Rational flap selection and timing for coverage of complex upper extremity trauma

Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 760e768

REVIEW

Rational flap selection and timing for coverage ofcomplex upper extremity trauma

F. Herter a, M. Ninkovic b, M. Ninkovic a,*

a Klinikum Muenchen-Bogenhausen, Munich, Germanyb Department of Surgery, Division of Physical Medicine and Rehabilitation, Innsbruck Medical University,Innsbruck, Austria

Received 10 December 2006; accepted 7 March 2007

KEYWORDSFree flap selection;Upper extremitytrauma;Timing of defectcoverage

Summary Reconstruction of complex extremity trauma continues to be a challenging task forplastic surgeons. Characteristics of such injuries include destruction of functional structures,often due to high energy trauma that causes significant invalidity. Before the era of free flaps,pedicled fasciocutaneous and muscle flaps were the only option for reconstruction of the se-verely injured upper extremity. The management of complex injuries of the upper extremityhas changed with the development of reconstructive microsurgery.

Nowadays, we have a great variety of different free flaps to cover defects of the upperextremity and restore function by innervated free flaps. Sensibility, skin thickness, texture,colour, durability, binding of the flap to the underlying structures, donor site morbidity, possi-bility of secondary reconstructive procedures, the surgeon’s experience and operative facilitiesmust all be taken into consideration for choosing the optimal reconstructive procedure. Notonly the reconstructive und functional requirements but the timing of reconstruction isextremely important for final result.

The purpose of this paper is to define the principles of flap selection and timing of flap recon-struction, according to the assessment of trauma in the upper limb.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

* Corresponding author. Address: Technical University Munich,Department of Plastic, Reconstructive and Hand Surgery, BurnCentre, Klinikum Muenchen- Bogenhausen, Englschalkinger Str. 77,81925 Muenchen, Germany. Tel.: þ49 89 92702031; fax: þ49 8992702036.

E-mail address: [email protected](M. Ninkovic).

1748-6815/$-seefrontmatterª2007BritishAssociationofPlastic,Reconstrudoi:10.1016/j.bjps.2007.03.008

Assessment of damaged structures inupper limb injury

The mechanism and time of injury, location and extent ofsoft tissue and bone loss (size and depth of defect), degreeof nerve or tendon injury, quality of vascular supply,presenting contamination or infection as well as the qualityof the neighbouring tissue have to be taken into

ctiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

mailto:[email protected]

Rational flap selection and timing of extremity trauma 761

consideration in order to define the optimal choice ofreconstructive procedure. If we analyse the aetiology ofthe defect, we have to know full spectrum of severity. Is ithigh velocity trauma, or not? According to the location andanatomical specificity, such as palmar glabrous skin, thereconstructive requirements have to be characterized con-cerning the particular aims in restoration of function,sensibility and aesthetic. Furthermore, the functional re-quirements in massive muscle loss ask for innervated muscletransfer and/or tendon transfers. The quality of vascularsupply dictates the need for immediate revascularisation byperforming direct anastomosis, interposition of vesselsgraft, or a flow-through free flap. Pre-operative testing ofsensibility and motor nerve supply are essential for thedecision on the need for immediate nerve repair by suture orgrafting. Finally, aesthetic requirements put the accent onassessment to select the optimal reconstructive procedure.

Choice of reconstructive procedure

After assessment of damage, the reconstructive plan will bemade by analysing all the anatomical, functional andaesthetical reconstructive requirements. Age, sex, generalcondition of the patient, associated injuries, time ofreconstruction, need for secondary procedures, capabilityof the surgical team and equipment available in thehospital are taken into consideration in order to definethe optimal reconstructive procedure. Additionally flapcharacteristics like pliability, durability, bulk, sensibility,functioning motor units, composite flap possibilities (ten-don, nerve, bone) and donor site morbidity, significantlyinfluence the choice of reconstructive procedure.

