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CASE REPORTS
NUMBER 2-3 YEAR 2010
Local Perforator Flap for Elbow Reconstruction in Complex Trauma of the Upper Limb. Case Presentation
1 Clinic for Plastic Surgery and Reconstructive Microsugery, Hospital for
Rehabilitation, Iuliu Hatieganu University of Medicine and Pharmacy,
Cluj-Napoca

Correspondence to:
Alexandru Georgescu, Clinic for Plastic Surgery and Reconstructive
Microsugery, Hospital for Rehabilitation, Iuliu Hatieganu University of Medicine
and Pharmacy, 46-50 Viilor Av., Cluj-Napoca, Tel. +40-264-438852
E-mail: geordv@hotmail.com
REZUMAT
Traumatismul complex al membrului superior cu defect de parti moi la nivelul cotului si leziuni nervoase multiple este o cauza importanta de morbiditate si invaliditate. Lucrarea de fata prezinta cazul unui tânar implicat intr-un accident feroviar, cu un traumatism prin strivire al intregului membru superior drept, cu un defect de parti moi la nivelul cotului, sectiune de nervi radial si musculocutan si interesarea plexului brahial. Acoperirea defectului de parti moi si reconstructia nervului radial au fost realizate intr-o prima etapa, urmate de neuroliza plexului brahial si neurotizare directa musculara a nervului musculocutan, si apoi de transferuri tendinoase. Reintegrarea socio-profesionala a pacientului a fost completa la trei ani dupa traumatism. La recuperarea functionala excelenta au contribuit trei factori principali: acoperirea defectului de parti moi prin lambou local, rezolvarea terapeutica corecta a leziunilor asociate si inceperea precoce a programului de recuperare.

ABSTRACT
Complex trauma of the upper limb with elbow soft tissue loss and multiple nerves injury is an important cause of morbidity and invalidity. This paper presents the case of a young male involved in a train accident, who sustained a crush injury of the right upper limb, with an elbow soft tissue defect, transsection of the radial and musculocutaneous nerves and an injury of the brachial plexus. The soft tissue coverage by a local perforator flap and radial nerve reconstruction were performed in the first stage, followed by brachial plexus neurolysis with direct muscular neurotization of the musculocutaneous nerve and then tendon transfers. The social and professional reintegration of the patient was complete, 3 years after trauma. The excellent functional recovery is the result of three factors: use of a local flap for soft tissue coverage, proper surgical management of the associated lesions and early kinetotherapy.
INTRODUCTION

Despite the low incidence, posttraumatic elbow soft tissue defects have a negative impact over the global upper limb function. This impact is more severe if the elbow soft tissue loss is associated with other proximal and distal nerve lesions.1-2 In this context, an elbow soft
tissue loss could become a difficult problem to solve.3-5 In front of a complex case, it is often necessary to adopt a multiple stages reconstruction. A new method for elbow coverage is the use of local perforator flaps.4,5 As microsurgical non microvascular flaps, they
replace like with like, allow reinterventions and early mobilization without fear of vascular spasm, as in free transfers.6

CASE REPORT

To illustrate the multiple stages management of a complex upper limb trauma with elbow soft tissue defect and multiple levels of radial nerve (RN), musculocutaneous nerve (MCN) and brachial plexus (BP) lesions, a complex case of right upper limb crush injury in a 26 years old male patient, involved in a train accident, will be presented. He was initially evaluated and admitted in an outlaying hospital. After four
weeks, the patient was transferred in our department, presenting:
- The upper limb immobilized in adduction by a shoulder to wrist splint, with 90° elbow flexion;
- A 20 cm2 granulated wound on the volar side of the elbow, local infection and inflammation. (Fig. 1A)
After splint removal, the upper limb is hanging in adduction near the body, with internal rotation, a drooped shoulder and 30° elbow flexion. The active range of motion examination showed: no shoulder abduction, flexion and extension; adduction was possible but not against resistance; no elbow movements; no wrist and fingers movements, excepting 15° flexion in MP joints of fingers IV-V. Sensibility was lost on the dorsal aspect of the hand, thumb and forearm.
In the first stage, wound debridement was performed under general anesthesia. The volar aspect of the elbow joint and the biceps brahii tendon were exposed. Radial nerve was injured in the proximal third of the forearm, with a 5 cm gap, and its reconstruction was performed with 2 cable grafts from a sensitive branch of the RN. (Fig. 1B)

Figure 1. Soft tissue defect of the elbow and its surgical management. A - preoperative view of the defect; B – radial nerve re [...]
Figure 1. Soft tissue defect of the elbow and its surgical management. C – flap pedicle, represented by a brachioradialis musculocutan [...]

Elbow soft tissue coverage was performed by use of a local island forearm perforator flap of 25 cm2, rotated 75°, based on a brahioradialis musculocutaneous perforator pedicle from the radial artery. For filling the defect, a small piece of brahioradialis muscle was harvested with the flap. (Fig. 1C) The perforator pedicle was not dissected towards its origin from the radial artery, but just enough for the flap to rotate into the defect. The donor area was closed by split skin graft. (Fig. 2A) A splint was used for immobilization of the elbow, wrist and fingers in functional position. Passive mobilization of the non involved joints started 3 days and elbow's 5 days after surgery. Transitory flap congestion was noticed, but it had a spontaneous remission after one week. (Fig. 2B)

Figure 2. Perforator flap for elbow coverage and its donor area skin grafted. A – 2 days after surgery;
Figure 2. Perforator flap for elbow coverage and its donor area skin grafted. B – 14 days after surgery; C - 3 years after surg [...]

