Journal of Trauma and Injury

Case Report

Expediting venous drainage in large anterolateral thigh flaps for scalp electrical burns in India: two case reports on the use of primary vein grafts for second vein anastomosis: Jyotica Jagadish Chawaria, Parvati Ravula, Nazia Tabassum, Srikanth Rangachari; J Trauma Inj. 2023;36(4):404-410. Published online November 30, 2023; DOI: https://doi.org/10.20408/jti.2023.0054

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Abstract PDF: Large scalp defects resulting from high-voltage electrical burns require free flaps, preferably skin, to permit optimal coverage and enable future or simultaneous cranial vault reconstruction. The anterolateral thigh permits the harvest of a large area of skin supplied by a reliable perforator. The superficial temporal vessels offer the proximate choice of recipient vessels to enable adequate reach and coverage. The lack of a second vein at this site implies the inability to perform a second venous anastomosis; however, this obstacle can be overcome by using an interposition vein graft, to the neck veins primarily. This assures adequate venous drainage and complete flap survival.; Summary

Original Articles

Proximally based sural artery flap for the reconstruction of soft tissue defects around the knee and proximal third of the leg in India: a clinical study: Palukuri Lakshmi, Sreedharala Srinivas, Dharmapuri Madhulika, Sanujit Pawde, Ajo Sebastian, Swathi Sankar, Sandeep Reddy Chintha; J Trauma Inj. 2023;36(4):369-375. Published online November 23, 2023; DOI: https://doi.org/10.20408/jti.2023.0042

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Abstract PDF: Purpose
The reconstruction of defects around the knee and the proximal third of the leg necessitates thin, pliable skin with a stable and sensate soft tissue cover. This study analyzed the use of a proximally based sural artery flap for the coverage of such defects.
Methods
This prospective clinical interventional study involved 10 patients who had soft tissue defects over the knee and the proximal third of the leg. These patients underwent reconstruction with a proximally based sural artery flap. The study analyzed various factors including age, sex, etiology, location and presentation of the defect, defect dimensions, flap particulars, postoperative complications, and follow-up.
Results
There were 10 cases, all of which involved men aged 20 to 65 years. The most common cause of injury was trauma resulting from road traffic accidents. The majority of defects were found in the proximal third of the leg, particularly on the anterolateral aspect. Defect dimensions varied from 6×3 to 15×13 cm2, and extensive defects as large as 16×14 cm could be covered using this flap. The size of the flaps ranged from 7×4 to 16×14 cm2, and the pedicle length was 10 to 15 cm. In all cases, donor site closure was achieved with split skin grafting. This flap consistently provided a thin, pliable, stable, and durable soft tissue cover over the defect with no functional deficit and minimal donor site morbidity. Complications, including distal flap necrosis and donor site graft loss, were observed in two cases.
Conclusions
The proximally based sural fasciocutaneous flap serves as the primary method for reconstructing medium to large soft tissue defects around the knee and the proximal third of the leg. This technique offers thin, reliable, sensate, and stable soft tissue coverage, and can cover larger defects with minimal complications.; Summary

Distally based lateral supramalleolar flap for reconstructing distal foot defects in India: a prospective cohort study: Raja Kiran Kumar Goud, Palukuri Lakshmi, Sanujit Pawde, Madhulika Dharmapuri, Swati Sankar, Sandeep Reddy Chintha; J Trauma Inj. 2023;36(3):217-223. Published online September 18, 2023; DOI: https://doi.org/10.20408/jti.2023.0005

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Abstract PDF: Purpose
Defects involving the ankle and foot are often the result of road traffic accidents. Many such defects are composite and require a flap for coverage, which is a significant challenge for reconstructive surgeons. Various locoregional options, such as reverse sural artery, reverse peroneal artery, peroneus brevis muscle, perforator-based, and fasciocutaneous flaps, have been used, but each flap type has limitations. In this study, we used the distally based lateral supramalleolar flap to reconstruct distal dorsal defects of the foot. The aim of this study was to analyze the efficacy of the flap in reconstructing distal dorsal defects of the foot. The specific objectives were to study the adequacy, reach, and utility of the lateral supramalleolar flap for distal defects of the dorsum of the foot; to observe various complications encountered with the flap; and to study the functional outcomes of reconstruction.
Methods
The distal dorsal foot defects of 10 patients were reconstructed with distal lateral supramalleolar flaps over a period of 6 months at a tertiary care center, and the results were analyzed.
Results
We were able to effectively cover distal foot defects in all 10 cases. Flap congestion was observed in two cases, and minor graft loss was seen in two cases.
Conclusions
The distally based lateral supramalleolar flap is a good pedicled locoregional flap for the coverage of distal dorsal foot and ankle defects of moderate size, with relatively few complications and little morbidity. It can be used as a lifeboat or even substitute for a free flap.; Summary

