Cross Finger Research Articles

Cross finger flap cover for fingertip injuries

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Fingertip injuries are the most common form of hand injuries. Restoration of the anatomy is a technical challenge and is one of the basic tenets of the management of fingertip injuries. The cross finger flap is simple and easy to do and is a very useful tool in reconstruction of the pulp of the finger. The project aimed to study the efficacy of cross finger flap in the coverage of fingertip injuries.</span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">The study was conducted on a prospective basis in Sri Ramachandra University Hospital in Chennai. The study period was from May 2013 to August 2016. All adults who had fingertip injuries who had undergone cross finger flap cover were included in the study. Patients who had other flaps for reconstruction and who were lost for follow-up were excluded from the study. Preoperative parameters which were recorded were mechanism of injury, size of defect, size of the flap, location of donor site and method of coverage of secondary defect. Outcome measures recorded were flap viability, flap sensibility using two-point discrimination, range of motion of fingers, grip strength and presence of other complications</span>.<strong></strong></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">40 patients were included in the study. Six were lost for follow-up. Mean follow-up was 14 months. All flaps survived. Full range of motion was obtained in 87% of patients. Average grip strength was 94% for dominant hand injuries and 78% for non-dominant hand injuries. Mean quick DASH score was 10.5. Mean two-point discrimination was 15.4 mm. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">Cross finger flap is very effective for coverage of volar fingertip defects with minimal residual problems.</span></p>

Reconstruction of large area defect of the nail bed by cross finger fascial flap combined with split-thickness toe nail bed graft: A new surgical method.

Fingertip injury commonly results in avulsion of the nail bed. For large area defects of the nail bed with distal phalanx exposure, methods for reconstruction of soft tissue defects are scarcely mentioned in the literature.From May 2014 to January 2016, 6 patients with large area defects of the nail bed with distal phalanx exposure were enrolled. A new surgical method, cross finger fascial flap combined with thin split-thickness toe nail bed graft, was applied in all patients.All the 6 patients were followed-up at least 3 months. Good blood supply and no infections were observed. The lengths of the thumb or fingers were preserved. Acceptable appearance and nail bed growth were noted. The donor sites showed no dysfunction or deformity.Cross finger fascial flap combined with thin split-thickness toe nail bed graft is a new and rewarding surgical method to reconstruct large area defect of the nail bed with distal phalanx exposure.

A novel complete retroperitoneal laparoscopic nephroureterectomy via modified three ports approach

Objective To assess the clinical efficacy of a modified complete retroperitoneal laparoscopic nephroureterectomy via 3 port approach. Methods From August 2013 to February 2016, 23 patients with complete retroperitoneal laparoscopic renal and ureteral sleeve resection were treated with modified three port approach, including 15 males and 8 females. The average age was 67 years old (ranging 44-83 years old). All patients had complained about the hematuria before operation and urine exfoliated cells showed moderate to severe nuclear atypia. All patients accepted the abdominal CT and urography CTU examination, pre-operatively. All of them was diagnosed localized upper urinary tract malignant tumors based on those images, including 13 cases in the pelvis, and 10 cases in the upper segment of the ureter. No chemotherapy, radiotherapy or immunotherapy was performed before surgery. No patients have the history of severe basic disease or upper urinary procedure.The operations were performed under general anesthesia, patients take the contralateral back 30 degrees slope, low elevation head foot, waist bridge, side waist stretch. In the anterior superior iliac spine perpendicular to the line 2 cm parallel to the lower intersection of the rib border were disposed into the 12 mm trocar. Above the anterior superior iliac spine two cross finger level with the intersection of the anterior axillary node, we placed into the 10 mm trocar placement lens. Laparoscopic placement of third casing form an isosceles triangle with the first two casing. The renal fascia was incised with an ultrasonic knife from the renal dorsal side, and the renal hilum was isolated from the kidney by suction aspirator. The renal artery and vein were separated and closed by hem-o-lok. Along the psoas muscle surface to ureter, ureteral clipping by hem-o-lok but not to cut off the free distal ureteral, the lens is composed of first casing into, using ultrasonic knife to free ureter to the bladder wall segment, with 30 mm endoscopic stapler ureter and bladder wall cut off part. Operation time, blood loss and postoperative recovery were recorded in 23 cases. Results All 23 cases were successfully operated without related the operative complication. The operative duration ranged from 3.5 to 6.1 h (mean 4.8 h), the blood loss was 30-880 ml (mean 304 ml), and the postoperative stay was 8-30 d (mean 17.8 d). There are 3 cases of positive lymph node by postoperative pathological reports. Within 2 to 30 months following up, 2 patients died of tumor progression in 6 months after surgery. 4 patients were diagnosed with bladder cancer in 15 months, 15 months, 21 months, 24 months after surgery, respectively. And the transurethral resection of bladder tumor was performed. Conclusion The modified complete retroperitoneal laparoscopic nephroureterectomy via three ports is safe and reliable. Key words: Retroperitoneoscopic; Nephroureterectomy; Via three ports

