IMAGES FOR SURGEONS ANZJSurg.com
Use of flexor carpi radialis turnover in fasciotomy defects Compartment syndrome is a limb-threatening condition, with the potential to develop following crush injuries, pressure from prolonged periods of unconsciousness, severe burns, fractures or as an inadvertent result of surgical intervention. Fasciotomies are performed as emergency interventions to prevent or even treat this complication.1 Often, negative pressure wound therapy (NPWT) is applied to the fasciotomy wound to reduce oedema and swelling, to temporize the wound and to promote granulation tissue formation. In many cases, the wound cannot be closed directly, necessitating a graft or flap for wound closure. The granulation tissue encouraged by NPWT may accommodate a split skin graft (SSG),2 which affords a relatively simple and rapid solution to the problem of wound coverage. However, in circumstances where the wound is not graftable, for example, when there is exposed tendon, the surgeon requires additional skills to achieve a graftable bed. This report presents a case of a fasciotomy wound with a non-graftable bed, and in which a simple local option of flexor carpi radialis (FCR) turnover was utilized to achieve this goal while inflicting no additional morbidity. AM, a 49-year-old gentleman, sustained a high-energy injury when struck by an exploding barrel lid at work. On admission he was found to have midshaft fractures of the radius and ulna, and an open olecranon fracture. The following day, AM underwent open reduction and internal fixation of both the radius and ulna, and tension band wiring of the olecranon. The forearm was extremely swollen and bruised as a result of the high-energy injury (Fig. 1). Under tourniquet control, the forearm fractures were approached through a volar incision. The flexor compartment was noted to be very tight but
the muscles were viable. A clinical diagnosis of volar compartment syndrome was made and a thorough fasciotomy was performed. The fractures were reduced to an anatomical position and rigidly internally fixed. The extensor compartment was clinically assessed; however fasciotomy was not required. On release of the tourniquet, a laceration of the radial artery was noted, and the Plastic Surgery team was called. The radial artery was repaired directly, transposed under flexor musculature and NPWT was applied. Three days after the initial operation AM returned to theatre. On table, the fasciotomy wound was unable to be closed directly, and the FCR tendon was exposed (Fig. 1), presenting the problem of a non-graftable wound. Rather than continuing NPWT or importing vascularized tissue with a muscular or fasciocutaneous flap, a FCR turnover was designed. The muscle and tendon were left attached proximally and distally, and the muscle belly was rotated radially (clockwise) over the tendon until adequate turnover without tension was achieved. Thus, the deep surface of FCR faced superficially, and the superficial exposed tendon faced deeply (Fig. 2). No vascular pedicles of the FCR, a Mathes and Nahai3 type IV muscle required division. The muscle belly of FCR was sutured to the granulation tissue at the radial edge of the wound. Thus, the wound bed, which now possessed muscle facing superficially, was vascularized. A SSG was laid onto the wound bed, and NPWT was applied, after which a plaster backslab was applied dorsally over elbow and wrist. After 5 days, the graft was determined to have taken, and the patient was discharged. The patient was splinted for 3 weeks, allowing for restricted range of active movement of the wrist. Clinically, full wrist function of flexion and extension, radial and ulnar deviation as well as pronation
Fig. 1. Fasciotomy wound with exposed flexor carpi radialis tendon.
Fig. 2. Fasciotomy wound with flexor carpi radialis tendon turned over.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
shock.6 The deep surface of the FCR tendon has a muscular component. When the distal musculotendinous unit is turned over a graftable surface is therefore presented. A conventional volar forearm incision was made for surgical approach to the distal radius for open reduction and internal fixation. The presence of raised forearm intracompartment pressure was not recognized until this surgical approach had been made; the existing incision was therefore extended to accommodate a fasciotomy release. If a compartment syndrome is recognized or suspected preoperatively, the surgical incision could be adjusted to avoid FCR exposure by coming more ulnar. However, if the wound is taken too ulnar, then the median nerve may become exposed. This case report describes the use of an FCR turnover to provide a graftable bed in the setting of a volar forearm fasciotomy wound. The FCR turnover provides the surgeon with a local option that imposes no morbidity to the patient. There have been no reported cases of this technique in the literature to date. Fig. 3. Seven weeks post-flexor carpi radialis turnover flap and split skin graft. Complete coverage. Full flexion and extension of wrist.
and supination with full power was achieved at 6 weeks postoperatively (Fig. 3). Skin grafting is a common temporizing or even permanent measure for closure of a forearm fasciotomy wound. However, the surgeon is presented with particular difficulty when the wound bed contains structures that do not support grafts, such as an exposed tendon. Current options for wound closure impose significant morbidity on a patient, with either prolonged NPWT aimed at promoting granulation tissue or importing vascularized tissue by sacrificing function or further aesthetics. FCR is a wrist flexor arising from the common flexor origin innervated by the median nerve. This muscle receives arterial supply from the brachial artery, anterior interosseous artery at its origin from the ulnar artery and branches of the radial artery.4,5 In the middle of the forearm, the musculotendinous junction forms a flattened tendon, which more distally becomes rounded. As it passes distally to insert into the bases of the second and third metacarpals, the tendon demonstrates 180 degrees of clockwise rotation in the right forearm, and 180 degrees of anticlockwise rotation in the left forearm.6 This spiral torsion enables a degree of elasticity without transmitting the forces of
References 1. Harvey EJ, Sanders DW, Shuler MS et al. What’s new in acute compartment syndrome? J. Orthop. Trauma 2012; 26: 699–702. 2. Orgill D, Bayer L. Update on negative pressure wound therapy. Plast. Reconstr. Surg. 2011; 127: 105S. 3. Mathes S, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast. Reconstr. Surg. 1981; 67: 177–87. 4. Sukkar S, Saulis A, Dumanian G. Radial forearm skin with flexor carpi radialis muscle: a useful composite free flap. Ann. Plast. Surg. 2002; 49: 486–9. 5. Revol M, Lantieri L, Loy S, Guerin-Surville H. Vascular anatomy of the forearm muscles: a study of 50 dissections. Plast. Reconstr. Surg. 1991; 88: 1026–33. 6. Lantieri L, Hennebert H, Le Viet D, Guerin-Surville H. A study of the orientation of the fibers of the flexor carpi radialis tendon: anatomy and clinical applications. Surg. Radiol. Anat. 1993; 15: 85–9.
Marc A. Seifman, MBBS, BMedSc Damon J. Thomas, MBChB, FRACS Department of Plastic, Reconstructive and Hand Surgery, Barwon Health, Geelong, Victoria, Australia doi: 10.1111/ans.13044
© 2015 Royal Australasian College of Surgeons
Use of flexor carpi radialis turnover in fasciotomy defects Compartment syndrome is a limb-threatening condition, with the potential to develop following crush injuries, pressure from prolonged periods of unconsciousness, severe burns, fractures or as an inadvertent result of surgical intervention. Fasciotomies are performed as emergency interventions to prevent or even treat this complication.1 Often, negative pressure wound therapy (NPWT) is applied to the fasciotomy wound to reduce oedema and swelling, to temporize the wound and to promote granulation tissue formation. In many cases, the wound cannot be closed directly, necessitating a graft or flap for wound closure. The granulation tissue encouraged by NPWT may accommodate a split skin graft (SSG),2 which affords a relatively simple and rapid solution to the problem of wound coverage. However, in circumstances where the wound is not graftable, for example, when there is exposed tendon, the surgeon requires additional skills to achieve a graftable bed. This report presents a case of a fasciotomy wound with a non-graftable bed, and in which a simple local option of flexor carpi radialis (FCR) turnover was utilized to achieve this goal while inflicting no additional morbidity. AM, a 49-year-old gentleman, sustained a high-energy injury when struck by an exploding barrel lid at work. On admission he was found to have midshaft fractures of the radius and ulna, and an open olecranon fracture. The following day, AM underwent open reduction and internal fixation of both the radius and ulna, and tension band wiring of the olecranon. The forearm was extremely swollen and bruised as a result of the high-energy injury (Fig. 1). Under tourniquet control, the forearm fractures were approached through a volar incision. The flexor compartment was noted to be very tight but
the muscles were viable. A clinical diagnosis of volar compartment syndrome was made and a thorough fasciotomy was performed. The fractures were reduced to an anatomical position and rigidly internally fixed. The extensor compartment was clinically assessed; however fasciotomy was not required. On release of the tourniquet, a laceration of the radial artery was noted, and the Plastic Surgery team was called. The radial artery was repaired directly, transposed under flexor musculature and NPWT was applied. Three days after the initial operation AM returned to theatre. On table, the fasciotomy wound was unable to be closed directly, and the FCR tendon was exposed (Fig. 1), presenting the problem of a non-graftable wound. Rather than continuing NPWT or importing vascularized tissue with a muscular or fasciocutaneous flap, a FCR turnover was designed. The muscle and tendon were left attached proximally and distally, and the muscle belly was rotated radially (clockwise) over the tendon until adequate turnover without tension was achieved. Thus, the deep surface of FCR faced superficially, and the superficial exposed tendon faced deeply (Fig. 2). No vascular pedicles of the FCR, a Mathes and Nahai3 type IV muscle required division. The muscle belly of FCR was sutured to the granulation tissue at the radial edge of the wound. Thus, the wound bed, which now possessed muscle facing superficially, was vascularized. A SSG was laid onto the wound bed, and NPWT was applied, after which a plaster backslab was applied dorsally over elbow and wrist. After 5 days, the graft was determined to have taken, and the patient was discharged. The patient was splinted for 3 weeks, allowing for restricted range of active movement of the wrist. Clinically, full wrist function of flexion and extension, radial and ulnar deviation as well as pronation
Fig. 1. Fasciotomy wound with exposed flexor carpi radialis tendon.
Fig. 2. Fasciotomy wound with flexor carpi radialis tendon turned over.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
shock.6 The deep surface of the FCR tendon has a muscular component. When the distal musculotendinous unit is turned over a graftable surface is therefore presented. A conventional volar forearm incision was made for surgical approach to the distal radius for open reduction and internal fixation. The presence of raised forearm intracompartment pressure was not recognized until this surgical approach had been made; the existing incision was therefore extended to accommodate a fasciotomy release. If a compartment syndrome is recognized or suspected preoperatively, the surgical incision could be adjusted to avoid FCR exposure by coming more ulnar. However, if the wound is taken too ulnar, then the median nerve may become exposed. This case report describes the use of an FCR turnover to provide a graftable bed in the setting of a volar forearm fasciotomy wound. The FCR turnover provides the surgeon with a local option that imposes no morbidity to the patient. There have been no reported cases of this technique in the literature to date. Fig. 3. Seven weeks post-flexor carpi radialis turnover flap and split skin graft. Complete coverage. Full flexion and extension of wrist.
and supination with full power was achieved at 6 weeks postoperatively (Fig. 3). Skin grafting is a common temporizing or even permanent measure for closure of a forearm fasciotomy wound. However, the surgeon is presented with particular difficulty when the wound bed contains structures that do not support grafts, such as an exposed tendon. Current options for wound closure impose significant morbidity on a patient, with either prolonged NPWT aimed at promoting granulation tissue or importing vascularized tissue by sacrificing function or further aesthetics. FCR is a wrist flexor arising from the common flexor origin innervated by the median nerve. This muscle receives arterial supply from the brachial artery, anterior interosseous artery at its origin from the ulnar artery and branches of the radial artery.4,5 In the middle of the forearm, the musculotendinous junction forms a flattened tendon, which more distally becomes rounded. As it passes distally to insert into the bases of the second and third metacarpals, the tendon demonstrates 180 degrees of clockwise rotation in the right forearm, and 180 degrees of anticlockwise rotation in the left forearm.6 This spiral torsion enables a degree of elasticity without transmitting the forces of
References 1. Harvey EJ, Sanders DW, Shuler MS et al. What’s new in acute compartment syndrome? J. Orthop. Trauma 2012; 26: 699–702. 2. Orgill D, Bayer L. Update on negative pressure wound therapy. Plast. Reconstr. Surg. 2011; 127: 105S. 3. Mathes S, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast. Reconstr. Surg. 1981; 67: 177–87. 4. Sukkar S, Saulis A, Dumanian G. Radial forearm skin with flexor carpi radialis muscle: a useful composite free flap. Ann. Plast. Surg. 2002; 49: 486–9. 5. Revol M, Lantieri L, Loy S, Guerin-Surville H. Vascular anatomy of the forearm muscles: a study of 50 dissections. Plast. Reconstr. Surg. 1991; 88: 1026–33. 6. Lantieri L, Hennebert H, Le Viet D, Guerin-Surville H. A study of the orientation of the fibers of the flexor carpi radialis tendon: anatomy and clinical applications. Surg. Radiol. Anat. 1993; 15: 85–9.
Marc A. Seifman, MBBS, BMedSc Damon J. Thomas, MBChB, FRACS Department of Plastic, Reconstructive and Hand Surgery, Barwon Health, Geelong, Victoria, Australia doi: 10.1111/ans.13044
© 2015 Royal Australasian College of Surgeons
