Radial Forearm Flap for Elbow Coverage



Radial Forearm Flap for Elbow Coverage


Kodi K. Azari

W. P. Andrew Lee



Indications/Contraindications

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).



Preoperative Planning


Preparation of the Wound Bed

In cases of complex elbow wounds, it is extremely important to gain control over the wound before definitive soft tissue reconstruction. Osseous injuries and dislocations need to be stabilized with appropriate internal or external fixation and ligament reconstruction. When soft tissue injuries are present, it is mandatory to perform serial debridement of devitalized tissues until only viable tissues remains. Infections require appropriate debridement and culture-specific antibiotic coverage. It should be noted that meeting the above requisites as quickly as possible will allow for earlier definitive vascularized wound coverage with radial forearm flap and thus afford a more successful functional outcome.


Assessment of the Arterial Vascularity of the Hand

It is imperative to assess the arterial vascularity of the hand by performing a modified Allen’s test before performing the radial forearm flap. A modified Allen’s test is performed by occluding the radial artery at the wrist crease and evaluating the perfusion of the digits using a hand-held pencil Doppler. In particular, one must ensure that there are Doppler signals to the thumb digital arteries once the radial artery is occluded. If the modified Allen’s test shows evidence of vascular insufficiency, then one must be prepared to reconstruct the arterial tree using a saphenous vein graft or choose a soft tissue reconstruction technique other than the proximally based radial forearm flap.


Surgery


Patient Positioning

For optimal position, patients are placed supine on the operating room table. The entire upper extremity from axilla to hand is prepped and draped in standard surgical fashion, and a sterile proximal arm tourniquet applied.


Technique

Jun 13, 2016 | Posted by in ORTHOPEDIC | Comments Off on Radial Forearm Flap for Elbow Coverage

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