Adipofascial plus cross-finger flap augment reconstructive options in thumb defects: A case report

Cross-finger flaps are a powerful tool in terms of soft tissue reconstruction for defects of the fingers and thumb. In conditions where the cause is based on to infection or inflammation, there is always doubt on the part of plastic surgeons with regards to skeletonizing the pedicle for ease of transfer. Here, we present a case of cross finger flap with inclusion of an adipofascial component for reconstruction of the thumb soft tissue defect. The adipofascial component helps in reducing donor site exposure to extensor expansion and helps by filling up the deficit in recipient defect. In the current study, we used a hyperbaric oxygen therapy as an adjunct during the treatment process. The results were satisfactory with no flap complications.

Algorithmic approach to the prevention of unnecessary fasciotomy in extremity snake bite

BackgroundIn the literature, there is a lack of a consensus about the occurrence of the compartment syndrome due to the snake bites. There are different concepts for the surgical treatment of the threshold value of the chamber pressure. There are many different classifications and assessment criteria for the snakebites. PurposeThere is not any appropriate classification in order to the assessment of extremity snake bites while making a decision for fasciotomy. We aimed to standardize the follow-up and decision making to perform fasciotomy with a new classification system for the snakebites using objective data. Patients and methodsThe data of all patients were recorded prospectively between 2006 and 2011. A total of 97 patients (64 male, 33 female) with a mean age of 30.94±14.04 were followed-up. During the evaluation of the patients, we used a new classification system that was improved for the extremity bites. We classified the patients due to their signs into four groups as for the classification system. Results40 patients with compartment like symptoms were carefully followed for 48–72h, and only three patients required fasciotomy where full recovery was achieved in 37 patients. Coverage of the defects was performed with full thickness skin grafting in 4 patients and cross finger flap in two patient. In two patients, the defects were located on the palmar aspect of the thumb. Thus, we applied Kite flap for skin coverage. Reverse dorsal digital artery flap was performed in eight patients and dorsal interosseous metacarpal flap in six patients. Four patients underwent an amputation. Two patients had web reconstruction due to first web contracture. ConclusionsWe present a large series of snake bite injuries and propose a classification and treatment recommendations. Fasciotomy should only be done while the measurement of intra-compartment pressure is above 55mmHg as snakebite can mimic the compartment syndrome. Level of evidenceIII–IV.

A Simple Dressing Technique Following Dermofasciectomy and Full Thickness Skin Grafting of the Fingers in the Treatment of Severe Dupuytren's Contracture.

