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Functional microsurgical reconstruction in a severe case of contact burn of the forearm
burns 35 (2009) 606–609
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Functional microsurgical reconstruction in a severe case of contact burn of the forearm B. Azzena *, C. Tiengo, A. Salviati, A. Amabile, F. Mazzoleni Burn Unit and Plastic Surgery, University of Padova Medical School, Via Giustiniani 2, 35100 Padova, Italy
article info Article history: Accepted 11 May 2008
1.
Introduction
The most common causes of muscle loss of the forearm are direct trauma, Volkmann’s ischemic paralysis, electrical burns, post-replantation and gas gangrene [1–4]. Forearm injuries caused by prolonged contact with hot surfaces are quite rare, but can cause severe damage to skin, muscles, tendons, nerves and bones. When the extension of the lesions is limited, with involvement of single muscletendinous units, functional recovery can be achieved by relatively simple palliative surgical procedures. However in the presence of complete loss of dorsal or ventral compartments of the forearm with loss of functionality of the hand, free innervated-muscle transplantation is the only surgical option to achieve acceptable functional recovery [5,12].
2.
Case report
We present the case of a 24-year-old man involved in a severe road accident while he was driving a motorcycle. The patient was found unconscious with the dorsal surface of his left forearm in contact with the motorcycle’s exhaust pipe. On admission the patient presented with multiple rib fractures and bilateral pneumothorax, fractures of the third lumbar vertebra and of the left acetabulum, and a full thickness burn of the dorsal surface of the left forearm. After orthopaedic and neurosurgical treatment, the patient was transferred to our * Corresponding author. E-mail address: [email protected] (B. Azzena). 0305-4179/$36.00 # 2008 Published by Elsevier Ltd and ISBI. doi:10.1016/j.burns.2008.05.024
unit on day 16th from trauma. On clinical examination (Fig. 1) the patient was able to flex the wrist, the long fingers and the thumb, but complete flexion was limited by adhesions of distal extensor tendon stumps. The patient was unable to extend the proximal and distal interphalangeal joints and the wrist. Some degree of extension of the metacarpophalangeal joints was present, due to the integrity of intrinsic musculature. Sensitivity was conserved in the radial, ulnar and median nerves territories of the hand. No functional or sensation alterations of the elbow, the arm and the shoulder were present. Radiographic study of the upper limb showed no signs of bone fractures. Serial surgical necrectomies were performed, tissues of questionable viability were retained and covered with homologous skin grafts. Once the lesions became defined and cleaned from residual necrotic tissue, there was complete loss of all muscles of the extensor compartment of the forearm with exposure of the dorsal aspect of radial and ulnar bones. The dorsal sensation branch of the radial nerve appeared to be undamaged, whereas the posterior interosseous nerve was interrupted 3 cm from its origin. Angiographic study showed no alterations of radial and ulnar arteries. On day 62 from injury, we performed the microsurgical reconstruction of the extensor compartment with a free myocutaneous gracilis muscle flap from the right thigh. The motor branch to the gracilis muscle was collected and anastomosed with the posterior interosseous nerve. A termino-lateral anastomosis was performed with the radial artery and two termino-
burns 35 (2009) 606–609
607
Fig. 1 – View of the left forearm at day 16th from trauma.
Fig. 3 – The gracilis myocutaneous flap. terminal venous anastomoses were performed with commitant veins. The transposed gracilis muscle was sutured proximally to the elbow, and it was split distally in two muscle-tendinous units that were sutured to two tendon groups: (1) extensor tendons of 2nd- 3rd- 4th- 5th finger; (2) extensor longus and brevis of the thumb and abductor longus of the thumb. The flexor carpi radialis tendon was disconnected from its insertion, passed through the interosseous membrane and sutured to the insertion of the extensor carpi radialis to obtain stabilization of the wrist. No post-operative complications were observed, and the patient was discharged on day 91 after admission. An appropriate rehabilitation program, which included a dynamic orthesis, was instituted (Figs. 2–5). The follow-up showed progressive improvement of the extensor functionality of the left hand. Electromyographic study performed at 3, 6 and 15 months from surgery
revealed progressive reinnervation of the transplanted muscle. MRI study performed at 15 months from surgery showed good morphology of the transplanted muscle. At 18 months on clinical examination, the patient was able to flex the long fingers and the thumb without limitations; complete extension of proximal and distal interphalangeal joints was established with minimal limitation of extension of the metacarpophalangeal joints ( 108). Complete thumb extension was evident. Wrist movements were severely limited: active and passive extension range was 58 and 308 respectively; active and passive flexion range was 58 in both (Figs. 6–8). The patient was able to perform common life activities, with a satisfactory recovery of strength and dexterity.
