Reconstruction of post-traumatic upper extremity soft tissue defects with pedicled flaps: An algorithmic approach to clinical decision making

Abstract

Purpose: Pedicled flaps are still the workhorse flaps for reconstruction of upper limb soft tissue defects in many centers across the world. They are lifeboat options for coverage in vessel deplete wounds. In spite of their popularity existing algorithms are limited to a particular region of upper limb; a general algorithm involving entire upper limb which helps in clinical decision making is lacking. We attempt to propose one for the day to day clinical practice.

Methods: A retrospective analysis of patients who underwent pedicled flaps for coverage of post-traumatic upper extremity (arm, elbow, forearm, wrist & hand) soft tissue defects within the period of January 2016 to October 2017 was performed. Patients were divided into groups according to the anatomical location of the defects. The flaps performed for different anatomical regions were enlisted. Demographic data and complications were recorded. An algorithm was proposed based on our experience, with a particular emphasis made to approach to clinical decision making.

Results: Two hundred and twelve patients were included in the study. Mean age was 27.3 years (range: 1-80 years), 180 were male, and 32 were female. Overall flap success rate was 98%, the following complications were noted marginal flap necrosis requiring no additional procedure other than local wound care in 32 patients (15%), partial flap necrosis requiring flap advancement or extra flap in 15 patients (7%), surgical site infection in 11 patients (5%), flap dehiscence requiring re-suturing in 5 patients (2.4%), total flap necrosis 4 patients (2%).

Conclusion: The proposed algorithm allows a reliable and consistent method for addressing diverse soft tissue defects in the upper limb with high success rate.

Keywords: Algorithm; Decision making; Pedicled flaps; Reconstruction; Soft tissue defect; Upper limb.

Fig. 1

Flow chart of algorithm for reconstruction of upper limb soft tissue defects with pedicle flaps. LDMF: latissimus dorsi musculocutaneous flap; FDMA: first dorsal metacarpal artery. *Workhorse flap in the author's unit, flaps typed in bold letters indicate that they are used for larger defects.

Fig. 2

Images showing coverage of anterior arm defect by pedicled LDMF. A: open comminuted left humerus fracture following gunshot injury; B: wound debridement and humerus fracture stabilization; C: ipsilateral pedicled LDMF before inset; D: well settled flap; E: Well united fracture site. LDMF: latissimus dorsi myocutaneous flap.

Fig. 3

Images showing coverage of posterior arm defect with pedicled LDMF. A: Posterior arm defect with exposed hardware and triceps tendon following humerus fracture fixation; B: X-ray showing in situ hardware; C: flap marking; D and E: ipsilateral pedicled LDMF before and after inset; F: Well settled flap and donor site. LDMF: latissimus dorsi myocutaneous flap.

Fig. 4

Images showing coverage of circumferential arm defect by pedicled LDMF. A: Left arm defect with exposed humerus plate and brachial vessels following mid arm replantation. B and C: ipsilateral pedicled LDMF covering the circumferential defect. LDMF: latissimus dorsi myocutaneous flap.

Fig. 5

Images showing coverage of ventral soft tissue defect of right elbow. A: composite defect of with exposed for brachial artery repaired with vein graft blue arrow (contused median nerve yellow arrow); B: ipsilateral pedicled LDMF with inverted ‘T’ shaped skin paddle for easier closure of donor and recipient wounds; C: early postoperative period image; D and E: well settled flap and donor site. LDMF: latissimus dorsi myocutaneous flap.

Fig. 6

Images showing coverage of posterior elbow wound by pedicled LDMF. A and B: exposed elbow joint cavity, distal end of humerus and proximal end of ulna following side swipe injury of left elbow and harvested pedicled LDMF before inset; C: after inset and skin grafting of adjacent wound; D: the distal most part of the skin paddle was gangrenous it was debrided and covered with skin graft. LDMF: latissimus dorsi myocutaneous flap.

Fig. 7

Images showing coverage of dorsal elbow wound with thoracoabdominal flap. A: exposed elbow joint and large soft tissue defect; B: thoracoabdominal flap inset.

Fig. 8

Coverage of ventral elbow defect with brachioradialis flap. A: elbow defect with exposure of repaired brachial artery, biceps tendon; B and C: coverage with brachioradialis flap and skin graft.

Fig. 9

Coverage of dorsal elbow soft tissue defect with random abdominal skin flap. A: scar at the donor site; B: well settled flap.

Fig. 10

Images showing coverage of extensive avulsion injury of left upper limb extending from the mid arm to the distal forearm. A: lost elbow flexors; B: wound was covered with ipsilateral pedicled LDMF; C: Good postoperative elbow flexion and stable wound coverage. LDMF: latissimus dorsi myocutaneous flap.

Fig. 11

Images showing of dorso-radial forearm soft tissue defect with covered with TUF. A: design of TUF; B: TUF after inset; C: well settled flap. TUF: thoraco-umbilical flap.

Fig. 12

Images showing coverage of soft tissue defect over the palm with pedicled groin flap. A: groin flap inset; B: donor site; C–E: following single stage defatting well settled flap.

Fig. 13

Images showing coverage of soft tissue defect over the dorsum of hand. A: exposed 5th metacarpal shaft fracture; B: pedicled groin flap insitu; C: well settled flap following division.

Fig. 14

Images showing coverage of soft tissue defect over dorsum of hand and fingers with hypogastric flap. A: Exposed metacarpal fractures and extensor tendons; B: X-ray showing multiple comminuted fracture fixed with K wires; C: left hypogastric flap harvest with pointer at superficial inferior epigastric artery; D: flap inset covering hand and multiple fingers; E and F: well settled flap.

Fig. 15

Images showing coverage of web space and finger defect. A: left hand railway tract injury with exposed metacarpal and flexor and extensor tendons of ring finger; B: marking insitu; C: flap inset; D: well settled flap and donor site skin graft; E: tripod pinch.

Fig. 16

Images showing groin flap coverage for amputated thumb stump. A: 2-year-old child with near total amputation of left hand; B: following revascularization and repair of tendons and nerves, child sustained gangrene of thumb and sutured skin margins leading exposure of vein graft used to repair the arterial gap; C: coverage of the defect with pedicled groin flap; D: well settled groin flap.

Fig. 17

Images showing coverage of hand wound with reverse radial forearm adipofascial flap and skin graft; A: soft tissue defect over the dorsum of hand following crush injury; B–D: harvested reverse radial forearm adipofascial flap before and after inset and skin graft.

Fig. 18

Images showing tubed groin flap cover over thumb defect. A: Amputation of thumb with exposed distal phalanx; B: marking of groin flap; C: flap after tubing and inset; D: maintained length of thumb following division and inset.

Fig. 19

Images showing coverage of finger defects with pedicle flaps. A: coverage of index finger pulp defect with cross finger flap; B: harvested first dorsal metacarpal artery flap; C: inset of FDMA flap over thumb amputated stump; D: well settled flaps. FDMA: first dorsal metacarpal artery flap.