Case reports

Case I
S.A., a 23-year-old steel worker, sustained a deep Burn of the flexor aspect of the elbow region.
The patient was first admitted to a peripheral hospital and later transferred to our department. The lesion was already infected and the eschar was firmly adherent. The median-nerve innervated territory was hypaesthesic, while the u1nar and radial territories showed no impairment. The median-nerve innervated intrinsic muscles were paralysed and the u1nar muscles were normal. The epitrochlear muscles were hypopotonic.
The first procedure was surgical debridement carried down until the muscles were widely exposed. The epitrochlear muscles were partially necrotic and were debrided together with part of the biceps tendon. The median nerve was necrotic and was excised for 12 cm of its length. The wound was covered with split-thickness meshed skin grafts.
The skin grafts were subsequently removed and the wound covered with a turn-over adipofascial flap. In the same procedure the median nerve was isolated, the stumps were trimmed, and a silicone tube was sutured to the cut ends (Fig. 4). The exposed deep surface of the fascia was then covered with split-thickness skin grafts (Fig. 5).

Fig. 4 - After excision of the necrotic median nerve, trimming of stumps and suturing of silicone tube to cut ends. Hand to the left. Fig. 5 - Fascia finally covered with split-thickness skin graft.

One month later the silicone tube was removed and the median nerve was reconstructed with a cable graft of sural nerve pulled through the pseudo-sheath surrounding the silicone tube (Fig. 6). At the same time the superficial flexor tendons of the ring and little fingers were transferred for reanimation of index finger flexion and thumb anteposition (Fig. 7).

Fig. 6 - Silicone tube removed and nerve continuity restored with cable-nerve graft pulled into pseudo-sheath. Fig. 7 - Opposition restored by means of tendon transfers. Fig. 8 - Late result with good sensitive recovery and good functional results.

The patient is now doing well. The elbow has a satisfactory range of motion, and the biceps muscle has good strength! The median territory has satisfactory sensibility with a standing two-point discrimination of 10-12 mm and a moving two-point discrimination of 8 turn.

Various types of flaps are available for resurfacing the elbow region. Among these the adipofascial turn-over flap of the brachial fascia can be a good solution for reconstruction of severe lesions of the elbow and proximal forearm soft tissues, especially when the main vascular axis is impaired.
Pedicled flaps involve prolonged immobilization, while free flaps often require longer operating times and suitable recipient vessels.
The u1nar fasciocutaneous flap is very reliable and its pivot point is in a favourable position. However, a major blood vessel of the forearm has to be sacrificed, and it is thus imperative that Allen's test be performed before the flap is raised.
A similar disadvantage is presented by the posterior interosseous flap, which is also tedious to dissect. Moreover, the interosseous nerve sometimes crosses the pedicle, thus shortening the pedicle length available.
The adipofascial tum-over flap is raised on the volar aspect of the arm by means of an H-shaped incision and includes the brachial fascia and some subcutaneous fat. Vascularization occurs through perforators of the rete cubiti and the distal fascia of the biceps muscle. Its maximum length of 20 cm allows it to reach the proximal forearm anteriorly and the olecranon posteriorly.
Thanks to its pattern of vascularization, this flap can be elevated even when the forearm and hand are perfused through a compensatory circulation.
By grading the thickness of the subcutaneous layer, defects of different depth can be appropriately filled. The fat paddings also represent a suitable bed for nerve reconstruction, even if grafts are required.
A further advantage is the good appearance of the donor site, with maintenance of the arm contour.

RESUME. Les lésions graves du coude qui intéressent les nerfs sont très communs, et diverses techniques ont été proposées pour la couverture de cette région anatomique: les lambeaux pédiculés à distance, les lambeaux musculaires et musculocutanés, les lambeaux fasciocutanés et les lambeaux libres. Les indications pour toutes ces techniques sont encore controversées. Récemment certains Auteurs ont décrit les lambeaux adipofasciaux retournés (tum-over), qui peuvent être levés sans sacrifier le derme surjacent et façonnés dans l'épaisseur pour remplir des défauts de différent degré. Il faut délinéer le lambeau sur l'aspect fléchisseur du bras et exposer la couche sous-cutanée à travers une incision à forme de H. Ensuite il faut passer à la dissection de la peau au niveau dermal, et le niveau sous-cutané, avec le faisceau profond, est élevé dans la mesure désirée. Il faut laisser un pédicule intact de 2 cm proximalement au défaut et retourner le lambeau, afin de le remplir. Les Auteurs présentent deux cas traités avec cette technique.