Fig. 2 – View of the left forearm after serial surgical debridements.
608
burns 35 (2009) 606–609
Fig. 4 – Preparation of the distal tendinous stumps (ELP: extensor longus pollicis; ECD: extensor digitorum communis; ERC: extensor carpi radialis; EUC: extensor carpi ulnaris; FRC: flexor radialis carpi, emerging from the interosseous membrane).
Fig. 5 – Positioning of the flap. Arrows indicate the two muscle-tendinous units.
3.
Figs. 6–7 – Post-operative view at 18 months from trauma.
Discussion
Contact burns with hot surfaces, especially in functional areas, often result in deep lesions; the correct management requires early excision of necrotic tissues and adequate coverage of the wound bed in order to prevent the worsening of the anatomic damage [3]. In this young patient, the plastic surgical treatment was delayed because priority was given to the neurosurgical management of the vertebral trauma. The extensive deep burns of the forearm, which could have benefited from early surgical treatment, caused a complete loss of cutaneous and muscular tissues. Our reconstructive strategy privileged the functional recovery of the thumb and the long fingers, sacrificing wrist mobility. We chose the gracilis muscle for three main reasons: its strap morphology ensures a good potential range of excursion,
that is directly proportional to the overall muscle length; the well represented tendinous portion allows to split the muscle in two main units, one for the four long fingers and one for the thumb; finally the low donor site morbidity is very important, especially in young patients. These properties represent main advantages in comparison with other muscles commonly used for functional reconstruction, such as serratus, pectoralis major and latissimus dorsi [4–12]. The key point of the surgical procedure was the correct tensioning of the transplanted muscle, in order to assure the full range of flexion and extension of the fingers. Skin coverage could be gained either by a simple skin graft over the transplanted muscle or by harvesting a myocutaneous flap. We chose the myocutaneous flap in order to avoid fibrotic adhesions, which are common sequelae of skin grafting, furthermore, the patient was slim, and so the skin island was not bulky.
Fig. 8 – MRI of the left forearm at 18 months from trauma.
burns 35 (2009) 606–609
The key point of skin coverage is the adequate coverage of the distal tendons sutures, to avoid scar adhesions. Some authors recommend utilization of groin flaps, abdominal flaps, free flaps or tissue expanders as a preliminary procedure for the coverage of this region [4]. In this case, we harvested a very long skin island (18 cm), and more the tendon sutures were covered by the dorsal skin of the hand; skin graft was limited to a small area at the muscle-tendinous junction. All of these solutions guaranteed a good tendon gliding also confirmed by the MRI study. Finally post-operative rehabilitation for at least one year after surgery was essential to obtain satisfying functional results [9]. The rehabilitation program, with the wearing of dynamic orthesis, was designed to obtain full passive muscle extension and overcome any tendency to myotonic contracture.
[3] [4] [5]
[6] [7] [8]
[9]
[10]
references [11] [1] Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg 1976;58:407–11. [2] Lai Chung-Sheng, Lin Tsai-Ming, Lee Su-Shin, Tu Chao-Hung, Chen I-Heng, Chang Kao-Ping C, Tsai Chih-Cheng, Lin Sin-Daw. Case studies in contact
[12]
609
burns caused by exhaust pipes of motorcycles. Burns 2002;28(4):370–3. Hendon DN. Total Burn Care. 2nd ed. Saunders; 2001. pp. 170–181. Green DP. Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993. pp. 1159–1178. Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. J Plast Reconstr Aesthet Surg 2007;60(7):760–8. Manktelow RT, Mckee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg 1978;3:416. Manketow RT, Zuker RM, Mckee NH. Functioning free muscle transplantation. J Hand Surg 1984;9A(32). Manktelow RT, Mckee NH, Vettese T. An anatomical study of the pectoralis muscle as related to functioning free muscle transplantation. Plast Reconstr Surg 1984;73:751–5. Shieh S-J, Lee J-W, Chiu H-Y. Long term functional results of primary reconstruction of severe forearm injuries. J Plast Reconstr Aesth Surg 2007;60:339–48. Logan SE, Alpert BS, Buncke J. Free serratus anterior muscle transplantation for hand reconstruction. Br J Plast Surg 1988;41:639–43. Tobin GR, Shusterman M, Peterson GH, Nichols S, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637–41. Sauerbier M, Ofer N, German G, Baumeister S. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007;119(2):605–15.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Functional microsurgical reconstruction in a severe case of contact burn of the forearm B. Azzena *, C. Tiengo, A. Salviati, A. Amabile, F. Mazzoleni Burn Unit and Plastic Surgery, University of Padova Medical School, Via Giustiniani 2, 35100 Padova, Italy
article info Article history: Accepted 11 May 2008
1.
