Wound Coverage Techniques for the Injured ExtremityGil Ortega, MD, MPH

Original Author: David Sanders, MD; Created January 2006New Author: Gil Ortega, MD, MPH; Revised September 2009

ObjectivesReview multi-disciplinary approach to evaluation and treatment of Soft Tissue injuriesReview up to date methods of coverageOpenPrimary vs. Secondary Skin graftingFlapReview Non-surgical and Surgical Options for Soft-Tissue injuriesReview current literature concerning Soft-Tissue injuries and Wound Coverage Techniques

Initial AssessmentHistoryTime and mechanism of injuryFunctional demands of the patientPatient variablesAgeDiabetesMalnutritionObesityInfectionSmokerMedicationsUnderlying physiologyOccupation

Initial AssessmentPhysical examSeverity of InjuryEnergy of InjuryMorphology of associated fractureBone lossBlood supplyLocation

Initial TreatmentManagement of soft tissue injury requires:Early aggressive debridement in OREarly intravenous antibioticsSkeletal stabilizationTimely soft tissue coverageTetanus prophylaxisProphylactic antibiotics: 1st generation cephalosporinClindamycin if penicillin allergyPenicillin for clostridia-prone wounds

Wide Variety of Soft Tissue Injuries; Similar Initial Treatment OptionsInjury:Realignment/splintNeurovascular examCover wound with sterile dressingRadiographs

Wound ColonizationInitial colonization of traumatic woundIncreases with timeNeed to debride necrotic muscle, dead space, and poorly vascularized tissue including bony injuries

Wound Excision- DebridementConversion of traumatic wound to a surgical wound with debridement of all devitalized tissue skin, fascia, and boneUnless gross contamination, evidence unclear as to best time for operative debridement as to whether 0-6 hours, 6-12 hours or > 12 hours to decrease risk of infection, however, patient must receive IV antibiotics promptly

Tripuraneni K et al. The Effect of Time Delay to Surgical Debridement of Open Tibia Shaft Fractures on Infection Rate. ORTHOPEDICS 2008; 31:1195.

Initial Management After DebridementRestore vascularityStabilize skeletal injurySplintingExternal FixationEarly Total Orthopaedic Care vs. Damage Control OrthopaedicsRepair nervesRepair musculotendinous unitsPLAN reconstructionWhen patient is best physiologically stableWhen best team is available for reconstruction(s)

Reconstructive LadderMethodsTypesDirect closure

Skin Grafts

Local and Regional Flaps

Distant Pedicle Flaps

Free FlapsPrimarySecondary

STSGFTSG

RandomAxial

RandomAxial

(See next slide)

Reconstructive LadderFree flapsCutaneousFascial/ FasciocutaneousMuscle/ MusculocutaneousOsteocutananeous

Direct ClosureDirect closure is simplest and often most effective means of achieving viable coverageMay need to recruit more skin to achieve a tension free closure

Direct closureDecreasing wound tension can be accomplished by:Relaxing skin incisionsPie crusting of the skin under tension (perpendicular to the direction of tension)Application of negative pressure wound therapy

Negative pressure therapyAdvantages: Increased neovascularizationIncreased granulation tissue formation, Decreased bacterial countDecreased seroma formationWound contractureDisadvantages:Device CostCant see wound when sponge is in place

Negative pressure therapyComponents:Apply a polyvinyl sponge to woundImpermeable membrane sealing wound from the external environmentLow or intermittent negative pressure vacuum suction [i.e. KCI Vacuum Assisted Closure, or V.A.C. Therapy System]

Negative pressure therapyRoutine use of VAC with open tibia fractures is safeAccording to Bhattacharyya et al, in Gustilo Type IIIB tibia fractures, vacuum-assisted closure therapy does not allow delay of soft-tissue coverage past 7 days without a concomitant elevation in infection rates

Bhattacharyya et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg. 2008 Apr;121(4):1263-6.