Free microvascular flap or pedicled flap

Local, random and distant axial pattern flaps were fre-quently used before the introduction of free microvascularflaps. Local flaps have limited application because there isa paucity of expendable donor tissue, especially in the handwhere flap mobility is restricted. Additional injury to theadjacent tissues, in the case of trauma, may impair theirviability for transfer. Regional pedicled flaps can be usedsafely for coverage of defects, but their use is limited by thearc of rotation, by the extent of injury to the extremity andby the location of the injury. In addition, the surgeon mustassess the risk of adding a donor site to the already injuredextremity. We think that the practice of compromisinga severely injured limb further by sacrificing a local muscleor segment of intact skin, should be avoided. An exception isthe upper arm, where regional fascio-cutaneous or muscleflaps (latissimus dorsi muscle) from the back are indicated.We are increasingly of the opinion that free tissue transferprovides the most appropriate repair for most severe injuriesof the extremity. Microvascular free tissue transfer providesenough skin territories, and can be combined with fascia,muscles, bone, tendons and blood vessels. Some pedicledflaps may also be harvested as a combined flap for re-construction of the bone, but cannot yield as much tissue asa free flap, and also have significant donor site morbidity.1

The pedicled groin flap is also suitable for the treatmentof large defects on the hand, but because of the

uncomfortable position of the patient’s arm, the need fora second or third operation, and the possibility of jointcontracture, we do not use it. The free groin flap transfer isa safe and very applicable procedure, although hindered byunstable anatomy and a short pedicle. Additionally, the riskof free flap failure is especially low in the upper limb.2

The free flap needs a longer operation time and causesgreater initial costs than a pedicled flap, but early re-habilitation, and the avoidance of amputation and invalid-ity legitimate these costs (see Table 1).

Principles of flap selection

The criteria for the selection of a flap include the patient’sage, sex, aesthetic demand, general condition, and associ-ated injuries, the complexity and size of defect, thepresence of local infection, local vessels, and the intra-operative position of the patient, as well as the patient’spreference for donor site. Furthermore, the necessity forrestoring sensation to the defect, on secondary operationsfor reconstruction of tendons or nerves, and the expectedaesthetic result have to be taken into account. Poly-traumaand other serious diseases that do not allow a long operationtime could be a contra-indication for a free flap transfer.

The easiest way to cover superficial defects, withoutexposed deep structures is split or full thickness skingrafting. However, skin grafts may cause secondary con-tractures and loss of mobility in the hand. Furthermore, theaesthetic results are significantly inferior. Better functionaland aesthetic results may be achieved using INTEGRA� forprimary closure and secondary split thickness skin-grafting.3

Alternatively, local flaps may be used for small defectsbut not for complex reconstruction Regional pedicled flaps,such as those utilising the latissimus dorsi or pectoralis majormuscle can be employed in arm reconstruction, either forsoft tissue coverage, or for both functional and soft tissuereconstruction (biceps or triceps muscle).4,5 On some occa-sions, a pedicled fascio-cutaneous scapular or para-scapularflap can provide adequate soft tissue coverage in upper arminjury. In other regions of the upper extremity a free flap

Table 1 Advantage/disadvantage of free flaps versuspedicled flaps in the upper extremity

Free flap Pedicled flap

Large size Small sizeDonor-site outwith the

injured extremityDonor-site close to theinjury

Donor-site in a hidden area Donor-site in visuallyexposed area

Good blood flow Minimum blood flowLow rate of flap failure in

the upper limb

Long operation time Short operation timeSurgeon must be

experienced inmicrosurgery

Specialised infrastructure(microscope etc.)necessary

762 F. Herter et al.

reconstruction is our method of choice. Well- vascularised,free flaps provide adequate healthy tissue and facilitate vas-cular growth of new surrounding soft tissue. This increasedblood flow has the advantage of improving bone healingand providing greater local resistance to infection.6e8

The hand is not only a tool, but also an organ forcommunication, and therefore the aesthetic result mustespecially be taken into consideration. The colour andtexture of the flap should be similar to the surroundingtissue. The flap should not be too bulky; otherwise thinningwill require a second operation. If it is necessary, this isdone by liposuction under local anaesthesia. Needless tosay, the transplanted skin flap should not be too hairy.

