Full Length Article
Long-term outcomes of homodigital
neurovascular island flap reconstruction
of fingertip injuries in children
Tugrul Yildirim , Ozgun Baris Gunturk, Kubilay Erol and
We evaluated the long-term functional and cosmetic results of homodigital neurovascular island flap (NIF)
used to reconstruct extensive pulp defects with bone exposure in children. Twenty-three children (mean age
4.8 years, range 1–10 years) with fingertip injuries were reconstructed with a pedicled homodigital NIF and
evaluated in terms of sensation quality, cold intolerance, scar formation, nail deformity, range of motion and
overall finger length at a mean follow up of 7.8 years (range 2–13). Eleven patients reported cold sensitivity in
the operated fingertip, and 15 presented with hook nail deformities at the final follow-up. The total active
motion of the injured finger was significantly lower than that of the uninjured side (p<0.001). NIFs is a safe,
reliable reconstructive treatment for fingertip loss in children, but commonly encountered issues in the long
term include an extension lag of the interphalangeal joints, hook nail deformities and cold intolerance.
Level of evidence: IV
Children, fingertip injuries, fingertip defect, homodigital neuvascular island flap
Date received: 2nd June 2022; revised: 1st December 2021; accepted: 23rd May 2022
Fingertip injuries are extremely common in children
(Kubus et al., 2011; Macgregor and Hiscox, 1999).
The majority of these can be treated conservatively
by conventional semi-occlusive dressings or silicone
finger caps with excellent results (Georgoulis et al.,
2021; Hoigne et al., 2014; Schultz et al., 2018).
However, about 25% of these injuries are reported
to be more severe and necessitate surgical treat-
ment (Macgregor and Hiscox, 1999; Schultz et al.,
2018). These are usually characterized by severe
soft tissue loss with exposed bone, requiring soft
tissue coverage in order to provide reliable wound
healing and the prevention of osteomyelitis. Distal
fingertip replantation may confer the best results in
more proximal amputations if technically possible
but if not, composite grafting may be considered
(Dubert et al., 1997). When the distal part is missing,
flap reconstruction with a V-Y advancement flap can
be an option for limited soft tissue loss, however,
a pedicled flap may be necessary in more extensive
defects (Haehnel et al., 2019; Usami et al., 2015).
The homodigital neurovascular island flap (NIF) is
an established local flap used especially for volar
oblique pulp loss exceeding 1 cm in diameter with
exposed bone (Kayalar et al., 2011). It is relatively
simple to harvest with several theoretical advan-
tages, including reconstruction of lost pulp using
similar tissues, retained sensibility and minimal
donor-site morbidity (Adani et al., 1997; Varitimidis
et al., 2005; Venkataswami and Subramanian, 1980).
Although its application and long-term results in
Hand Microsurgery Orthopedics Traumatology Hospital (EMOT),
Tugrul Yildirim, Hand Microsurgery Orthopedics Traumatology
Hospital, 1418 Sk. No.14 Kahramanlar, 35230 Izmir, Turkey.
Journal of Hand Surgery
2022, Vol. 47(8) 845–850
!The Author(s) 2022
Article reuse guidelines:
adults have previously been reported in several
articles, the outcomes of this flap in children have
not been studied extensively, with only a single arti-
cle in the literature favouring its use in pulp defects
(Wang et al., 2011).
The aim of this study was to evaluate the long-
term functional and cosmetic results of homodigital
direct flow NIF used to reconstruct extensive pulp
defects with exposed bone in children.
This is a retrospective case series involving children
whose fingertip loss was reconstructed with a pedi-
cled homodigital NIF. The study was approved by the
institutional review board of the hospital, where all
the patients were treated. Exclusion criteria included
patients older than 12 years of age at the time of
operation, patients with multiple finger injuries,
cases with less than 2 years follow-up and those
who had an injury or operation of the same finger
on the contralateral hand.
