UCSF Ortho SMART Trauma

SMART Trauma
Overview

About this Course

The SMART Course is a modular skills based curriculum for orthopaedic surgeons from developing countries to gain practical knowledge in the management of musculoskeletal trauma. The course utilizes a combination of case-based didactics and hands-on skill sessions by both orthopaedic and plastic surgeons to teach core principles in fracture management and soft-tissue reconstruction driven by local input and feedback from annual attendees. The supplementary material in this online course provides a resource of instructional videos and content that learners can access outside of the annual course.

Requirements

The IGOT Portal is meant to be supplementary learning material to concepts and skills reviewed at the SMART Course. Learners should be practicing surgeons or surgeons in training who treat traumatic injuries needing surgical management and reconstructive intervention. It is recommended that before accessing the IGOT Portal that you have attended an IGOT International SMART Course.

Course Staff

Faculty Contributor:

Dr. Dave Shearer
Dr. Michael Terry
Dr. Nicolas Lee

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Lee
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Terry
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Shearer
Open Fracture Management

Learning Objectives

  • Recognize the importance of soft-tissue coverage in open fractures
  • Familiarize with common techniques for coverage of the tibia

Webinar Presentation

Soft Tissue Reconstruction

Gastroc Flap

Learning Objectives

In this section we will review the basic technique for a Gastrocnemius Rotational Flap "Gastroc Flap". The material covered in this section should supplement what was reviewed at the IGOT International SMART Course. You should reference all or parts of this section when preparing for or reviewing how to do a gastroc flap.

This section includes:

  • Indications
  • Anatomy
  • Positioning & Markings
  • Surgical Technique (Instructional video)
  • Tips, Tricks & Precautions

Indications

This section will review the Indications for the Gastrocnemius Flap:

  • Coverage
  • Proximal 1/3 of lower extremity
  • Inferior thigh Knee

Anatomy

This section will review the Muscle Anatomy for the Gastrocnemius Flap:

  • Most superficial muscle of the posterior calf
  • Two separate heads: medial and lateral
  • Each head is considered a separate unit for purposes of flap design
  • Origin: medial and lateral femoral condyles
  • Insertion: calcaneus
  • Unites with the soleus to form the Achilles tenson
  • Function: plantar flexion of the foot
  • Either or both heads are expendable if the soleus is intact

Gastrocnemius Flap

Vascular Anatomy

Medial Gastrocnemius

-Major pedicle: medial sural artery and venae comitantes

-Regional source: popliteal artery and vein

-Length: 6cm

-Enters deep surface of muscle, adjacent to fibers of muscle origin at medial condyle

-Minor pedicle: anastomotic vessels between muscle heads

-Regional source: paired sural arteries and associated venae comitantes

-Location: distal half of each muscle extending between the midline raphe between muscle heads

Lateral Gastrocnemius

-Major pedicle: lateral sural artery and venae comitantes

-Regional source: popliteal artery and vein

-Length: 6cm

-Enters deep surface of muscle, adjacent to fibers of muscle origin at medial condyle

-Minor pedicle: anastomotic vessels between muscle heads

-Regional source: paired sural arteries and associated venae comitantes

-Location: distal half of each muscle extending between the midline raphe between muscle heads

Legs

Positioning

-Generally supine with the leg in either external or internal rotation as required for muscle flap exposure
-Occasionally necessary to place in lateral decubitus position
-Allows for medial gastrocnemius muscle flap elevation, particularly in patients with hip joint stiffness
-Preferred for elevation of the lateral gastrocnemius flap

Markings

Medial Gastrocnemius

-2cm medial to medial edge of tibia
-Posterior midline
Medial Gastroc Mark
Lateral Gastrocnemius
-2cm lateral to posterior border of fibula
-Posterior midline

Markings

Lateral Gastrocnemius

-2cm lateral to posterior border of fibula
-Posterior midline

Lateral gastro mark

Gastroc Flap | Webinar Presentation

Gastroc Flap | Surgical Video

Trips, Tricks & Precautions

-To preserve foot plantar flexion, a medial or lateral gastrocnemius flap should not be used if the opposite head of the gastrocnemius and soleus muscles are no longer functional.

-A tourniquet is recommended during flap elevation to avoid injury to the tibial nerve within the popliteal fossa and the peroneal nerve located adjacent to the origin of the lateral gastrocnemius muscle.

-The peroneal nerve is subject to injury during the elevation of a tunnel over the lateral proximal leg for transposition of the lateral gastrocnemius muscle flap.

-Preoperative arteriography is recommended to confirm the patency of the sural arteries if there is clinical evidence of vascular disease or recent trauma or surgery involving the popliteal fossa.

