Flap within a flap: The benefit of a musculocutaneous flap over a pure muscle flap

摘要

Open lower limb fractures are a difficult problem and often present with significant bone loss and soft tissue damage, particularly in patients with contaminated crush injuries.1'3 Despite an initial thorough wound debridement, there maybe further soft tissue loss due infection or further compromise of the residual lower limb soft tissue vascu-larity. The recent BAPRAS/BOA National Lower Limb Guidelines re-emphasised the importance of several aspects of lower limb trauma management, including early wound closure.2 Following reconstruction of these defects it is sometimes necessary to undertake secondary wound debridement and closure by import of tissue in the form of a secondary free-flap to cover a new adjacent defect.4 We present a challenging case and a practical method to treat this potentially intractable problem in an area with limited surgical management options, which has already had successful free-flap reconstruction to close the initial soft tissue defect.The case in question was that of a 31-year-old man who sustained an open fracture to his right foot following a crush injury caused by a fork lift truck. The patient was taken to theatre for immediate exploration and debridement and was found to have sustained extensive soft tissue damage with skin loss over his hind foot and over 80% calcaneal bone loss. This was stabilised on the day of injury with external fixation and he returned to theatre on day 3 post-injury for definitive internal calcaneal fixation. On day 4 of admission, the patient underwent further debridement of his right heel, with coverage of the soft tissue defect and exposed bridging metal plate with a free gracilis muscu-locutaneous flap.