A standardized evaluation protocol was applied to
all patients during the last follow-up. Demographic
data, including age at the time of operation, sex,
operated finger and follow-up time of the patients,
were recorded. The initial and current radiographs
and operative pictures were reviewed in order to
classify injuries according to Ishikawa’s classification
of subzones and to determine the exact flap size
(Evans and Bernardis, 2000). An independent observ-
er (T.Y.), who is an orthopaedic surgeon with 4 years
of experience in hand surgery and not part of the
operative team, assessed the aesthetic and function-
al results of the operated fingers. The reconstructed
pulp was evaluated for atrophy, sensation quality,
cold intolerance, scar formation, nail deformity and
overall aesthetic appearance. The sensitivity of the
reconstructed pulp was assessed using Weber’s
static two-point discrimination test (s-2PD)
(Baseline Dellon 2-Point Disk-Criminator, NY, USA)
and the Semmes–Weinstein monofilament (SWM)
test (Baseline Tactile monofilament, 6-piece Set,
NY, USA). Hook nail deformity was classified using
the Lim classification (Lim et al., 2008) (Figure 1). An
11-point rating scale (0 ¼extremely dissatisfied,
10 ¼extremely satisfied) was used to evaluate over-
all patient satisfaction (Arsalan-Werner et al., 2019).
The operated finger was also evaluated for gener-
al atrophy, sensation quality on the donor half and
active range of motion of the metacarpophalangeal
(MCP), proximal interphalangeal (PIP), and distal
interphalangeal (DIP) joints of the fingers, as well
as the MCP and interphalangeal (IP) joints of the
thumbs, which were measured with a handheld goni-
ometer (Jamar Stainless Steel Finger Goniometer,
Pakistan). The total active motion (TAM) of the oper-
ated fingers was then calculated using Strickland’s
method, in which TAM equals the combined active
flexion minus the combined extension deficit of the
joints (Strickland and Glogovac, 1980). The distal
phalanx length of the operated side was measured
radiologically and compared with the same finger on
the opposite hand in order to detect any initial bone
loss effects on the hook nail deformity formation.
The middle and proximal phalanx lengths of the
operated fingers and proximal phalanx length of
the operated thumbs were also measured radiolog-
ically and compared with the uninjured contralateral
finger and thumb, respectively, to detect any general
finger atrophy due to the sacrifice of one of the two
neurovascular bundles during flap elevation.
All operations were performed under general anaes-
thesia, with a pneumatic tourniquet and loupe
Figure 1. Lim’s classification for degree of hook nail
deformity (Lim et al., 2008).
846 Journal of Hand Surgery (Eur) 47(8)
magnification. Following debridement of the wound,
the size of the flap was determined and marked on
the donor site, which was located just proximal to the
defect. Visualization of the integrity and quality of the
neurovascular bundle were always performed prior
to flap elevation. A volar lateral zig-zag incision was
preferred for preserving postoperative joint motion.
The flap was designed in a triangular shape with the
tip facing proximally, never extending beyond
the proximal IP joint crease (Figure 2(a)). Distally,
the dimensions of the flap were extended to the
entire width of the defect (Ventakaswarmi and
Subramanian, 1980). The neurovascular bundle was
freed up to the MCP joint crease with a cuff of soft
tissues around it in order to preserve the venous
inflow (Figure 2(b)). After dissection, the elevated
flap was advanced distally to cover the exposed
bone, and the distal end of the flap was sutured to
the nail matrix (Figure 2(c)). Care was taken to limit
excessive traction of the pedicle, and the finger was
brought to full extension before suturing the distal
end of the flap to the nail matrix in order to ensure
there was no limitation on finger extension. The
donor site was primarily closed in all cases.
Shapiro–Wilk test was used to assess normality
assumptions of continuous variables. For continuous
variables, bivariate analysis was performed using the
Mann–Whitney U test and Wilcoxon signed-rank test
depending on the normality of distribution. Software
was used for analysis, and p-values of less than 0.05
were considered significant.
Between 2005 and 2018, 36 children received the NIF
for fingertip reconstruction in our hospital and 28
met the above-mentioned evaluation criteria.
Among these, 23 patients consented to participate
in this study and were seen in the hospital for a
final evaluation. The patients were operated on by
a team of hand surgeons with Level 4 expertise
(Tang and Giddins, 2016). All patients were evaluated
at a mean follow-up time of 7.8 years (range 2–13)
postoperatively (Supplementary Table S1). The
mean age at the time of operation was 4.8 years
(range 1–10). The index finger was the most fre-
quently affected, followed by the middle finger, the
thumb, the ring finger and the little finger. The most
commonly injured zone was Ishikawa Subzone II.