The need for a long pedicle of a free flap is not so crucialin the upper extremity as in other parts of the bodies. Thenext artery and vein are mostly close to the recipient side.Therefore, we can often use the groin flap with its shortpedicle in the reconstruction of the upper extremity. Onthe other hand, in case of infection and significant fibrosis(secondary reconstruction), a long pedicle is needed tomake the anastomoses in healthy tissue.

Free muscle flap versus fascio-cutaneousflap or fascial flap?

Basic science studies report that the muscle flap and muscu-locutaneous flap have blood flow that is three times betterthan that of the fasciocutaneous flap.9 This rich blood supplyhas the advantage of improved bone healing and greater localresistance to infection.9 On the other hand, clinical studieshave also demonstrated successful extremity reconstructionwith fascio-cutaneous flaps.10 Clinically, muscles are highlypliable and can be divided along their longitudinal fibresinto multiple strands which can be placed in irregular defectsto obliterate dead space. Experimental and clinical evidencesuggests that complex contaminated wounds should be cov-ered with muscle flaps after debridement.

We prefer to use pure muscle flaps with split thicknessskin grafts for low extremity reconstruction. This type ofcoverage has no subcutaneous fat and skin grafts tend toadhere more rigidly. Muscle flaps with split skin graft lacksensation and undergo fibrosis and scarring.11 The advan-tage of fascio-cutaneous flaps compared to muscle flaps isrestoration of sensibility, which is extremely important forthe functional outcome in the reconstruction of the hand.Furthermore, fascio-cutanoeus flaps can better toleratesubsequent secondary surgical procedures that are oftenneeded for the restoration of the severely mutilated hand.In cases where the primary defect is very large, like forearmor arm injuries, and when secondary operations will benecessary, we prefer to apply musculocutaneous flaps. Skinislands may be used to improve the blood supply of the distalpart of a large musculocutaneous flap and are good forcontouring the extremity. Skin islands do not undergo super-ficial fibrosis and can be used later as local fascio-cutaneousflaps in secondary operations.

Free fascial flaps covered with free skin grafts may bea satisfactory alternative, especially for coverage of smallpalmar defects,12 because these flaps provide a thin vascu-larised bed for grafts and a surrounding layer for tendongliding. The aesthetic and functional results seem to be

good.13 However, secondary contracture of skin graft anddifficulties created during secondary reconstructive proce-dures make this reconstructive option less applicable thanthe fascio-cutaneous flap. Furthermore, limited size andthickness are the major disadvantages of free fascial flap,therefore we do not apply this technique for hand recon-struction. For large and full thickness palmar defect, weintroduced the instep free flap providing the same glabrousskin.14 This way of reconstruction is superior to any otherflap technique (see Table 2).

Criteria for free flap selection

Nowadays, many of free flaps are available for coverage ofhand defects. Each of them has advantages and disadvan-tages which must be taken into consideration (see Table 3).There is no flap that provides a solution to all problems, sothe surgeon has to be aware of the features of many differ-ent flaps and be experienced in harvesting them quickly,and under emergency conditions.

Latissimus dorsi muscle flap

This flap can be indicated for huge skin and muscle defects onthe forearm (free flap), or upper arm a (pedicled flap).15 Itcan be used as a functioning muscle for replacement of miss-ing biceps muscle function or as an innervated free flap torestore the function of missing forearm musculature. Thelarge muscle provides enough tissue for coverage, and canbe divided along it’s longitudinal fibres into strands whichcan be placed into irregular defects to obliterate dead space.Additionally, large diameter vessels and a long pedicle withfew branches can be applied as flow-through free flap to re-vascularize an injured extremity, or to interpose an arterialgraft from the pedicle to repair segmental defects in vessels.

Furthermore, low donor site morbidity makes this flapvery useable.

Gracilis muscle flap

Is the most useable muscle flap for upper extremitycoverage or functional reconstruction.

It can be applied as muscle flap covered with splitthickness ski graft or as a big myocutaneous flap withtransverse skin island for coverage of large defects.16 Thedonor site morbidity is low, and secondary thinning is rarely

Table 2 Comparison of fascial, fasciocutaneous andmuscle flaps

Fasciocutaneousflap

Muscleflap

Fascialflap

Haemoperfusion þ/� þþ �Sensibilty þ � �Tridimensionality þ þþ �Possibility of secondary

proceduresþ � �

Thinness þ þ/� þ(þ) Good; (þ/�) Acceptable; (�) Not acceptable.


