A 20-year-old male referred from a hospital outside the city of Managua (Nicaragua) after suffering trauma to the left arm by a moving vehicle, which caused a non-repaired open fracture of the external third type C.
He arrived at our hospital 12 hours after the accident.
In the directed physical examination of the upper extremity we found absence of distal peripheral pulses radial and ulnar, Allen test negative and temperature decrease.
We performed a real-time doppler study with a B-mode high frequency linear probe showing flow with attenuated waves in the proximal brachial artery, but not in its middle and distal portions in which there is a distal flow.
The patient was admitted to the operating room where we found a linear wound on the anterior surface of the arm and complete section of the biceps brachii in 1/3 medium, distal and proximal cable length of brachial artery with displaced seda fracture 8 cm.
We kept the limb in warm ischemia and performed sequential limb reconstruction in two stages.
Primer reconstruction time: vascular repair
In collaboration with the Vascular Surgery Service termed anastomosis, we performed a 20 cm long saphenous vein graft harvesting of the left lower extremity and transposed it to the 10 cm nylorus magnal graft.
The fracture line is thus exposed.
We therefore achieved limb revascularization 16 hours after the accident.
Anterior forearm fasciotomy was also performed to treat the mental disorder associated with trauma.
Second reconstruction time: internal fixation and coverage
After showing adequate tissue perfusion at the site of the lesion and distal to it, and 48 hours after vascular repair, we performed an internal h fracture fixation with an 8 cm proximal intramedullary nail.
Once the possible reconstruction options for covering the neurovascular structures and the fracture line were evaluated, we performed transposition of the ipsilateral wide dorsal musculocutaneous flap.
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With the patient placed in the right lateral decubitus position, we outlined the flap area with a length of 22 cm. x 11 cm. width, seeking to reestablish the flexion function of the lateral elbow, taking only the lateral muscle lesion.
We focus on the lateral edge of the latissimus dorsi muscle to achieve adequate exposure and continue with the elliptical incision corresponding to the cutaneous component of the flap.
We followed the dissection cephaladly on the anterior surface of the muscle to the subscapular zone, performing submuscular dissection in the areolar plane near the chest wall.
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We locate the descending branch of the tocodorsal artery, first identifying the branches that go to the serrate muscle, and the circumflected scapular artery, which are ligated and divided to prevent clotting.
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Once the main defect of the flap is located, the medial section of the muscle is performed, ensuring that only the tissue needed for covering the defect is included.
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We focused on the axillary area in zigzag, with distal extension along the lateral edge of the latissimus dorsi muscle to transpose the latissimus dorsi flap to the anterior area of the arm and thus repair the saphenous graft.
We placed a closed drainage system with primary closure of the donor site.
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Once the flap was transposed, fixation was performed proximally to the coracoid process and to the remnant of biceps muscle belly fibers and distally, we fixed the bicipital tendon with non-absorbable sutures.
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The coverage of the rest of the muscle flap and fasciotomy was performed with partial thickness grafts 7 days after transposition of the latissimus dorsi flap, since the distal bacterial edema of the limb had not decreased and there was no clinical colonization.
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The patient was hospitalized for 10 days, presenting adequate distal perfusion of the tissues, being evident by auscultation with 8 MhZ manual doppler vascularization of the superficial and deep palm arch.
The latissimus dorsi flap, with no data on venous congestion or arterial insufficiency, provided stable coverage on the smokeless fracture line on saphenous vein grafts to brachial vessels.
The donor area also had no complications, and the closed drainage system was removed 13 days after surgery.
Graft integration was 100%.
The patient started physical therapy 4 weeks after the initial procedure, with elbow flexion and extension movements.
After a 6-month follow-up, it presents flexion and extension ranges between 60-180 degrees, even with some limitation to the function of complete flexion, which would require more physical therapy, such as performing work or performing daily tasks.