Introduction
The most common causes of muscle loss of the forearm are direct trauma, Volkmann’s ischemic paralysis, electrical burns, post-replantation and gas gangrene [1–4]. Forearm injuries caused by prolonged contact with hot surfaces are quite rare, but can cause severe damage to skin, muscles, tendons, nerves and bones. When the extension of the lesions is limited, with involvement of single muscletendinous units, functional recovery can be achieved by relatively simple palliative surgical procedures. However in the presence of complete loss of dorsal or ventral compartments of the forearm with loss of functionality of the hand, free innervated-muscle transplantation is the only surgical option to achieve acceptable functional recovery [5,12].
2.
Case report
We present the case of a 24-year-old man involved in a severe road accident while he was driving a motorcycle. The patient was found unconscious with the dorsal surface of his left forearm in contact with the motorcycle’s exhaust pipe. On admission the patient presented with multiple rib fractures and bilateral pneumothorax, fractures of the third lumbar vertebra and of the left acetabulum, and a full thickness burn of the dorsal surface of the left forearm. After orthopaedic and neurosurgical treatment, the patient was transferred to our * Corresponding author. E-mail address: [email protected] (B. Azzena). 0305-4179/$36.00 # 2008 Published by Elsevier Ltd and ISBI. doi:10.1016/j.burns.2008.05.024
unit on day 16th from trauma. On clinical examination (Fig. 1) the patient was able to flex the wrist, the long fingers and the thumb, but complete flexion was limited by adhesions of distal extensor tendon stumps. The patient was unable to extend the proximal and distal interphalangeal joints and the wrist. Some degree of extension of the metacarpophalangeal joints was present, due to the integrity of intrinsic musculature. Sensitivity was conserved in the radial, ulnar and median nerves territories of the hand. No functional or sensation alterations of the elbow, the arm and the shoulder were present. Radiographic study of the upper limb showed no signs of bone fractures. Serial surgical necrectomies were performed, tissues of questionable viability were retained and covered with homologous skin grafts. Once the lesions became defined and cleaned from residual necrotic tissue, there was complete loss of all muscles of the extensor compartment of the forearm with exposure of the dorsal aspect of radial and ulnar bones. The dorsal sensation branch of the radial nerve appeared to be undamaged, whereas the posterior interosseous nerve was interrupted 3 cm from its origin. Angiographic study showed no alterations of radial and ulnar arteries. On day 62 from injury, we performed the microsurgical reconstruction of the extensor compartment with a free myocutaneous gracilis muscle flap from the right thigh. The motor branch to the gracilis muscle was collected and anastomosed with the posterior interosseous nerve. A termino-lateral anastomosis was performed with the radial artery and two termino-
burns 35 (2009) 606–609
607
Fig. 1 – View of the left forearm at day 16th from trauma.
Fig. 3 – The gracilis myocutaneous flap. terminal venous anastomoses were performed with commitant veins. The transposed gracilis muscle was sutured proximally to the elbow, and it was split distally in two muscle-tendinous units that were sutured to two tendon groups: (1) extensor tendons of 2nd- 3rd- 4th- 5th finger; (2) extensor longus and brevis of the thumb and abductor longus of the thumb. The flexor carpi radialis tendon was disconnected from its insertion, passed through the interosseous membrane and sutured to the insertion of the extensor carpi radialis to obtain stabilization of the wrist. No post-operative complications were observed, and the patient was discharged on day 91 after admission. An appropriate rehabilitation program, which included a dynamic orthesis, was instituted (Figs. 2–5). The follow-up showed progressive improvement of the extensor functionality of the left hand. Electromyographic study performed at 3, 6 and 15 months from surgery
revealed progressive reinnervation of the transplanted muscle. MRI study performed at 15 months from surgery showed good morphology of the transplanted muscle. At 18 months on clinical examination, the patient was able to flex the long fingers and the thumb without limitations; complete extension of proximal and distal interphalangeal joints was established with minimal limitation of extension of the metacarpophalangeal joints ( 108). Complete thumb extension was evident. Wrist movements were severely limited: active and passive extension range was 58 and 308 respectively; active and passive flexion range was 58 in both (Figs. 6–8). The patient was able to perform common life activities, with a satisfactory recovery of strength and dexterity.
