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An
open fracture of the distal one-third of
the leg may need soft tissue coverage if
skin and subcutaneous tissue are lost,
or if infection develops. A muscle
free flap will bring in healthy tissue
and good blood supply to help heal the
wound and prevent infection.
Preoperative
Evaluation
Like any
lower extremity injury a thorough
history and physical examination is
obligatory before developing the most
appropriate treatment regimen. The
following are critical elements:
-
Neurological
evaluation - lack of sensation on
the plantar aspect of the foot may
point to nerve injury or neuropathy
and preclude reconstruction.
-
Skeletal
examination - the requirement for
concurrent orthopedic treatment or
the need for secondary bone
reconstruction after coverage may
affect the choice and timing of flap
coverage.
-
Vascular
assessment - the presence of injury
to the vascular inflow to the foot
will often dictate the choice of
flap if microvascular
transplantation is indicated.
Clinical
Example
 This
patient developed an open fracture of
the tibia and fibula with loss of skin
over the ankle. The distal tibia
was exposed. An external fixator
had been placed at another institution
during his initial treatment along with
internal hardware, including plates and
screws.
 An
x-ray reveals a distal tibia fracture,
with internal hardware. If
hardware is firmly in position with no
signs of infection, and if there is no
sign of loosening, it can often be
retained. However, because there
was no rigid fixation of the tibial
fracture, an external fixator was
placed.
 A
preoperative arteriogram (angiogram) is
often performed in lower extremity
injuries to evaluate the vascular supply
reaching the limb. Often, in high
energy injuries that are able to break
strong bones like the tibia, a major
vessel or vessels can be injured or
transected.
 After
the soft tissues were debrided of
devitalized tissue and bone, a serratus
muscle flap was harvested from the right
chest of the patient. The lower
three slips of the muscle are harvested,
leaving the remaining upper slips behind
to continue the work of the serratus in
stabilizing the scapula.
 The
serratus is brought down to the
operative field and anastomosed to the
posterior tibial vessels of the
leg. The new external fixator is
seen in place. A skin graft from
the thigh is meshed and placed on the
muscle. The implantable
doppler is placed on the draining
vein for continuous post-operative
monitoring.
 The
patient is seen at six weeks post-op
when a bone graft was performed to the
tibia after elevation and replacement of
the muscle flap. Muscle flaps can
be elevated from the bone and allow an
excellent cover and blood supply for
delayed bone grafting.
 At
nine months after the muscle flap the
patient is seen standing with his shoe
and sock off. The flap has healed
properly with good contour and is is
free of any sign of infection or
underlying mal-union.
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