- Email: [email protected]
Brachioradialis forearm flap in a case of traumatic bone and skin loss at the elbow
BRACHIORADIALIS TRAUMATIC BONE M. BINNS,
FOREARM AND SKIN K. A. KUEH
FLAP IN A CASE OF LOSS AT THE ELBOW
and R. W. H. PHO
From the Department of Orthopaedic Surgery, National University of Singapore, Singapore General Hospital
A case of traumatic skin and bone loss at the elbow is described. This was treated by a long brachioradialis flap, allowing early movements with thick and sensate cover. Anatomical studies delineate the extent of this flap. Journal of Hand Surgery
(British Volume, 1990)
1.5B: 317-319
The brachioradialis forearm flap has been described for the reconstruction of posterior defects of the elbow (Mathes and Nahai, 1979). Lendrum (1980) described its use in covering a compound fracture dislocation of the elbow. Lai et al. (1981) using cadaveric injection studies showed, by selectively injecting the radial recurrent artery at the elbow, that the vascular territorial limits of this flap covers the postero-lateral lower half of the upper arm and the lateral and upper third of the forearm. We were able to extend a brachioradialis flap beyond these limits in one case. Injection studies show that the fascia-cutaneous blood supply via muscle belly and tendon extend to the insertion of brachioradialis.
despite loss of the olecranon, as the anterior capsule and radio-capitellar joint were preserved. The myo-cutaneous flap extended along the proximal two-thirds of the forearm, based on the brachioradialis muscle belly. The fascia-cutaneous portion extended beyond the muscle belly to just proximal to its tendinous insertionon the radius (Fig. 2). The defect was completely
Case report A 58-year-old man sustained a blast injury to the right elbow, with an open comminuted fracture of the olecranon and a skin defect of 10 by 5 ems. The wound was debrided and the olecranon excised as a primary procedure. Four days later, a brachioradialis flap was used to cover the defect of 10 by 10 ems. posteriorly (Fig. 1). The elbow joint remained stable in flexion and extension,
Fig. 2
Harvesting of brachioradialis flap.
Fig. 1 Skin defect; posterior aspect of right elbow with the joint exposed. VOL. 15B No. 3 AUGUST
1990
317
M.
BINNS, K. A. KUEH AND R. W. H. PHO
presence of dye in the subcutaneous tissues and paratenon almost as far as the tendon insertion (Fig.4). Latex injection of the brachial artery in one specimen shows that there is adequate anastomosis of the radial collateral branch of the profunda brachii with the radial recurrent artery which has a tortuous initial course (Fig. 5). This would indicate that the flap can be extended proximally to include the lateral arm flap, which would make this flap relatively large. Discussion
Fig. 3 One year later showing flap covering the elbow joint and skin defect covered by split skin graft.
covered and the donor area covered with a split skin graft. The limb was supported on a volar back-slab for ten days and then active mobilisation of the elbow begun. One year later, he has sensate and comfortable cover over the elbow with full extension and flexion to 125”; pronation is to 90” and supination to 45” (Fig. 3). Anatomy Previous studies have shown that the cutaneous vascular territory of the radial recurrent artery at the elbow includes the proximal one-third of the forearm. In four cadaveric forearms, the radial recurrent artery was selectively cannulated at the elbow and injected with methylene blue dye. We observed that the skin can be elevated over the tendon of brachioradialis with the
Fig. 4
(a) Following methylax blue injection of radial recurrent artery, injection of radial recurrent artery, the paratenon
methylene blue
318
A number of techniques have been described for reconstruction of defects over the posterior aspect of the elbow. A local flap to allow early elbow movement is preferred. Ohtsuka (1985) noted that the site of the vascular bundles to extensor carpi radialis were more proximal than those to brachioradialis and therefore more suitable for proximal lesions. Our anatomical studies indicate that there is extensive blood supply to the skin of the brachioradialis flap, based on the recurrent radial artery and radial collateral branch of the profunda brachii artery. At least two-thirds of the proximal forearm and one-quarter of the skin on the lateral aspect of the distal arm could be harvested to cover the extensive defect around the elbow joint. If the lateral cutaneous nerve of forearm can be preserved, a thick and sensate skin cover can be provided to allow early and protective movements of the elbow joint. Our dissection indicates that the flap is relatively safe to harvest. Because the pedicle is long, the flap is very suitable for local rotation. If a free flap is indicated, then it is also suitable as the vascular pedicle is relatively large.
