This 67 year old male sustained this injury while working with a circular saw. This is his dominat hand and he is hypertensive, retired carpenter and enjoys woodwork as a hobby now. This is an isolated injury with no other injury.

After debridement of the wound this is the image of the residual defect.

Describe the injury and residual defect

How would you go about managing this patient?

Describe you surgical management and the rationale for it?

A reverse radial forearm flap was used to reconstruct the defect. There was a digital nerve (ulnar) defect of 3 cm that was grafted using a PIN graft from the 4th dorsal compartment. This produces no sensory defect and is of ideal size to graft digital nerve as they are of approximately same diameter.

A fascio cutaneous flap was chosen as a pure fascial flap will not solve the contour defect that was present.The defect had composite tissue loss of skin,muscles nerves and vessels.

The donor defect has been resurfaced with SSG from the ulnar surface of the forearm keeping the surgical field local.

Read about radial forearm flap

THE RADIAL FOREARM FLAP

Skin and fascia: optional tendon and bone

Innervation: No.

Blood supply: Radial artery and perforators from the radial artery.

Artery: Large caliber artery.

Vein(s): The venae of the radial artery can be small. The subcutaneous venous system or cephalic vein can be used for drainage, making for a larger caliber vessel.

Pedicle length: Can be dissected up to the takeoff from the brachial artery just distal to the antecubital fossa.

The radial artery provides nutrient inflow to the flap via perforating vessels that pierce the antebrachial fascia as they course toward the subcutaneous fat and skin. The radial artery is easily palpable in the distal forearm and it's course can be marked by following the pulse proximally. Veins accompany the radial artery and the subcutaneous cephalic vein is at the radial most edge of the forearm. This large vein can be incoporated into the flap distalyl, or left behind to use for radial artery reconstruction after flap harvest.