Fig. 2 – View of the left forearm after serial surgical debridements.
608
burns 35 (2009) 606–609
Fig. 4 – Preparation of the distal tendinous stumps (ELP: extensor longus pollicis; ECD: extensor digitorum communis; ERC: extensor carpi radialis; EUC: extensor carpi ulnaris; FRC: flexor radialis carpi, emerging from the interosseous membrane).
Fig. 5 – Positioning of the flap. Arrows indicate the two muscle-tendinous units.
3.
Figs. 6–7 – Post-operative view at 18 months from trauma.
Discussion
Contact burns with hot surfaces, especially in functional areas, often result in deep lesions; the correct management requires early excision of necrotic tissues and adequate coverage of the wound bed in order to prevent the worsening of the anatomic damage [3]. In this young patient, the plastic surgical treatment was delayed because priority was given to the neurosurgical management of the vertebral trauma. The extensive deep burns of the forearm, which could have benefited from early surgical treatment, caused a complete loss of cutaneous and muscular tissues. Our reconstructive strategy privileged the functional recovery of the thumb and the long fingers, sacrificing wrist mobility. We chose the gracilis muscle for three main reasons: its strap morphology ensures a good potential range of excursion,
that is directly proportional to the overall muscle length; the well represented tendinous portion allows to split the muscle in two main units, one for the four long fingers and one for the thumb; finally the low donor site morbidity is very important, especially in young patients. These properties represent main advantages in comparison with other muscles commonly used for functional reconstruction, such as serratus, pectoralis major and latissimus dorsi [4–12]. The key point of the surgical procedure was the correct tensioning of the transplanted muscle, in order to assure the full range of flexion and extension of the fingers. Skin coverage could be gained either by a simple skin graft over the transplanted muscle or by harvesting a myocutaneous flap. We chose the myocutaneous flap in order to avoid fibrotic adhesions, which are common sequelae of skin grafting, furthermore, the patient was slim, and so the skin island was not bulky.
Fig. 8 – MRI of the left forearm at 18 months from trauma.
burns 35 (2009) 606–609
The key point of skin coverage is the adequate coverage of the distal tendons sutures, to avoid scar adhesions. Some authors recommend utilization of groin flaps, abdominal flaps, free flaps or tissue expanders as a preliminary procedure for the coverage of this region [4]. In this case, we harvested a very long skin island (18 cm), and more the tendon sutures were covered by the dorsal skin of the hand; skin graft was limited to a small area at the muscle-tendinous junction. All of these solutions guaranteed a good tendon gliding also confirmed by the MRI study. Finally post-operative rehabilitation for at least one year after surgery was essential to obtain satisfying functional results [9]. The rehabilitation program, with the wearing of dynamic orthesis, was designed to obtain full passive muscle extension and overcome any tendency to myotonic contracture.
[3] [4] [5]
[6] [7] [8]
[9]
[10]
references [11] [1] Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg 1976;58:407–11. [2] Lai Chung-Sheng, Lin Tsai-Ming, Lee Su-Shin, Tu Chao-Hung, Chen I-Heng, Chang Kao-Ping C, Tsai Chih-Cheng, Lin Sin-Daw. Case studies in contact
[12]
609
burns caused by exhaust pipes of motorcycles. Burns 2002;28(4):370–3. Hendon DN. Total Burn Care. 2nd ed. Saunders; 2001. pp. 170–181. Green DP. Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1993. pp. 1159–1178. Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. J Plast Reconstr Aesthet Surg 2007;60(7):760–8. Manktelow RT, Mckee NH. Free muscle transplantation to provide active finger flexion. J Hand Surg 1978;3:416. Manketow RT, Zuker RM, Mckee NH. Functioning free muscle transplantation. J Hand Surg 1984;9A(32). Manktelow RT, Mckee NH, Vettese T. An anatomical study of the pectoralis muscle as related to functioning free muscle transplantation. Plast Reconstr Surg 1984;73:751–5. Shieh S-J, Lee J-W, Chiu H-Y. Long term functional results of primary reconstruction of severe forearm injuries. J Plast Reconstr Aesth Surg 2007;60:339–48. Logan SE, Alpert BS, Buncke J. Free serratus anterior muscle transplantation for hand reconstruction. Br J Plast Surg 1988;41:639–43. Tobin GR, Shusterman M, Peterson GH, Nichols S, Bland KI. The intramuscular neurovascular anatomy of the latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637–41. Sauerbier M, Ofer N, German G, Baumeister S. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007;119(2):605–15.