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Specific sites

Chapters 4-7 have described the various region of the body and highlighted ther specific needs during
reconstruction. In traumatc defect, some specific body region, such as the lower leg and the hand, are
worthy of special mention due to the additional demands placed upon the reconstruction surgeon in there
areas.
Lower third of leg
Few areas of the body are as challenging in terms of reconstruction as the lower one-third of the leg.
Trauma to this region is common, with falls and motor vehicle accidents representing two of the most
common causes. This region displays minimal soft tissue laxity, and soft tissue defect in this area can
expose bone, joint, multiple vessels and tendons that will require definitive coverage. With the exception
of the foot, is the most dependent region in the body and can suffer from chronic problem, suc as venous
or arterial insufficiency, lymphoedema and neuropathies. Any reconstructive option should have reliable
vascularity, especially for it’s venous drainage, and promote early mobilisation and rapid return of daily
activities of living/quality of life. As a result of these features, soft tissue reconstruction in this region is
problematic and often few option may seem available except free-tissue transfer. The keystone island flap
(and it’s design variants) can provide raliable soft tissue coverage of these defect where appropriate
patient and defect selection is undertaken. Closure of the defect with only physiological tension may
necessitate the use of a small skin graft to the donor site, but this can usually be undertaken without
significant additional risk or morbidity )as shown in figs 10.1 and 10.3).
Hand trauma
The hand is densely constructed of important nerves, vessels, tendons, bones and joints, with overlying
soft tissues arranged to provide appropriate glide planes for these structures to permit the complex hand
movement required for the activities of daily living. Each of the subregions of the hand can recreate the
features and characteristics of native hand tissues, and ‘like wike like’ reconstruction should be
considered the gold standard. As described in chapter 5, there are nomerous suitable vascular perforators
throughout the hans for use in locoregional flap reconstruction. The inherent focal elasticity of regions of
the hand can be utilised to provide tissue for reconstruction of even modest-sized defect. Trauma to the
hand is treated in a similar manner to the lower limb, focusing on appropriate patient assesment and
management as a whole, bony stabilisation and timely vascularised soft tissue coverage of surgically
prepared wounds that emphasies return to function as early as possible. Figures 10.5 and 10.6 demostrate
two cases where these principles have been applies for soft tissue reconstruction following trauma to the
upper limb.
Management of the primary defect
Assuming that an appropriate assessment of the patient and the injury(ies) is undertaken, management of
the primary defect involves the surgical debridement of the wound with removal of all devitalised tissue
followed by appripriate wash-out. Tissue biopsies may be taken at this time needed. Temporary or
definitive bony fixation will assist woung closure and minimise ongoing tissue damage. As described
above, where injury is significant or the surriunding potential donor sites

the Achilles tendon is ready for reconstruction b) Doppler ultrasound is used to identify peroneal artery perforators as the basis for a laterally based flap due to proximity of the defect to the tibia medially and the oblique angle of the wound. or with skin grafting to the donor site in some free fascioucutaneous flap.1 A 39 year old man present with a circular saw injury to his left posteromedial calf involving transection of an Achilles tendon and significant soft tissue loss (4 x 13 cm soft tissue defect) a) Following excisional wound debridement and pulse lavage.Keystone flao reconstruction. j) & k) At 3 weeks.1 demonstrates an example of its use in acute trauma in this region. with or without skin grafting of the secondary defect. revascularisation. full-thickness skin graft is applied laterally to avoid excessive tension. Figure 10. This would not be as certain without identification of nearby perforators in the keystone flap. Conjoint flap vascularity . Any number of flaps could be elevated on the identified perforators. functional or denervated muscle transfer. with acceptable aesthetic and function. Where a skin graft is used for the secondary defect. c) & d) A peroneal perforator keystone island flap is designed to incorporate the posterior aspect of the calf e) The flap incorporates numerous perforators and wound permit the narrowed area of the lower part of the flap without compromise. h) The medial aspect of the wound is closed using 3/0 and 4/0 nylon. such as the sort saphenous vein and sural nerve. such as free tissue transfer. the wounds have healed. or defect eith insufficient local donor tissue availability) are not met. Fig 10. with the exception of a small granulated are that responded well to simple dressing within 1 week.g provision of vascularised bone. The patient progressed to normal weight-bearing. while demonstrating reliable healing and acceptable aesthetics. is a simple and reliable reconstructive tool for the management of trauma. where split-thickness skin may be use directly on muscle flaps with poor cosmetics and used functional results. even in difficult areas such as the lower third of the leg. walking and activities and directed by his Achilles tendon repair. i) A small. The lowest perforator is sought so that the flap may be narrowed to limit exposure over the fibula at the flap donor site. this compares favourably with alternative form of reconstruction. with preservation of longitudinal neurovascular structures. It is an excellent reconstructive choice for free-tissue transfer (e. f) & g) The Achilles tendon repair is complete and the flap islanding is undertaken circumferentially through the deep fascia. less morbid operation that limits surgical morbidity ti the affected area alone. Keystone flap reconstruction provides a shorter.

