Functional reconstruction of a zone one digital defect
using a homodigital island flap with vascularized extensor
tendon in a young musician. A worthwhile operation?
Arndt von Campe
Received: 8 August 2011 / Accepted: 10 October 2011 / Published online: 2 December 2011
Functional reconstruction of Mallet III defects requires
restoration of the extensor tendon function in the DIP joint
with adequate soft-tissue cover. Tissue covering is mostly
done with local flaps. Also, distant and free flaps have been
described. Mainly, the tendon reconstruction is very
complicated. Carrying out an arthrodesis is a short and
alternative surgical way to go, but some patients, like
musicians, need a good functional result in the distal
A 22-year-old musician and restorer sustained a defect
through all layers (2.8×1.7 cm) of the DIP joint of the
right index finger while working with a power sander
(Mallet Finger Class III). The skin, subcutaneous tissue,
and tendon enthesis were missing from the whole area
of the defect, which was open dorsally with the bone
exposed (Fig. 1).
The patient requested restoration of joint function as he
was reliant on this, especially to play the guitar. The defect
was repaired in two stages. First, after surgical debridement,
the defect was temporarily covered with artificial skin.
Permanent repair was performed 7 days later. In a
first step, temporary immobilization of the terminal joint
with two K-wires (1.0) was induced. A homodigital
chimeric reverse pedicle island flap with a 5-mm-wide
strip of extensor tendon vascularized by the ulnar vessel
was then elevated from dorsal to palmar, carefully
avoiding the ulnar nerve, and transposed into the distal
defect (Figs. 2, 3, 4, 5,and6). The extensor tendon was
fixed distally to the distal phalanx using a transosseous
suture. A traditional extensor tendon suture was used
proximally with non-absorbable 4-0 thread. The flap
defect was closed using a full-thickness skin graft from
the forearm. After 4 weeks of immobilisation, the joint
was mobilised by a hand physiotherapist. The patient was
able to return to work 8 weeks after surgery.
The patient was able to use his finger at work and
when playing his guitar with no restriction of movement
3 months after surgery. The range of movement
(flexion–extension) in the DIP joint of the index finger
was (45–0–0°) (Figs. 7 and 8). The final result of defect
healing was inconspicuous (Fig. 9).
The primary factor in the success of reconstruction of
defects through all layers in zone 1 of the extensor
apparatus is adequate soft-tissue cover. Local plastic
surgery is usually not possible because little soft tissue is
available for flap surgery in this region, and it is not easy to
perform. Extensor tendon reconstruction using segments of
free tendon is difficult in this zone.
Reversed cross-finger flap surgery  and palmar cross-
finger flap surgery are suitable for small defects .
Alternatives to these are small distant flaps, such as groin
B. Strub (*)
A. von Campe
Eur J Plast Surg (2012) 35:483–486