Skin GraftingSplit thickness (STSG)Full thickness (FTSG)

STSGAdvantagesMay be meshedLarge areaRequire less revascularizationTemporary coverageDisadvantagesPoor cosmesisLimited durabilityContracts over timeDonor site problemsPainInfection

FTSGAdvantagesNo wound contractureIncreased sensibilityIncreased durabilityBetter cosmesisPrimary closure of donor siteDisadvantagesLonger to revascularizeCannot meshRecipient site must have rich vasculature

Wound Preparation for GraftsVascularityHemostasisDebride all necrotic tissueOptimize co-morbid conditions

Donor Site SelectionSTSG0.015 inches thick (thickness #15 scalpel)Lateral buttockAnt. and Lat. ThighLower abdomenAvoid medial thigh and forearmFTSGDepends on area to be coveredLarge grafts-lower abdomen and groinSmall- medial brachium and volar wrist creasePlantar skin from instep

Skin Harvest for STSGSterile preparationLubricateSet depth (0.012 inch most common)Traction with tongue bladeMay use mineral oil for skin

Skin Harvest for FTSGUse templateCut out ellipseDefat after harvestApply and compress with moist bolster

Donor Site CareOpenSemi-openSemi-occlusiveOcclusiveBiologic

Indications for Flap CoverageSkin graft cannot be usedExposed cartilage, tendon (without paratenon), bone, open joints, metal implantsFlap coverage is preferableSecondary reconstruction anticipated, flexor joint surfaces, exposed nerves and vessels, durablitiy required, multiple tissues required, dead space present

Classification of Soft Tissue FlapsRandomAxialLocalAdvancementRotationDistantDirect TubedFree

Classification of Soft Tissue FlapsDirect cutaneousMusculocutaneousSeptocutaneous

Direct Cutaneous FlapsGroin flap- superficial circumflex iliac artery Deltopectoral flap-2nd and 3rd perforating br. Of int thoracic artery

Musculocutaneous FlapsMathes ClassificationType I- one vascular pedicleGastrocnemiusTensor fascia LataType I: Tensor Fascia Lata

Musculocutaneous FlapsMathes ClassificationType II- one dominant vascular pedicle close to insertion with additional smaller pedicles entering along the course of the muscleBrachioradialisGracilisSoleusType II: gracilis

Musculocutaneous FlapsMathes ClassificationType III - two dominant vascular pediclesRectus abdominisGluteus maximusType III: Gluteus Maximus

Musculocutaneous FlapsMathes ClassificationType IV- multiple pedicles of similar sizeGenerally of less use in reconstruction than single or double pedicled muscles

Type IV: Sartorius

Musculocutaneous FlapsMathes ClassificationType V- one dominant pedicle and several smaller segmental vascular pediclesLatissimus DorsiPectoralis major Type V: Latissimus Dorsi

Septocutaneous FlapsCormack, et. alType A- flap dependent on multiple fasciocutaneous perforators

Septocutaneous FlapsCormack, et. alType B-based on single fasciocutaneous perforator of moderate size consistent in presence and location Parascapular flap- circumflex scapular arterySaphenous artery flapLateral thigh flap- 3rd profunda perforator

Septocutaneous FlapsCormack, et. alType C- supported by multiple perforators which pass from a deep artery thru a fascial septum

Radial forearm flapPosterior Interosseous flap

Septocutaneous FlapsCormack, et. alType D -type C septocutaneous flap removed in continuity with adjacent muscle and bone to create a osteo- myo-fasciocutaneous flap

Free fibula osteocutaneous flap

Principles of Free Tissue TransferPre-operative AssessmentPhysical ExaminationVascular StatusArteriogramAlternative methodsChoice of donor siteLength and width necessary to fill defectVascular pedicle lengthInnervated or composite with bone

Principles of Free Tissue TransferSurgical ConsiderationsTeam approachComfortable settingAnesthesia- regional block/ epiduralTemperatureVolume replacementCareful surgical techniquePREVENT SPASM

Principles of Free Tissue TransferPost-operative ManagementICU for monitoring Maintain body temperatureFluid balanceGood pain reliefMonitoring flap- temperature, doppler, photoplethysmography