Case Reports

Hyperbaric oxygen therapy for the treatment of a crush injury of the hand: a case report: Pedro Henry Neto, Zamara Brandão Ribeiro, Adriano Bastos Pinho, Carlos Henrique Rodrigues de Almeida, Carlos Alberto de Albuquerque Maranhão, Joaquim da Cunha Campos Goncalves; J Trauma Inj. 2022;35(3):209-214. Published online May 26, 2022; DOI: https://doi.org/10.20408/jti.2021.0048

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Abstract PDF: We describe a case of hyperbaric oxygen therapy (HBOt) as an adjunct to treatment of a crush injury to the hand. A 34-year-old male paramedic was involved in a motor vehicle accident and admitted for diagnosis and surgical treatment. He sustained a crush injury to his right hand and presented with significant muscle damage, including multiple fractures and dislocations, an avulsion injury of the flexor tendons, and amputation of the distal phalanx of the little finger. He underwent reconstructive surgery and received HBOt over the following days. In the following 2 months, he lost the distal and middle phalanges of the little finger and recovered hand function. Posttraumatic compartment syndrome responds well to HBOt, which reduces edema and contributes to angiogenesis, as well as promoting the cascade of healing events. High-energy trauma causes massive cell destruction, and the blood supply is usually not sufficient to meet the oxygen demands of viable tissues. Hyperbaric oxygenation by diffusion through interstitial and cellular fluids increases tissue oxygenation to levels sufficient for the host’s responses to injury to work and helps control the delayed inflammatory reaction. HBOt used as an adjunct to surgical treatment resulted in early healing and rehabilitation, accelerating functional recovery. The results suggest that adjunctive HBOt can be beneficial for the treatment of crush injuries of the hand, resulting in better functional outcomes and helping to avoid unnecessary amputations.; Summary

Successful management of a Comatose Patient with Traumatic Brain Exposure with a fronto-Parieto-occipital flap: Charles Chidiebele Maduba, Ugochukwu Uzodimma Nnadozie; J Trauma Inj. 2020;33(1):48-52. Published online March 30, 2020; DOI: https://doi.org/10.20408/jti.2019.037

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Abstract PDF: Composite skull defects in patients with severe head injuries are very challenging to manage. The dilemma when deciding whether to perform a definitive reconstruction is how long to wait for physiological recovery before an intervention complicates the situation. The inability of such patients to tolerate prolonged anesthetic exposure is a driving factor for performing the minimal intervention necessary to facilitate recovery. Herein, we present a case involving the successful immediate reconstructive treatment of a severely head-injured adolescent with a composite scalp defect secondary to trauma. A 14-year-old boy sustained a severe head injury from a motor vehicle accident with a composite scalp defect in the right fronto-parietal region. The frontal lobe was exposed, and the right eye was crushed and devitalized. The patient was deeply unconscious for 3 days, without any significant improvements before reconstructive surgery was proposed due to fear of possible meningitis resulting from the exposure of brain structures. We successfully managed the patient with a fronto-parieto-occipital flap, after which the patient promptly recovered consciousness.; Summary

Bilateral Free 2nd Toe Pulp Flap for Reconstruction of Soft Tissue Defect in Traumatic Finger Injuries: Jeongseok Oh, Seok Chan Eun; J Trauma Inj. 2019;32(3):181-186. Published online September 30, 2019; DOI: https://doi.org/10.20408/jti.2019.014

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Abstract PDF: Finger reconstruction involves paramount significance of both functional and aesthetic aspects, due to its great impact on quality of life. The options range from primary closure, skin grafts, local flaps, pedicled flaps, and free flaps. The optimal method should consider various circumstances of the patient and surgeon. We would like to report a case of a young woman who initially presented with cellulitis and necrosis of the left second finger-tip who underwent reconstruction with bilateral toe pulp free flap. The patient could successfully return to her job that involves keyboard typing and playing the piano, with acceptable donor site morbidity.; Summary

Reconstruction of a Large Infected Midline Abdominal Wall Defect Using a Latissimus Dorsi Free Flap: Han Gyu Cha, Eun Key Kim, Suk-Kyung Hong; J Trauma Inj. 2018;31(2):91-95. Published online August 31, 2018; DOI: https://doi.org/10.20408/jti.2018.31.2.91

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Abstract PDF: Managing large infected midline abdominal defects are clinically challenging and technically demanding. The alloplastic materials, regional flaps, and component separation are usually infeasible because of the size, location, depth, and state of the defects. In these cases, the free flap is the only option with a large well-vascularized tissue that is free to inset regardless of the location. Herein, we report a case of 44-year-old man with a large infected midline abdominal wall defect who was completely treated with a latissimus dorsi myocutaeous free flap followed by negative pressure wound therapy.; Summary

Upside-down Adipofascial Flap for the Medial Foot Soft Tissue Defect after Trauma: Case Report: Min Bom Kim, Young Ho Lee, Gil Joon Seo, Goo Hyun Baek; J Trauma Inj. 2015;28(1):27-30. Published online March 30, 2015; DOI: https://doi.org/10.20408/jti.2015.28.1.27

