AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

AAHS Poster Presentations
Upper Extremity Reconstruction with Radial Forearm Fascia Flaps
Institution where the work was prepared: University of Washington, Seattle, WA, USA
Jeffrey B. Friedrich, MD; Nicholas B. Vedder, MD; University of Washington
Introduction:
The radial forearm flap has been an important development in upper extremity reconstruction. However, it is also known that the donor defect can be a source
of significant morbidity. One method of donor management that has been put forth is use of a radial forearm fascia-only flap, leaving the donor site skin
intact, with application of a split skin graft to cover the flap itself. We report our experience with the use of the radial forearm fascia flap for upper extremity
reconstruction.
Methods:
A review of patients who underwent upper extremity reconstruction with a radial forearm flap was conducted. Records were analyzed for type of reconstruction
(fascia + skin graft versus fasciocutaneous), reconstruction complications, and donor site complications.
Results:
Fourteen patients underwent radial forearm flap reconstruction from 1997 to 2005. Seven were fascia-only, seven fasciocutaneous. In all cases of fascia-only
reconstruction, the flap contour was judged to be excellent, whereas some of the fasciocutaneous reconstructions were found to be bulky, requiring secondary
reduction. Additionally, the donor sites in the fascia-only group were judged to be of superior aesthetic quality. In the fascia group, there were no donor
site complications, however, there was 1 partial skin graft loss on a flap, and 4 partial flap necroses. In the fasciocutaneous group, there were 2 episodes of
skin graft loss on the donor site, and no full or partial flap losses.
Conclusions:
While upper extremity reconstruction with a radial forearm fascia flap has the potential for donor improvement and improved contour of the flap compared
with fasciocutaneous reconstructions, the flap itself can be more tenuous in the fascia-only reconstructions.
Post-Traumatic Ulnar Artery Pseudoaneurysms: A Report of Two Cases and Associated Complications
Institution where the work was prepared: Albert Einstein Medical Center, Philadelphia, PA, USA
Sue Y. Lee, MD1; Laurie Hirsh, MD1; James Raphael1; Minn Saing1; Rashad Choudry, MD2; Michael Salvatore, BS2; (1)Albert Einstein Medical Center, (2)Temple University
Hospital
Introduction:
Arterial pseudoaneurysm following upper extremity penetrating injury is a rare complication that is likely under-reported in the surgical literature. Ulnar artery
pseudoaneurysms may present a serious threat to digit perfusion and hand function. Potential risks include pain, arterial disruption, symptomatic expansion,
and ulnar nerve dysfunction. The close proximity of the ulnar nerve places it in jeopardy and the resulting neuropraxia is often the presenting complaint.
Variations in arterial anatomy alter clinical presentations and ultimately may impact management. These lesions are often deceptively innocent at presentation,
but may have profound sequelae. To date, management is poorly defined in the literature. We recommend prompt surgical management to avoid devastating
complications.
Cases:
We reviewed two cases of ulnar artery pseudoaneurysm as a result of penetrating injuries to the upper extremity. The first patient suffered impalement of glass
following a close proximity explosion. Development of a claw deformity secondary to intrinsic paralysis, increasing pain, and swelling prompted evaluation. A
MR angiogram and duplex ultrasound confirmed the diagnosis and a patent palmar arch. The second patient sustained multiple gunshot wounds, including
one to the right forearm. His injuries included a scapular fracture and diffuse brachial plexus injury, with dense anesthesia in the ulnar nerve distribution and
no ulnar motor function. Evaluation confirmed complete arches distally with good perfusion. Spontaneous rupture occurred in the office during a routine follow-up
examination.
Both patients underwent surgical exploration and resection of their respective lesions. At surgery, both ulnar nerves were explored and found to be intact. In
the first case, resection of a large (6 cm) pseudoaneurysm was electively scheduled. The second patient required emergency resection of the ulnar artery
pseudoaneurysm to prevent life-threatening arterial hemorrhage. Pre-operative clinical and radiographic evaluation proved useful in delineating the forearm
anatomy and confirming the diagnosis. Both patients continue to have significant ulnar nerve dysfunction at latest follow up.
Discussion:
The natural history of upper extremity pseudoaneurysms remains unpredictable. They should be carefully evaluated clinically prior to surgical treatment. A number
of available imaging techniques can assist in pre-operative localization and diagnosis. Due to the close proximity of the ulnar nerve and potential for lifethreatening
hemorrhage, we support operative treatment in all cases. Repair or ligation should be performed in all patients to minimize the risks of compressive
nerve injury, subsequent hand deformity and dysfunction, and spontaneous rupture.
(Arteriograms, duplex ultrasound, and intraoperative images available and to be included.)
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