and children and the recom-mended site in the adult male as well. The tie-over bolster~°-12 is advocated by many authors,but in the convex dorsum of the finger, thismay actually create sulci at the margins and apotential space for hematoma to collect. Tackingsutures around the periphery of the graft, at-tention to hemostasis, and compression of thegraft with the dressing material usually resultin excellent take of the graft without the needfor a bolster.

The uncommon complication of flap loss (inour series) is usually related to poor patientselection, for example, an uncooperative patientor a diabetic. (The remaining instances of flaploss in our series are seemingly inexplicable andmay be related to technique.) One flap was lostin a patient, who, during readmission 4 months

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

Cross-Finger Flap 681

¯ ,:sults in.:,all graft.m. Full-:mperior

~g. 5). Ifregionalcan be

!;ore the:: site of, recom-The tie-authors,

:.,,er, this,is and aTacking

.’-,yaft, at-m of thei y result~he need

, loss (inpatient

- patient7s of flap:able and. was lostt months

METHODS

Figure 5. "Small" flaps and hyperpigmented split-thick-ness skin grafts.resulted in a less than satisfactory appear-anee of donor sites.

Our material consists of 205 patients seenover a period of 11 years. A questionnaire ~vasmailed to all patients requesting historical dataregarding the nature of the accident, the injury,and work status at the time of the injury andsubsequent to it. Information was also re-quested about lost work time, requirements fortherapy, and eventual disability awards, if any.

Twelve questions were also included to beanswered with the description of excellent,good, fair, or poor as the patient’s perceptionof his or her result. These questions specificallyaddressed motion, task performance, pain, du-rability, sensibility, and appearance. Those pa-tients responding to the questionnaire weresubsequently seen for objective measurementsin our hand rehabilitation unit.

Individual and cumulative motion was re-corded for the joints of all digits in the injuredhand. Pinch and grip strengths were quanti-tared. Sensibility was compared using pressuremonofilaments, and two-point discrimination ofthe flap, the contralateral fingertip, and thedonor site on the dorsum of the finger wasassessed. A timed dexterity test was also per-formed.~4 In addition, a Ninhydrin (triketohy-,:lrindene hydrate) test as described by Moberg~4.

was carried out On each patient.

er flap wasepitenon.

l-thickness

later for finger tip revision, was found to havemetastatic carcinoma.

Timing of division is most often 12 to 14days,~, s. ~ but early as 7 days has been referredto in the literature. Delaying division until 3o~;eeks or longer~’ ~s is seldom indicated and maycontribute to stiffness of the fingers.

Inset of the flapt= requires reconstituting theoriginal defect by elevating the raw edge of thedefect under the pedicle of the flap prior tosuturing this last edge into the recipient finger.This results in a flatter, smoother flap. The flapis also divided at its origin near the midlateralline and the excess is discarded,n again foroptimal appearance of the donor site. Any sub-sequent tendency to form hypertrophic sear9!ong the edge of the donor site is treated with~: 1-inch Coban pressure wrap for severalmonths. Occasionally, after inset of the flap inan asymmetric defect, the Coban wrap alsoproves to be helpful in "shaping the stump."

Following final inset of the flap, an intensiveprogram is begun to regain any lost motion andeliminate stiffness. This facilitates a rapid returnto work and minimizes any residual disability.

RESULTS

In the initial phase of the study, 23 patientsresponded to the questionnaire and were avail-.able for objective testing. Thirty-eight chartswere available for review of the clinical courseand operative notes. It was at least 6 monthspostinjury for all patients. Males outnumberedfemales more than 4 to 1. The patients’ agesranged from 1V~ to 76 years. As would beexpected, the majority of the patients belongedto the labor portion of the work force. Crushingpredominated as a cause of injury.

Lost work time averaged 67 days. Manage-ment level patients, however, often returnedto work during the period between stages.Nearly half of the patients received hand ther-apy, which we believe is, in large part, respon-sible for the minimal loss of range of motion.

Of 23 job-related injuries, there was only onefinancial disability settlement in a patient with-out associated injuries or amputations, and itwas sixteen hundred dollars. All patients re-turned to their job, except one who had sufferedmultiple other injuries and partial amputations.