Table

3Cri

teri

afo

rfr

ee

flap

sele

ctio

nin

reco

nst

ruct

ion

of

upper

ext

rem

ity

defe

ct

Fla

pSe

nsi

bilit

yThic

kness

Aest

heti

cColo

ur

Pliabilit

yCom

posi

teflap

Pedic

lele

ngt

hSi

zeD

onor

site

morb

idit

yPosi

tion

of

harv

est

ing

Gro

inþ

þþ

þþþ

bone,

fasc

ia�

þþ

þþ

supin

eALT

þþ

þ/�

þ/�

þ/�

fasc

ia,

musc

leþþ

þþ

þþ

supin

eSF

F�

þþ

þbone,

musc

leþþ

þþþ

late

ral

ElA

Pþ

þ/�

þþ

þþ

þþ

þþ

þþ

supin

eD

IEP

þþ

/�þ

þþ

þþ

þþ

þþ

þþ

supin

eG

raci

lis

�þ

þþ

/�þ

/�sk

inþ

þþþ

supin

eLa

tiss

imus

dors

i�

þþ

þ/�

þ/�

bone,s

kin,f

asc

iaþþ

þþ

þla

tera

lToe

tohand/fi

rst

web

space

þþ

þþ

þþ

þþ

þþ

þþ

/�þ

/�su

pin

e

TPF

þþ

þþ

þþþ

þþþ

late

ral

Radia

lfo

rearm

þþþ

þþ

þþ

bone,

fasc

iaþþ

þ�

supin

eIn

step

þþþ

þþ

þþ

þþ

/�þ

/�su

pin

e

necessary.16 The pedicle is long enough for defect coveragein upper extremity wounds. The flap can be raised in supineposition and a two- team approach is possible.

Extended lateral arm flap (ELAF)

This flap has a large area of thin, expandable tissue over thedistal arm and proximal forearm region, with sensorypotential, and very acceptable donor-site morbidity.17 Therestoration of sensation is obtained after co-aptation ofthe posterior cutaneous nerve of the forearm to a recipientnerve. With regard to the donor site morbidity, the ELAF issuperior to any other innervated fasciocutaneous flap. Inaddition to the scar on the lateral side of the distal part ofthe upper arm and the proximal part of the forearm, thereis a small area of sensory disturbance in the lateral proximalpart of the forearm. Only the extended part of this flap is thinenough for reconstruction of the dorsal site of the hand or forinterdigital space. The proximal part on the upper arm flap istoo thick (fat) and therefore the conventional lateral armflap is not indicated for hand reconstruction.

Radial forearm flap

The popular radial forearm flap, either pedicled or free,18 inour opinion has an unacceptable aesthetic donor site mor-bidity, plus the sacrifice of the radial artery. In addition,the palmar arterial arches may be damaged by a severepalm injury, which prohibits the application of a pedicled ra-dial forearm flap. On the other hand, functional morbidity tothe hand and wrist following harvest of a radial forearm fas-cio-cutaneous free flap seem to be low.19,20 The skin of theflap is pliable and thin, and the possibility of co-aptation ofsensory nerves makes the flap useful in sensory restorationof the hand. This flap is manly used by surgeons who do notperform microsurgery.

Sensory flaps from the first web space of the foot

A sensory flap from the first web space may be used toreconstruct critical areas like pulp defects of the finger, thatneed good sensitive recovery, in order to regain function ofthe hand.21 The flap can be raised with only the pulp of thefibular aspect of the great toe or combined with parts of thenail and the tibial side of the second toe.

Free instep flap from the sole of the foot

An ideal functional and aesthetic reconstruction of thepalmar surface with acceptable donor site morbidity can beachieved by a free flap taken from the sole of the foot, dueto its similar anatomical structure.14 Small defects shouldbe reconstructed, using the first interdigital free flapfrom the foot, whereas the free instep flap should be re-served for complete palmar re-surfacing.

