Secondary Logo

Share this article on:

Free Flap Transfer with Arteriovenous Loop Establishment for Upper Limb Salvage in a Crush Injury

Radwan, Mohammad S., MD*; Barakat, Ammar Z., MD; Jaber, Mohammad M., MD; Mashal, Ashraf A., MD§

Plastic and Reconstructive Surgery – Global Open: November 2018 - Volume 6 - Issue 11 - p e1913
doi: 10.1097/GOX.0000000000001913
Case Report

Summary: Constructing arteriovenous (AV) loops saves a crushed limb when healthy recipient vessels are unavailable at the site of injury by supporting a transferred free flap. Literature about using AV loops in the upper limb defect is scarce. We present a case with a devastating upper limb crush injury that was successfully managed with fibula flap transfer preceded by AV loop construction. A 38-year-old woman was admitted to our hospital with severe crushing trauma to her right forearm and hand. There was significant skin loss with injuries to blood vessels and tendons. She underwent multiple staged operations beginning with repair of the ulnar artery, debridement of necrotic tissue, and placement of 2 K-wires to stabilize the bones. Thereafter, a long saphenous AV loop was constructed between the brachial artery and the basilic vein. Finally, transfer of the fibula flap to the forearm. We used the staged procedure to provide adequate time for the AV loop maturation and adaptation. At around the patient’s 7-month follow-up visit, her forearm and hand were stable, no complications related to the AV loop or the transferred fibula flap were noted. Utilizing AV loops to support transferred free flaps upper limb defects showed a promising successful outcome.

From the *Bethlehem Arab Society for Rehabilitation Hospital, Bethlehem, State of Palestine

An-Najah National University, Nablus, State of Palestine

An-Najah National University Hospital Orthopedic Surgery Department, Nablus, Palestine

§Bethlehem Arab Society for Rehabilitation Hospital, Head of Plastic and Reconstructive Surgery Department Bethlehem, Palestine.

Published online 28 November 2018.

Received for publication November 22, 2017; accepted July 11, 2018.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Ashraf Ahmad Mesh’al, MD, Cremizan Street, Beit Jala, Bethlehem, Palestine, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Large upper limb tissue defects caused by crush trauma continuously challenge reconstructive surgeons. Limb salvage requires complex reconstructive strategies to keep the possible residual limb function and cosmetic outcome. A possible approach is combined vascular reconstruction and free flap transfer.1 Lower extremity injuries repaired this way are discussed in the literature. However, scarce data discuss similar upper extremity injuries. (see figure, Supplemental Digital Content 1, which displays the right distal forearm and dorsal hand devastating crush injury resulting in a large defect, exposing the tendons, nerves and vessels,

Often, in the defect vicinity, local tissues are insufficient to achieve effective and adequate coverage. Moreover, the peripheral vasculature may be nonreconstructable and unsuitable to support transferred tissue, which limits the therapeutic options.2 This can be overcome by constructing an AV loop between a recipient and distant healthy vessels.

AV loop construction and free tissue transfer can be performed as a single operation, applied in 1 setting, or in staged procedure. These 2 approaches were compared in several studies; each option carries different outcomes, rates of complications, and morbidities.3 Single operation has better physical and psychological effects, allows operating through clear field, decreases scarring rate, results in better bone union and stability, and reduces healing time, with less infection and a shorter hospital stay.4 However, 2 manageable operations would be safer, especially in high risk patients with more complicated injuries; also it provides more reliable loop and lowers failure risk by distending the vessel at the physiologic pressure.5 , 6 A recent meta-analysis concluded to individualize the decision according to comorbidities, defect etiology, size, and type of free flap to be transferred.7

Here, we present our experience at Bethlehem Arab Society for Rehabilitation Hospital with devastating right upper limb crush injury. Successful microvascular free flap transfer with a preliminary AV loop creation rescued the limb.

Back to Top | Article Outline


A 38-year-old Palestinian woman, who was previously healthy, was referred to Bethlehem Arab Society for Rehabilitation Hospital with severe crush injury to her right upper limb after it was trapped into a wheat processing machine.

She had around 15 cm defect extending from the distal third of her right forearm to the proximal half of the hand over the dorsal surface, displaced Gustilo grade IIIC forearm bones fracture with loss of soft tissue and distal radius. Right forearm x-ray showed fractures in distal right forearm, carpal, and metacarpal bones.

She underwent debridement of the necrotic tissue, ulnar artery repair, and bone stabilization by inserting 2 Kirschner wires (K-wires) between the hand and forearm.

At postoperative day 10, she underwent fibula flap transfer to the right forearm. However, the flap did not survive and was removed 3 days later. At postoperative day 16, split-thickness skin graft was utilized to close the defect.

Loosening of the K-wires with time resulted hand instability.The orthopedic team was consulted; their opinion was to replace the lost right radius with the right ulna. However, the ulna was too brittle and fractures easily with minor manipulation, so this option was canceled. An AV loop was constructed between the brachial artery and the basilic vein using the long saphenous vein. Loop viability and patency were monitored by regular physical examinations and Doppler ultrasound.

Around 4 months later, she underwent microsurgical flap transfer of the second fibula to the right forearm.

Back to Top | Article Outline


The sequelae of complex crush injuries may extend beyond the obviously involved skin margins and render blood vessels nonreconstructable. These vessels must be repaired or bypassed to ensure dependable blood flow to support tissue viability. Features suggesting diseased vessels include loss of dissection plane between vascular sheath and vessels, loss of vasa vasorum and vasospasm tendency8 (see figure, Supplemental Digital Content 2, which displays the 3D image of the constructed long saphenous loop in the right forearm,; see figure, Supplemental Digital Content 3, which displays the patient’s right upper limb after transfer of the fibula free flap,

Significant psychological consequences follow limb amputation. Prosthesis may be uncomfortable, heavy, have unstable attachments, and lack sensation or sufficient power.8 However, free flap transfer may help avoid these issues. Free flap selection depends on size, depth and mechanism of injury, exposed structures, and surrounding tissues.9 The fibula graft with its long vascularized soft-tissue envelope and diaphysis dimensions close to the radius or ulna is considered suitable for reconstructing forearm defects.10

In our first transfer attempt, we tried to transfer a fibula flap with end-to-end anastomosis between the remaining proximal radial artery and the fibula pedicle. However, the proximal part of the radial artery was avulsed by the injury, blood flow to the flap was weak, and thrombosis occluded the vessel; hence the flap did not survive.

Because of the structural complexity of the upper extremity and because we lost one fibula, we could not risk losing the other one, so we preferred the staged procedure.

We utilized the long saphenous vein to construct an AV loop, which was anastomosed end-to-side with the brachial artery and end-to-end with the basilic vein. This loop was long enough to prevent any tension during upper limb movement. The loop was connected to the flap pedicle through end-to-end anastomosis.

Complications, failure, or revision were reported in 1–28% of cases. The chance depends on etiology, defect location, and the patient’s vascular status.6

Our patient was followed up with subjective, objective, and radiographic assessment. At around 7-month follow-up visit, her upper limb was stable; no complications had occurred. Full range of extension-flexion movements at the elbow can be performed. However, no supination can be performed. Very limited active hand movements can be executed except for 30° flexion of the thumb metacarpophalangeal joint. Passive range of metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints extensions is very limited ranging from 0° in some to 30° in others. Further operations to reconstruct her extensor tendons and carpal bones, and to debulk the fibula, and physiotherapy sessions would improve her hand function. (See Supplemental Digital Content 3, which displays the patient’s right upper limb after transfer of the fibula free flap.)

Back to Top | Article Outline


With appropriate planning, AV loop construction and free flap transfer can salvage the upper limb in severe crush injury with prominent tissue defect and bone loss (see video, Supplemental Digital Content 4, which displays our patient’s right forearm post fibula transfer, moving her fingers, doing flexion-extension at the elbow,

Back to Top | Article Outline


Our case had devastating right upper limb crush injury and extensive tissue loss that could have been amputated, but it was salvaged with staged operations; an AV loop was constructed, followed by free fibula flap transfer. The patient’s hand has been salvaged with stable skeletal structure and skin coverage. Restoration of active motion and flap debulking will be necessary to achieve an acceptable functional and cosmetic outcome.

Back to Top | Article Outline


1. Meyer A, Goller K, Horch RE, et al. Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia. J Vasc Surg. 2015;61:1239–1248.
2. Lin C-H, Mardini S, Lin Y-T, et al. Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts. J Trauma Acute Care Surg. 2004;56:1107–1117.
3. Lind B, McCarthy W, Derman G, et al. Arteriovenous loop grafts for free tissue transfer. Vasc Endovascular Surg. 2012;46:30–33.
4. Dabb RW, Davis RM. Latissimus dorsi free flaps in the elderly: an alternative to below-knee amputation. Plast Reconstr Surg. 1984;73:633–640.
5. Atiyeh BS, Sfeir RE, Hussein MM, et al. Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot. Plast Reconstr Surg. 1995;95:1062–1069.
6. Singh B, Cordeiro PG, Santamaria E, et al. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg. 1999;103:403–411.
7. Knackstedt R, Aliotta R, Gatherwright J, et al. Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: a meta-analysis of the literature. Microsurgery. 2017;38:706–717.
8. Acland RD. Refinements in lower extremity free flap surgery. Clin Plast Surg. 1990;17:733–744.
9. Wang D, Levin LS. Composite tissue transfer in upper extremity trauma. Injury. 2008;39:S90–S96.
10. Jupiter JB, Gerhard HJ, Guerrero J, et al. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am. 1997;79:542–550.

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.