Soft Tissue Coverage for the TibiaConventional teachingProximal 1/3 Tibial defect- Gastrocnemius rotational flapMiddle 1/3 Tibial defect - Soleus rotational flapDistal 1/3 Tibial defect - free flapLarge defect- Latissimus Dorsi Smaller defect- radial forearm, Sural artery Fasciocutaneous flap

Medial Gastrocnemius for Proximal 1/3 Tibia

Soft Tissue Coverage for the Middle 1/3 TibiaSoleus flapNarrower muscle belly compared to gastrocs and a somewhat less robust vascular supplyLess tolerant of tension compared to gastrocs flap so harvesting and mobilization of muscle belly can be technically demanding

Soft Tissue Coverage for the Distal 1/3 Tibia

Soft Tissue Coverage for the TibiaWhen treating limbs with severe underlying bone injury (ASIF/ OTA type C), use of a free flap for soft tissue coverage was less likely to have a wound complication than use of a rotational flap, regardless of location.Zone of injury may be larger than anticipated and may include rotated muscleMore muscle tissue available in free flapsPollak, A et.al. Short-Term Wound Complications After Application of Flaps for Coverage of Traumatic Soft-Tissue Defects About the Tibia. JBJS 82-A: 1681-1691, 2000.

Soft Tissue Coverage for the TibiaTiming: best results obtained with early soft tissue coverage (< 72 hours) for Type III-B open tibial fracturesDefinitive bony and soft tissue surgery may not always be possible within 72 hours because of concomitant injuries or delayed referralTherefore, according to Steiert AE and Karanas et al., both groups have showed high success rates with delayed (> 72 hours) with meticulous microsurgical treatment planning and vessel anastomoses outside of zone of injurySteiert et al. have shown that the use of Damage Control Orthopaedics may enable surgeon to treat injury definitely beyond 72 hour window with similar results to that of definitive surgeries within 72 hours

Steiert AE et al. J Plast Reconstr Aesthet Surg. 2009 May;62(5):675-83.Karanas et al. Microsurgery. 2008;28(8):632-4Cierny G. et al. Clin Orthop 178: 54-63, 1983Fischer et al. JBJS 73-A: 1316-1322, 1991Godina M. Plat Reconstr Surg 78: 285-293, 1986

Soft Tissue Coverage of the Ankle/ FootOpen wounds in this area remain a challengeDonor site optionsMedial plantar flap for reconstruction of the heel Abductor hallucis flapFlexor digitorum brevis

Soft Tissue Coverage of the Ankle/ Foot

Soft Tissue Coverage of the Ankle/ FootIncreasingly popular method among reconstructive surgeons is use of a distally based sural artery flapSupplied by most distal perforating artery of peroneal artery which is located approximately 5-7 cm above tip of lateral malleolus According to Ros-Luna et al, the sural fasciocutaneous offers technical advantages such as easy dissection with preservation of more important vascular structures in limb, complete coverage of soft tissue defect without need of microsurgical anastomosis

Ros-Luna et al. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury. 2007 Jul;38(7):824-31.

Soft Tissue Coverage of the ElbowSkin graft for wounds that are well-vascularized without injury to neurovascular or osseous structures.

Soft Tissue Coverage of the ElbowFlapsInfection or dead space-use muscle flapExtensive soft tissue avulsion- parascapular flapFunctional restoration of elbow flexion - latissimus dorsi

Considerations for Flap Coverage of the ElbowRegionalFCU- Ulnar recurrent arteryBrachioradialis- radial recurrent arteryIntermediateRadial artery fascio-cutaneous flapPosterior Interosseous flap

Distant pedicleLatissimus dorsi - Thoracodorsal arterySerratus anterior- Thoracodorsal arteryFree tissue transferLatissimus dorsiRectus Abdominis - deep inferior epigastricParascapular - circumflex scapular artery

Flap Coverage of the Elbow: Example of Latissimus Dorsi Local Transfer Flap

Soft tissue coverage of the HandSheet STSG for dorsum of hand

FTSG for volar aspect of hand

Soft Tissue Coverage of the HandCommon flapsCross finger flapThenar flapRadial forearm flapPosterior interosseous flapGroin flap

Dorsal Soft tissue avulsion injuryCoverage with radial forearm flapFlaps for Hand Reconstruction

Limb Salvage Vs. AmputationLower Extremity Assessment Project (LEAP) study provides evidence for outcomes of limb salvageLargest study with followup up to 7 yearsCompares functional outcome of patients with limb salvage vs. amputation

Bosse et al. A prospective evaluation of the clinical utility of the lower extremity injury severity scores. JBJS Am. 83: 3-14, 2001.