After one month, the flap survival was 100%. No significant improvement of the upper limb active range of motion was noticed. Early after trauma, electromyography (EMG) did not present signs for a BP rupture or avulsion. The second EMG, two months later, suggested biceps brahii, extensor digitorum communis, triceps brahii and deltoid muscle denervation and polyphasic motor unit potentials for abductor digiti minimi muscle.
Due to a possible fibrosis, a compressive neuropathy of the BP was considered. Surgical BP exploration was decided and performed. Important fibrosis surrounding BP was noticed, without continuity loss. Neurolysis of the BP was performed.
The dissection was extended to the arm, where MCN was avulsed, with loss of nervous substance from its distal part. Direct muscular neurotization of the MCN to biceps brahii was performed. Shoulder was immobilized in abduction with a brace, and a volar splint was used to maintain the hand extension. An intensive rehabilitation program started next day after surgery. Monthly clinical examination and every
3 months EMG were performed. One month after surgery muscle flicker was noticed, but without upper limb movements. One month later, full active long fingers flexion and abduction/adduction was possible; after 4 months, active shoulder abduction, flexion, extension, and forearm active flexion and pronosupination were present; after 16 months, full active shoulder abduction, flexion and extension, active
elbow, wrist and fingers flexion and elbow extension were present, but no extension distal to the wrist joint.
The reinervation of the RN was considered incomplete and tendon transfer is proposed to the patient. Flexor carpi ulnaris on extensor digitorum communis and extensor polici longus transfer, pronator teres on both extensor carpi radialis brevis and longus and palmaris longus to extensor polici brevis and abductor policis longus transfers are performed 32 months after trauma. Next day after surgery the rehabilitation program was initiated, and after one month, excellent wrist, finger and thumb extension was achieved.

RESULTS

The social and professional reintegration of the patient was complete, highlighted by a 5.8 DASH score 3 years after trauma. (Fig. 3) The flap and skin graft were perfectly integrated, with a good aesthetic aspect. (Fig. 2C)

Figure 3. Upper limb rehabilitation, 3 years after trauma. A, B, C - elbow and shoulder full recovery
Figure 3. Upper limb rehabilitation, 3 years after trauma. D, E, F - hand recovery with digital pinch and use of tenodesis effect for ac [...]


DISCUSSION

A complex trauma of the upper limb with a combination of soft tissue defect and multiple levels nerves injuries requires precise evaluation and management for a good functional outcome.7 Early all-in-one reconstruction is the attitude of choice.8
Clinical evaluation and EMG could explain the multiple stage management for the case presented; initially, their results suggested a lesion in continuity of the BP with the possibility of spontaneous recovery. This is the reason for elbow soft tissue and RN reconstruction in the first intervention, followed early by intensive rehabilitation therapy. The local perforator flap allowed early mobilization, and the use of the brahioradialis musculocutaneous perforator flap was the perfect choice due to the vicinity to the defect and the need for a small muscular segment in order to fill the defect. For flap harvesting, the Doppler investigation is not required in the forearm, but only a meticulous microsurgical dissection.5,9 The reasons which have led to the decision of BP exploration and MCN neurotization were the clinical examination and EMG. Staged management, with elbow soft tissue coverage and RN reconstruction, BP neurolysis and direct neurotization of the MCN to biceps brachii followed by tendon transfers, allowed complete rehabilitation of the upper limb.

CONCLUSIONS

Complex upper limb trauma requires prompt, precise and complex surgical approach, starting with soft tissue reconstruction and associated lesions management. Soft tissue coverage by a local flap allows early active and passive movements and early professional and social reintegration of the patient.
REFERENCES

1. Noble J, Munro CA, Prasad VS, et al. Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries. J Trauma 1998;45(1):116-22.
2. Taylor CA, Braza D, Rice JB et al. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87(5):381-5.
3. Regel G, Weinberg AM, Seekamp A, et al. Complex trauma of the elbow. Orthopade 1997;26(12):1020-9.
4. Hallock GG. A buried interpolated local fasciocutaneous flap for tension – free closure of the chronic olecranon wound. Ann Plast Surg 2009;62(6):630-2.
5. Frost-Arner L, Björgell O. Local Perforator Flap for Reconstruction of Deep Tissue Defects in the Elbow Area. Ann Plast Surg 2003;50(5):491-7.
6. Georgescu AV, Matei I, Ardelean F, et al. Microsurgical non-microvascular flaps in forearm and hand reconstruction. Microsurgery 2007;27(5):384-94.
7. Carter PR. Crush injury of the upper limb. Early and late management. Orthop Clin North Am 1983;14(4):719-47.
8. Georgescu AV, Ivan O. Emergency free flaps in solving complex trauma of the upper limb. J Hand Surg 2003;28(1):74-5.
9. Innocenti M, Baldrighi C, Delcroix L, et al. Local perforator flaps in soft tissue reconstruction of the upper limb. Handchir Mikrochir Plast Chir 2009;41(6):315-21.
10. Evans PJ, Nandi S, Maschke S, et al. Prevention and treatement of elbow stiffness. J Hand Surg Am 2009;34(4):769-78.



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