Distal degloving injury is a common hand surgery injury with various repair methods, but improper treatment will seriously affect the post-operative appearance and function (1). Although revision amputation is simple, the length defect of the finger is compromised after operation. Although abdominal pedicled tubular flap can preserve the length of the finger, the finger is edematous and the sensory recovery is poor after surgery. Free toenail flap transplantation is a difficult operation with high risk, great damage to patients, and high requirements for surgeons (2–6).

At present, the digital dorsal fascial island flap has been widely used to repair the soft tissue defect of the dorsal or ventral finger (7–10). The crossfinger flap can repair the soft tissue defect of finger palmar and reconstruct the flap sensation, and it has the advantages of simple operation and low-operation risk (11, 12). Therefore, we designed and used digital dorsal fascial island flap combined with crossfinger flap to repair 19 cases of distal degloving injury of 19 fingers. The operation was safe and all the flaps survived with good clinical effect.

A total of 5 cases with post-operative flap blisters were treated at the time of dressing changes up to successful scab formation. Three cases with post-operative arterial crisis of finger arterial dorsal branch vessel were relieved after suture removal and tension reduction. All other skin flaps and skin grafts survived. Nineteen patients received follow-up between 3 and 26 months (average 14.6 months).

As shown in Table 2, the S-2PD score of dorsal finger flap was 6–11 mm (average 8.63 mm). The S-2PD score of the palmar finger flap was 5–10 mm (average 7.58 mm). The SWM score of the dorsal flap of the injured finger was 2.65–5.32 mm (average 4.11 mm). The SWM score of the palmar flap of injured finger was 3.23 to 5.13 mm (average 3.89 mm). Based on the CISS score, 17 patients with the dorsal flap of the injured finger reported no cold intolerance and 2 reported mild cold intolerance. A total of 15 patients of the palmar flap of injured finger reported no cold intolerance and 4 reported mild cold intolerance. According to the VAS score, 16 patients had no pain and 3 reported mild pain on the dorsal flap of injured finger. A total of 16 patients had no pain, 2 reported mild pain, and 1 experienced moderate pain on the palmar flap of the injured finger.

The active ROM of metacarpophalangeal (MCP) and IP joints of the injured fingers were satisfactory (Table 3). No statistical differences were observed in the ROM of MCP, proximal interphalangeal joint (PIP), and DIP compared with that of the contralateral side (pMCP = 0.157, pPIP = 0.120, pDIP = 0.301). The quality of the activity of the injured fingers showed no abnormality.

According to the Michigan Hand Outcomes questionnaire, 15 patients were strongly satisfied (score of 5) and 4 patients were satisfied (score of 4) with the appearance, whereas 16 patients were strongly satisfied (score of 5) and 3 patients were satisfied (score 4) with the function of the reconstructed finger. There was no obvious complication except for the low sensitivity of the skin flap and no nail plate growth.

The commonly used V-Y advancement flap, crossfinger flap, fascial island flap, and abdominal flap have their own advantages, disadvantages, and indications (19). V-Y advancement flap, cross-finger flap, and fascial island flap are effective in repairing small soft tissue defects in the fingers; however, it cannot achieve a good treatment effect for a large area of degloving injury (20). Although abdominal flaps can repair large areas of skin defects, their appearance is edematous, and the skin texture is very different from finger skin. In most cases, the sensation cannot be reconstructed, and a second operation is often required to repair the flap in the later period (19). However, local cutaneous flap provides better color, texture, minimal tissue contraction, and a higher survival rate, and is appropriate in case of tendon or bone exposure (21).

The digital dorsal fascial island flap and the crossfinger flap are commonly used in hand surgery with reliable blood supply. The crossfinger flap anastomosed with dorsal digital nerve can make the finger more sensitive and restore the sensory function earlier (12). We combined the two flaps to repair the soft tissue defect degloving injury of the distal segment of the finger, which can repair the wound defect at one time and preserve the function of the finger to the greatest extent (22, 23), while reducing the damage to the donor site and recovering the function of the affected finger as soon as possible. This method can change the large damage into several small damage areas, and change the large defect area into two small defects from the three-dimensional point of view. This operation method is suitable for clinical application and has a high application value.

The advantages of this method were as follows. (1) The digital dorsal fascial island flap and the cross-finger flap pedicle include the dorsal branch of the proper digital artery of the middle finger segment and surrounding fascial tissues, with rich blood supply, reliable blood circulation, and high survival rate. (2) The flap is easy to dissect without damaging the main nerve and vessels (15, 24). (3) The skin flap was removed from the tissue around the adjacent wound. The skin color and texture were similar to that of the original finger wound surface. The affected finger had good appearance without edema after repair. (4) Crossfinger flaps can carry bilateral dorsal branches of the proper digital nerves and anastomose the proper digital nerves in the recipient area to reconstruct the protective sensation of the flaps. (5) The ROM of the DIP of the injured finger after surgery is not different from the contralateral finger. The finger preserves the length of the finger and also obtains good function. There are some disadvantages. (1) Fingertip onychostroma needs to be completely excised, and there is no growth of the nail plate after the operation, which affects the appearance. (2) The dorsal finger skin is thin, and the digital dorsal fascial island flap contains the dorsal branch of the proper digital artery. The vascular pedicle of the skin flap leads to slightly edematous appearance on one side of the finger in some cases. (3). A second operation is needed to divide the pedicle of crossfinger flap. (4). After crossfinger flap surgery, the injured finger cannot move due to the connection between the adjacent finger and the injured finger. Three weeks after the pedicles were cut, finger stiffness may occur and active functional exercises are required.

The precautions for the method in our study were as follows. (1) When dealing with the venous return disorder of the flap, the suture should be removed and the tension should be reduced in 1–2 days after the operation, and the pedicle should be opened without suture. (2) During the sensory reconstruction of the crossfinger flap, the dorsal branch of the proper digital nerve needs to be dissected for a certain length to achieve an anastomosis with the stump of the proper digital nerve in the recipient area (25, 26). The nerve separation and anastomosis should be performed under a microscope. (3) Remaining damaged nail beds should be removed during the operation to avoid the formation of ingrown nails later. (4) The skin graft packing pressure should be appropriate in order to avoid the pedicle pressure caused by force transmission, affecting the blood supply of the flap. (5). When suturing the two-leaf tile flap, do not sew under tension, cover the pedicle with oily gauze, and do not press it when bandaging. (6). The patients started active ROM exercises with the help of a physical therapist after 3 weeks. Tactile stimulation was applied to the recipient site and continued until the patient returned to work.

There were some limitations in our study. The sample size was small and there was no control group. The follow-up time of this study was 3–26 months with an average of 14.6 months, and some patients had a shorter follow-up time. Therefore, large randomized controlled trials remain to be done in the future.

In conclusion, the digital dorsal fascial island flap combined with the cross-finger flap for repairing the distal degloving injury of the distal segment of the finger is a good surgical method, which is simple and easy to operate, can repair a large area of soft tissue defect, and obtain a satisfactory effect.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

The study was approved by the Ethics Committee of Tangshan Second Hospital (TSEY-LL-2020016). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

RH and YH conceived of the study and contributed to manuscript writing. RH, YH, and HW participated in data collection. RH, YH, HW, and WL contributed to results interpretation. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.