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Radial forearm flaps as durable soft tissue coverage for local nationals being treated in the field hospital setting
  1. KH Hanna1 and
  2. SLA Jeffery2
  1. 1Department of Orthopaedic Surgery, Naval Medical Center, San Diego, USA
  2. 2Department of Burns and Plastic Surgery, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
  1. Correspondence to Lt Col SLA Jeffery, Department of Burns and Plastic Surgery, The Royal Centre for Defence Medicine, The Queen Elizabeth Hospital, Mindlesohn Way, Birmingham, B15 2TH, UK; slajeffery{at}rcsed.ac.uk

Abstract

The current conflict in Afghanistan has seen the increasing use of Improvised Explosive Devices (IED) in insurgency attacks. In addition to the coalition forces killed and injured from these devices, local national civilians are also injured. Injuries often include amputations, open fractures and large areas of skin affected by fragmentation. Local national access to long-term care after an IED injury is limited, and often when the patient leaves a coalition hospital this concludes the care the patient will receive. Definitive, durable treatment options are needed for these patients. In the IED-injured patient with open extremity wounds and open metacarpal fractures, pedicled radial forearm flaps offer a suitable soft tissue coverage option. Four cases are reported on IED- injured Afghan patients treated at a Role 3 hospital facility.

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Introduction

The mission of the Role 3 hospital at Camp Bastion in Afghanistan, is to treat all coalition forces, Afghan National Security Forces and civilians affected by fighting efforts who sustain life or limb threatening injuries. Complex surgical reconstruction is not routinely available within the Helmand Afghani regional hospital service and so, by necessity to get functional skin cover and wound closure in local nationals, it has, on occasion, been necessary to perform flap surgery to allow definitive and durable treatment for these patients’ injuries.

Damage to the hands and upper extremities are common injuries resulting from explosive fragmentation from Improvised Explosive Devices (IEDs) and often result in open fractures with significant soft tissue loss. There are several options for soft tissue coverage for such defects, including split thickness skin grafting, local flaps, regional and distal pedicle flaps and free flaps and the choice of which option to utilise is affected in a deployed environment by both clinical and logistic factors. Regional pedicled flaps are an effective option for coverage of wounds requiring only simple instruments and the surgery can be performed relatively quickly. Patients can be followed on a short term basis and safely discharged back into the local hospital system for further follow-up. The aim of this article is to present a case series of four local national civilians with open fractures of the upper extremity managed by pedicled radial forearm flaps during a three month period in 2011 at the Role 3 hospital in Camp Bastion, Afghanistan.

Surgical technique of the radial forearm flap

Allens’ test should be performed in all patients, if possible, before the operation is considered, to ensure that the hand will survive without the radial artery. Ideally, pre-operative angiography should be used to confirm the adequacy of the vascular cascade in the hand. The patient is placed supine on the operating table with the arm abducted on a hand table. A template of the defect requiring flap coverage is made using paper. Using the base of the thenar eminence, where the radial artery disappears beneath the tendons of the abductor pollicis longus and extensor pollicis brevis as the pivot point, the template is rotated and placed on the forearm skin, ensuring as much of the flap as possible is located over the septum between flexor carpi radialis and brachioradialis.1 An extension of the flap is drawn with the apex at this pivot point, so there will be skin coverage over the artery once it is raised. The radial artery is then isolated via an incision proximal to the flap, and a vascular clamp applied. The tourniquet is then released, and the adequacy of hand circulation is assessed; if adequate, the artery is ligated; if the vascular supply to the hand is inadequate then the flap is abandoned. The fascia and overlying skin in the distribution of the marked area are raised as the flap, rotated and inset to cover the soft tissue defect. All remaining defects are split skin grafted and dressed with topical negative pressure (TNP) dressing for three days, leaving a window for assessment of the flap vascularity, by means of inspection and capillary refill testing.

Case 1

A local national presented after an IED blast, sustaining bilateral, high above knee amputations and significant fragment wounds to his right arm, forearm and hand. He sustained a degloving injury to the dorsum of his right hand with open comminuted middle finger metacarpal, base of ring finger metacarpal and thumb proximal phalanx fractures (Figure 1A). The middle finger fracture was treated with open reduction and percutaneous pinning. Due to the significant bone loss of his thumb proximal phalanx, the thumb was transfixed with a single 1.0 mm k-wire and kept pinned out to length (Figure 1B). The ring finger metacarpal base fracture was treated non-operatively. The patient underwent washout and debridement at presentation and again at 48 h prior to definitive treatment five days after injury. In the interim between debridement and definitive treatment, the patient's wounds were treated with TNP dressing. The radial forearm flap was raised as described and used for coverage of the open fractures (Figure 1C), with the remaining defects dressed with TNP dressings. Seventy-two hours later, the wounds were covered with autograft split thickness skin graft over a healthy granulation tissue bed. The patient was transferred to a local Afghan hospital the next day with a healthy vascularised flap.

