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Brachioradialis Flap for Soft Tissue Coverage of Posterior Elbow Wounds

Case Report and Surgical Technique

Sabbag, Orlando D., MD; DeDeugd, Casey M., MD; Wagner, Eric R., MD; Elhassan, Bassem T., MD

Techniques in Hand & Upper Extremity Surgery: March 2019 - Volume 23 - Issue 1 - p 2–5
doi: 10.1097/BTH.0000000000000209
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The posterior aspect of the elbow is an area prone to chronic wound complications due to its prominence and the tensile forces resulting from elbow range of motion. In situations in which local wound care fails, various options for soft tissue coverage are available, including the anconeus, lateral arm, radial forearm, extensor carpi radialis longus, and flexor carpi ulnaris flaps. Each option offers unique considerations depending on the complexity and extent of the soft tissue defect. In situations in which coverage of a large defect is required, or when primary soft tissue coverage options fail, an alternative option is the brachioradialis rotational muscle flap. We present a review of the literature, case report, and surgical technique using the brachioradialis muscle for coverage of a large posterior elbow wound after failure of an anconeus flap.

Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN

Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding.

Address correspondence and reprint requests to Bassem T. Elhassan, MD, Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail: elhassan.bassem@mayo.edu.

Because of the bony prominences, superficial location, and the tensile forces during elbow joint motion, the posterior aspect of the elbow is at an increased risk for wound complications.1 In the setting of revision surgery, trauma, or infectious/inflammatory olecranon bursitis or arthritis, soft tissue coverage may be required for resulting soft tissue defects. Different coverage options exist, each with advantages and disadvantages depending on the complexity and extent of the soft tissue defect.

Primary local reconstructive options include the local pedicled anconeus flap (LPAF) and the retrograde or antegrade lateral arm flap. In certain circumstances, the size of the defect or extent of soft tissue damage can limit the availability of these flap options. We describe the brachioradialis (BR) rotational flap, an alternative option for soft tissue coverage of the posterior elbow that can be used primarily or when other options fail.

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CASE DESCRIPTION

A 72-year-old right-hand dominant woman with advanced rheumatoid arthritis initially presented to our institution with a chronically draining right elbow wound resulting from septic olecranon bursitis in the setting of chronic immunosuppression. She had failed prior attempts at nonoperative treatment with local wound care, intravenous and oral antibiotics, and a 6-week period of immobilization. Examination revealed 2 areas of purulent drainage around the olecranon bursa posterolaterally. Cultures from wound swabs grew methicillin-sensitive Staphylococcus aureus. Radiographs were negative for signs of osteomyelitis. The patient underwent surgical exploration, which revealed a deep sinus tract down through the skin and subcutaneous tissues and extensive scarring throughout the area of the olecranon bursa. After thorough irrigation and debridement of devitalized tissues, the patient was left with ∼3 cm×4 cm soft tissue defect in the midline of the posterior elbow along the olecranon with exposed bone requiring coverage (Fig. 1). The bed surrounding the defect was healthy with clean bleeding tissues. An anconeus muscle flap was utilized for coverage given its relative proximity to the area of dissection. Postoperatively, the patient completed a 3-week course of broad-spectrum intravenous vancomycin.

FIGURE 1

FIGURE 1

At 2 weeks postoperatively, the patient developed a small area of wound dehiscence and persistent serosanguinous drainage. She failed conservative treatments with MIST therapy (Celleration Inc., Eden Prairie, MN) and oral antibiotics. She required 2 returns to the operating room for additional debridements, sinus track reexcision, and primary closure. The wound cultures from the second irrigation and debridement were positive for group G Streptococcus.

Because of a persistent, chronic draining wound on the posterior olecranon (Fig. 2) and infection with a newly identified organism, a more extensive surgical debridement was performed. Intraoperatively, a deep sinus tract was observed and resected. The anconeus flap was found to be devitalized secondary to the infection and multiple surgical interventions. There was gross purulence or bony involvement of the sinus track. After extensive debridement, a soft tissue defect of ∼8 cm×4 cm remained (Fig. 3A). A BR rotational flap was utilized to cover this defect.

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

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SURGICAL TECHNIQUE

In the supine position, after a thorough irrigation and debridement, the BR is elevated and harvested. A longitudinal incision is utilized in the distal forearm near the tendinous portion of the BR (Fig. 3B). The BR is identified, mobilized from musculotendinous junction to the distal tendon, and released from its insertion on the radial styloid (Fig. 3C). Important dangers to identify and protect include the superficial branch of the radial nerve (Fig. 3D) exiting the BR fascia at ∼9 cm proximal to the radial styloid, and the radial artery, coursing between the BR and the flexor carpi radialis muscle bellies. After detaching the tendon, the muscle is mobilized proximally (Fig. 3E). Proximally, it is possible to identify and protect the intramuscular communicating branches of the radial artery (Fig. 3F).

