PMC5738652_01
Case 1: right hand on initial presentation. (A) Dorsal view showing the skin defect. (B) X-ray revealing a comminuted fracture of the ring proximal phalanx.
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The extensor tendon of the ring finger was disrupted, but not lost (Figure 2).
Intraoperative findings in case 1. (A) Harvested flap comprising serratus anterior fascia and scapular bone vascularized with thoracodorsal artery. White arrowhead indicates the fascial component, and black arrowhead indicates the bone segment. (B) Flap is set, with split-thickness skin graft performed simultaneously. (C) Immediate postoperative X-ray showing skeletal reconstruction of the ring finger.
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After surgical debridement, an 8 x 8-cm area of serratus fascia and a block of bone measuring 3 x 1x0.5 cm from the scapula on the angular branch of the thoracodorsal artery were harvested concomitantly (Figure 3).
Appearance of case 1 at 8 months postoperatively. (A) Dorsal and volar view of the right hand. (B) Bone union shown on X-ray. Frontal and lateral view.
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However, since the stiffened fingers did not impede pinching or grasping, the patient required no additional surgery to improve range of motion of the ring finger (Figure 4).
PMC5738652_02
Case 2: left index finger on initial presentation. (A) Dorsal view showing skin defect and open fracture. (B) Volar site of the finger remains intact. (C) X-ray depicting comminuted fracture. Frontal and lateral view.
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Fortunately, the flexor tendons, neurovascular bundles and distal phalanx were relatively spared (Figure 5).
First operation in case 2. (A) Wire fixation of the remnant bone pieces. Defect of the expansion hood is apparent. (B) Original length of the index finger is preserved by wire fixation. (C) X-ray depicting bone defect. (D) Artificial dermis temporarily applied to cover the wound.
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K-wire interosseous pinning was performed to prevent shortening of the finger due to wound contraction, and the soft-tissue defect was temporarily replaced by artificial dermis the same day (Figure 6).
Second operation in case 2. (A) Intraoperative view of flap-harvesting procedure. White arrowhead indicates the fascial flap. (B) General view of the flap. White arrowhead indicates the fascial component, and black arrowhead indicates the bone segment. (C) Transferred flap after microsurgery with immediate split-thickness skin grafting. (D) X-ray showing skeletal reconstruction of the index finger with vascularized bone grafting fixed with surgical wire.
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A split-thickness skin graft was concomitantly applied over the serratus fascia without any compression (Figure 7).
Appearance of case 2 at 7 months postoperatively. (A) General view of the left hand. The reconstructed finger has atrophied. (B) Shortening of the index finger allows tripod pinch. (C) X-ray revealing union of grafted bone.
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Although the reconstructed finger became thinner than we had expected and the PIP joint was lost, the patient obtained a range of motion of 0/65  for the MP joint (Figure 8).