-Recent lower extremity deep vein thrombosis is a relative contraindication to use of the gastrocnemius muscle flap.

Soleus Flap

Learning Objectives

In this section we will review the basic technique for a Soleus Rotational Flap "Soleus Flap". The material covered in this section should supplement what was reviewed at the IGOT International SMART Course. You should reference all or parts of this section when preparing for or reviewing how to do a soleus flap. 

This section includes:

  • Indications
  • Anatomy
  • Positioning & Markings
  • Surgical Technique (Instructional video)
  • Tips, Tricks & Precautions

Indications

Coverage

-Distal 1/3 of lower extremity

Anatomy

The soleus muscle is a broad, large bipenniform muscle lying deep to the gastrocnemius muscle. The muscle has two separate muscle bellies, medial and lateral, with separate origins. The medial belly originates on the middle 1/3 of the the medial border of the tibia while the lateral belly originates on the posterior surface of the fibular head and body. The solues inserts on the calcaneus where it unites with the gastrocnemius to form the Achilles tendon. Although fused in the proximal half, the two bellies are separated by a midline intramuscular septum in the distal half. The soleus contributes to plantar flexion of the foot. With at least one head of the gastrocnemius intact, this function is preserved after transposition of the soleus as a flap.

Vascular Anatomy
Vascular Anatomy

PEDICLE LOCATION: The muscle is bipennate and the medial and lateral muscle bellies have an independent neurovascular supply. This allows longitudinal splitting of the muscle to create the medial and lateral hemisoleus flaps. The medial belly is supplied by branches of the posterior tibial artery and the lateral belly by branches of the peroneal artery. The posterior tibial artery runs between the soleus and the flexor digitorum longus, and the peroneal artery runs between the soleus and the flexor hallucis longus.

Major Pedicle: Muscular branches of popliteal artery and venae comitantes

REGIONAL SOURCE: Popliteal artery and vein

LENGTH: 0.5 to 1 cm

Major Pedicle: Proximal two branches of posterior tibial artery and venae comitantes

REGIONAL SOURCE: Posterior tibial artery and veins

LENGTH: 1 to 2 cm

Major Pedicle: Proximal two branches of peroneal artery and venae comitantes

REGIONAL SOURCE: Peroneal artery and venae comitantes

LENGTH: 1 to 2 cm

Minor Pedicle: Three or four segmental branches of the posterior tibial artery and veins

REGIONAL SOURCE: Posterior tibial artery and venae comitantes

LOCATION: Segmentally located along the medial border of the muscle (medial belly)    

Soleus vessels

Positioning & Markings

POSITIONING

The patient is placed supine on the operating table and the dissection is usually performed under tourniquet control.

MARKING

A line is drawn 2 cm medial to the medial edge of the tibia, or an existing open wound can be extended into a line along the medial border of the tibia. This will give access for a medial approach to the soleus. The lateral approach to the soleus is through a midlateral incision extending along the border of the fibula on the lateral side of the leg.

Soleus Markings

 

Soleus Flap | Webinar Presentation

Soleus Flap | Surgical Video

Trips, Tricks & Precautions

• The congenital adhesions between the soleus and gastrocnemius in the distal leg may need to be separated using sharp dissection.

• If there is evidence of peripheral vascular disease or severe trauma, a preoperative arteriogram is advised.

Reverse Sural Flap

Learning Objectives

At the end of this module, the learner should be able to:

1) Describe to locations of wounds that can be covered with a reverse sural flap

2) Understand the relevant anatomy of the reverse sural flap, particularly the necessary blood supply

3) Discuss in detail the operative planning and execution of reverse sural flap including:

-Skin paddle design

-Landmarks for incision

-Performance of “delay” procedure and reasoning

-Appropriate dissection of fasciocutaneous pedicle

Anatomy

Overview of blood supply:

The reverse sural flap is dependent on an arterial blood supply and venous drainage that comes in the opposite direction of normal flow, namely from distal to proximal instead of the other way around. 

This reverse flow is possible because of a reliable perforating arterial connection between the deep peroneal artery and the superficial sural artery that accompanies the lesser saphenous vein. This perforator is found 5-7 centimeters proximal to the lateral malleolus.

The lesser saphenous vein provides venous drainage for the flap.

The superficial sural artery has multiple connections with the artery accompanying the superficial sural nerve and both arterial supplies should be preserved for flap success.