the subcutaneous tissues of the distal forearm are stained. (b) Following of brachioradialis and fascia are stamed with dye. THE JOURNAL OF HAND SURGERY
BRACHIORADIALIS
FOkEARM’ FLAP
Fig. 5 Diagram of latex injection of brachial artery and dissection of front of elbow joint. The anastomosis between the radial recurrent artery and the radial collateral branch of profunda brachii is shown. The shaded area shows the extent of the flap based upon the vascular pedicle.
of the Elbow Joint Using an Extensor Carpi Radialis Longus Myocutaneous References Flap: Case Report. British Journal of Plastic Surgery, 38: 238-240. LAI, M. F., KRISHNA, B. V. and PELLY, A. D. (1981). The Brachioradialis Myocutaneous Flap. British Journalof Plastic Surgery, 34: 431434. Accepted: 18 October, 1988 LENDRUM, J. (1980). Alternatives to Amputation. Annalsofthe Royal College ProfauvKR. W. H. Pho, UniversityDepartment of Orthopaedic Surgery, Singapore General of Suraeons of Ennland, 62: 95-99. Hospital, SINGAPORE 0316 MATHES; S. and NAHAI, F. Clinical Atlas of MuscleandMusnclocutaneour Q 1990The BritishSocietyfor Sargeq of the Hand Flaps. St. Louis, C. V. Mosby, 1979: 433-439. OHTSUKA, H. and IMAGAWA, S. (1985). Reconstmctionof a PosteriorDefect 026&7681/90/0015-0317/510.00
VOL. 15B No. 3 AUGUST
1990
319
FOREARM AND SKIN K. A. KUEH
FLAP IN A CASE OF LOSS AT THE ELBOW
and R. W. H. PHO
From the Department of Orthopaedic Surgery, National University of Singapore, Singapore General Hospital
A case of traumatic skin and bone loss at the elbow is described. This was treated by a long brachioradialis flap, allowing early movements with thick and sensate cover. Anatomical studies delineate the extent of this flap. Journal of Hand Surgery
(British Volume, 1990)
1.5B: 317-319
The brachioradialis forearm flap has been described for the reconstruction of posterior defects of the elbow (Mathes and Nahai, 1979). Lendrum (1980) described its use in covering a compound fracture dislocation of the elbow. Lai et al. (1981) using cadaveric injection studies showed, by selectively injecting the radial recurrent artery at the elbow, that the vascular territorial limits of this flap covers the postero-lateral lower half of the upper arm and the lateral and upper third of the forearm. We were able to extend a brachioradialis flap beyond these limits in one case. Injection studies show that the fascia-cutaneous blood supply via muscle belly and tendon extend to the insertion of brachioradialis.
despite loss of the olecranon, as the anterior capsule and radio-capitellar joint were preserved. The myo-cutaneous flap extended along the proximal two-thirds of the forearm, based on the brachioradialis muscle belly. The fascia-cutaneous portion extended beyond the muscle belly to just proximal to its tendinous insertionon the radius (Fig. 2). The defect was completely
Case report A 58-year-old man sustained a blast injury to the right elbow, with an open comminuted fracture of the olecranon and a skin defect of 10 by 5 ems. The wound was debrided and the olecranon excised as a primary procedure. Four days later, a brachioradialis flap was used to cover the defect of 10 by 10 ems. posteriorly (Fig. 1). The elbow joint remained stable in flexion and extension,
Fig. 2
Harvesting of brachioradialis flap.