Groin flap

The characteristics of the groin flap such as its size, skintexture, thickness, and minimal donor site morbidity make


this flap the most useable skin flap for hand coverage.Another great advantage of the flap is the possibility tocombine it with bone from the iliac crest or the fascia fromthe abdominal wall.22 The main disadvantage of this flap isthe short pedicle and the inconstant anatomy of the artery.This short pedicle might be a problem in the presence of in-fection, when a long pedicle is needed to make the anasto-mosis in healthy non-infected tissue.

Anterolateral Thigh Perforator Flap (ALTP)

The ALTP has become an important flap in reconstructivemicrosurgery, especially as far as head, neck and extremitydefects are concerned. The advantages of the flap area long pedicle and a maximum dimension of 30 cm in lengthand 20 cm in width, nourished by a single dominant perfo-rator.23 It can be used as a sensate flap by including the lat-eral femoral cutaneous nerve.24 The flap can also be raisedwith fascia lata for reconstruction of biceps or triceps ten-dons.25 The disadvantage is a time-consuming dissection ofthe descending branch of the lateral circumflex femoralsystem, and the anatomical variations of its perforators.Furthermore, in our experience the subcutaneous fat layeris rather thick even in slim caucasian individuals, and oftenrequires primary or secondary thinning. Other groups reportthat the flap can primarily be thinned safely to 2e3 mm.26

The primary thinning of the flap will decrease the numberof debulking procedures and improve the aesthetic result.

In reconstruction of the upper extremity there is oftenno need for a long pedicle. Therefore the so-called ‘newanterolateral thigh flap’ with a short pedicle, as describedby Koshima27 may be an alternative to the conventionalALTP. Raising the flap only with a single perforator or a shortsegment of the descending branch of the lateral circumflexfemoral system can reduce the time for elevation to ap-proximately 30 min.

In acute upper extremity wound coverage, the flapshould be raised larger than the measured size of defect,so that there will be no disturbance to perfusion caused bytension in the wound closure, even after post-operativeswelling. For the same reason, one should raise the flapwith more than one perforator.

The relative consistency of anatomy, simple dissectionof the flap, long pedicle, the possibility of thinning the flapto 3 mm, itsgood texture the possibility of providing a sen-sate flap, the two- team approach on a supine patient, thepotential for a composite flap with muscle or fascia, itsminimal morbidity and primary closure at the donor-sitemake this flap a ‘workhorse’ in the coverage of defects inthe upper extremity, with the exception of the hand.

Scapular/Parascapular flap

These flaps provide the option of a combined flap, withmuscle (latissimus or serratus muscle) and scapular bone.The skin is hairless and large flaps can be harvested withminimal donor-site morbidity. The flap must be harvested ina lateral or prone position, which makes it necessary tochange the position of the patient during the operation. Notwo- team approach is possible and operation time will belengthened.

Deep inferior epigastric artery perforator flap(DIEP)

This flap may be used to cover extensive skin defects in theupper extremity up to 50 x 15 cm, when a bilateral pedicleis used.28 Yet, for obese patients, it may either be too thickfor coverage of the upper extremity or secondary thinningmay be necessary. We do this by liposuction under local an-aesthesia. Other advantages are the minimal donor sidemorbidity and a very long pedicle. The application of thisflap is extremely rarely indicated in upper extremityreconstruction.

Thoracodorsal perforator flap (TDAP)

The size of the flap can be up to 12� 20 cm, but this makesprimary closure of the donor site difficult.29 Other advan-tages of the flap are a long vascular pedicle of 15 cm, con-stant thickness, and the possibility of primary thinning.Compared to the ALT it is often less hairy and has a smallerarea of coverage. The scar at the donor site is more obvious.Another disadvantage is the need for a lateral position of thepatient to elevate the flap, so that one has to change the po-sition intra-operatively in order to cover a defect of theupper extremity. Very delicate and long lasting dissectionmakes this flap very rarely useable in our clinical practice.

