• D Maladry, C Fechant, K Guelmi, V Mitz, and J P Lemerle.
• Service de Chirurgie Réparatrice, SOS MAIN, Hôpital Boucicaut, Paris.
• Ann Chir Plast Esthet. 1994 Jun 1;39(3):362-71.

AbstractLarge open elbow fractures with extensive soft-tissue loss must be treated as an emergency. Vessels and nerves are often alvulsed. One stage reconstruction is very challenging. Ischemia of the distal part of the upper extremity is limited by a synthetic arterial shunt (SAS). After debridement, the authors install the SAS, then the complex procedure can begin. The authors purpose a new four-stage classification and prognostic factors. Debridement concerns crushed, devitalised soft and osteo-articular tissues. If it appears possible to salvage the hand and forearm with necessity of complex reconstructions (vessels, nerves, osteosynthesis, soft tissues) SAS is used. SAS was used 3 times on the group of large avulsions with ischemia (5 cases); it was quickly installed between the humeral and a distal artery and allowed section of the best distal artery for revascularisation. Seven external fixation devices allowed intra operative and post operative management of the wound. The coverage of these large, complex wounds was performed by the latissimus dorsi transposition flap (2 muscular and 5 musculo-cutaneous flaps). It should be considered the flap of choice. Local flaps, which include local skin transposition, muscle transposition or vascular axis, would be contra indicated in a wide zone of injury (the base of these local flaps are damaged by high energy trauma) or when distal ischemia is present because of arterial axis sacrifice. The dorsal decubitus position, the specific dissection of neurovascular pedicle proximally as far as the axillary artery, the muscular and cutaneous design can be used to cover anterior, posterior, internal and external parts of the elbow. Restoration of elbow function uses an innervated latissimus dorsi muscle (3 cases). If only coverage is wanted, this flap has significant advantages over local flaps and free transfer procedures when the recipient vessels are within the area of injury. Between the donor site and the recipient site, the muscular part of the latissimus dorsi flap is placed in an arm counterincision. It ensures closure of the elbow joint. Early progressive range of movement exercises can be performed.

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