a vascular flare gradually becomes evident. Exposed metal and bone are evident. b) Plain x-ray demonstrates a copious volume of metal wiring for fixation of the patella. with slough along the wound margins. f) With the tourniquet still applied. d) The arrow indicates perforator support for the flap as it raised during blunt dissection. h) & i) The wound on closure with suction drainage and the arrow indicating another point of red dot reactive hyperemia. The flap is aligned along the L3 dermatome. j) A meshed split-thickness skin graft is applied for secondary defect closure. yet good articular alignment. The lower third is left attached to capture medial geniculate perforators along with neurovascular supply to the region. an inferiorly based keystone island flap is raised medially with sharp incision through the skin followed by blunt dissection for flap elevation.2 to 10.Time (operation/cost) 90 minutes Life quality (and aesthetics) Good with normal function and acceptable aesthetics not limiting recovery of achilles tendon repair Complications Single site of granulation healed after 4 weeks Clinical cases The usefulness of the keystone island flap as a reconstructive tool for a variety of traumatic defects is demonstrated in the following clinical cases shown in figures 10. The patient refused long-term follow up. The white lines of tension in the subdermal plexus are temporary phenomena while the perfusional dynamics are supported by the underlying perforator system.7 Fig 10. e) With the flap in position. g) Upon release of the tourniquet. Additional VY advancement would normally be possible but caution was exercised to limit tension in the oedematous wound bed of the 4-week-old subacute wound. .2 A referral was made to our tertiary hospital from an outside health center of a truck driver managed by a local orthopaedic unit following a truck accident a) Appearance at 4-5 weeks following orthopaedic fixation of his patellar fracture. c) Following wound debridement. the debridement is completed to fit in with the flap alignment. k) Appearance at 7 days indicating good skin graft take and reliable flap healing. the red dot sign understandably demonstrates a cyanotic tinge. l) The appearance at 3 weeks with a full range of movement.

including of the splitthickness skin graft the lateral malleolus. d) The flap is completely islanded. j) The flap is insert and undergoes reliable healing. ensuring rapid healing. f) On completion. i) At the request of the patient. Following excision of the skin graft. c) Alignment with a skin hook to note appropriate apposition. Attempted closure by the orthopaedic unit was suboptimal. b) A keystone flap was elevated based upon peroneal perforators and superficial peroneal branches for neurovascular support.3 A 26 year old male with compound tibial fracture managed with internal fixation and plating. a posteriorly based keystone flap is elevated and used to closure the skin graft excision site directly. so temporizing measures were instituted and plastic surgery referral made. a scar revision was undertaken. as seen in (k). a) Wound appearance at referral following removal of tension sutures the exposed metal work.4 Complication Nil Nil. k) The contralateral leg has a seizeable tattoo. Debridement of the flap edge once sufficient flap mobility is provided to enable wound closure index physiological tension. The patient’s compliance postoperatively was problematic.Fig 10. e) Red dot sign confirming the hypervascularity (part of the quaternary response). The patient planned a tattoo for the operative leg once it wah healed. h) The site of previous skin grafting is dotted out. fracture and devitalized tissue margins. the vascular flare demonstrates another part of the quaternary response. The reliability of the flap with stood the issues with compliance despite this self-discharge within 24 hours. Conjoint flap vascularity Time (operation/cost) 80 minutes Life quality (and aesthtical) Non-complication – patient signed self out hospital to take posession on settlement of his recently purchased house 40 minutes (scar revision and Good with normal fuction keystone flap) and acceptable appearance Fig 10. patient undertook tattooing over the site . Option of free-tissue transfer or locoregional fasciocutaneous flap reconstruction with a keystone flap variant were considered. g) Appearance 3 months postoperatively demonstrating good healing. with good supply from the underlying peroneal perforators. with the patient self-discharging against medical advice for social reasons.