Serratus fascial flap

This flap has a maximum size of 20� 30 cm and yields a verythin and aesthetically good coverage of hand and fingers,after covering with split thickness skin graft.12,30 The func-tional results are good.13 The postoperative monitoring ofthe perfusion of the flap is difficult because refilling cannotbe checked. However, secondary splint thickness graft con-tracture significantly reduces the indications for applica-tion of this flap.

Toe to hand transfer as emergency procedure

In some very specific occasions, for example in un-replant-able thumb amputation, where the presented soft-tissuedefect must be reconstructed, second toe-to-hand transfercould be indicated. In our experience, emergency toe-to-hand transfer, if well selected, can be performed onhighly motivated patients as a primary procedure. This kindof surgery is possible only with a well- organized surgicalservice, including a microvascular team for 24 h a day.

Timing for coverage of complex upperextremity trauma

The timing of soft tissue reconstruction using flap tech-niques is extremely important. The advantages of early freeflap cover for severe extremity injuries are now well-established and include primary bone and soft tissuehealing, decreased risk of infection and a reduction in thelength of hospital stay and costs.31 (see Table 4)

The loss rate of free flaps in secondary reconstruction issignificantly higher than in primary or delayed primary


reconstruction.32,33 However, timing of free flap coverage isdiscussed conversely. As a reminder of war surgery and re-gardless of the introduction of microsurgery and the resultingavailability of practically unlimited amounts of tissue for re-construction, the principles of repeated debridement anddelayed wound closure are still being considered as a choiceof method for treating complex extremity traumas. There isa general reluctance among reconstructive surgeons toperform primary coverage of complex extremity injuries be-cause of a belief in the concept of progressive tissue necrosisafter high- energy trauma and subsequent infection, classi-cally requiring multiple debridements prior to wound cover-age. In attempts to salvage tissue, these debridements aredesigned to be quite conservative, when tissue viability isquestionable. Up to now, a primary rare debridement fol-lowed by several ‘second look’ operations to save as muchtissue as possible, is often used. This procedure is recommen-ded by Yaremchuk et al. (1987)34 who declare that delayingwound cover had no ill effects on clinical outcome. They sug-gested debridement at two to three day intervals and de-layed wound closure between seven to 14 days after injury.34

Other authors reported that patients whose wounds arenot closed in the first five days, experience a much highercomplication rate, resulting in soft tissue and bone in-fection.35 Even in electrical and thermal burn wounds, thatare believed to undergo progressive tissue necrosis, earlyfree flap coverage yields superior results compared to pro-tocols involving serial debridements.36

Infection of traumatic wounds may arise from contam-ination at the time of injury or secondary infection of thecompromised tissue. Radical debridement is, therefore, themost important aspect of early wound closure and the keyto successful primary free flap coverage of these complexwounds. Most traumatic defects exacerbated by debride-ment can be covered by free tissue transfer. Radicaldebridement should be performed only under tourniquetcontrol (see Table 5). The use of tourniquet maintains theborder between healthy and unhealthy, perfused tissueclear and minimizes blood loss. Debridement must be per-formed through healthy tissue, to ensure that non- viabletissue is removed. Any tissue believed to be only marginallyviable must be excised. Vital structures such as nerves,

Table 4 Advantages/disadvantages of pimary free flapcoverage versus secondary

Primary free flap closure Secondary free flap closure

Early rehabilitation Delayed rehabilitationShort hospital stay Long hospital stay,more

costsOne operation Numerous operations

Long initial operation time Short initial operation timeNot for patients with

associated injuries or badgeneral condition

Experienced surgeonnecessary

Special infrastructurerequire

tendons, and vessels are left in place. The remainingdead space should be eliminated by further excision, orthrough the transposition of neighbouring muscles. Smallbone fragments should be removed, and larger bone seg-ments, even if not attached to soft tissue, should becleaned, prepared and used as bone graft. After debride-ment the tourniquet is removed and very precise hemosta-sis should be accomplished. The presenting defect shouldbe revaluated and any devitalized tissue excised. Wound ir-rigation with liberal amounts of Ringer’s lactate solution isvery important.