682 David A. Kappel

Of the 23 returning the questionnaire, all but3 listed their motion as good or excellent. Two-thirds of the patients felt they performed finemotor tasks well. A similar number were rela-tively free from pain. Cold intolerance, how-ever, was a complaint in nearly half of tl~egroup. Subjective evaluation of sensation wasdisappointing, as only 9 described their sensi-bility as good or excellent. However, only athird felt that durability of the flap was a prob-lem or described strength as fair to poor. Over80 per cent were able to perform work taskswell. The appearance of the flap and the donorsite was described as good or excellent in two-thirds of the patients; there was a slight pre-ponderance of full-thickness grafts in this group.When asked if they could use their injuredhand normally, again, 80 per cent respondedpositively, and only 2 patients listed their over-all satisfaction as fair or pooli.

Right and left hands were equally injured.Index fingers were most commonly injured. Sixthumbs and 5 little fingers received flap cover-age. The long finger was the most commondonor finger, as would be expected fi’om itscentral location in the hand.

Division of the flap was performed as earlyas 11 days and as late as 24 days after the initialprocedure. The average period between stageswas i5.9 days.

Objective measurement of range of motionin patients under 50 years of age was uniformlygood. A close scrutiny of the five patients olderthan 50 years revealed a minimal decrease inmotion, except in two patients (Table 1). PatientM.R., the oldest patient at age 76, had aprevious injury to a PIP joint, with pre-existingstiffness. Patient G.SI required an intramed-ullary K-wire across the DIP joint for a fracturein the injured digit. The results in this groupare in contrast to results in patients older than50 years in other series)’ 12

Pressure monofilament testing consistentlyshowed a slight decrease in sensitivity in tlheflaps, but all of the fingers fell within the rangeof "normal results," which were established bytesting the contralateral fingertips in the group.

Two-point discrimination averaged 8.25 rumin the cross-finger flaps, which is somewhat

Table i. Range of Motion in Injured and

and Joanne G. Burech

higher than the 6.0 mm reported by Gellis.6

Kleinert has stated that a two-point discrmina-tion level of less than 8 mm is functional.Thirteen of the 24 patients had results of 7 mmor less and 5 had a discrimination level ofgreater than 10 mm. Interestingly, 17 patientsdemonstrated a two-point discrimination levelin the flap that was actually better than thedonor site on the contralateral hand. This wasalso observed by Sturman and Duran,~9 whonoted that the flap can take on the sensorycharacteristics of the recipient finger tip.

Dexterity testing, as described by Moberg,in 8 patients with injuries to thumb, index, orlong fingers revealed that the tasks were per-formed, on the average, just 17 per cent moreslowly. In performing these tests, four patientsavoided using the injured finger, in each casean index finger.

Grip strength correlated more closely withhand dominance than ~vith the hand of injury.Pinch strength, measured as lateral pinch, pulpto pulp, and "g-jaw chuck," showed mild dim-inution in the aforementioned 8 patients. Lab~ral pinch was 88 per cent of normal; pulp topulp, 80 per cent; and 3-jaw chuck, 91 per cent.

Assessment of sudomotor function ~vas at-tempted with the Ninhydrin test, but the re-sults were gehel~dly unreliable and difficult toreproduce.

SUMMARY

Cross-finger flaps have been performed byour group in more than 200 patients. Subjectivequestioning and objective testing in a randomgroup of 23 of these patients confirms the valueof this procedure for reconstruction of the in-jured finger. It is reliable and flexible in itsapplication. The patients usually report theirflaps to be functional, durable, and free of pain.Cold intolerance, as with other methods ofreconstruction, remains a problem. Sensibilityin the flaps proved to be functional in themajority of patients. The preservation of lengthand range of motion is reflected in the fact thatdisability settlement was a rare occurrence.

Donor Fingers of Patients Older than 50 Years

PATIENT

P~NGE OF MOTION (DEGREE~)INJURED

AGE DIGIT MP PIP DIP TotalDONORDIGIT

IZ~NGE OF MOTION (DEGREES)

alp PIP DIP Total

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

58 Thumb 24/66 0/4569 Long 0/80 0/92 0/64

58 Little 0/81 0/107 5/6176 Ring 0/90 0/84 40/7054 Long 0/95 9/99 0/11

87 Long 0/90 0/100 0/60 2602.36 Ring 0/82 0/91 5/60 228244 Ring 0/83 0/100 0/59 242204 Little 0/84 0/75 10/41 190

196 Ring 0/100 9/91 10/35 207

Cross-Finger Flap 683

:1 by Gellis.6

it discrmina-s fl~nctional.mlts of 7 mmtion level of,, 17 patientsdnation levelter than thend. This was)uran,19 whothe sensory

.~er tip,by Moberg,

nb, index, or;ks were per-~er cent morefour patientsin each case

closely withand of injury.al pinch, pulp,ed mild dim-patients. Lab,rmal; pulp to~, .91 per cent.ction was at-t, but the re-nd difficult to

This flap has been applied in patients ofwidely varying ages with minimal morbidity.Overall patient satisfaction has been quite re-warding.