Fig. 1 Skin defect; posterior aspect of right elbow with the joint exposed. VOL. 15B No. 3 AUGUST
1990
317
M.
BINNS, K. A. KUEH AND R. W. H. PHO
presence of dye in the subcutaneous tissues and paratenon almost as far as the tendon insertion (Fig.4). Latex injection of the brachial artery in one specimen shows that there is adequate anastomosis of the radial collateral branch of the profunda brachii with the radial recurrent artery which has a tortuous initial course (Fig. 5). This would indicate that the flap can be extended proximally to include the lateral arm flap, which would make this flap relatively large. Discussion
Fig. 3 One year later showing flap covering the elbow joint and skin defect covered by split skin graft.
covered and the donor area covered with a split skin graft. The limb was supported on a volar back-slab for ten days and then active mobilisation of the elbow begun. One year later, he has sensate and comfortable cover over the elbow with full extension and flexion to 125”; pronation is to 90” and supination to 45” (Fig. 3). Anatomy Previous studies have shown that the cutaneous vascular territory of the radial recurrent artery at the elbow includes the proximal one-third of the forearm. In four cadaveric forearms, the radial recurrent artery was selectively cannulated at the elbow and injected with methylene blue dye. We observed that the skin can be elevated over the tendon of brachioradialis with the
Fig. 4
(a) Following methylax blue injection of radial recurrent artery, injection of radial recurrent artery, the paratenon
methylene blue
318
A number of techniques have been described for reconstruction of defects over the posterior aspect of the elbow. A local flap to allow early elbow movement is preferred. Ohtsuka (1985) noted that the site of the vascular bundles to extensor carpi radialis were more proximal than those to brachioradialis and therefore more suitable for proximal lesions. Our anatomical studies indicate that there is extensive blood supply to the skin of the brachioradialis flap, based on the recurrent radial artery and radial collateral branch of the profunda brachii artery. At least two-thirds of the proximal forearm and one-quarter of the skin on the lateral aspect of the distal arm could be harvested to cover the extensive defect around the elbow joint. If the lateral cutaneous nerve of forearm can be preserved, a thick and sensate skin cover can be provided to allow early and protective movements of the elbow joint. Our dissection indicates that the flap is relatively safe to harvest. Because the pedicle is long, the flap is very suitable for local rotation. If a free flap is indicated, then it is also suitable as the vascular pedicle is relatively large.
the subcutaneous tissues of the distal forearm are stained. (b) Following of brachioradialis and fascia are stamed with dye. THE JOURNAL OF HAND SURGERY
BRACHIORADIALIS
FOkEARM’ FLAP
Fig. 5 Diagram of latex injection of brachial artery and dissection of front of elbow joint. The anastomosis between the radial recurrent artery and the radial collateral branch of profunda brachii is shown. The shaded area shows the extent of the flap based upon the vascular pedicle.
of the Elbow Joint Using an Extensor Carpi Radialis Longus Myocutaneous References Flap: Case Report. British Journal of Plastic Surgery, 38: 238-240. LAI, M. F., KRISHNA, B. V. and PELLY, A. D. (1981). The Brachioradialis Myocutaneous Flap. British Journalof Plastic Surgery, 34: 431434. Accepted: 18 October, 1988 LENDRUM, J. (1980). Alternatives to Amputation. Annalsofthe Royal College ProfauvKR. W. H. Pho, UniversityDepartment of Orthopaedic Surgery, Singapore General of Suraeons of Ennland, 62: 95-99. Hospital, SINGAPORE 0316 MATHES; S. and NAHAI, F. Clinical Atlas of MuscleandMusnclocutaneour Q 1990The BritishSocietyfor Sargeq of the Hand Flaps. St. Louis, C. V. Mosby, 1979: 433-439. OHTSUKA, H. and IMAGAWA, S. (1985). Reconstmctionof a PosteriorDefect 026&7681/90/0015-0317/510.00
VOL. 15B No. 3 AUGUST
1990
319