Early One Stage Functional Reconstruction of a Mangled Upper Extremity

Abstract

Background

A crush injury to the upper extremity with a MESS (Mangled Extremity Severity Score) more than or equal to 10 carries a poor salvage prognosis and functional outcome. Usually performing multiple staged surgeries in these patients make the follow up and rehabilitation regimen long and complicated. This means either the patient doesent return or fails to gain any function. In order to overcome this problem we have done a single stage functional reconstruction in a mangled upper extremity.

Case

A young female presented with a crush injuiry of the upper limb where a functional reconstruction with an LD (Latissimus Dorsi) flap was done 48 hrs after limb salvage surgery. The flap provided cover to the shoulder and elbow joint and also acted as a motor for elbow flexion.

Result

After 6 months following surgery, the patient had regained active motion in her elbow and shoulder joint, and at 1 year she was able to carry out activities of daily living without any external help.

Conclusion

Our case demonstrates that the mangled upper extremity can have varied presentations but the surgeon should use every knowledge and technique at their disposal to achieve the maximum chance of autologous functional reconstruction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00700-w.

Background

The mangled upper extremity is a devastating injury with long-term sequelae. Although salvage of this vital part is possible by early vascular repair, functional restoration is of utmost importance. Contrary to the lower extremity, partial amputation with a prosthesis cannot give adequate function. This means that even a salvaged upper limb can end up going for a delayed amputation because of loss of function [1].

Case presentation

A 19-year-old female patient of average built (wt 50–55 kg) presented to the Emergency Department (ED) 9 h after a road traffic accident with a crush injury to the left arm. She was hemodynamically unstable. On evaluating the injured arm, we found that the shoulder joint was open with head of the humerus away from the glenoid cavity (Fig. 1a, b). The fingers were cold, showing poor capillary refill, and Spo2 was 40–45% intermittently with the poor waveform on the injured side. No movement was present in the upper limb. There was no fracture in the humerus. Distal end of radius was found fractured with no fractures in the hand. Because of the high impact of the trauma leading to a limb with threatened vascularity, the MESS score was 10. The ABG showed a base deficit of -8 and increased lactate with SaO2 of 92% (Table 1).

Fig. 1.

a Extent of soft-tissue defect. b Patient in supine position with forearm pronated

Table 1.

Lab reports at time of admission to emergency department

Complete blood count
Hemoglobin	8.2 Gm/dl
Total WBC	5980
WBC differential	Polymorphs 60% Lymphocyte 31% Eosinophil 6% Monocytes 3%
Platelet count	102,000 /mm3
Kidney function test
Blood urea nitrogen	35 Mg/dl
Serum creatinine	0.9 Mg/dl
Serum sodium	138 Meq/L
Serum potassium	4 Meq/L
Serum calcium	9.3 Mg/dl
Arterial blood gas measured
pH	7.31
PaCo2	35 mm Hg
Lactate	3.5 Mmol/L
Calculated
HCO3	17 Mmol/L
Base deficit	− 8.1

After resuscitation, patient was shifted for surgery. First debridement of the necrosed biceps and coracobrachialis was performed so that only the distal ends remained. Partial debridement of the deltoid muscle was also done. Cut ends of the median nerve were tagged. The ulnar nerve was found intact. Revascularization of the limb was done using a 7 cm long reversed saphenous vein graft sutured to the brachial artery. The vein graft was buried under the remanent stump of biceps muscle. Further reconstruction was postponed for 48 h till the limb’s viability could be confirmed. Until then, the exposed humerus was covered with paraffin gauze. Patient was also started on antibiotics as the wound was grossly contaminated. In such cases, we prefer a combination of amoxycillinw + clavulanic acid with amikacin and metronidazole. In the next surgery, done 48 h later, we tackled the defects serially.

First, the left shoulder was reconstructed with primary repair of the capsule (Fig. 2). The torn supraspinatus was attached to the superior part of the capsule by barbed suture and remaining fibers used to reinforce the repair.