LEAP Study Major ConclusionsLimb threatening injuries severely impair patient outcomeWhen comparing limb salvage vs. amputation, the patient outcome is generally the same at 1-5 yearsLack of plantar sensation does not predict poor outcome after limb salvage

LEAP Study Patients with Poor OutcomesRehospitalization of major complicationLower level of educationNon whitePovertySmokersPoor social supportInvolved in social legal compensation

SummaryAppropriate debridement with first debridement being most importantAppropriate antibiotic regimeAppropriate bony stabilityEarly coverage to prevent dessication of critical structures and decrease risks of wound infectionChoose appropriate coverage methodDefect requirementsPatient needsSurgeon factorsProtect limb to appropriate healing

ReferencesClassicalCierny G. et al. Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. Clin Orthop 178: 54-63, 1983.Fischer et al. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. JBJS 73-A: 1316-1322, 1991.Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plat Reconstr Surg 78: 285-293, 1986.Serafin, Donald M.D.: Atlas of Microsurgical Composite Tissue Transplantation. W.B. Saunders Company, 1996.Webster, Martyn H. C. MBChB, FRCS (Glasg.), Soutar, David S. MBChB, FRCS (ED.): Practical Guild to Free Tissue Transfer. Butterworth & Co, 1986.

ReferencesClassicalMcCraw, John B. M.D., F.A.C.S., Arnold, Phillip G. M.D., F.A.C.S., et al: McCraw and Arnolds Atlas of Muscle and Musculocutaneous Flaps, Hampton Press Publishing Co.,1986.Cormack, George C. MA, MB, ChB, FRCS(ED), Lamberty, B. George H. MA, MB, BChir, FRCS: The Arterial Anatomy of Skin Flaps. Churchill Livingstone, 1986.Moy, Owen J. M.D., et al: Soft Tissue Management of Complex Upper Extremity Wounds. W.B. Saunders Company, 13-2: 163-318, May 1997.

ReferencesTechnique/Outcomes/Recent articlesTripuraneni K et al. The Effect of Time Delay to Surgical Debridement of Open Tibia Shaft Fractures on Infection Rate. ORTHOPEDICS 2008; 31:1195.Bhattacharyya et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg. 2008 Apr;121(4):1263-6.Pollak, et.al. Short-Term Wound Complications After Application of Flaps for Coverage of Traumatic Soft-Tissue Defects About the Tibia. JBJS 82-A: 1681-1691, 2000.Steiert AE et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth? J Plast Reconstr Aesthet Surg. 2009 May;62(5):675-83.Karanas et al. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery. 2008;28(8):632-4Bosse et al. A prospective evaluation of the clinical utility of the lower extremity injury severity scores. JBJS Am. 83: 3-14, 2001.

ReferencesTechnique/Outcomes/Recent articlesReuss BL et al. Effect of delayed treatment on open tibial shaft fractures. Am J Orthop. 2007 Apr;36(4):215-20.Gopal S et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000 Sep;82(7):959-66.Yazar S et al. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004 Nov;114(6):1457-66.Yazar S et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg. 2006 Jun;117(7):2468-75; discussion 2476-7.