Since the mid-1980s, there has been increasing enthusi-asm for early flap coverage of severe extremity injuries.Godina emphasized the importance of early coverage withinthe first 72 h and the advantages of free flap reconstructionvs. local flap technique.37 He reported a 1.5 percent rate ofinfection in 134 patients after early coverage and recon-struction as against an infection rate of17.5 percent in 167patients with delayed reconstruction.

Lister and Scheker first defined the emergency free-flapas a ‘flap transfer performed’ either at the end of primarydebridement or within 24 h after the injury.38 Chen et al.39

reported superior functional results performing early freeflap coverage in the ‘golden’ (within 24 h) period.

To standardize the nomenclature in free flap woundclosure Ninkovic et al. presented three categories: ‘primaryfree flap closure’ (within 12e24 h), ‘delayed primary free

Table 5 Principles of radical debridement

Performed by most experienced surgeonTourniquet control with bloodless fieldScalpel excision through margin of healthy tissue, vital

longitudinal structures spared (arteries, nerves)Foreign bodies removedDead space eliminated by further excision or muscle

transpositionAppropriate management of bone fragmentsSmall bone fragments debridedLarge bone fragments useful as graft in primary free flap

closureRadical bone debridement is eesential in secondary free

flap closureTissue perfusion revaluated after tourniquet removal,

further excision is necessaryLiberal irrigation

Table 6 Comparison of nomenclature of free flap closurewith the nomenclature of simple wound closure

Simple wound Free flap closure

Primary wound closurewithin 12 h

Primary free flap closurewithin 12 to 24 h

Delayed primary woundclosure within 2 to 7days

Delayed primary freeflap closure within 2 to 7days

Secondary wound closureafter 7 days

Secondary free flapclosure after 7 days


flap closure’ (2 to 7 days) and ‘secondary free flap closure’(after 7 days).40 (see Table 6)

This system is analogous to the standard terms ‘pri-mary’, ‘delayed primary’ and ‘secondary wound closure’. Itis consistent with known biologic and microbiologic princi-ples of wound closure in general and provides a simple basisfor classifying free flap wound closure.

One of the main reasons for performing a primary closureis to pre-empt the proliferation of bacteria, resulting in anestablished infection. All traumatic wounds are classified ascontaminated wounds. Primary factors affecting infectionare the inoculum and virulence of the invading organismhost defense capability and the time elapsed betweeninjury and treatment. Robson et al. demonstrated thata wound left untreated for more than 3 h has a potentialbacterial proliferation of 106 bacteria per gram of tissue.41

With antibiotics, the timing of closure can be somewhat ex-tended. Thus, we use 24 h as the cut -off for primary freeflap closure. A second reason to close the wound primarilyis to procure healing before the establishment of woundcontracture, fibrosis and a contaminated prolific granula-tion tissue.

Primary flap closure with primary repair signifies thatrepair of longitudinal structures such as nerves tendonsvascular structures, bone, etc. was performed at the timeof primary free flap closure (See Table 7). Primary free flapclosure with primary reconstruction signifies flap coverage,along with definitive reconstruction of missing segments oflongitudinal structures with primary grafting, vascularisedor otherwise, immediately after the initial radical debride-ment. This technique includes tendon grafting, bone graft-ing, vascular grafting, nerve grafting etc.

Primary flap closure with delayed reconstruction refersto primary closure with reconstruction at a later date,usually three months or more.

Patient selection

Primary free- and salvage-flaps are time-consuming surgicalprocedures, and they can be undertaken only after exactpre-operative assessment of the patient‘s fitness. Life-threatening associated injuries are absolute contraindica-tions for primary free-tissue transfer.

Table 7 Nomenclature of timing of reconstruction

Primary free flap closure (within 12 to 24 h)With primary repair by suture of longitudinal structures orbone stabilisationWith primary reconstruction by transplantation ortransposition of longitudinal structuresWith late reconstruction

Delayed primary flap closure (two to seven days)With primary repairWith primary reconstructionWith late reconstruction

Secondary free flap closure (after more than seven days)With late reconstruction

Example for primary free flap closure withprimary reconstruction by transplantation ortransposition of longitudinal structures

