Compound fracture management: hinged flaps for soft tissue defects
Definition: A fracture is a large soft tissue wound – with some broken bones.
The two main challenges in primary management of compound fractures:
- Prevent compartment problems: Early fasciotomy on clinical indications
- Full debridement within 8 hours: Compromises on “maybe-vital tissue” regularly causes fracture infection and osteomyelitis. The problem is that comprehensive debridements in high-energy injuries often leave the fracture site denuded of soft tissues. In this situation mobilization of well vascularised soft tissue flaps are mandatory: for re-vascularization and callus formation. Which techniques are feasible at the low-resource district hospital in the rural South?
Mobilization of a medial gastrocnemius flap is technically simple. The muscle flap is hinged on the proximal root and is the method of choice for defects at the upper 1/3 of tibia. The crucial point during dissection is to identify and not damage the perforator arteries (arrows) that regularly are located 5 – 6 cm below the level of the knee joint. The gastrocnemius flap technique therefore does not require preoperative angiography or Doppler examination.
The suralis flap is the method recommended for soft tissue defects at the lower 2/3 of tibia and the foot. This fascio-cutaneous flap is hinged on a distal lateral root, and can thus reach defects on the lower leg as well as the foot. The blood supply is based on a perforator artery from the posterior peroneal artery. This perforator is regularly located 6 – 8 cm proximal to the lower end of fibula. When the perforator is identified, the flap dissection is carried in the proximal direction, the suralis nerve and artery is cut, and the flap mobilized – either through a subcutaneous tunnel or (better) through a skin split to the fracture site.
TMC and partners are now conducting clinical trials on distally hinged fascio-cutaneous flaps