Full text of DOI:10.1016/S0020-1383(99)00205-3

Injury, Int. J. Care Injured 31 (2000) 215±218
www.elsevier.com/locate/injury
Donor ®nger morbidity in cross-®nger ¯aps
P. Paterson*, O.G. Titley, J.D. Nancarrow
West Midlands Regional Centre for Plastic Surgery, Wordsley Hospital, Stourbridge, UK
Abstract
We reviewed 16 patients who had cross-®nger ¯ap procedures carried out between 1991 and 1996 at the West Midlands
Regional centre for Plastic and Reconstructive Surgery. We looked speci®cally at the donor ®nger morbidity of each patient
with a median follow up interval of 43 months.
At follow up there were 10 patients with cold intolerance, eight patients with subjective joint sti€ness and a documented
reduced range of ®nger joint movement. Skin graft reconstruction of the secondary defect was associated with poor colour
match in eight cases (seven hyperpigmented, one hypopigmented) and visible contour deformity in eight cases. There were no
clinically signi®cant di€erences between split skin graft or full thickness skin graft for donor ®nger reconstruction.
Although cross-®nger ¯aps may provide soft tissue cover in a variety of ®nger pulp injuries, these results show an alarming
incidence of donor ®nger morbidity associated with such procedures. 7 2000 Elsevier Science Ltd. All rights reserved.
1. Introduction
®nger pulp injuries reconstructed with a cross-®nger
¯ap. All these injuries involved the loss of volar soft
tissue down to but not including bone. All the ¯aps
were performed as an emergency procedure by middle
grade surgeons out of normal working hours. The
cross-®nger ¯aps were raised leaving the paratenon
intact and sutured to the recipient site. No form of
splintage was employed postoperatively. After division
and inset of the ¯ap between 12 and 17 days, patients
were shown a range of passive and active motion exer-
cises. Mean hand clinic follow up was 8 months.
Patients were sent a questionnaire that focussed on the
problems associated with their donor ®nger and were
invited to a follow up clinic for an objective assess-
ment.
Cross-®nger ¯aps may be used in ®ngertip injuries
to reconstruct soft tissue losses resulting in exposed
tendon or bone. These ¯aps are relatively straightfor-
ward to perform and novice hand surgeons may be
tempted to use them. However, cross-®nger ¯aps are
associated with donor ®nger sti€ness, particularly in
those patients over 50 [1]. As an alternative more tech-
nically demanding homodigital ¯aps have been rec-
ommended [2,3]. Despite `common knowledge' of
donor ®nger morbidity after cross-®nger ¯aps only
anecdotal evidence exists in the literature to support
this. In an attempt to qualify and quantify donor ®n-
ger morbidity we reviewed patients who had under-
gone cross-®nger ¯aps in our unit in the preceding 5
years.
Sixteen patients (17 cross-®nger ¯aps), were reviewed
and examined. Fourteen patients were male age ranged
from 6 to 59 years ꢀmedian ˆ 41 years). Fifteen patients
were right handed; 10 had injured their dominant
hand; nine male patients were manual workers and all
sustained their injuries at work. Of the remaining ®ve
males three were students and two were unemployed.
One female patient was a housewife who sustained a
slicing injury on a knife; the other was involved in a
2. Patients and methods
Sixteen patients between 1991 and 1996 had their
* Corresponding author.
0020-1383/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.
PII: S0020-1383(99)00205-3

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P. Paterson et al. / Injury, Int. J. Care Injured 31 (2000) 215±218
road trac accident and required two cross-®nger
¯aps.
3. Results
Patients were asked to score their donor ®nger for
(a) sti€ness, (b) pain and (c) cold sensitivity each being
graded as excellent, good or poor. The same assessor
recorded: (i) colour matching (normal, hypo-, hyper-
pigmented); (ii) degree of contour deformity (none, de-
pressed, raised) and (iii) measured active and passive
range of movement at the metacarpophalangeal joint
(MCPJ), proximal interphalangeal joint (PIPJ) and dis-
tal interphalangeal joint (DIPJ) using a standard goni-
ometer measured to the nearest 58. These
measurements were also made in the same ®nger on
the other side to act as a control. From these measure-
ments the Strickland index [4] was calculated and the
outcome for each donor ®nger classi®ed as excellent,
good, fair or poor. Full thickness grafts were com-
pared to split thickness grafts with respect to donor
®nger sti€ness, colour match and contour deformity.
These results were analysed using chi-squared analysis
with Yates' correction, Fishers exact test and the
Mann±Whitney U-test.
Sixteen patients with 17 cross-®nger ¯aps were
reviewed. The time from injury to assessment ranged
from nine months to 64 months ꢀmedian ˆ 43:5). The
donor ®nger was the middle in 10 cases, the ring in
three and the index in four. The ¯ap was raised at the
level of the middle phalanx in 10 cases and proximal
phalanx in seven. The donor ®nger defect was recon-
structed with a full thickness skin graft (FTSG) in 11
cases (seven from the groin, three antecubital fossa
and one forearm). Five of these skin grafts were as-
sociated with donor ®nger sti€ness, seven were poorly
matched for colour (six hyperpigmented; one hypopig-
mented) and ®ve had a visible contour deformity.
Split thickness skin graft (SSG) reconstruction of
the donor ®nger was carried out in six cases (three
from the forearm, two from the thigh and one from
the hypothenar eminence). Four of these were associ-
ated with sti€ness, one was poorly matched for colour
(hypopigmented) and three had a visible contour de-
formity.
Although clinically there was a greater tendency for
the FTSG to become hyperpigmented Figs. 1 and 2,
Fig. 1. A FTSG used to cover the donor ®nger defect of a 51-year-
old Asian lady showing hyperpigmentation and a visible contour de-
formity.
Fig. 2. Another FTSG in a Caucasian male showing pigmentary
change.