Thank You

Gil Ortega, MD, MPHSonoran Orthopaedic Trauma SurgeonsSite Director, Phoenix Orthopaedic Residency ProgramScottsdale Healthcare Trauma CenterScottsdale, AZ

Return to General/Principles IndexE-mail OTA about Questions/Comments

**General ReferencesSerafin, Donald M.D.: Atlas of Microsurgical Composite Tissue Transplantation. W.B. Saunders Company, 1996.Webster, Martyn H. C. MBChB, FRCS (Glasg.), Soutar, David S. MBChB, FRCS (ED.): Practical Guild to Free Tissue Transfer. Butterworth & Co, 1986.McCraw, John B. M.D., F.A.C.S., Arnold, Phillip G. M.D., F.A.C.S., et al: McCraw and Arnolds Atlas of Muscle and Musculocutaneous Flaps, Hampton Press Publishing Co.,1986.Cormack, George C. MA, MB, ChB, FRCS(ED), Lamberty, B. George H. MA, MB, BChir, FRCS: The Arterial Anatomy of Skin Flaps. Churchill Livingstone, 1986.Moy, Owen J. M.D., et al: Soft Tissue Management of Complex Upper Extremity Wounds. W.B. Saunders Company, 13-2: 163-318, May 1997.

**Objectives of this talk are as stated.

Options for coverage will be discussed for the tibia, foot, elbow and hand. More proximal sites such as the shoulder and hip are generally covered with rotation flaps if skin grafting is not adequate.**Evaluation of the injured extremity should begin with a targeted and thorough history and physical examination. With regard to history, all details listed should at a minimum be taken into account. If there is vascular compromise, the time from injury takes a higher precedence. In upper extremity injuries, hand dominance is important to know.**The physical exam should be systematic including an evaluation of all these components. If the injured extremity is dysvascular, restoration of circulation becomes a treatment priority if salvage is anticipated. The extent of injury, depth and size of the wound and degree of contamination should be ascertained at the initial debridement, however, the degree of tissue viability may not be readily apparent and may require several debridements before a final determination can be made.**Tetanus prophylaxis****Debridement should be carried out promptly, ideally within 6-8 hours from the time of injury to lessen the chance of infection. All devitalized skin, fascia, and bone should be removed, hence the term wound excision. Picture of dorsal soft tissue avulsion injury of the hand from roll-over MVA. Injury will require wound excision and eventually reconstruction of extensor tendons and coverage with some type of vascularized tissue (flap).**Obviously if injured extremity is dysvascular at initial presentation, the priority of treatment is to restore the vascularity, however, a quick debridement of obviously dead and contaminated tissue should be carried out while preparing for revascularization. The choice of restoring vascularity or stabilizing the fracture should be made in conjunction with the vascular surgeon and in most circumstances will be dictated by the ischemic time of the injured extremity. **In general, soft tissue coverage of an injured extremity should be performed using the simplest and most reliable method taking into account the size and extent of the injury and the expertise of the surgeon. A stepladder approach should be considered starting with the easiest method. Obviously, direct closure either by primary or secondary means would be the simplest means of obtaining closure. If this cannot be accomplished, skin grafting should be considered followed by local/ regional flaps, distant pedicled flaps and finally free flaps. **The ability to move tissue from one area of the body to an entirely different area has revolutionized methods of soft tissue coverage. Free tissue transfer is now an established and reliable method for reconstructive surgery, however, microsurgical skills are a prerequisite, as a minimum of one arterial and one venous anastomosis are required for successful transfer of soft tissue as free flap. Free flaps are classified by the type of tissue being transferred. For example, if a latissimus muscle is transferred with a paddle of skin it would be classified as a free latissimus musculocutaneous flap. A radial forearm flap is transferred with skin and fascia and therefore would be classified as a free radial forearm fasciocutaneous flap.************Skin grafting is the simplest form of coverage. This graft by definition is non-vascularized and requires capillary in growth from the recipient tissue being covered for the dermal elements of the graft to survive The graft may be harvested as a split thickness or full thickness graft. In general, most wounds on injured extremities are covered with STSGs. Small areas or wounds on the volar side of the hand are generally covered with a FTSG. Critical areas of the sole of the foot may also benefit from FTSG.