Blood supply

Nerve Anatomy:

The superficial sural nerve which runs from the lateral malleolus to the median raphae between the heads of the gastrocnemius muscles, will necessarily be sacrificed to capture the arterial supply with it.  This will result in permanent numbness of the lateral aspect of the foot and patients should be counselled that they are trading bony coverage and the avoidance of amputation for this numbness.  The nerve in the distal 2/3 of the flap is intimately associated with the superficial sural artery and lesser saphenous vein which lie just superficial to the muscle fascia and below Scarpa’s fascia. The sural nerve and its accompanying artery separate from the bundle and perforate the muscle fascia about 2/3 of the way up the leg. 

Nerve anatomy

Muscular Anatomy:

The only relevant muscular anatomy in a reverse sural flap is a basic understanding of the gastrocnemius muscles.  There are two heads to the muscle, medial and lateral, which meet in the midline of the posterior calf at a raphae.  This can be palpated through the skin in the upper aspect of the middle third of the lower leg using a firm rolling motion from side to side to appreciate a depression between the muscles. The muscles have an investing muscle fascia which is relevant in the flap dissection.  Deep to this, the gastrocnemius proximally and distally has a thick white adherent muscle fascia which supports the tendinous origin and insertion.  This is to be left in place during flap dissection.

Origin: Medial and lateral condyles of the femur

Insertion: Achilles tendon

Blood supply: Medial and lateral sural arteries, branching from popliteal on proximal and deep surface of each muscle.

Action: Plantar flexion of the foot

Muscular anatomy

Positioning & Markings

Patient Positioning:

The patient can be placed prone for easiest visualization of anatomy, however if this is unsafe for any reason, markings can be made preoperatively while patient is awake and surgery can then be performed in a lateral position. 

A Note on Anesthesia:

This flap is most commonly performed under general anesthesia for convenience, but it is possible to perform under local anesthesia as it is a superficial (skin and fascia only) operation.  Recommendation for local anesthesia would be infiltration of a long acting local anesthetic such as bupivacaine or locally available equivalent. Infiltration should be performed after surgical markings are performed so that anesthetic effect is focused on the operative area of interest.  Anesthetic should be infiltrated in the deep subcutaneous plane and allowed at least ten minutes for anesthetic effect.

Surgical Markings:

Surgical markings should begin with identification and marking of important anatomic landmarks.

1)    Place a circular mark over the apex of the lateral malleolus

2)    Place a vertical line marking the palpable median raphae (or posterior midline of the calf if not palpable) from the popliteal crease to a point half way down the calf.

3)    Draw a horizontal line across the entire posterior aspect of the lower calf at a height 7cm proximal to the lateral malleolus.  This is the location of the deep peroneal perforator and dissection should not proceed distal to this line.

4)    Draw a horizontal line across the entire posterior aspect of the calf 10cm distal to the popliteal crease. 

Incision markings should be made after the above landmarks are clearly marked.

1)    A template of the defect should be made using a sterile piece of thin material such as the paper of a glove wrapper.

2)    This template should be traced onto the posterior calf centered over the midline vertical marking with its superior edge touching the horizontal mark 10cm below the popliteal crease, so that the entire skin paddle is below this line and centered. Be aware that the skin paddle will turn 180 degrees as the flap is rotated (ie. the superior aspect of the skin paddle will become the inferior aspect when placed in the defect).

3)    If performing this flap with a “delayed” two-stage approach (recommended), mark a 3cm portion at the superior edge of the skin paddle which delineates the area not  to be cut until the second operation.

4)    Mark the pedicle incision from the anterior side of the lateral malleolus to the musculotendinous junction of the gastrocnemius muscles with the Achilles tendon (approximately at the junction of the middle and lower thirds of the lower leg.

5)    Extend proximally from this incision line vertically up the midline to the inferior edge of the skin paddle.

Flap Coverage Area

Locations of wounds that can be covered by reverse sural flap:

1) Medial malleolus

2) Lateral malleolus

3) Achilles tendon

4) Medial and lateral calcaneous

5) Heel

Surgical Dissection

First Stage Flap Pedicle Dissection:

A knife is used to make the vertical incision as previously marked and described above but only the portion of it from the transverse line 7cm proximal to the lateral malleolus to the inferior aspect of the skin paddle.  This incision should only be deep enough to be completely through the dermis but not into the subcutaneous tissue.

An incision of the same depth should be made around the skin paddle except for the 3cm swath at the superior edge.

Cautery, on the “cut” setting if available, is then used to elevate flaps of skin with a thin stippling of subcutaneous fat medial and lateral to the vertical incision for a distance of 2cm on either side, revealing a 4cm wide adipofascial pedical for the flap.

Cautery is then used to incise through fascia to bare muscle along the vertical lines 2cm to either side of the central aspect of the adipofascial pedicle.  Care should be taken to not narrow the pedicle at the most distal aspect of the dissection.