Dupuytren's disease with severe finger contractures and recurrent contractures following previous surgery often have extensive skin involvement. In these severe cases, excision of the diseased chord along with the involved skin is a good option to reduce the risk of recurrance. The resulting skin defect can be covered with a full thickness skin graft (FTSG) or a cross finger flap. Cross finger flaps have donor finger morbidity and hence a full thickness graft is usually preferred. The FTSG extending to the midlateral margins on both sides of the finger reduces the risk of joint contracture due to graft shrinkage. Once the FTSG is sutured in place, the standard practice is to compress and secure the graft to its recipient bed with a tie-over dressing and this can be time consuming. We present a simple dressing technique to secure the FTSG without the need for a tie-over dressing.

Hyperbaric oxygen therapy improves outcome of snake envenomation: tertiary center experience

Aim: Snakebite injuries of the extremities are common in tropical India among those involved in farming and outdoor activities. These injuries often complicated by cellulitis, gangrene, regional lymphadenopathy, compartment syndrome, bleeding abnormalities, septicemia, hypotension, and disseminated intravascular coagulation, resulting in significant morbidity and mortality. The purpose of the study is to share our experience of hyperbaric oxygen (HBO) therapy in the management of snakebite injuries. Methods: All patients who were treated for snakebite injuries in our department between October 2012 and October 2013 were included in the study. Results: Out of a total 395 patients, 174 patients treated with anti-snake venom with a mortality of 17 posttreatment. Forty-four out of the 174 patients was in the pediatric age group. Out of the patients referred to our department, 23 presented with cellulitis, 7 with compartment syndrome and 17 for the management of soft tissue cover over the extremities. Of the 47 patients, 30 involved the lower extremity and rest involved the upper extremity. All patients were subjected to HBO therapy as an adjunct. Six patients required flap cover: cross finger flap (n = 2), anterolateral thigh free tissue transfer (n = 1), lateral supramalleolar flap (n = 1), groin flap (n = 1), and dorsal metacarpal artery flap (n = 1). There was no need for fasciotomy among the patients who suffered impending compartment syndrome. Conclusion: HBO therapy may reduce the incidence of fasciotomy and increase the effectiveness of plastic surgical modalities if administered early and may be used as a useful adjunct in the management of snake envenomation injury.

Covering the Dorsal Finger Defect with Reverse Cross Finger Flap

Covering the Dorsal Finger Defect with Reverse Cross Finger Flap

Macrosurgery for fingertip amputations

Due to the high concentration of sensitive receptors, the fingertip is widely used in plenty of activities and, therefore, frequently exposed to trauma and amputation. Simple revision amputation was used in the past for the treatment of these injuries. However, replantation, revascularization, or reconstruction allows preservation of the nail, length of the digit, and, mainly, sensibility of the pulp. Undoubtedly, the best way to restore function to an amputated digit is to restore the amputated part by microsurgical vascular anastomosis. However, the replantation of very distal segments is technically challenging due to the size and fragility of the vessels. Furthermore, the amputated part is not always available. Reattachment of the amputated part without vascular anastomosis is described as composite graft [1]. Other authors described different ways for improving the success rate. Brent [2] described the reattachment in amputations that occurred between the lunula and the DIP joint by performing deepithelization of the amputated part and embedding it in a subcutaneous pocket in the contralateral chest. Arata et al. [3] modified this procedure using the ipsilateral palm as the pocket site. We consider subzone 1 Ishikawa level as suitable for reconstruction without replantation. In this case, a local flap can adequately restore function and appearance. The neurovascular homodigital advancement flap [4] is the most useful flap for coverage of the amputated part. For larger areas that cannot be covered with a homodigital advancement flap, we use innervated cross finger flaps [5]. The Moberg flap is a good option to reconstruct medium-size defects of the pulp of the thumb [6]. For covering larger areas, we use the first metacarpal island flap [7]. Raising a racket flap as proposed by Holevich [8] adds safety regarding venous congestion, once a subcutaneous tunnel is avoided, and can improve cold intolerance, since it transfers more nerve branches to the thumb allowing for a better temperature control [9]. The nail complex tissues, as hyponychium, paronychium, and sterile matrix cannot be reconstructed with local tissue. If the amputated part is available, these parts can be used as grafts applied to the flap used to reconstruct the pulp[10]. The eponychial flap [11] can be used to increase the exposed part of the nail bed. This is achieved by removing a rectangle of dorsal skin and performing a proximal translocation of the eponychium.

