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The radial forearm — flexor carpi radialis myocutaneous flap: case report
Brrrkh Journal ojP/asrir 0
Surgery (1992). 45. 322-323
1992 The British Assmarioo
of Plastic
Surgeons
Case Report The radial forearm R. B. Hamilton
flexor carpi radialis myocutaneous flap : case report
and T. W. Proudman
Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, Australia SUMMARY. A patient sustained a compound fracture of the elbow resulting in a deep soft tissue defect with exposed bone, joint and nerve. The flexor carpi radialis (FCR) muscle was incorporated within the radial forearm island flap to cover the defect. Wrist flexion was not compromised by this procedure. The blood supply and applications of the radial forearm - flexor carpi radialis myocutaneous flap are described.
Case report A 36-year-old man, involved in a motor vehicle accident, suffered a compound fracture of the right elbow. Following debridement and fracture stabilisation a deep medial elbow defect was evident, extending into the elbow joint and
exposing the proximal ulna and ulnar nerve (Fig. 1). Flap coverage was eventually required for this wound and in view of the depth and nature of the defect, muscle was highly desirable.
Fig. 2
Fig. 1
Fig. 3 Figure I-The soft tissue defect at the elbow showing the exposed ulnar nerve (A), elbow joint (B), and proximal ulna (C). Figure Z&The pedicled island radial forearm - FCR myocutaneous flap, showing the radial artery pedicle (A), with the FCR muscle (B) divided proximally and distally. Figure 3-Postoperative result displaying full wrist flexion performed by palmaris longus and flexor carpi ulnaris.
Case Report
323
A proximally pedicled radial forearm island flap was raised, incorporating the entire FCR muscle based on the muscular branches of the radial artery (Fig. 2). The flap was positioned with FCR filling the medial elbow cavity. The donor site was skin grafted. The flap survived without complication and the patient returned to work with gradual resolution of his ulnar neuropraxia. Despite sacrificing the FCR muscle, he still had satisfactory wrist flexion using palmaris longus and flexor carpi ulnaris (FCU) (Fig. 3).
Discussion FCR is primarily supplied by 6 to 8 segmental vessels, arising from the medial side of the radial artery (Fig. 4). These vessels average 0.3 mm in diameter (Cormack and Lamberty, 1986; Parry er al., 1988). With the accompanying venous tributaries, they are easily preserved when raising the cutaneous flap. This makes FCR an ideal muscle to be raised in conjunction with the radial forearm flap. The radial forearm - FCR myocutaneous flap has advantages over other forearm muscle flaps in filling
large soft tissue defects at the elbow. The brachioradialis muscle will only cover small lateral and posterior defects, while the FCU myocutaneous flap has the disadvantage of exposing the ulnar artery and the ulnar nerve (Hodgekinson and Shepard, 1983). FCU is also the most powerful wrist flexor and ulnar deviator and its sacrifice should be carefully considered (Hollinshead, 1982). In the case presented, the FCR muscle component obliterated the dead space where bone, joint and nerve were exposed and enabled rapid healing (Mathes et al., 1982). The skin flap provided additional soft tissue cover as the defect was large in area. This flap also has the potential for use as a free flap. Despite sacrifice of the FCR muscle. there was negligible loss of wrist flexion in this case.
References Cormack, G. C. and Lamherty, B. C. H. (1986). The urrerial unatomy oj’skin,flaps. Edinburgh, Churchill Livingstone, p. 180. Hodgekinson, D. and Shepard, G. H. (1983). Muscle musculocutaneous and fasciocutaneous flaps in forearm reconstruction. Annals of’ Plastic Surgery, 10,400. Hollinshead, W. H. (Ed.) (1982). Analomy /iv sur,qeon.s. Vol 3. New York, Harper and Rowe. p. 358. Mathes, S. J., Alpert, B. S. and Chang, N. (1982). Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plastic and Reconsfructke Surgery. 69. 815. Parry, S. W., James, W. W. and Mathes, S. J. (1988). Vascular anatomy of the upper extremity muscles. Plastic and Recon.stru&)e Surgery, 81. 358.
The Authors
Fig. 4 Figure 4- -Cadaver dissection of the left forearm, showing the radial artery (A) and flexor carpi radialis muscle (B). Six segmental vessels can be seen passing from the radial artery to the muscle with the most proximal passing over the pronator teres muscle.
T. W. Proudman, MB, BS, Registrar. R. B. Hamilton, FRACS, Consultant Plastic and Reconstructive Surgeon and Head of Unit. Department of Plastic and Reconstructive Surgery, Flinders Medical Centre. Bedford Park 5042, South Australia. Requests
for reprints
to Mr R. B. Hamilton.