Figure 1

(A) Significant dorsal skin degloving with associated open metacarpal and phalanx fractures. (B) Fluoroscopy image after open reduction and percutanous pinning. (C) Transposed pedicled radial flap providing definitive coverage of open metacarpal and thumb proximal phalanx fractures.

Case 2

A local national presented after an IED blast, sustaining a right below-knee amputation, left above-knee amputation and left elbow open Grade IIIb comminuted olecranon fracture (Figure 2A and B). He had his initial debridement on presentation and then at 48 h post-presentation. At five days post initial presentation, the patient had an open reduction and internal fixation with a 2.0 mm k-wire tension band construct of his left elbow olecranon fracture (Figure 2C). During the same surgical intervention, the patient had a proximally-pedicled radial forearm flap transposed for coverage and autograft split thickness skin grafting to the flap donor site and remaining soft tissue defects. The patient was transferred the next day to a local Afghani hospital with a viable, perfused flap.

Figure 2

(A) Right open Grade 3b olecranon fracture after debridement. (B) 3D Reconstruction of comminuted olecranon fracture. (C) Open reduction and internal fixation with tension band construct of Grade 3b olecranon fracture.

Case 3

A local national presented after an IED blast, sustaining a right below-knee amputation, multiple left leg and thigh fragmentation wounds and a right hand dorsal degloving wound (Figure 3A) with an exposed index finger metacarpal fracture. He had an initial debridement and the dorsal hand defect covered with TNP. He had a second debridement at 72 h and the definitive soft tissue coverage at five days post injury. The metacarpal fracture was treated non-operatively with splinting. A distally-pedicled radial forearm flap was transposed for coverage (Figure 3B) with an autograft split thickness skin graft used for coverage of the donor site and remaining dorsal hand wounds. The patient was discharged the next day.

Figure 3

(A) Right hand dorsal degloving wound and associated open index finger metacarpal fracture. (B) Right hand with metacarpal fracture coverage and remaining healthy tissue to accept a skin graft.

Case 4

A local national presented after an IED blast, sustaining a volar degloving injury of the left palm and fragmentation wounds to the chest, scalp and face. After debridement, the patient had an exposed flexor pollicis longus tendon that rendered his volar hand wound inappropriate for simple skin grafting (Figure 4A). The patient underwent definitive soft tissue coverage 72 h after his index debridement with a distally pedicled radial forearm flap, which provided excellent coverage and allowed for gliding of his flexor pollicis longus tendon (Figure 4B). The patient was skin grafted during the same procedure, had a TNP dressing placed overnight and was discharged back into the Afghan medical system the next day.

Figure 4

(A) Exposed flexor pollicis longus tendon in the volar hand wound. (B) Final complete coverage of the exposed FPL tendon.

Discussion

The aim of this article was to re-emphasise the utility of the radial forearm flap in the management of upper extremity fractures associated with soft tissue loss in a logistically constrained environment. The aim of reconstructive surgery is to use the simplest method possible to obtain satisfactory functional and aesthetic results; in contrast to such surgery in the United Kingdom or USA, the constraints imposed by lack of microsurgical equipment and early discharge of local nationals into an immature health system must be considered.

Autograft split thickness grafting is easy to harvest and easily available, though without associated fascia it does not provide appropriate coverage for exposed tendon or fractures. Local flaps are effective if there is adequate local healthy tissue available for mobilization; however, the area of injury from fragmentation is often wide and local skin is often compromised. Distal pedicled flaps, most commonly the groin flap, for hand coverage has historically provided a readily available and effective fasciocutaneous coverage.2 However, distal pedicle flaps require long hospital stays while the flap is revascularising, which is too resource-intensive in a Role 3 hospital setting. Free flaps are time intensive and require microvascular work, which is not available in the austere operating environment.

We believed that the radial forearm fasciocutaneous flap was a suitably robust and easy to raise flap with immediate vascularity, thus obviating the need for prolonged hospitalisation in the Role 3 facility.

We have presented a case series of four local national civilians with open fractures of the upper extremity operated on at a Role 3 hospital in Afghanistan. In all cases the procedure was successful and the patient was able to be discharged from the hospital the day after the flap procedure. We do acknowledge that the sacrifice of the radial artery, particularly in an already injured hand, is not ideal because of the potential for cold intolerance, the cosmetic defect it causes and the risk of completely devascularising the hand.3 ,4 Due to the constraints of available radiology, pre-operative angiography was not undertaken in our cases. However, microsurgery is not an option in this Field Hospital, and there are no other local facilities that we would be able to refer these patients to for such surgery. We also did not have the ability to keep our patients for long follow-up periods, and we therefore undertook this surgery in an effort to provide rapid and robust soft tissue coverage for open fractures and tendons in a local population in Afghanistan.

Conclusions

This case series demonstrates that the radial forearm free flap is a viable, durable treatment option for patients with open fractures or exposed tendons needing definitive soft tissue coverage following fragmentation wounds from IEDs, where evacuation to a more advanced level of care is not possible.

References

Footnotes

  • Disclaimer The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.