P. Paterson et al. / Injury, Int. J. Care Injured 31 (2000) 215±218
217
statistically, there were no signi®cant di€erences
between the use of FTSG and SSG in covering the
donor defect.
advancement ¯aps scored better than the cross-®nger
¯aps which scored the same as a simple split skin
graft.
Eight patients had subjective joint sti€ness and a
documented reduced range of ®nger joint movement
within the donor ®nger Table 1. The remaining eight
patients scored a Strickland index of 100.
To our knowledge our study is the ®rst to speci®-
cally address the problem of donor ®nger morbidity
following a cross-®nger ¯ap procedure. Half of our
patients su€ered long-term ®nger joint sti€ness; half
had either a hyperpigmented or a hypopigmented
donor site and half had a visible contour deformity.
Because of our small study group we found no statisti-
cally signi®cant di€erence between the use of split
thickness and full thickness skin grafts in providing
donor ®nger cover. However, the data and our clinical
experience leads us to believe that the simpler split
skin graft compares favourably to the more time con-
suming full thickness graft.
Sti€ness occurred in seven out of nine patients
whose age was greater than the median (41 years)
range 43±59 years and in one out of seven whose age
was less than the median, range 6±41 years. Because of
the small number of patients in our group it was not
possible to assume normality of the data and a Mann±
Whitney U-test gave a p-value of 0.058 which was not
signi®cant at the 95% level for age related ®nger sti€-
ness. Ten patients su€ered cold intolerance in the
donor ®nger; although not speci®cally assessed cold
intolerance was common in the injured digit too.
Three patients were troubled with eczematous
changes at the junction of the graft and it's inset.
None of the patients complained of pain within the
donor ®nger.
Of the eight donor ®ngers that were poorly matched
for colour, seven became hyperpigmented Ð six of
those were covered with a FTSG (®ve harvested from
the groin) only one SSG showed a similar colour
change out of a total of six grafts. This ®nding contra-
dicts earlier work which states that SSG's are more
likely to become pigmented than FTSG's (Ponten, B
1960). Anecdotally the groin donor site is said to pro-
duce grafts which become more readily pigmented
when compared to those taken from around the head
and neck region. There are no studies available to con-
®rm or deny this, however in the light of our results
we suggest that if FTSG are used it may be more
appropriate to avoid the groin donor site in those
areas exposed to the sun.
4. Discussion
Cross-®nger ¯aps are a relatively straightforward
method of ®nger and ®nger tip soft tissue reconstruc-
tion. These ¯aps can provide cover for exposed bone
and tendon with a reliable, durable pad of soft tissue
[1,5,6] However, others have increasingly condemned
these ¯aps for reconstructing ®nger tip injuries citing
morbidity associated with them.
Ma et al. [7] carried out a prospective randomised
study of seven methods of treating simple ®nger tip
injuries in a group of 200 patients. They compared
split skin grafts, local advancement ¯aps, amputation,
simple dressings and cross-®nger ¯aps. They concluded
that cross-®nger ¯aps provided little advantage over
other methods of reconstruction and were associated
with more healing problems, a greater degree of weak-
ness and a greater loss of total active movement in the
Kleinert, suggested avoiding cross-®nger ¯aps in
patients over the age of 50 because of sti€ness in the
reconstructed ®nger [1]. Our study concentrated on
donor ®nger sti€ness which we found to be clinically
problematic in patients over the age of 41 years. With
the small number of patients in our study group nor-
mality of the data could not be assured and a Mann±
Whitney U-test gave us a p-value of 0.058 for age -re-
lated donor ®nger sti€ness. More patients would need
to be recruited before statistical signi®cance could be
achieved.
injured ®nger. From
a cosmetic view the local
We have seen an alarming incidence of donor ®nger
morbidity. Half of our patients su€ered joint sti€ness;
reduced range of movement; colour mismatch and con-
tour deformity. We can con®rm the anecdotal reports
of donor ®nger morbidity. We have shown that these
are in fact a common occurrence, and at times produce
a donor ®nger which is both sti€ and cosmetically dis-
pleasing.
Table 1
Age related donor ®nger sti€ness a Strickland index of 100 is normal
Age
Strickland index
51
46
37
59
45
43
46
49
71
83
75
84
This morbidity is acceptable if other methods of
reconstruction are not practical. However the unse-
lected use of cross-®nger ¯aps for ®nger reconstruction
is no longer acceptable. If ¯ap reconstruction is needed
for a ®nger injury we support the view that, in order
93
82; 65
70
64

218
P. Paterson et al. / Injury, Int. J. Care Injured 31 (2000) 215±218
to con®ne the injury to one ®nger, homodigital ¯aps
should be used where possible.
References
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skin grafts are preferable to full thickness and aggres-
sive therapy and splintage of the donor ®nger are
essential.
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Acknowledgements
Mr. M.F. Fatah for allowing us to recruit his
patients into our study. Kim McAllister (Audit coordi-
nator) Wordsley Hospital for her help with data collec-
tion. Guy Tuxford (research assistant) Department of
Public Health Medicine Dudley Health Authority, for
his help in providing the statistical data. Medical pho-
tography at the Wordsley Hospital for providing the il-
lustrations and colour slides.
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