A 36-year-old male patient presented after an extensivemotor saw injury of the right lower arm. The distalradioulnar joint is destroyed, a long part of the ulnarartery and nerve are missing and there is a an extensivesoft tissue defect (see Fig. 1). The patient underwent pri-mary radical debridement with scalpel excision throughmargin of healthy tissue, vital longitudinal structures (ra-dial artery, median nerve) spared. (see Fig. 2). An ar-throdesis of the distal radioulnar joint was carried out.The tendons were repaired and the soft tissue defect of35� 15 cm was closed with a free latissimus dorsi flapwith skin island and split thickness skin graft. The latissi-mus dorsi flap was used as a flow through flap to recon-struct the ulnar artery. In the same operation the ulnarnerve was reconstructed with an interpositional graftfrom the Nervus thoracicus longus and the Nervus cuta-neus antebrachii lateralis (see Fig. 3). The good func-tional and aesthetic result 6 months after the operationis documented in Figs. 4 and 5.

Figure 1

Figure 2


Rehabilitation program after complex upperextremity injury

Rehabilitationafter complex injury involveshelpingapatientto help herself/himself to achieve maximum physical, social,psychological, and vocational functioning within the limitsimposed by the injury and its treatment. In order to achievethis goal, the individual tailored rehabilitation programshould be created based on the knowledge about theinjury-related consequences and on the information re-ceived throw the procedures of the Rehab. Cycle. The tasksof the rehabilitation team are identifying the rehabilitationproblems and maintaining the rehabilitation process.

According to the time of reconstruction, the primaryfree flap closure gives the best pre-requisites for immedi-ate introduction of the rehabilitation program. This typeof extensive (early-acute) rehabilitation includes preven-tion of joint stiffness, pain and swelling control, thrombosisprophylaxis and wound care shortly after primary surgicalprocedure. The immediate mobilisation is thus facilitatedin terms of increasing the passive and active physiologicalmovements, as well as performance of, for example, com-plete decongestive therapy or sensibility training.

The therapy measures as well as the frequency ofrehabilitation procedure should be intensified gradually.After discharging a patient, the same program of

Figure 3

Figure 4

rehabilitation will be continued in the Out-Patients’ clinic.This concept of surgical and rehabilitation proceduresprovides the optimal achievement in functional recoveryof complex upper extremity injuries.

Inpatientswithdelayedprimaryflapclosure the somecon-cept of rehabilitation could generally be applied. However,the main point is to concentrate on keeping the present func-tion and preparing patients for definitive reconstruction, liketendons and nerve repair. After definitive reconstruction, theprogram of rehabilitation will be continued; the main pointbeing the treatment of definitively reconstructed structures.

In secondary flap surgery, the optimal time for rehabil-itation is lost, therefore the rehabilitation program isdivided into two or three parts. Firstly, pre-operativerehabilitation is introduced to keep passive joint movementand to-control pain and swelling. After secondary recon-struction, rehabilitation will be continued to preparea patient for definitive reconstruction. Final rehabilitationwill concentrate upon functional recovery.

Conclusion

The selection of a suitable flap for defect coverage of theupper extremity must take into account the anatomical,functional and aesthetic requirements at the recipient siteand the donor-site morbidity. Furthermore, the patient’sgeneral condition, aetiology of defect, the surgical experi-ence and capability as well as infrastructures in a hospitalwill influence the doctrine of treatment. A great variety offlaps are available and the surgeon should understand thefeatures of all flaps because only individual selection andapproach can guarantee the optimal result.

Radical debridement and primary free flap cover within24 h in complex isolated upper extremity injuries should beregarded as the golden rule, because it produces improved

Figure 5


functional and aesthetic results, lessens morbidity with psy-chological benefit to the patient and reduces the incidenceof free flap failure, postoperative infection, secondaryoperative procedures, invalidity, hospital stay and costs.The primary coverage of the wound within 24 h makes thisprotocol practical to perform and avoids mistakes by an in-experienced, tired surgical team at night and enables a freshoperating team to undertake definitive reconstruction in themorning. On only rare occasions (politrauma, poor generalcondition, or when treatment was started in another hospi-tal) should wound coverage be delayed.

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Rational flap selection and timing for coverage of complex upper extremity trauma