The distally-based brachioradialis muscle flap

British Journal ofPIostic Surgery (1991). 44,3&32 0 1991 The Trustees of British Association of Plastic Surgeons

The distally-based brachioradialis muscle flap D. D. McGeorge, P. M. Arnstein and J. H. Stilwell Mersey Regional Plastic Surgery and Burns Centre, Whiston Hospital, Prescot, Merseyside SUMMARY. We describe the brachioradialis muscle flap based distally on the radial artery. It is quickly raised and provides excellent cover for soft tissue defects of the hand. In the two clinical cases the brachioradialis tendon has also been used for extensor tendon reconstruction.

The provision of adequate soft tissue cover of complex hand wounds can be a challenging problem. This is especially so in dirty, potentially infected wounds and when bone, joints or tendons are exposed. In these situations muscle provides the ideal cover with its rich blood supply, but to date this has meant free tissue transfer using microvascular techniques (Logan et al., 1988). Previously described by Lendrum (1980) and later by Lai et al. (1981), the brachioradialis muscle has been used based proximally to cover soft tissue defects around the elbow. We describe its use, based on the distal radial artery and venae comitantes, for soft tissue cover of the hand and distal forearm.

Recurrent artery

radial

artery Brachioradialis-

Anatomy (Fig. 1)

The brachioradialis is the most superficial muscle on the radial side of the forearm. It arises from the upper two-thirds of the supracondylar ridge of the humerus and lateral intermuscular septum, and inserts via flat tendon into the lateral aspect of the distal radius. The breadth of origin is usually about 7.5 cm, with the muscle providing a triangular piece of tissue some 15 cm long. The blood supply is from branches of the radial artery and a variably dominant vascular branch of the recurrent radial artery.

Fig. 1 Figure l-The

anatomy

Figure 2-The

distally-based brachioradialis

of the brachioradialis

muscle.

Surgical technique

After performing an Allen’s test (1929), the skin and fascia of the forearm are reflected from the muscle through a lazy S incision, The muscle is then reflected radially, exposing the vascular pedicle. The radial artery, the recurrent radial artery and the muscle are divided proximally and then raised as a unit, maintaining the vascular connections between the flap and vessels (Fig. 2). By freeing the vascular pedicle distally, a wide arc of rotation can be achieved, allowing the flap to cover any part of the hand. After insetting, the muscle is shaved to a suitable 30

muscle flap.

The Distally-Based Brachioradialis contour and covered skin graft.

Muscle Flap

with a meshed

split thickness

If necessary the brachioradialis tendon can be used to reconstruct tendons or ligaments.

31 alis tendon grafts and the muscle used to cover the defect (Fig. 3B). At 8 weeks there was full extensor tendon function with metacarpo-phalangeal joint flexion to 90” and no extensor lag. The cosmetic result was good (Fig. 3C, D, E).

Case reports

Case 2

Case I G.P., age 28 years, sustained multiple injuries in a road traffic accident, including a deep abrasion injury to the dorsum of his left hand. The metacarpal bones were exposed in the base of the wound with extensor tendon loss to his index, middle and ring fingers (Fig. 3A). Tendon reconstruction was performed with brachioradi-

N.R., age 31 years, sustained a head injury and an abrasion of the dorsum of his right hand in a road traffic accident (Fig. 4A). Extensor tendon reconstruction was performed using the brachioradialis tendon which was covered with the brachioradialis muscle. The functional result was compromised by damage to several finger joints, but wound healing was uneventful (Fig. 4B).

Fig. 3 Figure Zt-Case 1. (A) Defect left after wound excision with exposed metacarpals and extensor tendon loss to index, middle and ring fingers. (B) Extensor tendon reconstruction with brachioradialis tendon grafts; muscle flap ready to be inset. (C) Appearance at 3 months. (D, E) Functional result.

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British Journal of Plastic Surgery

Fig. 4 Figure 4-Case

2. (A) Defect after wound excision; open joints, bone and extensor tendon loss. (B) Appearance at 3 months.

Discussion

The distally-based brachioradialis muscle flap provides good soft tissue cover for the hand rapidly and reliably, without the need for microvascular tissue transfer. However, it does suffer the disadvantage of any flap which involves division of a main hand artery. The muscle belly readily conforms to irregular contours eliminating dead space and, with its rich blood supply, minimises the risk of infection. As a result, primary bone and tendon grafting and joint replacement can be performed. The brachioradialis tendon itself can be used for tendon grafting. The donor site scar is better than that from most radial forearm flaps and in the two cases described there has been no noticeable weakness of elbow flexion, one patient returning to his sport of rowing.

Lai, M. F., Kriabna, B. V. and PeBy,A. D. (1981). The brachioradialis myocutanwus gap. British Journal of Plastic Surgery, 34,431. Lendrum,J. (1980). Alternatives to amputation. Annafsof rhe Royal College of Surgeons of England, 62,95.

Logan, S. E., Alpert, B. S. and Bun&e, H. L. (1988). Free serratus anterior muscle transplantation for hand reconstruction. British Journal of Plastic Surgery, 41,639.

The Authors DouglasD. McCeorge, MB, ChB, FRCSE, Registrar. Peter M. An&&, FRCSEng, FRCSEd, Senior House Officer. John H. StBweU, BSe, FRCS, Consultant. Mersey Regional Plastic Surgery and Bums Centre, Whiston Hospital, Prescot, Merseyside, S35 5DR.

References ABen,E. V.(1929). Thromboangitisobliterans:methodsofdiagnosis of chronic occlusive arterial lesions distal to the wrist, with illustrative cases. American Journal of Medical Science, 178, 237.

Requests for reprints to Mr McGeorge. Paper received 17 January 1990. Accepted 5 June 1990 after revision.