In the properly selected patient, the carefullyperformed procedure provides a superior meansof reconstruction for the injured finger with lossof significant soft tissue.

REFERENCES

1. Barclay, T. L.: The late results of finger-tip injuries.Brit. J. Plast. Surg., 8:38-42, 1955.

2. Bennett, J. E.: Fingertip avulsion. J. Trauma, 6:’249,1966.

~. Brody, G. S., Cloutier, A. M., and Woolhouse, F. M.:The finger tip injury--an assessment of management.J Plast. Reconstr. Surg., 26:80-90, 1960.

4. Buncke, H. J., and Harris, G. D.: Skin coverage forchallenging hand injuries. In Strickland, J. W., andSteichen, J. B. (eds.): Difficult Problems in HandSurgery. St. Louis, C. V. Mosby, 1982.

5. Curtis, R. M.: Cross-finger pedicle’ flap in hand sur-gery. Ann. Surg., I45:650-655, 1957.

6. Gellis, M., and Pool, R.: Two-point discrilninationdistances in the normal hand and forearm. J. Plast,Reconstr. Surg., 59:57-63, 1977.

7. Gurdin, M., and Pangman, W. J.: The repair of surfacedefects of fingers by trans-digital flaps. J. Plast.Reconstr. Surg., 5:368-371, 1950.

8. Horn, J. S.: The use of full thickness hand skin flapsin the reconstruction of injured fingers. J. Plast.Reconstr. Surg., 78:463, 1951.

9. Johnson, R. K., and Iverson, R. E.: Cross-finger ped-icle flaps in the hand. J. Bone Joint Surg.,53A:913-919, 197i.

10. Ketchum, L. D.: Skin flaps. In Green, D. P. (ed.):Operative Hand Surgery, Vol. 2. New York, Church-ill Livingstone Inc., 1982.

11. Kislov, R., aud Kelly, A. P., Jr.: Cross-finger flaps indigital injuries, ~vith notes ou Kirschner wire fixation.J. Plast. Reconstr. Surg., 25:312-322, 1960.

12. Kleinert, H. E., McAlister, C. G., MacDonald, C. J.,eta].: A critical evahmtion of cross finger flaps. J.Trauma, 14:756-763, 1974.

13. Miller, A. M.: Single finger tip injuries treated bythenm" flap. Haud, 6:311-319, 1974.

14. Moberg, E.: Objective methods for determining thefunctional value of sensibility in the hand. J. BoneJoint Surg., 40B:454-476, 1958.

15. Nicolai, J. P. A., and Hentenaar, G.: Sensation incross-finger flaps. Hand, 13:12-16, 1981.

~. Porter, R. W.: Fnnctional assessment of transplantedskin in volar defects of the digits. J. Bone Joint Surg.,50A:955-963, 1968.

17. Russell, R. C., VanBeek, A. L., Wavak, P., et al.:Alternative hand flaps for amputations and digitaldefects. J. Hand Surg., 6:399-405, 1981.

18. Smith, J. R., and Bom, A. F.: An evaluation of finger-tip reconstruction by cross-finger and palmar pedicle

~/~ flap. J. Plast. Reconstr. Surg., 35:409-418, 1965.¯ Sturman, M. J., and Duran, R. J.: Late results offinger-tip injuries. J. Bone Joint Surg., 45A:289-298,1963.

20. Tempest, M. N.: Cross-finger flaps in the treatment ofinjuries to the fiuger tip. J. Plast. Reconstr. Surg.,9:205-222, 1952.

2!. Thomson, H. G., and Sorokolit, W. T.: The cross-finger flap in children: A fbllow-up study. J. Plast.Reconstr. Surg., 39:482-487, I967.

22. Winspur, I.: Fingertip injuries. In Boswick, J. A., Jr.(ed.): Current Concepts in Hand Surgery. Philadel-phia, Lea and Febiger, 1983.

1300 Chapline StreetWheeling, West Virginia 26003

performed by~ts. Subjective,~ in a randomirms the value:ion of the in-flexible in its~, report their~d flee of pain.r ~nethods ofm. Sensibility~tional in theation of lengthn the fact that,ccurrence.

~ar8

~TION {DEGREES)

DIP Total

0/60 2605/60 2280/59 242

10/41 19010/35 207