Soft tissue defects involving the posterior aspect of the elbow are not uncommon and can be challenging to manage. Tissue defects can be from trauma, burns, post-oncologic resection, pressure ulcers, extravasation injury, chronic bursitis, or chronic infection (4,7,15). In addition, elbow prosthetic devices can be exposed with devastating consequences. The goals of treating posterior elbow soft tissue defects is to provide wound closure, decrease the risk of infection, decrease edema, and allow the initiation of early rehabilitation (2,12). The soft tissue reconstruction must be aesthetically acceptable, durable, and elastic enough to allow for the constant unhindered movement of skin over the olecranon with elbow flexion and extension (7).

Many soft tissue reconstructive options exist and must be tailored to the needs of the patient’s wound characteristics. Superficial wounds can be addressed by primary wound closure. Wounds with exposed “white structures” such as tendons, neurovascular structures, bone, and joint will necessitate flap coverage (9). Available flap options include regional muscle and musculocutaneous flaps, distant staged pedicle flaps, and microvascular free tissue transfer (8). Although these flaps are useful for elbow soft tissue coverage, they can carry significant morbidity. For example, regional muscle and musculocutaneous flaps necessitate the harvesting of a functional muscle; distant pedicle flaps (such as the groin or thoracoepigastric flap) require the binding of the extremity to the flank for several weeks with significant discomfort and ensuing stiffness; and free flaps introduce the added complexity of microsurgery and prolonged surgical time (4,8). Because of the liabilities of the previously mentioned flaps, local fasciocutaneous flaps have gained popularity (10), of which the proximally based radial forearm flap is the recognized workhorse for elbow soft tissue coverage (8).

The radial forearm flap is composed of the skin, subcutaneous fat, and fascia that, if needed, can be elevated to include the entire volar surface of the forearm (13) (see Fig. 10-2). This is a reliable flap with a rich arterial supply from the septocutaneous perforator branches of the radial artery (see Fig. 10-3). The deep venous drainage for the flap is provided by the paired venae comitantes that run parallel with the radial artery and the superficial venous drainage is by branches of the cephalic vein. The radial forearm flap is versatile because it may be transposed either in the radial or ulnar direction and can be made sensate by encompassing the cutaneous nerves of the forearm. Furthermore, this flap can provide stable soft tissue coverage while still preserving elbow range of motion.

Contraindications to the use of the radial forearm flap include any injury to the radial artery, severe forearm soft tissue injuries, and inadequate collateral flow to the hand and thumb. A possible relative contraindication is recent cannulation of the superficial venous system of the upper extremity, as this may result in venous thrombus formation in the flap and subsequent venous congestion (5).