**Advantages and disadvantages of STSG as listed. Split grafts may provide a biologic dressing over critical structures such as nerve, vessels, tendon or bone while awaiting definitive (free tissue) coverage preventing dessication.**Advantages and disadvantages of FTSGs as listed**In order for a skin graft to survive, the wound to be covered must be prepared. The surface to be covered must contain a capillary bed capable of ingrowth. Bleeding must be controlled meticulously. A hematoma which forms under a graft will prohibit capillary ingrowth which is a frequent cause of failure. All necrotic tissue must be thoroughly debrided. A quantitative tissue culture may be a useful tool for determining graft-bed suitability, especially in cases of gross contamination. Systemic medical conditions and nutritional status must be optimized prior to graft placement.**The goal of harvesting donor tissue is to approximate the appearance and durability of the original tissue while causing minimal morbidity at the donor site. The thicker the graft the more donor site morbidity. **Numerous power dermatomes are available for harvesting STSGs Generally the width of the dermatome is set to the thickness of a #15 scalpel blade (0.012 to 0.015 inch). When just the bevel fits, the thickness will be .01 inches. It is important to lubricate the undersurface of the dermatome to allow it to smoothly advance. By providing traction to the skin surfaces, the skin surface flattens allowing the dermatome to function more efficiently.**Most areas can be safely covered by a STSG, however, the palm of the hand is probably best covered with a FTSG. Prior to suturing the FTSG it is important to defat the graft which is best done with a pair of sharp scissors. Do not scrape the fat of with a scalpel because this will cause unnecessary damage to the dermis. Suturing a moist bolster over the graft will keep it adherent to the underlying recipient bed and encourage capillary ingrowth.**There are several techniques for managing the donor site. For STSGs the dermis is covered with regenerated epithelium in 7-14 days. Leaving the wound open to air can be accomplished after hemostasis has been obtained using a fine mesh gauze saturated with lidocaine containing a 1:200,000 epinephrine solution which is left in place for 10 min. until a fibrin layer develops. Disadvantage is that it is painful during the 1st 24 hrs until the wound dries. Fine mesh gauzes are considered semi-open and allow for egress of fluid and bacteria from the wound. Disadvantage is pain when removing the adherent gauze. Biobrane is a composite of a silicone membrane and flexible nylon fabric covalently bonded to porcine collagen peptides which diminishes the adherence and lessens the pain with removal. Disadvantage is the expense of the product. Opsite and Tegaderm are considered semi-occlusive dressings because the are vapor permeable and bacteria and liquid impermeable. Disadvantage: seromas may develop under the material and increase the risk of infection. Duoderm is completely occlusive. Exudate is more acidic which potentially limits bacterial growth Excess skin graft or porcine xenografts can be used as a biologic dressing but may not be practical in most situations.For FTSGs primary closure should be performed if possible.**There are two general indications for performing soft tissue coverage with a flap which are listed on this slide .**There are several classifications for soft tissue flap. McGregor (1972) introduce the concept of random and axial flaps. A random flap is one that lacks any significant bias in its vascular pattern. Without a definitive recognized arteriovenous system, elevation of the flap is generally restricted, that is the length of the flap to be raised should be no greater than the width of the base of the flap which is providing the necessary blood flow thru the sub-dermal plexus. There are several techniques for extending the length of random flaps. One such technique is known as delay where parallel incisions are created and the base of the flap is undermined and then sutured back in place for a period of about 2-3 weeks. The blood flow is then channeled and thus allow extension of the flap margin beyond the 1:1 ratio. An Axial pattern flap is single pedicled flap that has an anatomically recognized arteriovenous system running along its long axis. An axial pattern flap is not restricted to the same 1:1 ratio of flap elevation.