Once the muscle has been dissected and elevated, the tendon stump is then tagged and an incision is made just distal to the elbow crease along the radial border of the BR (Fig. 3G). The BR flap is then passed below the skin and retrieved from the proximal incision (Figs. 3H–K). The length of the flap is checked before tunnel from anterior to posterior by pulling it over the posterior olecranon wound (Fig. 3L). Blunt dissection is used to create a tunnel between the anterior forearm wound and the posterior elbow wound (Fig. 3M) and the BR flap is pulled through the tunnel subcutaneously from posterior to anterior (Figs. 3N–Q). The flap can then be draped over the olecranon to cover the defect (Fig. 3R), and it is sutured to the surrounding tissue with the use of interrupted 3-0 Vicryl (Ethicon Inc., Somerville, NJ) and 3-0 PDS (Ethicon Inc., Somerville, NJ) (Fig. 3S). In addition, the tendon is tagged with Nylon suture (Ethicon Inc., Somerville, NJ), which is brought percutaneously through the skin and sutured over a piece of felt to maintain the muscle in place until it has healed (Fig. 3T). The tourniquet is then deflated and the wounds are thoroughly irrigated. Depending on the amount of soft tissue resection performed, the skin can often be closed primarily (Fig. 3U). Alternatively, a skin graft can be used to cover the flap. The skin can be closed over a Jackson-Pratt drain, which can be removed on postoperative day 1 or 2 depending on the amount of drainage observed. The donor sites are then closed in a subcuticular manner using 3-0 Monocryl (Ethicon Inc., Somerville, NJ) (Fig. 4). After dressing the wound, a well-padded elbow extension splint is placed to reduce tension over the graft site.

FIGURE 4

FIGURE 4

Postoperatively, the patient is kept in this extension splint for 2 to 3 weeks. Weight-bearing is limited through the operative extremity until the wound is fully healed. Wrist, hand, and finger range of motion is allowed immediately postoperatively. Sutures can be removed 10 to 14 days postoperatively. After a period of 2 to 3 weeks, and once the flap shows signs of healing, the felt is removed and range of motion at the elbow can be slowly introduced.

Our patient demonstrated excellent results with this technique in the revision setting, with full wound healing and recovery of full range of motion at 6 weeks. Moreover, she exhibited no postoperative complications and clinically insignificant functional loss from the BR muscle harvest. At 1-year follow-up, the patient reported very high satisfaction with the results. On clinical evaluation, her skin was completely healed (Fig. 5), her elbow prominence was very well padded, and she had full and painless elbow range of motion from full extension to 135 degrees of flexion.

FIGURE 5

FIGURE 5

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DISCUSSION

Large soft tissue defects of the posterior elbow can be challenging to manage, particularly in the setting of previously failed muscle flaps. In either the primary or revision setting, the surgeon and patient have various options to cover these wounds.

The LPAF is one of the most reliable options for posterior elbow wounds given its anatomic proximity and low donor-site morbidity.2 This flap is ideal for patients with small wound defects, particularly in the primary setting. In a case series by Elhassan and colleagues of 20 patients treated with a LPAF for coverage of small soft tissue defects (average of 4×3 cm), all patients demonstrated successful wound healing by an average of 3 weeks postoperatively. Moreover, all patients reported excellent satisfaction scores and had full elbow range of motion postoperatively with no reported complications.2 Nevertheless, in the revision setting, especially when the posterior approach to the elbow has been utilized, the anconeus blood supply can be compromised, making this option less reliable.3

Two alternative options to the LPAF that are commonly used in the primary and revision setting are the lateral arm flap and radial forearm flap. The lateral arm flap, a septofasciocutaneous flap based on the posterior branch of the radial collateral artery is favored by many surgeons due to its versatility; as the flap can be oriented in an antegrade or retrograde manner to better contour to different soft tissue defects. Yet, despite theoretically avoiding functional defects, some studies have found high rates of donor-site morbidity, including forearm paresthesias and extensive scarring.4,5 The radial forearm flap offers the advantage of an excellent blood supply to the recipient site, which may be valuable in circumstances where the wound has been significantly devascularized due to extensive surgical dissection or injury. However, altering flow dynamics to the donor hand as a result of flap elevation has the potential to result in potential long-term consequences, such as accelerated atherosclerotic changes, decreased grip strength, and altered thermoregulation.6–8

Other flap options with limited donor-site morbidity include the extensor carpi radialis longus (ECRL) and the flexor carpi ulnaris (FCU) flaps. The ECRL flap offers additional advantages due to its ease of elevation and generous rotational arc. However, the ECRL flap often requires more soft tissue dissection and must be separated from its attachment to the extensor carpi radialis brevis. With the FCU flap, the 2 heads of the FCU can be differentially split to limit functional deficits.1 Yet, given the small size of the FCU muscle belly, it is only a reliable option for coverage of small and moderate-sized defects of up to 4 cm in length.3

In circumstances in which coverage of a large soft tissue defect is required, or in the revision setting when other flap options fail, the BR rotational muscle flap is a viable option. The use of the BR rotational muscle flap for coverage of posterior elbow defects has been well characterized by anatomic studies.9 With an average muscle belly length of 17 cm and an average width of ∼4 cm at its widest portion, the BR muscle is ideal for coverage of large wounds. In addition to its size, the BR flap can have a thickness of ∼2.6 cm, providing excellent padding of bony prominences and facilitating gliding with elbow range of motion.10