Partial or total flap necrosis, infection at the
exposed distal phalanx or evident atrophy of the
flap were not observed in any patient (Figure 3(a)).
Three patients were able to feel the 3.61 monofila-
ment (diminished light touch), and 20 patients
were able to feel the 2.83 monofilament (normal)
at the reconstructed fingertip. Two-point discrimina-
tion was less than 3 mm in 17 patients and between
3–6 mm in six patients. Eleven patients reported cold
sensitivity at the operated fingertip. Additionally,
another 11 patients experienced scar formation
at the surgical site, which did not cause pain or func-
tional limitations to the operated finger.
In total, 15 of 23 fingers showed a hook nail defor-
mity at final follow-up; according to the Lim classi-
fication: three fingers showed Grade 4 beaking,
four fingers showed Grade 3 beaking, three
fingers showed Grade 2 beaking and five fingers
showed Grade 1 beaking. The appearance of the
Figure 2. The preoperative (a), intraoperative (b) and early postoperative (c) pictures of a patient with a fingertip injury
with exposed distal phalanx and intact nail matrix.
Yildirim et al. 847
reconstructed pulp was rated as normal in 17 chil-
dren and flat and atrophic in six children. The
average patient satisfaction was found to be 6.7
(range 3–9) on an 11-point rating scale.
There was no reduced sensation in the donor half
of the finger at the last follow-up, and no visible atro-
phy was detected on the operated finger in any of the
patients when assessed radiologically. The mean
distal phalangeal lengths of the operated and unin-
jured contralateral hand were 10.1 mm (range 3–18)
and 13.5 mm (range 11–20), respectively. There was
no significant correlation between the amount of
shortening of the distal phalanx and the grade of
hook nail deformity (p>0.05). Also, the final length
of the middle and proximal phalanges of the operat-
ed and contralateral fingers/thumbs did not demon-
strate any significant difference (p>0.05).
Thirteen patients exhibited minor flexion contrac-
tures of the involved finger joints, which did not limit
hand function. None of the patients exhibited limita-
tions of flexion in any joints of the operated fingers
(Figure 3(b) and (c)). There was no statistically sig-
nificant correlation between scar formation at the
operation site and the TAM results for the operated
finger (p>0.05). However, the Wilcoxon signed-rank
test revealed that the TAM of the injured finger was
significantly lower than that of the uninjured hand in
all patients (p<0.001).
In this study, we demonstrated that the NIF is a safe,
reliable flap for children with fingertip defects where
cover of exposed bone is necessary. We experienced
no partial/total necrosis or any distinct atrophy of the
flap in the longer term. Near normal sensation was
achieved in all reconstructed fingertips, which is
rated as ‘excellent’ according to the modified
American Society for Surgery of the Hand guidelines
for the stratification of 2PD (Mermans et al., 2012).
A long-segment neurovascular pedicle dissection
and NIF harvesting in paediatric patients did not
cause an adverse effect on the growth of the operat-
ed fingers and phalangeal bones. Harvesting one of
the two main arteries of a growing finger with the
flap did not cause any apparent soft tissue atrophy
and stripping one of the two digital nerves also does
not seem to diminish the quality of sensation on
the donor side of the finger. However, 47% of
our patients reported cold intolerance, revealing
that nerve healing may be incomplete even in
Surgeons may differ in their indications for flap
reconstruction of fingertip injuries. It has been
shown that when treated with semi-occlusive dress-
ings, human fingertips are able to regenerate soft
tissue and skin following amputation injuries with
excellent cosmetic and functional results with no
reported joint stiffness (Georgoulis et al., 2021;
Hoigne et al., 2014; Schultz et al., 2018). As a
result, conservative treatment should be the first
choice in the majority of fingertip amputations in
children and even in adults (Allen, 1980; Krauss
and Lalonde, 2014). However, when the defect is
extensive and bone is exposed, a local flap may be
an alternative for covering up the exposed bone end
without shortening. This practice not only preserves
the length of the bone and nail bed, but also shortens
healing time, restores fingertip sensation and less-
ens the risk of osteomyelitis (Kayalar et al., 2011).
It has been reported that fingertip injury recon-
struction in children with an extensive soft tissue
defect remains a challenge for surgeons due to
the smaller size of the fingers, making pedicle dis-
section and flap elevation more difficult and demand-
ing (Das and Brown, 1978; Ljungberg et al., 2003).