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Abstract PDF: A child sustained a car tire friction injury and had multiple soft tissue wounds. She had a severe soft tissue defect in the medial foot and ankle aspect which requiring flap coverage. We performed an adipoafscial flap with upside-down pattern for the treatment of the medial foot and ankle soft tissue posttraumatic defect. The flap is based on the perforator artery from the posterior tibial artery. Because it gave a thin coverage for the foot, the patient could walk with normal foot wear.; Summary

Early Resurfacing Using Gastrocnemius Muscle Flap Transposition for Degloving Injury with Exposure of Proximal Tibia: Hii Sun Jeong, Hye Kyung Lee; J Korean Soc Traumatol. 2008;21(2):140-143.

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Abstract PDF: Degloving injuries result from the tangential force against the skin surface, with resultant separation of the skin and the subcutaneous tissue from the rigid underlying muscle and fascia. These injuries are associated with extensive soft tissue loss and occasionally with exposure of bone, and they require reconstructive modality for resurfacing and successful rehabilitation that considers the vascular anatomy and the timing of the operation. A 19-year-old male patient was transferred to our facility with degloving injury extending from the lower third of the right thigh to the malleolar area. The tibial bone was exposed to a size of 2x3.5 cm2 on the upper third of the lower leg at the posttraumatic third day. The exposed soft tissue was healthy, and the patient did not have any other associated disease. At the posttraumatic sixth day, one-stage resurfacing was performed with a medial gastrocnemius muscle flap transposition for the denuded bone and a split-thickness skin graft for the entire raw surface. The transposed gastrocnemius muscle attained its anatomical shape quickly, and the operating time was relatively short. No transfusion was needed. This early reconstruction prevented the accumulation of chronic granulation tissue, which leads to contracture of the wound and joint. The early correction of the gastrocnemius muscle flap transposition made early rehabilitation possible, and the patient recovered a nearly full range of motion at the injured knee joint. The leg contour was almost symmetric at one month postoperatively.; Summary

Original Articles

Reconstruction of Lower Extremities using Anterolateral thigh Perforator Free Flaps: Tae Gon Kim, Min Gu Kang; J Korean Soc Traumatol. 2007;20(2):119-124.

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Abstract PDF: PURPOSE
Management of the soft tissue defect in the lower extremity caused by trauma has always been difficult. Coverage with local and free muscle flaps after complete surgical excision of necrotic soft tissue and bone is a major strategy for treatment. There is no doubt that muscle provides a good blood supply, thus improving bone healing and increasing resistance to bacterial inoculation. However, accompanying problems are seen in cases with shallow dead space. This research was conducted to assess the efficacy of raising anterolateral thigh flaps and transferring them to the defect after complete debridement of non-viable, infected, and scar tissue as an alternative way to use local or free muscle flaps.
METHODS
From March 2005 to October 2007, 18 cases of soft tissue defect on lower extremities were re-surfaced with an anterolateral thigh perforator free flap.
RESULTS
The follow-up period ranged from 1 to 31 months with a mean of 15.9 months. All flaps survived completely. Satisfactory aesthetic and functional results were achieved. Under a two-point discrimination test, 13 patients had sensory recovery from 11 mm to 20 mm after 6 months postoperatively.
CONCLUSION
Reconstruction of the lower extremity with anterolateral thigh perforator free flaps after appropriate debridement is a good alternative way to use local or free muscle flaps.; Summary

Reconstruction of Soft Tissue Defect with Free Flap in Pediatric Patients: Jin Woo Song, Joon Pio Hong; J Korean Soc Traumatol. 2010;23(2):157-162.

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Abstract PDF: PURPOSE
Free flap reconstruction in the pediatric population is difficult. However, microsurgery has had remarkable success rates in children. The aim of study is to present our clinical experience using free flap for reconstruction of soft tissue defects in children and to describe long-term follow-up results.
METHODS
Between June 2002 and July 2010, 30 cases of pediatric reconstruction were performed with free flap. The authors analyzed several items, such as the kind of flap, associated complications, and growth problems.
RESULTS
Among the 30 cases, 21 cases were due to traffic accidents, 5 to cancer, and 4 to falls and other soft tissue defects. The lower leg and foot were the most common sites of the lesion. In the free flap operations we have done, 20 cases involved an anterolateral thigh perforator free flap, 6 a superficial circumflex iliac perforator free flap, and 4 an upper medial thigh perforator free flap. In early postoperative complications, partial necrosis was seen in 2 cases, infection in 1 case, and the hematoma in 1 case. A satisfactory success rate and functional results were achieved.
CONCLUSION
Free flap reconstruction in children allows satisfactory function with no significant effect on growth. Free flaps are regarded as the primary choice for selective pediatric reconstructive cases.; Summary

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