EMERGENCY SURGICAL REPAIR OF EXTENSIVE SOFT-TISSUEDEFECTS IN UPPER LIMB OF A CHILD, USING FLAP GRAFT

LIN LI, M.D.,* TAN XIONGJIN, M.D., and CHEN GUOFEN, M.D.

Extensive soft-tissue defects in the upper limb of a child are rare, and emergency surgical repair presents a challenge to the clinician andrequires high proficiency in operating skills. The use of common regular flaps fails to completely cover the trauma. We report on a case inwhich the skin defect, reaching 42 x 15 cm, was repaired by the use of a scapula latissimus dorsi musculo-cutaneous flap, and the functions ofthe affected limb were maintained to the utmost extent. Thus the patient has escaped amputation. ª 2003 Wiley-Liss, Inc.

Primary skin-flap transfers or transplantations to re-pair tissue defects possess a great many merits.1 In thispaper, we report on our experience of successful emer-gency surgical repair using flap transplantation in a 12-year-old boy with extensive soft-tissue defects in the leftupper limb, admitted to our hospital in October 2001.

CASE REPORT

The left upper limb of the boy was smashed by acotton-processing machine in an industrial accident,causing extensive soft-tissue loss. The patient was ad-mitted to the emergency room of our hospital 8 hr later,with blood pressure of 10/4.8 kPa, heart rate 120/min,and Hb 10.8 g/l. A1 general inspection found the skindefect reaching 42 · 15 cm, extending from the medianpart of the humerus to the wrist on the flexion side ofthe injured arm. The muscle tendon of the left bicepswas broken, and a considerable portion of tissue wasmissing from the antecubital fossa. The flexion side ofthe left ulnar and radius, from below the neck of theradius, was exposed at full length. Among the flexorgroup, only the digitorum profound and ulnar flexormuscle of the ring and little fingers survived the acci-dent, with an exposed ulnar nerve sheath and weakenedpulsation of the ulnar artery (Fig. 1). The skin temper-ature of all fingers was low. The vascular reaction of theblood capillary of the king, ring, and little fingers wasfaintly detected.

After immediate transfer of the patient to the oper-ating room, the subscapular artery and its majorbranches (the thoracodorsal artery and circumflexscapular artery) were identified in preoperative checkup,followed by antishock measures. Debridement was per-

formed to clean the grease stain and the cotton left in thewound, with special care to avoid further damage to theremaining ulnaris blood vessel and nerves. Under a mi-croscope, the radial artery and two accompanying veinsnear the cubital fossa as well as the basilic vein werecarefully extricated from the mess, and ligated at thedistal end for later use. The wound was then temporarilydressed with sterilized gauze bandage.

An upside-down L-shaped skin flap was designed inaccordance with the lining of the blood vessels whichhad been preoperatively detected. The flap was inte-grally freed from the scapula latissimus dorsi, with onlythe axilla vascular pedicle linking to the body (Figs. 2,3). The skin circumscribing the donor site, after beingdetached along the margins from the adhering tissues,was directly sutured (Fig. 4). The L-shaped flap wassubsequently transferred to the cleaned wound, and withinterrupted sutures along the margins of the flap withthose of the skin around the wound, the flap was fixedto facilitate later procedures. Anastomoses between thesubscapular artery and the radial artery, and then be-tween the two subscapular veins, respectively, with theradial vein and the basilic vein, were performed (Fig. 5).

Finally the injured arm was plastered for fixation atthe functional position of the wrist, with the elbow bentat an angle of 120�. Subsequent routine treatments wereimplemented. One week later, a skin fissure about 2 · 3cm near the neck of the radius occurred, which was di-rectly sutured, and after 2 weeks’ routine wound dress-ing, the patient was discharged, fully recovered.

DISCUSSION

This scapula latissimus dorsi musculo-cutaneous flapwas composed of a scapula flap with the circumflexscapular artery and a latissimus dorsi-cutaneous flap,2�4

pedicled by the thoracodorsal artery and the subscapu-laris artery and veins. Since the subscapularis artery hasa comparatively longer pedicle, larger caliber, and twoaccompanying veins, scapula latissimus dorsi musculo-cutaneous flaps can be designed in irregular shapes, oreven annular shapes, with greater length or width, in

Department of Traumatology and Orthopedic Surgery, Nanfang Hospital,First Military Medical University, Guangzhou, China

*Correspondence to: Lin Li, M.D., Guangzhou Hengsheng Hand SurgeryHospital, No 155 Hengfu Road, Guangzhou, 510095, Guangdong Province,China. E-mail horse0510@163.com

Received 28 April 2003; Accepted 7 July 2003

Published online 29 December 2003 in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/micr.10202

ª 2003 Wiley-Liss, Inc.

accordance with the irregularity of the traumas that areto be repaired, which is often impossible with a routinesingle flap. This flap, if necessary, can also be used as amuscle ossa flap to cover the open wounds and restorenormal functions of the skin. The advantages of such aflap graft are obvious in that the donor site is less con-spicuous, where the skin around the flap can be directlysutured after the margins are freed.