Paper received 7 August 1991. Accepted 22 November 1991. after revision.
Surgery (1992). 45. 322-323
1992 The British Assmarioo
of Plastic
Surgeons
Case Report The radial forearm R. B. Hamilton
flexor carpi radialis myocutaneous flap : case report
and T. W. Proudman
Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Adelaide, Australia SUMMARY. A patient sustained a compound fracture of the elbow resulting in a deep soft tissue defect with exposed bone, joint and nerve. The flexor carpi radialis (FCR) muscle was incorporated within the radial forearm island flap to cover the defect. Wrist flexion was not compromised by this procedure. The blood supply and applications of the radial forearm - flexor carpi radialis myocutaneous flap are described.
Case report A 36-year-old man, involved in a motor vehicle accident, suffered a compound fracture of the right elbow. Following debridement and fracture stabilisation a deep medial elbow defect was evident, extending into the elbow joint and
exposing the proximal ulna and ulnar nerve (Fig. 1). Flap coverage was eventually required for this wound and in view of the depth and nature of the defect, muscle was highly desirable.
Fig. 2
Fig. 1
Fig. 3 Figure I-The soft tissue defect at the elbow showing the exposed ulnar nerve (A), elbow joint (B), and proximal ulna (C). Figure Z&The pedicled island radial forearm - FCR myocutaneous flap, showing the radial artery pedicle (A), with the FCR muscle (B) divided proximally and distally. Figure 3-Postoperative result displaying full wrist flexion performed by palmaris longus and flexor carpi ulnaris.
Case Report
323
A proximally pedicled radial forearm island flap was raised, incorporating the entire FCR muscle based on the muscular branches of the radial artery (Fig. 2). The flap was positioned with FCR filling the medial elbow cavity. The donor site was skin grafted. The flap survived without complication and the patient returned to work with gradual resolution of his ulnar neuropraxia. Despite sacrificing the FCR muscle, he still had satisfactory wrist flexion using palmaris longus and flexor carpi ulnaris (FCU) (Fig. 3).
Discussion FCR is primarily supplied by 6 to 8 segmental vessels, arising from the medial side of the radial artery (Fig. 4). These vessels average 0.3 mm in diameter (Cormack and Lamberty, 1986; Parry er al., 1988). With the accompanying venous tributaries, they are easily preserved when raising the cutaneous flap. This makes FCR an ideal muscle to be raised in conjunction with the radial forearm flap. The radial forearm - FCR myocutaneous flap has advantages over other forearm muscle flaps in filling
large soft tissue defects at the elbow. The brachioradialis muscle will only cover small lateral and posterior defects, while the FCU myocutaneous flap has the disadvantage of exposing the ulnar artery and the ulnar nerve (Hodgekinson and Shepard, 1983). FCU is also the most powerful wrist flexor and ulnar deviator and its sacrifice should be carefully considered (Hollinshead, 1982). In the case presented, the FCR muscle component obliterated the dead space where bone, joint and nerve were exposed and enabled rapid healing (Mathes et al., 1982). The skin flap provided additional soft tissue cover as the defect was large in area. This flap also has the potential for use as a free flap. Despite sacrifice of the FCR muscle. there was negligible loss of wrist flexion in this case.
References Cormack, G. C. and Lamherty, B. C. H. (1986). The urrerial unatomy oj’skin,flaps. Edinburgh, Churchill Livingstone, p. 180. Hodgekinson, D. and Shepard, G. H. (1983). Muscle musculocutaneous and fasciocutaneous flaps in forearm reconstruction. Annals of’ Plastic Surgery, 10,400. Hollinshead, W. H. (Ed.) (1982). Analomy /iv sur,qeon.s. Vol 3. New York, Harper and Rowe. p. 358. Mathes, S. J., Alpert, B. S. and Chang, N. (1982). Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plastic and Reconsfructke Surgery. 69. 815. Parry, S. W., James, W. W. and Mathes, S. J. (1988). Vascular anatomy of the upper extremity muscles. Plastic and Recon.stru&)e Surgery, 81. 358.
The Authors
Fig. 4 Figure 4- -Cadaver dissection of the left forearm, showing the radial artery (A) and flexor carpi radialis muscle (B). Six segmental vessels can be seen passing from the radial artery to the muscle with the most proximal passing over the pronator teres muscle.
T. W. Proudman, MB, BS, Registrar. R. B. Hamilton, FRACS, Consultant Plastic and Reconstructive Surgeon and Head of Unit. Department of Plastic and Reconstructive Surgery, Flinders Medical Centre. Bedford Park 5042, South Australia. Requests
for reprints
to Mr R. B. Hamilton.
Paper received 7 August 1991. Accepted 22 November 1991. after revision.