Furthermore, cadaveric studies have showed that the BR arc of rotation supports excellent coverage of posterior and posterolateral elbow soft tissue defects.9,10 Its long pedicle reduces tensile forces that facilitate radial and ulnar rotation. A potential drawback of the BR flap is that it does not consistently provide enough coverage of large posteromedial defects. However, studies by Leversedge and colleagues have demonstrated that when the muscle belly is completely detached from its origin, the arc of rotation can be increased up to 1.6 cm medially, allowing it to offer better posteromedial coverage.10

Another advantage of this flap is its consistent and robust blood supply. Its major pedicle arises from the radial recurrent artery (RRA) found ∼9 cm proximal to the BR musculotendinous junction. Vascular injection studies have showed that the entire muscle belly of the BR can be elevated when it is harvested with the RRA as well as a 3 cm segment of the radial artery immediately distal to the origin of the RRA.9 This combined vascular pedicle can supply close to 90% of the BR muscle belly as well as its overlying fasciocutaneous tissue distal to the RRA.

Aside from its versatility and excellent blood supply, the BR flap results in minimal donor-site morbidity. In harvesting the flap, no major blood vessels of the upper extremity are sacrificed. In addition, there is minimal functional loss, demonstrated by multiple biomechanical studies that show the muscle acts mainly as a weak forearm flexor and secondary pronator.11,12 Nevertheless, when performing a BR flap, care must be taken to avoid injury to the superficial branch of the radial nerve and the associated paresthesias over the dorsoradial aspect of the forearm and wrist. Moreover, intermuscular branches arising from the radial artery proper are at risk of injury during flap elevation. These branches supply the BR muscle belly distally and could compromise the flap vascularity if injured.

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SUMMARY

The BR flap offers a robust, highly vascular, and cosmetically acceptable alternative for coverage of large posterior elbow soft tissue defects. It is useful as a primary option for large defects, or in the revision setting when other coverage options fail. Its versatility stems from its large muscle belly and resultant ability to cover large soft tissue defects, with a consistent and vigorous blood supply, and a generous rotational arc of motion. Moreover, it has the theoretical advantage of minimal donor-site morbidity and functional deficits resulting from harvesting the flap. We present a case report and surgical technique in which a BR muscle flap was used with great results in a patient with a large complex posterior elbow wound that had failed prior coverage with an anconeus flap. Minimal donor-site morbidity was observed and the patient demonstrated excellent wound healing without complications. Additional studies are needed to further characterize the role of the BR muscle flap compared with the other more common alternatives.

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REFERENCES

1. Patel KM, Higgins JP. Posterior elbow wounds: soft tissue coverage options and techniques. Orthop Clin North Am. 2013;44:409–417.
2. Elhassan B, Karabekmez F, Hsu CC, et al. Outcome of local anconeus flap transfer to cover soft tissue defects over the posterior aspect of the elbow. J Shoulder Elbow Surg. 2011;20:807–812.
3. Bayne CO, Slikker W III, Ma J, et al. Clinical outcomes of the flexor carpi ulnaris turnover flap for posterior elbow soft tissue defects. J Hand Surg Am. 2015;40:2358–2363.
4. Tung TC, Wang KC, Fang CM, et al. Reverse pedicled lateral arm flap for reconstruction of posterior soft-tissue defects of the elbow. Ann Plast Surg. 1997;38:635–641.
5. Hamdi M, Coessens BC. Evaluation of the donor site morbidity after lateral arm flap with skin paddle extending over the elbow joint. Br J Plast Surg. 2000;53:215–219.
6. Gaudino M, Anselmi A, Serricchio M, et al. Late haemodynamic and functional consequences of radial artery removal on the forearm circulation. Int J Cardiol. 2008;129:255–258.
7. Gaudino M, Serricchio M, Tondi P, et al. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg. 2005;130:9–12.
8. Suominen S, Ahovuo J, Asko-Seljavaara S. Donor site morbidity of radial forearm flaps. A clinical and ultrasonographic evaluation. Scand J Plast Reconstr Surg Hand Surg. 1996;30:57–61.
9. Leversedge FJ, Casey PJ, Payne SH, et al. Vascular anatomy of the brachioradialis rotational musculocutaneous flap. J Hand Surg Am. 2001;26:711–721.
10. Rohrich RJ, Ingram AE Jr. Brachioradialis muscle flap: clinical anatomy and use in soft-tissue reconstruction of the elbow. Ann Plast Surg. 1995;35:70–76.
11. Boland MR, Spigelman T, Uhl TL. The function of brachioradialis. J Hand Surg Am. 2008;33:1853–1859.
12. Tirrell TF, Franko OI, Bhola S, et al. Functional consequence of distal brachioradialis tendon release: a biomechanical study. J Hand Surg Am. 2013;38:920–926.
Keywords:

brachioradialis flap; posterior elbow wounds; soft tissue coverage

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