Emergency large-flap transplantations are highlyrisky and therefore require great proficiency in operatingskills. Based on our experience, we urge surgeons to givetheir attention and priorities to the following three issues:

1) A thorough and careful debridement is most crucialfor flap graft success.

2) Preoperative ultrasound Doppler inspection shouldbe performed to ascertain whether the subscapularis,

thoracodorsal, and circumflex blood vessels still exist.The initial excision should be made in Z-shape at thecupular part of the axillary fossa to prevent a possibleincision scar in the axilla posterior wall that mayhamper the abduction of the affected limb. Only afterthe subscapularis blood vessel and its two majorbranches are freed, should the scapula latissimusdorsi musculo-cutaneous flap be incised. In this pre-sent case, the child had much subcutaneous fat andnumerous tiny vessel branches in the axillary fossa,and the arteries and veins were not so readily distin-guishable as is the case with adults; in addition, thepoor flexibility and anti-injury ability of the bloodvessels, in comparison with adults, rendered the ves-sels vulnerable to operative injury and stimulationsthat are liable to result in spasm. All these factors

Figure 1. Left upper hand at admission. Exposed radius.

Figure 2. Incising flap from left scapula dorsi in operation. Latissi-

mus dorsi.

Figure 3. Incising flap from left scapula dorsi in operation (lateral

view). Subscapularis blood vessel pedicle and nerve. Serratus an-

terior muscle.

Figure 4. Donor site was directly sutured without dermoplasty.

Emergency Surgical Repair 57

made acute incision and gentle performance necessarywhen vessels were being separated.5 The pedicle couldbe separated along with some connective tissue andcut off from as close as possible to the axilla bloodvessel. Great care needs to be taken in the followingprocedures. First, thorough hemostasis should beperformed. Electric coagulation is recommended forthe hemorrhagic spots in the flap distant from thepedicle, and obvious bleeding near the pedicle shouldbe treated by ligation with thin thread. When theblood circulation is resumed in the grafted flap,nonthorough hemostasis might cause subcutaneoushematoma at least and complications such as massivebleeding that may even lead to shock, the worstconsequence that can be expected. The effects of thedrugs and loss of innervation in the flap only increasethe possibility of such a disaster. Second, the warmischemia time of the musculo-cutaneous flap shouldbe shortened, because a musculo-cutaneous flappossesses less tolerance against ischemia than docommon skin flaps. Prolonged ischemia may induceischemia-reperfusion injuries, causing the productionof hazardous substances such as nitrogen monox-ide.6�9 So before the pedicle is cut off, the skin aroundthe donor site should be freed and sutured, leavingonly the site where the pedicle connects to the bodynot sutured, to reduce warm ischemic time. Once thepedicle is cut, the donor site should be immediatelyand completely sutured. Third, the flap vessel shouldbe cut off at the spot as close as possible to the axillablood vessels, and all severed blood vessels need to becarefully marked to avoid mistakes in anastomosis.

3) Superficial and deep veins can be anastomosed tohelp relieve the swelling of such a large flap aftergrafting.10 For the utmost recovery of flexion func-tion of the elbow, one of the broken ends of the

latissimus dorsi muscle tendon may be sutured withthe broken end of brachii muscle biceps tendon,while the other end of the2 former tendon may besutured with the distal end of deep flexor muscle ofthe fingers after tension adjustment.

Although in the present case, the blood circulationaround the wound depended merely on the remainingulnar vessels, the existence of a superficial and deeppalmar arch, postoperative recovery of blood volumeand collateral blood circulation around the wrist, use ofblood vessel-dilating agents, and vascular innervation ofthe thumb and index fingers all help the radial fingerssurvive on the blood supply from the ulnar artery, whichnormally depends on a supply from the radial artery. Itis most important that amputation of the fingers wasavoided.

CONCLUSIONS

Primary emergency repair of such an extensivetrauma can be advantageous in that the anatomical viewof the wound is clear, and as much viable tissue aspossible can be maintained. The chances for complica-tions can also be reduced, with lowered cost andshortened hospitalization time. In addition, the prob-lems of multiple ends for anastomoses, as are typical offlaps in serial or paralled connection with the donorside, can be avoided, since only one end of one vesselgroup needs to be anastomosed.

REFERENCES

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Figure 5. Ten days after operation on left upper hand.

58 Li et al.