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A 19-year-old cable fitter sustained a Gustilo IIIB fracture of the left tibia and fibula as a result of a road traffic accident. He sustained a penetrating injury from medial to lateral, leaving lower third tibial and fibular fractures (Fig. 1, Fig. 2) and soft tissue defects on either side of the ankle. The posterior tibial neurovascular bundle was exposed.
The wounds were debrided on two occasions and the tibia was nailed and the fibula plated. This left two soft tissue defects; medially measuring 10×5 cm and laterally 5×5 cm, with bone and metal exposed on either side.
Seventy-two hours post injury the patient was transferred to the regional plastic surgery unit. Wound closure was then undertaken. The patient was tall and thin with a reasonable pre-existing retro-tibial tunnel. It was therefore elected to raise a single, distally based fasciocutaneous flap on the remaining perforator approximately 1 cm proximal to the medial wound. Following elevation, the perforator was islanded to allow the flap to rotate through 180° so that the base covered the medial wound. The central portion of the flap was then de-epithelialised creating a second, distal, island (Fig. 3) and this portion tunneled posteriorly, between the fracture and the Achilles tendon, allowing the distal end of the flap to cover the lateral wound. The flap was inset into both defects (Fig. 4, Fig. 5) and the donor-site was covered with a split skin graft.
Fig. 3Medial fasciocutaneous flap raised and central portion de-epithelialised.
Potential options for distal wound cover in the lower leg can be broadly divided into the use of local flaps or free tissue transfer. Available local flap options include muscle, myocutaneous and fasciocutaneous flaps.
In the lower third of the leg the fasciocutaneous flap is a good choice with respect to both the quantity of tissue available and the ability to reach a distal defect without tension. An islanded flap allows a greater arc of rotation. While there is good evidence to support the distally based, islanded fasciocutaneous flap as a safe option for wound cover in this region,
the problem of covering two separate holes remains unsolved.
2.1 Procedure
This type of flap design offers a useful solution for several reasons. A local flap provides a simple and reliable method of wound cover. By using a single flap to cover both defects the resulting donor site morbidity was kept to a minimum. The de-epithelialised central portion of the flap which was tunneled between the two wounds provided a broad but thin pedicle suitable for passing through such a space.
Postoperatively the patient made an uneventful recovery and was discharged on the sixth post operative day. Both portions of the flap have healed completely as has the grafted area (Fig. 6, Fig. 7) . There is evidence of callus formation at the fracture sites and the patient is fully weight bearing.
Fig. 6Medial view left leg showing healed split skin graft and flap.
The distally based islanded fasciocutaneous flap is a well described and commonly used procedure in modern plastic surgical management of lower limb trauma which can usefully be adapted to cover two defects.
References
Wu W.C.
Chang Y.P.
So Y.C.
Yip S.F.
Lam Y.L.
The anatomic basis and clinical application of flaps based on the posterior tibial vessels.
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