Flaps may also be classified as either local or distant on the basis of their proximity of the donor site to the recipient site. Local flaps can be further categorized by the nature of their pedicle into advancement or rotation flaps.**As the knowledge of skin vascularity has increased, the incorporation of tissues other than skin and subcutaneous tissues in the coverage of more substantial defects has become more successful By default, a nomenclature system has developed based on flap composition. The terms cutaneous, fasciocutaneous and myocutaneous are used to describe the incorporation of skin, fascia, or muscle. Eventually, other structures such as bone, nerve and tendon have been incorporated into the flap. These are known as compound flaps.

Since most flaps are designed around the tissues vascular pedicle, perhaps the most justified method of classification is one based on the flaps vascular origin. It is now accepted that there are three basic patterns of blood supply:Direct cutaneousMusculocutaneousSeptocutaneousEach of these flaps will be discussed on the following slides.

**The direct cutaneous flap has arteries that run immediately above the muscle and fascia in the subdermal fat with a specific directional orientation. An excellent example is the direct cutaneous flap is the groin flap which is supplied by the superficial circumflex iliac artery.**Muscle flaps have been categorized by Mathes. (Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, Toronto, London; CV Mosby, 1982, pp3-27)Musculocutaneous flaps have been categorized according to the five muscle types depending on their vascular anatomy. Each pattern has significance for arc of rotation skin territory , whether it can be elevated as a distally based flap and whether it can be elevated as a free flap.A type I flap has one dominant pedicle. They cannot be raised as distally based rotation flaps because there are no secondary vessels perforating distally. Examples are listed.Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982

**These flaps can be raised as free flaps based on the dominant proximal vessel or as distally based rotation flaps based on the smaller pedicles entering along the course of the muscle. Examples are listed. The BR is based on a dominant perforator off the radial artery in the mid-substance of the muscle. The Gracilis is supplied by the ant. Br of the obturator artery. The soleus is supplied by a branch off the post. tibial artery.Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982

**A type III flap has two dominant vessels which allows for rotation from either end. The rectus abdominis flap is supplied by the deep inferior epigastric artery, which is the dominant vessel and will reliably supply the entire muscle. The superior epigastric artery will reliably supply the upper two-thirds of the muscle .

The gluteus maximus is supplied by both the superior and inferior gluteal arteries. The inferior gluteal vessel is dominant but an excellent intramuscular vascular connection allow the gluteus to be supplied by either vessel. These vessels are separated by the piriformis muscle as they exit the pelvis. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982

**Type IV muscles are generally not used for soft tissue reconstruction because they lack a distinct pedicle and cannot be rotated reliably on the small perforating branches. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982

**The type V flaps have a dominant pedicle which allows them to elevated as a free flap or rotation flap. Since there is segmental blood supply to the muscle at the distal end, half the muscle can be harvested on the dominant pedicle while the remainder of the muscle is nourished from the segmental vascular pedicles.The latissimus dorsi which is the workhorse muscle flap for soft tissue coverage is an example of a type V muscleMathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982

**

Septocutaneous flaps have arteries which traverse between the overlying muscles in distinct intermuscular septae and therefore are known as septocutaneous vessels. Septocutaneous flaps are classified into 4 types based on the location and number of the vascular pedicles as well as flap composition