Neglected post burns contracture of hand in children: Analysis of contributory socio-cultural factors and the impact of neglect on outcome

No study has ever evaluated the causes and effect of neglect on the outcome of post burns contractures of hand in children. 66 hands in 61 children (mean age 12.22 years) with a mean neglect of 11.6 years (range 5-17 years) were assessed for the causes of neglect and the outcome of surgery. Average follow up was 6.6 years. The results were assessed in two groups of 5-10 years neglect as group I and >10 years neglect as group II. In a total number of 134 contracted rays in 66 hands, the surgical procedures included local Z/V-Y flap (51 rays), cross finger flap (48 rays), full thickness graft (35 rays). Additional external fixator with a distracter was used in 3 patients treated at a delay of 14, 16 and 17 years. 50 (81.96%) patients belonged to rural and slum areas. The reasons for delayed treatment included poverty - 33 patients, lack of awareness of surgical treatment - 16 patients; and indifference of parents - 12 patients. 44 (72.13%) children were illiterates. With treatment the average DASH score improved from 65.10 to 36.90 (p<.000) and from 68.14 to 45.93 (p<.000) in group I and II respectively. The results were significantly superior in group I (p<.000). The main factors for neglect in treatment of post burns contracture include poverty, lack of awareness and illiteracy. All the patients showed significant improvement in function after the surgery. Contractures with higher neglect had significantly inferior outcome.

Which nostril should be used for nasotracheal intubation: the right or left? A randomized clinical trial

Study ObjectiveTo determine which nostril is more suitable for nasotracheal intubation in patients with normal patency of both nostrils. DesignProspective, randomized clinical trial. SettingOperating room of a university medical center. Patients191 ASA physical status 1 and 2 patients scheduled for elective oral surgery requiring general anesthesia with nasotracheal intubation. InterventionsPatients were randomized to two groups to undergo nasotracheal intubation through the right nostril (Group R; n = 96) or the left nostril (n = 95). Standard traditional nasotracheal intubation was performed using the Macintosh laryngoscope. Tube rotation was attempted for alignment toward the glottis, and Magill forceps were then used to assist intubation, as necessary. MeasurementsEpistaxis was inspected in the pharynx after the tube tip was passed through the nasal cavity and 15 minutes after nasotracheal intubation was completed. Intubation time was the interval between when the anesthesiologist opened the patient’s mouth with the cross finger maneuver and when the tube was connected to the anesthetic circuit after nasotracheal completion. Main ResultsThe frequency of epistaxis was significantly lower in Group R than Group L (P = 0.0006). Although there was no significant difference in nasal passage time between two groups, the intubation time in Group R (24.5 ± 9.4 sec) was shorter than in Group L (30.5 ± 15.6 sec; P = 0.0015). ConclusionNasal intubation via the right nostril is more safely performed than with the left nostril. Because of less epistaxis and faster intubation.

Succesfull multidisciplinary treatment in a case of Buerger

A 58-year-old male patient had diagnosed with Buerger's disease for 30 years. Patient referred us with non-healing scar on his right thumb. In another center, amputation was suggested due to his non-healing scar. We have assessed the patient multidisciplinary with cardiovascular and plastic reconstructive esthetic surgery for non-healing scar. During the multidisciplinary surgical treatment we applied radial artery endarterectomy, cross finger flap reconstruction, after operation medically we have treated with cilostazol. Patient's scar completely healed. Follow up one year patient have no problem and radial artery in angiography was opened.

Cross Finger Dorsal Adipofascial Flap-is It a Aesthetically Better Variant?

The cross finger flap is a useful option for coverage of finger defects. The Adipofascial flap, a variant has been a good option being aesthetically more acceptable. Since hand is generally exposed part, we tried to find out the aesthetic value of the adipofascial cross finger flap. We operated on 15 patients who had complex defects on the fingers, who needed a flap cover and accepted for the adipofascial variant. We asked for ten independent non-medical literate persons to rate the photos of donor site and recipient site of these patients. We also requested the same ten people to rate the photos of similar, paired defects of the standard flap, which were obtained from the department archive. All the flaps survived. The mean score for adipofascial flap donor finger was 3.859 and it was 3.6 for the donor finger of the standard cross finger flap. The Cornbach's alpha of the interpretors was more than 0.7 for donor fingers and more than 0.9 for recipient fingers. The ICC was 0.767 foradipofascial donor finger and more than 0.9 for recipient fingers of both flaps. Adipofascial cross finger flap may be an aesthetically better flap.

Clinical comparison on cross finger flap and reverse dorsal digital island fascial flap for repairing of fingertip defects

Objective To investigate the best operative method for repairing of fingertip defect,we evaluated the functional recovery of fingertip defect which was repaired by cross finger flap or by reverse dorsal digital island fascial flap.Methods Form January 2009 to June 2011,80 cases (88 digits) of fingertip defects were treated with surgical flaps.Emergency operations were performed in 72 cases of 78 fingertip defects.Selective operations were performed in 8 cases of 10 fingertip defects.The flaps measured 1.5 cm × 1.5 cm to 2.5 cm×2.0 cm.The cross finger flap group (group A) contained 38 cases of 42 fingers.The reverse dorsal digital island fascial flap group (group B) contained 42 cases of 46 fingers.Three months later,the functional recovery of the injured fingers was compared between the two groups.Results All flaps survived completely.According to the hand functional evaluation criteria,the results of group were graded as excellent in 10 digits,good in 24 and fair in 8,with 81.0％ overall excellent and good rate.The results of group B were rated as excellent in 25 digits,good in 19 and fair in 2,with 95.7％ overall excellent and good rate.The hand functional evaluation was significantly different between the two groups (P ＜0.05).Conclusion Reverse dorsal digital island fascial flap is an effective,scientific and reliable method to repair fingertip defects. Key words: Surgical flap; Finger injuries; Treatment outcome

Comparison of repair distal soft tissue defect with two kind of reverse digital artery island flaps

Objective To analysis the clinic outcome (similarities & differences, indication and caution) of repairing fingertip soft tissue defect with two kind of reverse digital artery island flaps with the palmar cutaneous branch of proper digital nerve. Methods From January 2000 to Auguest 2008, all 500cases (514 fingers) were repaired with reverse homodigital artery island flap (263 fingers of 250 cases) and reverse cross finger digital artery island flap(251 fingers of 250 cases).All cases were followed up from 3-8years,compared with flap range,finger extension,sensory rehabilitation,et al. Results All flaps (A & Bgroup) of 500 cases (514 fingers) survived.According to flap range,cross finger flap was better than homodigital flap (P ＜ 0.05); according to finger extension,homodigital flap better than cross finger flap (P ＜0.05); according to sensory rehabilitation,homodigital flap little better than cross finger flap(P ＜ 0.05); according to long-term follow-up, all had no obviously different (P ＞ 0.05). Conclusion Homodigital flap can cover distal soft tissue defect less than 2.0 cm× 2.5 cm, cross finger flap is a better choice for more than 2.0cm×3.0cm of distal soft tissue defect. According to the flap cover area, cross finger flap is first choice,and to finger extension & sensory rehabilitation,homodigital flap is first choice; accoding to finger movements,two kinds of flaps are all good choice. Key words: Homodigital flap; Cross finger flap; Island flaps; Finger; Microsurgery

Distally based cross-finger flaps for amputation stumps in avulsion amputations

Background:Though advances in microsurgery have resulted in better survival rates of replants, replanting crushed and avulsed digits are difficult. If replantation is not possible these digits need local tissue cover to retain length.Patients and Methods:Twenty seven patients underwent distally based cross finger flaps for coverage of exposed vital structures over the amputation stumps.Results:All the flaps survived well. They provide good quality thin pliable tissue over the fingertips and help in achieving near normal range of movements in injured digits.Conclusion:Distally based cross finger flap gives tissues of right dimensions, at the most desired site, making reconstruction of these difficult problems quiet easy.

Correction of Long Standing Proximal Interphalangeal Flexion Contractures with Cross Finger Flaps and Vigorous Postoperative Exercises

PurposeWe reviewed the results of cross finger flaps after surgical release and vigorous postoperative exercises for long-standing, severe flexion contractures of the Proximal Interphalangeal (PIP) joints of fingers.Materials and MethodsIn 9 patients, all contracted tissue was sequentially released and the resultant skin defect was covered with a cross-finger flap. The cause of the contracture was contact burn in 4, skin graft in 3, and a previous operation in 2. The mean follow-up period was 41.2 months.ResultsThe mean flexion contracture/further flexion in the joints were improved from 73.4/87.8° to 8.4/95.4° at the last follow-up. A mean of 19.5° of extension was achieved with vigorous extension exercise after the operation. The mean gain in range of motion (ROM) was 79.4°. Near full ROM was achieved in 3 cases. There were no major complications.ConclusionsIn severe flexion contractures with scarring of the PIP joints of fingers, cross finger flaps after sufficient release and vigorous postoperative exercise seems to be a reasonable option to obtain satisfactory ROM of the joints.

Vohwinkel syndrome: treatment of pseudo‐ainhum

Vohwinkel syndrome or keratoderma hereditaria mutilans is a rare autosomal dominant palmoplantar keratosis which manifests in infants and becomes more evident in adulthood. Patients with this mutation present hyperkeratosis of the palms and soles, constricting bands of the digits, usually at the fifth, and starfish-shaped hyperkeratosis on the dorsal aspects of the hands and feet. The disease mostly occurs in white women, where constricting fibrous bands appear on the digits and can lead to progressive strangulation and auto-amputation (pseudo-ainhum). The treatment of this keratoderma is very difficult and tends to be symptomatic: topical keratolytics and systemic retinoids have been used to treat hyperkeratosis, but without consistent results. Reconstructive surgery is utilized for the treatment of pseudo-ainhum. In this study, we present an additional case of Vohwinkel syndrome in which constrictive bands of the fifth digit in the left hand were treated with a cross finger flap, with a favorable outcome after 18 months of follow-up.

A reverse flow cross finger pedicle skin flap from hemidorsum of finger

A reverse-flow cross-finger pedicle skin flap raised from the hemidorsum has been used, which is a modification of the distally based dorsal cross-finger flap. The flap is raised from the hemidorsum at a plane above the paratenon, the distal-most location of the base being at the level of the distal interphalangeal joint. Thirty-two flaps were used from as many fingers of as many patients. Of these, 31 (97%) flaps survived fully; there was stiffness of finger in one (3%) patient and the two-point discrimination was 4-8mm (n=14). Follow-up period was 2 months to 3 years, the median being 1 year and 3 months. The advantages of this flap are that there is less disruption of veins and less visible disfigurement of the dorsum of the finger when compared to other pedicled cross-finger skin flaps. The disadvantage of this flap is its restricted width. It is recommended as the cross-finger pedicle skin flap of choice when the defect is not wide.

Reversed Dermis Cross finger flap for dorsal finger defects: A Case Report

Digital trauma associated with exposure of deep structures can lead to significant functional loss unless prompt soft tissue coverage is provided. The dorsal digital defect always poses a challenge for the reconstructive surgeon as not many options are available loco-regionally. The Reversed deepithelialized cross finger flap, which is a modification of the traditional cross-finger flap, provides a good cover and has been found to be a reliable option for reconstructing dorsal defects of the digit.