Journal of Emergencies, Trauma, and Shock

LETTER TO EDITOR
Year
: 2014  |  Volume : 7  |  Issue : 1  |  Page : 53--55

Emergent free flow-through anterolateral thigh flaps for Gustilo-Anderson III fracture of the upper extremity


Masaki Fujioka1, Kenji Hayashida2, Chikako Murakami2,  
1 Department of Plastic and Reconstructive Surgery, Nagasaki University; Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan
2 Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan

Correspondence Address:
Masaki Fujioka
Department of Plastic and Reconstructive Surgery, Nagasaki University; Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization, Nagasaki Medical Center, Nagasaki
Japan




How to cite this article:
Fujioka M, Hayashida K, Murakami C. Emergent free flow-through anterolateral thigh flaps for Gustilo-Anderson III fracture of the upper extremity.J Emerg Trauma Shock 2014;7:53-55


How to cite this URL:
Fujioka M, Hayashida K, Murakami C. Emergent free flow-through anterolateral thigh flaps for Gustilo-Anderson III fracture of the upper extremity. J Emerg Trauma Shock [serial online] 2014 [cited 2020 May 30 ];7:53-55
Available from: http://www.onlinejets.org/text.asp?2014/7/1/53/125642


Full Text

Sir,

Gustilo-Anderson III C open fracture requires both bony and soft tissue reconstruction, as well as vascular repair. The main problem of this severe injury is the total absence or extreme deficiency of blood flow to bone fragment or fractured stumps. Late resurfacing with local flap sometimes leads to sequestration and osteomyelitis, necessitating prolongation of the period of external fixation. [1] What is the best treatment for these complex sever injuries? We believe the answer should be an early wound resurfacing with well-vascularized soft-tissue. We present a successful case of a Gustilo-Anderson III C bone-exposing wound surgical treatment with emergent use of a free flow-through anterolateral thigh flap.

A 32-year-old male patient was referred to our emergency unit complaining of a Gustilo-Anderson III C fracture of the right forearm due to being crashed by a falling telephone pole [Figure 1]. Patient had an open fracture of the radius and severe crush of the forearm muscles with wide abrasion of the skin and flexor muscles. Circulation of the right hand had ceased because the ulnar artery was mutilated and about 5 cm the radial artery had been lost [Figure 2].{Figure 1}{Figure 2}

After the crushed radius was destructed and underwent external fixation, the bone-exposing wound was repaired with a free anterolateral thigh flap with a 12 cm × 5 cm elliptical skin island [Figure 2]. The T-portion of the descending branch of the lateral circumflex femoral vessel was interposed to the defect of the radial artery. Two veins were connected to the cutaneous veins. Consequently, the interrupted radial artery resumed normal blood flow [Figure 3] and [Figure 4]. The viability of the skin flap was favorable without infection or necrosis [Figure 5], [Figure 6], [Figure 7].{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}

The conventional options to treat Gustilo-Anderson III C injuries are vascular repair and bone reduction along with a skin graft or local or distant flap. [2] Conservative treatments cannot lead to a favorable wound bed on bone; thus, it requires some flap surgeries to resurface the wound. [1] Sometimes, the reconstruction is planned as a two-stage surgery. [3] However, early wound coverage with a free flap within 72 h was recommended, because the highest risk of infection and flap loss occurred in the delayed period. [4]

These vascular injuries requires vascular repair immediately after an injury, such as direct repair, an interposed vein graft and bypass graft, to supply sufficient blood flow to the distal area of the injured extremity. [5] On the other hand, microsurgical flow-through flaps is beneficial, because blood flow of the distal forearm can be maintained normally while the soft-tissue-insufficient wound can be resurfaced at one time. The lateral circumflex femoral arterial system is a favorable source of the T-anastomosis pedicle as it has a long descending branch and a reliable proximal transverse branch. This technique enables both vascular and soft-tissue reconstruction at once with minimal donor site problems, which are potential advantages over conventional methods.

In conclusion, we believe that emergent use of free flow-through anterolateral thigh flap is the primary choice for reconstruction for Gustilo-Anderson III C fracture with soft-tissue defects.

References

1Fujioka M, Hayashida K, Murakami C. Artificial dermis is not effective for resurfacing bone-exposing wounds of Gustilo-Anderson III fracture. J Plast Reconstr Aesthet Surg 2013;66:e119-21.
2Soni A, Tzafetta K, Knight S, Giannoudis PV. Gustilo IIIC fractures in the lower limb: Our 15-year experience. J Bone Joint Surg Br 2012;94:698-703.
3Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008;28:632-4.
4Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92.
5Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al. Vascular injury associated with extremity trauma: Initial diagnosis and management. J Am Acad Orthop Surg 2011;19:495-504.