A Type A flap is a pedicled flap containing fascia and skin that depends on multiple fasciocutaneous perforators at the base and that is oriented with the long axis of the flap at the level of the deep fascia**This is a pedicled or free flap depending upon a single and consistent fasciocutaneous perforator off an artery feeding a plexus at the level of the deep fascia. The sural artery fasciocutaneous flap is supplied by the last perforator of the peroneal artery which can be found approximately 5-7 cm above the lateral malleolus. The parascapular flap is based on the parascapular br of the circumflex scapular artery. Remember, these flaps are all supplied by well defined perforating vessels.Shown is a picture of a distally based sural artery flap with the pedicle easily visualized.**A Type C flap is supported by multiple small perforators along its length which reach it from a deep artery by passing along a fascial septum. The radial forearm flap was one of the first of of this type to be described. **This is a compound flap which incorporates other structures such as muscle and bone. A radial forearm flap can be raised with a half the diameter of the radius. Another example of this flap is the fibula osteocutaneous flap**A complete physical examination is essential with particular importance given to the vascularity of the injured extremity. The absence of suitable vessels is a contraindication for free tissue transfer. A careful clinical evaluation by palpating peripheral pulses and occluding vessels distally is often sufficient. Noninvasive studies such as doppler evaluation is useful. However if there is significant ASPVD or significant trauma to the extremity, further evaluation with an arteriogram should performed. Simpler, alternative measures should always be considered prior to embarking on free tissue transfer. The choice of donor site is ever-increasing and is dependent on a number of factors such as the length and width of the pedicle , the thickness of the flap, and whether sensory reinnervation or composite tissue is desired. Finally, and the surgeons own experience with a particular flap will be an important factor to consider. **Performing a free tissue transfer is a complex task that requires a team approach from the surgeon, assistant surgeon, anesthesiologist and the nursing personnel. The room should be comfortable and familiar with the surgeons sitting in a relaxed position. Many advances have been made in anesthesia, particularly regional anesthesia which may have a role in promoting vasodilation of the vessels and minimizing spasm.Temperature should be closely monitored and maintained throughout the procedure. A reduction in the circulating volume will cause a reflex vasoconstriction and therefore, it is vital to fluids need to be replaced prior to losses. Careful surgical technique goes without saying. The majority of failures can be attributed to poor technique. Spasm can be a very difficult problem. Ways to control spasm involve items discussed above as well as direct application of a local anesthetic(4%lidocaine) or verapamil hydrochloride.**Strong consideration should be given to monitoring these patients for the first 24-48 hours in the ICU where body temperature, fluid balance and pain relief can be monitored closely. Monitoring the flap post-operatively is very much surgeon dependent. Several of the methods are listed but such technology should not replace good sound clinical judgement such capillary refill, color, and turgor. If thrombosis is suspected early exploration is essential if the free tissue transfer is to be saved.**Conventional teaching for soft tissue coverage of the tibia**Medial head of Gastrocnemius based on the sural artery (branch from the popliteus) is a proximally based flap that can be rotated to cover proximal 1/3 defect of the tibia. Can also be used in the distal femur and knee. Careful release of the origin preserving the artery can provide additional length as can crosshatching the fascia. Lateral gastrocs can also be used if the medial gastrocs is unavailable, or in addition to the medial for larger wounds. Disadvantages include less rotational mobility and careful dissection required to mobilize around the peroneal nerve. ****There are seldom local flap coverage options for defects in the distal 1/3 of the leg. Generally free flaps are required as demonstrated above (latissimus dorsi free flap).****Local tissue flaps are frequently compromised during the accident and should be used with caution in the acute post traumatic setting.**Coverage of defect in some areas of the ankle and foot remain a challenge to reconstructive surgeons. The difficulty comes from the limited mobility and availability of the overlying skin, the unique weight-bearing requirements and the relatively poor circulation of the skin. Possible reconstructive options include local distant and free flaps. Local flap reconstruction remains popular because it is a simple reliable one-stage procedure. Options include the medial plantar flap which is the best option for coverage overlying the exposed calcaneus. Other smaller flaps include the Abductor hallucis and flexor digitorum flap are helpful for covering small defects but have limited use because of their small arc of motion.******As stated****There are a number of regional and pedicled flaps which can be used to gain coverage of elbow wounds. Listed on this slide are some of the flaps one might consider. ****When wound closure cannot be obtained by primary means, flexor and extensor tendons are not exposed and there are no plans for subsequent reconstructive procedures then STSG can be used for the dorsum of the hand and generally FTSG is used for the palm of the hand. **An in-depth discussion on soft tissue coverage of the hand is beyond the scope of this lecture but listed are common flaps that are used that the general orthopaedic surgeon should be familiar with.Cross finger flap covers volar defects on ;the finger from an adjacent digitThenar flap- provides coverage to the IF/ MF fingertip. Generally it is not a good choice for the elderly patient because of flexion contractures of the PIPJRadial Forearm Flap is a common flap use for soft tissue avulsion injuries, particularly for the dorsum of the hand. Must ensure that the hand has a complete arch by performing either non-invasive doppler evaluation or arteriogram if there is a question.Posterior Interosseous Flap is gaining more popularity as a retrograde flap. The post. Interosseous artery is found between the EDQ and ECU and the nerve to the ECU from the PIN may limit its elevation. The groin flap is still an excellent method of obtaining coverage over the back of the hand and first web space. The disadvantage is that it is bulky and may require subsequent operations to defat the flap.

**Dorsal soft tissue avulsion injuries are a common injury in rollover motor vehicle accidents oftentimes requiring extensor tendon reconstruction. There are several methods for obtaining coverage over the dorsum of the hand such as shown with this radial forearm flap. Groin flaps and free flaps such as the temporal mandibular flap and lateral forearm flap have been use for soft tissue coverage of the dorsum of the hand.******************