Salvage of a Short Below-Elbow Amputation with Pedicle Flap Coverage
JAMES H. HERNDON, M.D., MAJ., MC ALCIDE M LaNOUE, M.D., LT.C, MC
In the healthy young amputee, the primary objective of the treating physician is to achieve a well-shaped stump covered with normal skin. It should be painless and function well, without skin breakdown 6 , in a prosthesis.
Salvage of a short-below-knee amputation stump covered by adherent scar by means of a cross-leg pedicle flap has been well described 1,5 . In upper-limb amputations adherent scars are not as troublesome as in the lower. Occasionally, however, the amputee may not be able to wear his prosthesis because of continued skin breakdown or insufficient skin coverage. A full-thickness pedicle flap may be transferred directly from the trunk without difficulty thus avoiding any unnecessary shortening of the amputation stump.
At Valley Forge General Hospital recently we treated successfully a very-short-below-elbow amputee with inadequate skin coverage by means of a pedicle flap. The short stump with excellent elbow function was preserved.
E.B., a 20-year-old male, was injured by a grenade explosion in Vietnam on Mar. 4, 1971, sustaining multiple fragment wounds and a traumatic left below-elbow amputation. He was initially treated by debridement of all wounds. He arrived at Valley Forge General Hospital about two weeks after injury with healing wounds and a 234 in. left below-elbow open amputation with the distal radius exposed ( Figs. 1-A and 1-B ).
The stump was clean and the patient was placed in skin traction. Skin coverage anteriorly and distally was deficient and skin traction achieved very little. Elbow motion was good and the patient used a plaster practice prosthesis quite well ( Fig. 2 ). Every effort was made, therefore, to preserve the short stump. On Apr. 5, 1971, skin flaps were undermined to allow them to be pulled distally with skin traction, but it was easily seen that insufficient skin was present and that stump coverage would not be obtained by skin traction. On Apr. 22. 1971, a split-thickness skin graft was applied to the slump. It healed uneventfully.
The patient continued to use his practice prosthesis but had pain over the distal end of the stump where the skin graft was adherent to bone. This area often ulcerated despite attempts to protect the area by relieving the prosthesis.
On July 16, 1971, an abdominal pedicle flap was applied directly to the stump after the skin grafts, scar tissue and bony prominences had been removed. The flap was divided and inset four weeks later. Upon the completion of healing the patient was fitted with a conventional Munster prosthesis. He was also accepted for the Veterans Administration field study of externally powered components and was fitted with a switch-controlled, battery-powered prosthesis, with a supracondylar modification of the Munster-type suspension ( Fig. 3 ). He used both prostheses well, but preferred the standard Minister and terminal device over the battery-powered prosthesis because of the extra weight of the latter. With his very short stump it was difficult and tiring for him to use a relatively heavy prosthesis. The flap has remained intact ( Fig. 4 and Fig. 5 ). The stump has continued to function well, with a good range of elbow motion. Follow-up of the case has extended over a period of one year.
In any amputation every effort must be made to preserve all possible length. In the healthy young amputee aggressive surgical plastic repair has been very successfully utilized in the lower limb 1,5,6 . Similar procedures have rarely been reported in upper-limb amputations 3 . Forces applied across soft tissue are greater in the lower limbs because of weight-bearing, but in specific cases of upper-limb amputations we believe that plastic and surgical procedures should be equally as aggressive to maintain length and preserve the elbow joint. Preservation of stump length and normal function with a prosthesis in contact with healthy soft tissue are of prime importance.
In the case described the stump measured only 2 1/2 in. The elbow was normal and the patient used a practice prosthesis quite well. He had been in such a prosthesis since his arrival at Valley Forge General Hospital where temporary plaster prostheses are used for both upper- and lower-limb amputations 3,4 . A split-thickness graft was not sufficient to keep this patient functioning in his prosthesis. No difficulties have been encountered since pedicle-flap coverage was carried out and the patient continues to wear his prosthesis daily without skin problems. Also, the elbow was preserved which is analogous to preservation of the knee in the lower-limb amputee ( Fig. 6 ).
With increasing numbers of traumatic amputations seen in young civilians, we think that cases similar to the one presented may be seen in the future. With good soft tissue and preservation of length, the young amputee can be fitted with a prosthesis of simple design without excessive harnessing and suspension. This should result in a higher acceptance of the prosthesis by the patient.
A 2 1/2-in. below-elbow stump with inadequate soft-tissue coverage was preserved with pedicle tissue. Follow-up has extended over one year and the patient is a successful wearer and user of a modified Minister prosthesis. His pedicle flap has remained intact.
1. Ascott, J. R., Skin transfer to amputation stumps. Brit. J Plastic Surg., 6:115-122, 1950.
2. Burgess, E. M., and R. L. Romano, The management of lower extremity amputees using immediate post-surgical prostheses. Clin. Orthop. and Related Research, 57:137 146,1968.
3. Dupertius, S. M., and J. A. Henderson, Amputation rehabilitation; Plastic and reconstructive surgery of amputation stumps. U. S. Naval Med. Bull. (Suppl.), 46:65-77, 1946
4. Keblish, P. A., A. M LaNoue, and P. A. Deffer, Early management of the battle-incurred amputee at Valley Forge General Hospital. Presented at the Eastern Orthopedic Association Meeting, Absecon, N.J., 1970.
5. ,Keblish, P. A., A. M. LaNoue, and P. A. Deffer, The use of cross-leg pedicle flaps to salvage the short below knee amputation. Presented at the Eastern Orthopedic Association Meeting, Absecon, N J , 1970
6 Thompson, T. O , and R. H. Alldredge, Amputations: Surgery and plastic repair. J. Bone and Joint Surg., 26:639-644, 1944.