b) X-ray demonstrates the comminuted nature of the fracture to the base of the second metacarpal. the lymphoedema resolved.5 A 78 years old retired pilot received a compound fracture to his right (dominant) second metacarpal as a result of starting the propeller of an original World War II fighter plan by hand. His quality of life improved dramatically by 1 year despite the addition of more scar. Fourteen operation had failed to resolve the ulcer and unstable scar. An ulnar-based keystone flap is devised to assist wound closure following pulse lavage. Marked unilateral lymphoedema significantly limited activities of daily living/quality of life. A single axial K-wire is used to maintain alignment and an additional two transverse wire are used to control the fragments. a) b) c) d) e) f) g) h) Chronic ulcer of anterior shin directly over the previously fracture tibia. & Following uneventful wound healing. with the patient able to stand and work all day without significant swelling and with resolution of peripheral oedema after 32 years. with preservation of cutaneous perforators (arrow). and acceptable aesthetic Complication Nil Fig 10. with through wash-out of the wound. with loss of lyphoedema during normal work day (32 years history previously). Excision debridement of the ulcer is undertaken. The lower end of the keystone flap is elevated while maintaining important neurovascular structures. Transposition of the distal end of the flap achieves wound closure. c) Following appropriate wound debridement. A laterally based keystone flap is planned. Conjoint flap vascularity Time (operation/cost) 68 minutes Life quality (and aesthetic) Good. but the open fracture is hidden by the skin that has beesn pushed down within the fracture. Blunt dissection deep to the deep fascia is performed. the fracture fragments are evident within the central aspect of the wound and the cutaneous defect is significantly larger. . and split-thickness skin graft is undertaken for the secondary defect. a) The initial appearance does not demonstrates significant soft tissue loss.A 48 year old male with a chronic no healing ulcer over a compound tibial fracture from 32 years previously.

with full-thickness tissue loss. Good mobility with no significant restriction in function compares with preinjury levels was evident a 6 month follow up.d) An additional radially based keystone flap is devised. based upon the size of the defect and swelling within the tissues. f) Appearance at 7 days postoperation with sound early healing and noticable keratosis from rest in a splint. e) Closure is undertaken over a small suction drain with use of Luer-lok syringe-based suction.6 A 42 year old. the V-Y points of the ulnar flap are progressiing well. a) Staged debridement of the injury resulted in exposure of the median nerve proximally and the transverse carpal ligament in the palm via a 4 x 3 cm defect. Protected range of motion exercises are begun for the thumb. Conjoint flap vascularity . e) A billateral flap advancement (type IV) is undertaken over a small suction drain. g) Appearance at 6 weeks with good function and aesthetic. c) & d) The inherent laxity of the hypothenar complex permitted direct closure of the defect. f) Due to untoward tension. b) A hypothenar keystone island flap based on a conjoint supply via perforators from the ulnar neurovascular bundle and the palmar cutaneouse branch of the ulnar nerve. little and ring fingers. right-handes man fell off his bicycle njures the palmar surface of his right hand. Conjoint flap vascularity Time (operation/cost) 90 minutes Life quality (and aesthetical) Good with normal function and acceptable aesthetics Complication Nil Fig 10. with division of the radial aspect of Guyon’s canal to facilitate advancement into the defect. i) Excellent skin graft take is evedent. Immediate reconstruction was a necessity. showing good skin graft take and reliable healing of both keystone flaps. h) Despite swelling. g) Appearance at 9 days. a small fenestrated full-thickness skin graft is applied to the radial flap’s secondary defect over the thumb.

Free-flap reconstruction was considered but a local option was sought. robust vascularised soft tissue coverage that is suitbale for many traumatic defects and has suitable aesthetics. three are often multiple competing problems. In cases of severe trauma. based in peroneal musculocutaneous perforators. The keystone flp rovides reliable. f) A vsacular flare is evident. wound breakdown that occurred with exposure of the full length of the fibula. It is most suited to isolated. g) Appearance once the flap is inset with even tension and subsequent good wound healing. with previous trauma to the flap indicated by a healed split-thickness skin graft. Through assessment of the trauma patient is essential for successful outcomes. and is most suitable where revascularisation. Conjoint flap vascularity Time (operation/cost) 70 minutes Life quality (and aesthetics0 Goood with normal function and acceptable aesthetics Complications Nil Summary Flap reconstruction in trauma should follow the principle of complex assessment followed by the use of the simplest. c) A keystine flap over the posterolateral aspect of the leg is devised. e) The red dot sign indicated reliable vascularity (the quaternary response). acceptable appearance Complications Nil Fig 10. but can be used very . including within the skin graft on the flap. composite tissue or large volume reconstruction are required. d) The flap is elevated eith division of the deep fascia. Careful consideration of all reconsttructive option in the given patient (and setting) maximises the chances of correctly identifying the simples form of reconstruction that will achieves the most appropriate outcomes. following removal of the plate fixation. Free-tissue transfer is a complex form of reconstruction for taumatic defects.7 A 46 year old male with previouse open reduction. most appropriate solution. internal fixation and. simple low-velocity trauma in the subacute setting. a) & b) Defect size 25 x 3 cm with noticeable screw hole defect in the bone.Time (operation/cost) 45 minutes Life quality (and aesthetics) Good—back to riding his bike to collect his wine.

A systematic approach to the trauma patient shouls correctly identifity those patients with the most to benefit from such a reconstructive approach. .effectively in other presentations with consideration and care.