Among the numerous flap options for coverage
of fingertip injuries, the best surgical results are
Figure 3. Photographs taken in the third postoperative year showed no atrophy at the reconstructed pulp (a), no limitation
of flexion and extension (b) but a hook nail deformity of the fingernail (c).
848 Journal of Hand Surgery (Eur) 47(8)
reported from V-Y advancement flaps (Ma et al.,
1982). When the defect is large and beyond the
reach of this flap, a homodigital pedicled advance-
ment flap becomes a better option. While reverse
flow variants of homodigital flaps have been reported
with excellent results in adults, these flaps necessi-
tate a more detailed dissection and are harder to
perform in children (Niranjan and Armstrong,
1994). Finally, although there are more straightfor-
ward procedures, such as thenar flap or cross finger
flap, that avoid microdissection, these require longer
immobilization time of the hand and the need for
multiple surgeries, thereby decreasing their popu-
larity for use in small children (Barr et al., 2014;
Fitoussi et al., 2004).
The NIF remains a good option for reconstructing
large pulp defects with exposed bone in children as a
one-stage operation and does not necessitate pro-
longed immobilization of the injured finger. Wang
et al. (2011) reported satisfactory results with the
use of NIF in children, stating that normal sensation
and motion were achieved in all patients, with no
reported cold intolerance. The authors attributed
these superior results, when compared with adult
reconstructions, to children’s increased capacity for
healing and regeneration. However, their patient
group was limited to 11 cases, and follow-up time
was only 15 months on average, meaning that eval-
uation was performed prior to finger maturation in
all of their cases. We aimed to evaluate a larger
group of patients with a longer follow-up period of
7.8 years on average, where finger growth had
ceased in most patients. This may be a reason for
the difference in results that were reported in this
Hook nail deformity seems to be a frequently
encountered complication, impairing the aesthetic
results of paediatric fingertip reconstructions
(Varitimidis et al., 2005), with an incidence of 7–50%
in adults (Arsalan-Werner et al., 2019; Kayalar et al.,
2011). Our study revealed that this problem is more
common in paediatric patients, which does not seem
to be related to the amount of bone loss supporting
the nail bed. Lim et al. (2008) suggested that nail
beaking in reconstructed fingertips might worsen
over time due to chronic flap contraction and the
remodelling of soft tissues, even if the initial results
were satisfactory. Also, as the finger grows longitu-
dinally in children, the flap pedicle may not elongate
as much and becomes tethered, pulling the flap and
nail bed in a palmar and proximal direction, and this
tethering may explain the increased incidence of
beaking of the nail bed in children. Since the main
complaint of patients enrolled in this study was the
deformity of their nails, aesthetic results of this flap
in children may not satisfy the majority of patients in
the long term.
Restoration of unrestricted motion without con-
tractures is essential in the treatment of fingertip
injuries at all ages. While 13 out of 23 cases (56%)
in this series showed an extension loss (10–20)of
the involved finger joints, active and passive flexion
was full in all cases. The extensor lag may again be
related to the tethering effect of the flap pedicle and
the surrounding scar tissues in a growing finger,
resulting in impending soft tissue contracture on
the palmar aspect of the digit. If a decision is made
to reconstruct a finger with a NIF in children, parents
should be informed about the long-term complica-
tions of this flap preoperatively.
The major limitations of our study were its retro-
spective design and small sample size. Additionally,
we did not perform a comparison of flap coverage
with conservative treatment of fingertip loss, which
have been considered a reliable option in children.
Further large-scale, prospective, randomized studies
are needed to define the most appropriate treatment
for these injuries.
In conclusion, NIFs is a safe and reliable flap for
reconstruction of fingertip loss in children, although
there are long-term complications a slight loss of
terminal extension, formation of a hook nail deformi-
ty and cold intolerance.
Declaration of conflicting interests The authors
declare no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Informed consent Written informed consent was
obtained from the representatives of patients for their ano-
nymized information to be published in this article.
Ethical approval Ethical approval to report these cases
was obtained from Hand Microsurgery Orthopedics
Traumatology Hospital Ethics Committee (2021/02).
ORCID iD Tugrul Yildirim https://orcid.org/0000-0002-
Supplemental material Supplemental material for this
article is available online.
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