Cautery is then used to incise through the lateral aspects of the skin paddle all the way to bare muscle. Be sure to leave the 4cm inferior connection of the adipofascial pedicle attached at the inferior aspect of the skin paddle, and the 3cm skin bridge at the superior aspect of the skin paddle if performing a delay procedure.  If a single stage flap is being attempted, this superior skin bridge is incised through fascia down to bare muscle.

Tenotomy scissors (with cautery for hemostasis) are used to separate the pedicle from the underlying muscle in the areolar plane from the transverse line 7cm proximal to the lateral malleolus to the superior edge of the skin paddle.  Of note, there will likely be 1-3 perforating vessles from the muscle to the pedicle fascia that need to be cauterized.  Please do so in a way that does not coagulate the vessels within the fascial pedicle (ie. cauterize toward the muscle side of the perforator).

Note that the sural nerve will penetrate the deep aspect of the fascial pedicle and dive between the heads of the gastrocnemius muscles near the upper third of the pedicle. Continue to elevate the sural nerve with the flap as far as feasible, then transect the nerve.  If performing under local anesthesia, additional infiltration may be necessary before this maneuver.

If performing a delayed two-stage flap, the skin is then laid back over the pedicle and a quick running nylon suture is used to close the skin temporarily over the pedicle (with care not to penetrate the pedicle with the suture during closure.

Second Stage Flap Dissection – Division and Inset of Flap:

The second stage is performed at least one week after the first stage (up to 3 weeks is acceptable).

The nylon running skin closure is re-opened.  Blunt finger dissection is used to separate the skin flaps from the superficial aspect of the pedicle and the muscle from the deep aspect of the pedicle and skin paddle.  Cautery is then used to transect the 3cm skin bridge remaining at the superior aspect of the skin paddle.

The flap is now free to be rotated into the defect. A channel will need to be incised in the skin between the distal aspect of the flap pedicle to the defect with skin flaps elevated widely enough to allow the width of the pedicle to lay in the channel.  Do not attempt to close the skin flaps over the pedicle or to tunnel the pedicle under un-incised skin.

The skin paddle is inset using nylon sutures. 

The skin flaps of the calf are closed with suture taking care to not compress the pedicle with the distal aspect of the closure.

The pedicle and the calf defect at the site of skin paddle harvest need to be skin grafted.

Reverse Sural Flap | Webinar Presentation

Trips, Tricks & Precautions

The reverse sural flap is one of the few local tissue options for ankle and heel coverage.

It is most reliable when performed as a two-stage procedure.  Both are possible to perform under local anesthesia if that is the only option.

Remember the following important details:

1)    The preoperative markings are imperative to success.  They should be as precise as possible.

2)    The adipofascial pedicle dissection is the critical portion of the operation.  It should be 4cm wide and composed of the subcutaneous tissue and the investing muscle fascia.

3)    Do not dissect below the mark 7cm above the lateral malleolus.

4)    The pedicle should have a gentle curve at the time of inset.  Stretch or tight kinking will result in skin paddle necrosis.

5)    The skin flaps overlying the area where the adipofascial pedicle was dissected make undergo marginal necrosis.  This will not affect flap success and can be managed with debridement and local dressing care.

 

Post-Operative Dressings and Care

Dressings:

The skin grafted sites should be covered with any non-stick dressing or, at minimum, a layer of ointment and gauze. No compression should be used.

Post-operative Care:

Elevation of the operated extremity should be continued for a minimum of five days. This prevents excessive swelling of the flap and compressive kinking of the pedicle which could cut off blood flow.

Gradual return to dependent leg position should be accomplished over the course of several days, progressing by 30 minute increments as long as excessive swelling is not detected.

Patients should not bear weight on the operated extremity for 2-3 weeks, until the suture line of the inset skin paddle is completely healed.

Radial Forearm Flap

Radial Forearm Flap | Surgical Video

Reverse Radial Forearm Flap

Reverse Radial Forearm Flap - Guadalajara SMART Course

Latissimus Flap

Latissimus Flap | Surgical Video

Groin Flap

Groin Flap | Surgical Video

SIGN/IGOT SMART Webinars

Open Fractures and Soft-Tissue Reconstruction

SIGN/IGOT Webinar: Open Fractures and Soft-Tissue Reconstruction

Pelvic and Acetabular Fractures

Limb Deformity Correction

Limb Deformity Webinar

Tibial Plateau Fractures

Tibial Plateau Fractures (April 30, 2021)

Advanced Flaps

Pelvic Ring Injuries

Pediatric Femur Fractures