Fig. 2.

Capsule repair

Sural nerve cabled grafts were used to bridge the 8 cm defect in the median nerve. Epineural stitches with fibrin glue were used for neurorrhaphy (Fig. 3).

Fig. 3.

LD flap with nerve repair

Next came elbow flexion restoration. This was done using latissimus dorsi (LD) musculocutaneous flap. LD muscle was harvested with a skin paddle of 14 × 8 cm oriented obliquely across the back. This design offers the advantage of reorienting the oblique fibers running to the humerus in a vertical direction (Fig. 3). The reorientation occurs as the muscle belly swings medially and inserts at the elbow. Another advantage of this orientation was that it provided support to the anterior aspect of the shoulder joint as the subscapularis cover from the anterior aspect of the joint was lost. The insertion at the humerus was not detached, making it a unipolar transfer. The new insertion was created with the LD under maximal tension and sutured into the insertion of brachialis at the ulnar tuberosity, with the elbow joint in 90° flexion. The skin paddle of the LD was utilized to cover the nerve repair and a few proximal fibers of the muscle to reinforce the shoulder repair and cover the sutures applied at the supraspinatus insertion. The split-thickness skin graft was applied to the proximal portion of the muscle. The loss of tissue over volar aspect of forearm was managed by split-thickness skin graft as the extensor muscles were intact (Fig. 4). After surgery, a back slab was applied to keep flexion of 90° at the elbow joint and the wrist in a neutral position, to immobilize the fractured distal radius.

Fig. 4.

Final appearance after reconstruction

After 4 weeks of immobilization, patient was started on regime of passive abduction of the shoulder joint, flexion at elbow and fingers. The neuropraxia of the ulnar nerve gradually recovered by 3 months post-op. At 6 months post-op, the patient achieved 20–30° of active shoulder abduction and elbow flexion. By 1 year, patient had achieved M4 power in elbow flexion, and 90° range in active shoulder abduction (Video taken with patient consent).

Discussion

In this patient, the MESS score was 10, which is usually an indicator of poor salvage [2]. Delay in revascularization more than 6 h has a high chance of reperfusion injury and compartment syndrome. A second look surgery is thus advocated [3]. The cold ischemia time in our case was 9 h. Hence, the prime concern was to monitor for reperfusion injury before embarking on any further reconstruction. Once limb viability is ensured, functional reconstruction has to be attempted. There was a huge soft-tissue defect of the upper arm with traumatic dislocation of the shoulder in our patient. The loss of elbow flexion was a major disability that was tackled with the other injuries. Published literature suggests ensuring the stability and function of one joint before managing the next one [4]. But as the patient was in extreme pain due to multiple injuries, we decided to perform an early surgery and manage all defects in the same setting. Coverage of the soft-tissue defect, the repaired median nerve, and elbow flexion restoration was done by pedicled LD flap. This robust flap is sometimes used as an elbow flexor in brachial plexus injury with results of up to M4 grade power and 100° range of motion [5]. Its use in acute trauma reconstruction is, however, rarely reported.

Conclusion

The established approach when managing extensive degloving injuries is to proceed in multiple steps with the goal of providing a functional limb. But as the there is a diverse nature of upper extremity injuries, no two cases are alike so there is no single preferred approach. The importance of this technique is to demonstrate that the reconstructive surgeon should always endeavor to provide a functional limb to the patient promptly so that the rehabilitation can be more effective as compared to multiple staged approach of reconstruction.

Supplementary Information

Below is the link to the electronic supplementary material.

Declarations

Conflict of interest

Dr Debarati Chattopadhyay has no conflict of interest, Dr Akshay Kapoor has no conflict of interest, Dr Praveen A Jayaprakash has no conflict of interest, Dr Tarun Goyal has no conflict of interest

Source(s) of Support

None.

Presentation at a Meeting

None.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient.