Principles and Practice of Wound Care

Malignant Wounds 
Chapter 28
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10. Naylor W. Malignant wounds: etiology and principles of
management. Nursing Standard. 2002;16:45-53.
11. Wood DK. The draining malignant ulceration. Palliative
management in advanced cancer. JAMA. 1980;244:820-2.
12. Collier M. The assessment of patients with malignant fungating
wounds: a holistic approach: Part 1. Nurs Times. 1997;93(44):
1-4.
13. Grocott P. The palliative management of fungating malignant
wounds. J Wound Care. 1995;4(5):240-2.
14. Grocott P. The management of fungating wounds. J Wound
Care. 1998;8:232-4.
15. Collier M. Management of patients with malignant fungating
wounds. Nursing Standard. 2000;15:46-52.
16. Brusis T, Luckhaupt H. Fetor from ulcerated head and neck
tumors: causation and therapy. Ann Otol Rhinol Laryngol.
1989;98:615-7.
17. Editorial. Management of smelly tumors. Lancet. 1990;1:141-2
18. Gallagher J. Management of cutaneous symptoms. Semin
Oncol Nurs. 1995;11:239-47.
19. Goldberg Mt, McGinn-Byer P. Oncology related skin damage.
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management, 2nd edition. St Louis MO: Mosby. 2000. pp.367-86.
20. McMurray V. Managing patients with fungating malignant
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21. Fletcher J. Exudate theory and the clinical management of
exuding wounds. Prof Nurse. 2002;17(8):875-8.
22. Walding M. Pressure area care and the management of fungating
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24. Haisfield-Wolfe ME, Baxeldale-Cox LM.
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27. Collier M. Assessing a wound. RCN nursing update (Unit 29).
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• Vesicants
• Irritants
• Risk Factors
• Initial Management

– General Considerations

– Antidotes
• Surgical Management Considerations

– Extravasation Ulcer

– Treatment of Ulceration
Mishaps are like knives that either serve us or cut us, as we
grasp them by the blade or by the handle.
—James Russell Lowell
Introduction
Extravasation is described as the unintended leakage of a drug
from a vessel into the surrounding tissues or the unintended
instillation of a drug directly into the perivascular tissues. It
is one of the most dreaded complications when administering
cytotoxic drugs, i.e. chemotherapy.

With more than one million daily infusions of chemo-
therapy worldwide, it is obvious that extravasations do
happen as accidents. The frequency of extravasation in adults
is considered to be somewhere between 0.1 and 6 percent of
peripheral intravenous infusions and probably much lower in’
implanted venous access port’ infusions. However, there is a
constant increase of 1 to 2.5 percent every year which is due to
an increase in the use of chemotherapy in several neo-adjuant
oncological protocols as primary treatment regimen.

In order to better track and code extravasations, the Center
for Medicare and Medicaid Services created a new international
classification of diseases code, 999.81 extravasation of chemo-
therapy which became effective on Oct 1, 2009.1

Extravasation injuries are among the most dangerous toxic
effects of chemotherapy and they should be avoided and prevented
rather than treated. This is because local damage is often serious
and because there are few specific treatments. Although vesicant
extravasation injuries usually occur in the peripheral tissues, they
may also occur in the mediastinum, lung and other areas when
central venous catheters rupture or migrate outside the vein.

The severity of tissue injuries after an untreated extra-
vasation depends on several factors, including the vesicant
potential of the drug, volume and concentration of the drug
and the anatomical location of the extravasation.

Based on their potential for causing local tissue injury,
chemotherapeutic agents are classified as vesicant, irritant
or non-vesicant. The boundaries between the categories are
not rigid: an irritant drug can actually give rise to an ulcer
depending on the drug concentration, volume, and the diluent.
Small extravasations of a vesicant drug, on the other hand, do
not always result in blistering and necrosis.

Vesicant drugs have the capability to induce the formation
of blisters and cause tissue destruction (e.g. anthracyclines,
amsacrin cisplatin, epirubicin, idarubicin, mitomycin c,
mitoxantrone, paclitaxel, vinca alkaloids).

Irritant drugs can cause pain at the injection site or along
the vein with or without an inflammatory reaction. Some of
these agents have the potential to cause soft tissue ulcers only
if a large amount cytotoxic agent solution is extravasated (e.g.
carboplatin, bendamustine, dacarbazin, docetaxel, etoposide,
gemcitabine, ifosfamide, melphalan, topotecan).
Chemo-Extravasation: Medical
and Surgical Management
Sandeep Mehta, Himesh Gupta
29
Chapter

Chapter 29
Chemo-Extravasation: Medical and Surgical Management 
337

Non-vesicant drugs, (neutral), if extravasated, rarely
produce acute reaction of tissue necrosis (e.g. asparaginase,
bleomycin, cyclophosphamide, cytarabine, fluorouracil,
folinic acid, irinotecan, methotrexate, rituximab, thiotepa).
VESICANTS
Vesicants are drugs that may cause severe and lasting tissue
injury and necrosis. Patients may complain of local swelling,
erythema, and pain or a burning sensation at the infusion
site. The symptoms may present immediately after the
extravasation incident or develop during following days or
even weeks. Blistering, induration, and discoloration may
develop (Figure 1). In severe cases, ulceration and progressive
tissue destruction may develop (Figure 2). Complicating
infections in the deep tissues and scar formation can lead
to long-term cosmetic and functional deficits. Treatment
delay, termination of chemotherapy, and even death may
be the ultimate result. Clearly, extravasation of vesicant
chemotherapy necessitates prompt action and close monitoring
of the patient. The anthracyclines, the vinca alkaloids, and
mitomycin C are the clinically most important vesicant drug
groups in chemotherapy extravasation.
Types of Vesicants
Vesicant chemotherapy agents can be divided into two
categories, DNA binding and non-DNA-binding.

Vesicants that bind to nucleic acids in DNA (e.g.
anthracyclines) bind to the DNA in the cells of healthy
tissue when they extravasate from the vein and promptly
cause cell death. DNA-anthracycline complexes are released
from dead cells in the tissues and are taken up by adjacent
healthy cells by endocytosis. This process of cellular uptake
of extracellular substances sets up a continuing cycle of tissue
damage as the anthracycline is retained in the tissues for a
long period of time and recirculated in the surrounding area.
The author has come across such cases when patient having
had a limited extravasation during chemotherapy for breast
cancer has presented with local discharging sinuses and
abscess formation 18 months later (Figure 3). Consequently,
Figure 1: Extravasation of vincristine, non-DNA binding
vesicant, seen after 48 hours
Figure 3: Extravasation ulcer that developed spontaneously 18 months
after suspected extravasation during adriamycin therapy for breast
cancer
Figure 2: Extravasation of adriamycin, DNA binding vesicant seen
after 3 weeks progressed to severe local tissue necrosis and infection.
Tendons are exposed in ever expanding necrotic tissue base

Section 3
  Types of Wounds and their Management
338
these extravasation injuries become larger in size, deeper in
depth and more painful over time.2

Vesicants that do not bind to DNA (e.g. plant alkaloids)
have an indirect rather than a direct effect on the cells in the
healthy tissue when they extravasate. Non-DNA binding
vesicants are eventually metabolized in the tissue and are
more easily neutralized than DNA binding agents. This type
of extravasation injury generally remains localized, is mild to
moderately painful and improves over time (Figure 1).

Vesicant chemotherapy extravasations have been called
a dreaded complication of chemotherapy and a preventable
catastrophe.5 Historically these extravasations were either
missed or ineffectively treated and often required surgical
intervention, such as debridement and skin grafting or flap
cover. Patients thereby required prolonged wound care, often
necessitating discontinuation of their anti-cancer treatment.

In recent years, the increased focus on chemotherapy
extravasation has led to the greater understanding about
how vesicant extravasation affects the tissue and how they
may be effectively treated. The tissue destruction in one of
the most dreaded types of extravasation (i.e. anthracycline
extravasation) now can effectively be prevented with a
specific antidote, dexrazoxane.
Irritants
Irritants are drugs that can cause an inflammatory reaction.
They are also referred to as non-vesicants. The symptom
complex after extravasation of irritant drugs often includes
swelling and pain, local warmth, discomfort, erythema, and
tenderness (Figure 4). Phlebitis, hyperpigmentation, and
sclerosis may develop along the vein. These symptoms often
resolve within days to weeks, and long-term sequelae are rare.
The platinum compounds, the taxanes, and the topoisomerase-
I inhibitors belong in this category, although few cases of
ulcerations after extravasation of high concentrations or large
volumes of both the platinum compounds and the taxanes
have been described.3,4
RISK FACTORS
Every patient who receives a vesicant is at risk for extravasation,
and remains thus throughout his course of treatment.

Risk factors for extravasation from peripheral veins include
the presence of small or fragile veins, obesity, multiple
previous venipunctures, skin diseases, patient movement
and prior treatment with low pH and caustic drugs, such as
chemotherapy. There may also be limited vein availability
because of lymph node dissection, lymphedema, limb removal
or other conditions. Sensory deficits that impair patient’s ability
to detect a change in sensation at the site of drug administration
increases the risk as it may go unnoticed.

When extravasation occurs on the dorsum of the hand,
wrist, or anticubital area, the tissue damage is greater and
underlying veins, arteries, tendons and muscles suffer easily
because of minimal tissue interface. On the contrary forearm
and arm areas are less vulnerable (Figure 5).

The risk of extravasation is increased when vesicants are
administered via rigid IV devices such as scalp or butterfly
needles because they can easily puncture the vein on patient
movement. Lack of availability of peripheral veins would
necessitate placement of implanted port or Hickman catheter
Figure 4: Extravasation of 'irritant' methotrexate, cellulitis like features
over the forearm and upper arm, treated with magnesium sulfate
dressings
Figure 5: Extravasation over the wrist. Deeper structures involving
neurovascular structures and tendons are vulnerable

Chapter 29
Chemo-Extravasation: Medical and Surgical Management 
339
Does Central Venous Access Device
(Chemoport) Reduce the Risk of
­Extravasation?
It is not necessary that a central venous access device
absolutely prevents extravasation. These devices definitely
reduce the risk but have their inherent problems leading to
extravasations. Undoubtedly those patients who are at greater
risk to fall prey to such accidents, viz. those with fragile veins,
obese, and all those in whom maintaining a good peripheral
vein access point is difficult, especially children are candidates
who should have either a PICC line, Hickman catheter or a
Chemoport for the complete duration of their chemotherapy
(Figure 7).

Vesicants should be administered in proper dilution at
specified rate and a blood return should be obtained prior
to any such administration (Figure 7). The IV line should
be flushed before chemotherapy is started, flushed between
agents administered, and flushed again when chemotherapy
has completed. During administration the site should be
monitored for swelling, redness, pain, or other symptoms. A
blood return should always be obtained before vesicants are
administered. Patients should be instructed not to leave the
clinical area while a vesicant is being administered.
General Considerations in Chem-
otherapy ­Extravasation—INITIAL
MANAGEMENT
If you look away from something you are supposed to be
looking for, that is called willful blindness, and willful
blindness is one aspect of determining the negligence.
—Michael Shapiro
Prevention is by far the most important approach to minimizing
the risk of extravasation. Drug-specific protocols and updated
local policies are instrumental in this respect. Staff training
and patient education are very important prevention methods
as well. For several decades, no widely accepted guidelines
existed for the handling of chemotherapy extravasation, thus
leaving patients at risk of unnecessary morbidity, including
long-term cosmetic and functional deficits. The European
Oncology Nurses Society (EONS) and the European Nurses
Society have now published updated and comprehensive
international guidelines. These guidelines are useful tools for
the treating staff in daily clinical practice.6,7

In the event of an extravasation, a stepwise action is usually
taken. First, it is important to stop the infusion, and not remove
the cannula. The affected limb should be elevated. Attempts
to aspirate as much drug as possible should be carried out
immediately through the existing needle (Figure 8). Clear
marking of the affected area is important in order to obtain
Figure 7: Central venous access device, chemoport with non-coring
needle in situ
Figures 6A and B: (A) Chemoport extravasation; (B) Chemoport
extravasation resolved
A
B
as central venous access devices (CVADs). Even these CVADs
are not averse to risk from extravasation (Figures 6A and B).
Difficulty encountered during insertion of the device, e.g.
inability to advance the guide wire or catheter, misplacement
outside the venous system into pleural space, etc. long dwell
time, six months or longer may lead to pinch off syndrome
when catheter is compressed between clavicle and first or
second rib. There can be backtracking of vesicant drug when
a fibrin sheath formed around the silicone catheter is blocked
by thrombus. The non-coring needle used to access the port
should securely reach the port-septum; otherwise rocking of
this needle can lead to extravasation at the site of port access.

Section 3
  Types of Wounds and their Management
340
a full documentation of the incident (Figure 9) (photographic
documentation should be obtained for patient insurance
matters). Demarcation may also be important, if surgical
intervention should become necessary. To correctly assess the
quantity of drug that has extravasated, the drug remaining in
the infusion bag or syringe should be noted and subtracted
from the total quantity at the start of infusion. This should be
done with the help of a syringe rather than ‘eyeballing’.

The next step in the treatment of chemotherapy extravasation
depends on the specific drug. If it is a nonvesicant compound,
intermittent cooling and observation is often sufficient.
Generally, the treatment decision in extravasation of vesicant
chemotherapy depends on whether the extravasated substance
should be dispersed, or whether it is better to localize and
neutralize the compound with an antidote. Dispersion or
dilution seems the most reasonable approach in the non-DNA
binding compounds such as the vinca alkaloids. In contrast,
the DNA-binding vesicant drugs, such as the anthracyclines,
mitomycin C, nitrogen mustard, and trabectedin, may give rise
to progressively spreading tissue destruction if not localized.
Whenever possible, an antidote should be administered
Table 1. Summarizes the currently recommended and most
frequently used antidotes in chemotherapy extravasation,
discussed below. The local intermittent application of ice
Table 1: Guidelines for antidote use after extravasation
Drug
Antidote
Advice
Anthracyclines
Dexrazoxane 1000 mg/m2 IV within 5 h of extravasation on day 1, 1000 mg/m2 on day 2,
500 mg/m2 on day 3 DMSO, apply locally as soon as possible and repeat every 8 h for 7
days (when quantity of drug extravasated is small)
Ice packs
Mitomycin C
DMSO apply locally as soon as possible and repeat every 8 h for 7 days
Nitrogen mustard
Sodium thiosulfate 2 ml of a solution of 4 ml sodium thiosulfate + 6 ml sterile water for
injection sc
Vinca alkaloids
Hyaluronidase 150–1500 U sc
Hot packs
(DMSO: Dimethylsulfoxide; IV: Intravenously; sc: Subcutaneously)
Figure 8: Chemoport being prepared for chemotherapy. Blood return being obtained before starting the drug therapy
Figure 9: Extent of extravasation marked and photographs taken for
future course of action immediately after extravasation
can serve as pain relief and is often used. Due to the local
vasoconstriction, cooling should be used with caution before
the injection (being local or systemic) of an antidote. Topical
cooling should not be used in combination with systemic
anthracycline extravasation antidote dexrazoxane because

Chapter 29
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341
vasoconstriction will counteract its beneficial effects. It
is advisable to stop cooling for next few hours after the
antidote has been injected at a different site. Moreover, local
heating rather than cooling is recommended in extravasation
of vinca alkaloids to increase blood flow to the area, which
helps distribute the extravasated vesicant and promotes its
absorption.
Antidotes in Chemotherapeutic Drug
­Extravasations
Anthracyclines
The anthracyclines daunorubicin, doxorubicin, epirubicin,
idarubicin are DNA-binding agents known to cause significant
tissue injury when they extravasate and are left untreated. In
the past patients with anthracycline extravasation typically
required surgical intervention and wound management
and were left with permanent disfigurement. Fortunately
these extravasations can now be effectively treated with
dexrazoxane when recognized early.

Dexrazoxane has been used for many years to minimize
the cardiotoxic effect of anthracyclines. Langer et al found
that it had a protective effect against the development of
anthracycline extravasation injuries as well. It binds to iron
and prevents the formation of free radicals, which are thought
to play a major role in development of extravasation – induced
tissue necrosis. It also binds to DNA topoisomerase II at a
different step in the catalytic cycle than anthracyclines and
locks the enzyme in a form that is no longer affected by the
anthracyclines.

Recently,
dexrazoxane
became
the
recommended
treatment of anthracycline extravasation by the European
Nurses Society and by the Oncology Nurses Society. The
preclinical evidence from an extensive series of animal
experiments that has shown significant and specific antidotal
effect of dexrazoxane in anthracycline extravasation has
been confirmed in three clinical studies.8 Dexrazoxane was
administered as an intravenous infusion over one to two hours;
1000 mg/m2 (max dose 2000 mg) was given within six hours
after the extravasation injury, 1000 mg/m2 24 hours later, and
500 mg/m2 (max dose 1000 mg) another 24 hours later.8

Topical application of 99 percent Dimethyl Sulfoxide
(DMSO) may have a beneficial effect in small anthracycline
extravasations, but the lack of a biopsy-verified diagnosis and
detailed information in published cases makes it very hard
to conclude whether real benefit has been obtained. DMSO
treatment may be associated with significant side effects,
and the routine use of DMSO is still controversial. In some
studies when the extravasation has been limited to 1 to 3 ml
of doxorubicin, topical application of Dimethyl Sulfoxide 99
percent solution applied as thin layer and left exposed to dry,
surface cooled for 20 minutes six hourly, with repetition every
eight hours for up to one week has shown to prevent any tissue
necrosis.10 Mitomycin C extravasations have been treated in
this manner by some authors but EONS do not approve it as
standard of care and suggests further studies on the same.
The concomitant use of topical DMSO and intravenous
dexrazoxane is not recommended.

Dexrazoxane is the only treatment that has received
European Commission authorization and USFDA approval
for anthracycline extravasation treatment. The overall efficacy
has been found to be 98 percent in patients with peripheral
anthracycline
extravasations
verified
by
fluorescence
microscopy. Dexrazoxane must be administered intravenously
in a large vein within six hours of an anthracycline
extravasation in an area away from the extravasated site,
e.g. opposite arm. Side effects included nausea, infusion site
reactions and transient increase in liver transaminases.9

Mechlorethamine (Nitrogen mustard) is a DNA binding
vesicant. Sodium thiosulfate has been used as an antidote.
It prevents alkylation and subsequent tissue destruction
by providing a substrate for alkylation in the subcutaneous
tissues. A 1/6 molar solution obtained by mixing 4 ml of ten
percent sodium thiosulfate with 6 ml of sterile water is locally
injected into the area of extravasation; 2 ml of this solution is
injected for each milligram of mechlorethamine suspected to
have extravasated.

Plant alkaloid extravasations (vinblastine, vincristine,
vindesine, vinorelbine, etc.) commonly known as vinca alkaloids
and taxanes can be associated with local irritation along the
infusion vein. The drugs are also vesicant upon extravasation.
Hyaluronidase is a protein enzyme that degrades hyaluronic
acid, promotes drug diffusion, and enhances drug absorption. It
is found to be effective in preventing plant alkaloid and taxane
induced irritation and tissue necrosis in animal models.10

Current recommendations are to subcutaneously inject
1 to 6 ml of a 150 iu/ml solution into the area of extravasation
in a clockwise manner (Figure 10). The usual dose is 1 ml of
solution for each ml of extravasation. Local heat application for
20 minutes four times daily for one to three days is continued.
Repeat injections with hyaluronidase may be continued if
symptoms of original drug irritation persist.

Liposomal anthracyclines, cisplatin and paclitaxel are
irritant drugs and can be vesicants only when extravasated
in large amounts or in high concentrations. Topical use of
hyaluronidase is suggested by some authors together with
surface heating to promote drug dispersion and absorption.11

Section 3
  Types of Wounds and their Management
342
SURGICAL MANAGEMENT
­CONSIDERATIONS
Nine-tenths of wisdom consists in being wise in time.
—Theodore Roosevelt
Clinical course of extravasation of vesicant drugs and
of anthracyclines: An anthracycline extravasation is
characterized by swelling and redness and is often very
painful. Over a period of days or weeks this may progress
to tissue necrosis producing tissue sloughing and ulceration
with large wounds requiring surgical debridement and/or skin
grafts (Figure 11). In the absence of therapy, approximately
one-third of vesicant extravasations will result in ulcerations,
some of which necessitate plastic surgery to cover the soft
tissue defects (Figure 12). Anthracyclines can persist in tissues
for weeks or even months after extravasation. Furthermore, the
local area of extravasation is at high risk of infection, because
of both the local necrosis and in general by the impaired
immunological state of most patients receiving this kind of
treatment. The progression rate to ulceration of significant
volume of (10 ml and more) anthracycline extravasation
ranges between 25 and 50 percent. The tissue damage may
progress over days and weeks, causing pain and increasing
the risk of infection, destruction of tissues and permanent
dysfunctional and cosmetic changes in the involved area.
The need for amputating the extremity is possible in case of
anthracycline extravasation.12-14

A statement that has been perpetuated in the literature is
that- ‘surgery is required for one third of all extravasations’
(schrijvers, 2003) is based on the review done by David Larson
at MD Anderson hospital, Houston, Texas in 1980s. He had
recommended that when an extravasation is suspected, the IV
line is removed, ice is intermittently applied for three days and
the area observed closely without any local intervention. If
the patient became asymptomatic at ten days, it was observed
that no other care was usually required. However if the pain
persisted or ulceration progressed, the area was debrided and
a skin graft was applied two to three days later. Using this
conservative or ‘watch and see’ approach, only a third of the
patients that Larson studied required surgery. Limitations
Figure 11: Adriamycin extravasation that has lead to loss of skin, soft
tissues and extensor tendons on dorsum of the hand. The conservative
debridement and granulating wound seen after 5 weeks
Figure 12: Defect overlying the dorsum of hand as a result of
extravasation ulcer requiring reconstruction
Figure 10: Injection of hyaluronidase administered at the site of
vincristine extravasation

Chapter 29
Chemo-Extravasation: Medical and Surgical Management 
343
in this study were that the nature of vesicant, whether DNA
binding or non-DNA binding, their quantity and concentrations
and patient risk factors were not accounted for. In contrast
another study by Cedidi et al in 2001 comparing early versus
late surgical debridement, concluded that all patients who
were referred later than 22 days of the extravasation required
extensive debridement with cover using skin graft or flap
depending on the depth of necrosis.

As increasing numbers of patients received vesicant
chemotherapy and incidence of accidental extravasations
increased, other approaches to manage them emerged. Most
advocated among them were the saline infilteration dilution
technique (Gault), saline and suction technique(scuderi,
nepoli) and emergency local exploration, subcutaneous
debridement, lavage and primary closure (Telisselis P et al ).

Subcutaneous wash-out procedure (SWOP) for the
treatment of chemotherapeutic extravasations.13

Extravasation injuries should be considered as oncological
medical-surgical emergencies to be treated immediately
(within a few hours rather than days) to limit damage and
prevent those severe and disfiguring ulcerations which lack of
treatment can provoke.

This technique is particularly useful for extravasations of
vesicant anthracyclines, when the quantity of extravasated
drug is equal or above 10 cc. ‘‘Wait and See’’ protocol is to
be condemned because of high risk of progressively worse
ulcerations and necrosis of skin and surrounding soft tissues
provoking irreversible damage seen with these drugs.
Surgical Technique
First of all, this technique contemplates infiltration of saline
solution in subcutaneous tissues where the extravasation
has occurred as soon as possible. The treatment starts by
administering subcutaneous local anesthetic and hyaluronidase
(<600 UI). The quantity to be injected is directly proportional
to the area to be treated and to tissue tension (20 ml on wrist, 40
ml on dorsum of hands, 60 to 90 ml for forearm and anti-cubital
fossa). During this stage the aim is to dilute the extravasated
drug in order to make aspiration easier. Some eight to ten
small holes in the skin are created with a stab knife. Through
them subcutaneous tunnels are created to aspirate the liquid by
means of lipoaspiration cannulas measuring 2 mm protecting
superficial vessels, nerves and tendons. Then, through these
skin holes, a second infiltration of saline solution is done
which varies between 500 and 3,000 ml—depending on the
area—and serves as an abundant irrigation. This infiltration
is followed by another aspiration. The skin holes are never
sutured; they are just covered with vaseline gauze and Soft,
compressive bandage is applied which favors further liquid
drainage by means of imbibition and capillarity (Figure 13).

Finger mobilization is encouraged in order to favor
drainage. Postoperative edemas disappear after 24 to 40 hours
and the skin holes heal in four to eight days. Patients who are
treated within a few hours do not show any inflammation and
heal faster. Functionality is preserved and no skin ulcerations
or damage to soft tissues progresses.

As cytotoxic consequences, such as tissue breakdown, can
occur until days to weeks after extravasation, chemotherapeutic
agent dilution and at least partial removal by SWOP is
advisable until about 72 hours after extravasation injury in
DNA binding vesicant chemotherapeutic agents or even later
in cases of still expanding inflammatory tissue reactions.
The general measures found in the literature recommend the
aspiration of the agent from the extravascular space using an
indwelling application catheter. However, in clinical practice,
this does not result in the aspiration of relevant volumes of the
chemotherapy agent. In an article published in 1993, Gault et
al first mentioned liposuction as a method for the treatment
of chemotherapeutic extravasation injuries.15 The procedure
described was carried out without the use of tumescent
liposuction solution, and as such was unable to provide any
dilution effect.

To avoid tissue necrosis and soft tissue defects, including
loss of function in the extremities due to the destruction of
structures such as muscles, tendons and nerves, it is recommend
that patients be referred to a plastic surgery unit immediately.
Extravasations of chemotherapeutic drugs should be diluted
and aspirated using the SWOP procedure to minimize the risk
of tissue necrosis. The skin should be examined carefully and
SWOP be repeated if necessary and combined with specific
chemotherapeutic agent antidote therapy provided the clinical
Figure 13: Subcutaneous wash out procedure after saline infiltration
at the site of extravasation a liposuction cannula is used to remove
the subcutaneous tissue and fluid

Section 3
  Types of Wounds and their Management
344
findings do not improve. In cases where the tissue necrosis has
already set in, the plastic surgeons should be ready to interfere
with debridement to prevent subsequent injury to neighboring
tissues.16,17
Emergency Local Exploration
A recently published article by Telisselis et al recommends
the immediate, open surgical treatment of chemotherapeutic
extravasations. The open surgical excision of the entire area
affected by the agent along with irrigation, using Ringer’s
solution, of the subcutaneous tissues and subsequent primary
skin closure is presented as equally effective in diluting the
toxic effect of chemotherapeutic agent.18
Extravasation Ulcer
An ulcer caused by extravasation of cytotoxic drugs is one of
many challenging fields in plastic surgery.

There still occur unfortunate cases of extravasations even
with all the known risks and the standard protocols in use
which are either not recognized in time or those which inspite
of all conservative treatment advance into progressive tissue
necrosis and formation of an extravasation ulcer (Figure 14).

The history of development of such extravasation ulcer
is unique. The cause of progress from the innocuous redness
and swelling experienced at the time of anthracycline vesicant
extravasation to a widely necrotic and ever spreading ulcer
has been explained earlier. But, the failure to realize this at
the outset by the treating oncologist, administering nurse
and the patient herself leads to much delay in seeking proper
referrals and plastic surgery consultations. It is not uncommon
to find that the ‘complaints’ of patient that were overlooked at
Figure 14: Extravasation ulcer
previous cycle of chemotherapy are brought to notice more
forcefully during the next round of chemotherapy. This has
allowed the progressive damage to continue for over three
weeks and the situation is beyond conservative management
with either the antidote or subcutaneous wash out procedure.
As one cannot turn the clock back, it becomes a horrendous
task, managing the ulcer with ever progressive necrosis. It
is known that the DNA binding vesicant remains ‘fixed’ to
the site of extravasation as each one of the affected cell on
its death leaves behind the cell debris which are secondarily
bound to the next living neighbor cell, and the process
continues, presumably for 10 to 12 weeks. This also explains
the much wider tissue necrosis than the original extent of
extravasation. The site of such an ulcer is usually the dorsum
of hand or forearm (Figures 11,12 and 14) and the functional
and cosmetic outcome of it can well be imagined! Such ulcers
tend to become chronic, and in most cases are resistant to
traditional conservative treatment. It is difficult to prevent
extension of the necrosis and this is exacerbated by continuing
cytotoxic treatment (recall phenomenon).19,20

The cytotoxic drug may persist at the site of extravasation
for many months after the initial trauma.21

The sites involved are areas of anatomical importance
functionally (the dorsum of the hands, the cubital fossa, and
the forearm) and the fact that the lesions affect subjects already
greatly debilitated by malignant disease, makes treatment
even more complex.
Treatment of Ulcerations
It is the neglect of timely repair that makes rebuilding
necessary.
—Richard Whately
If injury occurs, the patient may develop ulceration with a
raised, red, painful edge and a necrotic yellow base. These
ulcers lack granulation tissue and there is very little peripheral
epithelial ingrowth. They do not heal and tend to increase in
size and depth.

In patients with ulcerations due to anthracycline extra-
vasation, two surgical approaches are possible. One surgical
treatment option is to perform early extensive surgical
debridement within 24 hours to 1 week after extravasation
with delayed closure of the wound. Pain is an indication for
immediate surgery. The extent of surgery may be determined
by fluorescence microscopy. Excision of all fluorescence-
positive tissues leads to less late sequelae when performed
within seven hours. The wound may be temporarily covered
with a biological dressing. Once the wound is clean, a delayed
application of a skin graft (split-thickness) may be applied
after two to three days (Figures 15 and 16).

Chapter 29
Chemo-Extravasation: Medical and Surgical Management 
345

Most surgeons opt for a conservative approach since only
one third of vesicants will give rise to ulceration. However,
continued swelling, erythema and pain without ulceration,
persisting after conservative therapy or the presence of large
areas of tissue necrosis or skin ulcerations are indications for
surgery. In this case, surgery is usually performed two to three
weeks after extravasation.

All subjects need wide excision of necrotic tissue. This
is not easy to standardize in terms of margins of excision
and clearance of tissue, but is fundamental for a successful
reconstruction. Initially, the drugs often spread around the
lesion and deeply without clinical signs, so incomplete removal
of all the affected tissue can compromise a good reconstruction.

When choosing the type of reconstructive procedure, one
must consider that cytotoxic drugs reduce the ability of tissues
such as tendon sheaths, nerves, and large vessels to regenerate.
They may allow a conservative excision of necrotic tissue that
in some cases permits a simple reconstructive technique using
partial thickness skin grafts. Deep structures are often affected
and flaps are required. Some authors consider the use of grafts
as the gold standard.22

In other cases it is necessary to use different flaps, making
the choice after careful evaluation of the extension, site, and the
state of the lesion. Often, the choice of the flap is also dictated
by the perilesional vascular anatomy, and it is common to find
that it has been compromised by previous cytotoxic drugs or
previous extravasation. Where the ulcers are located distally
and on the dorsum of the hand, the distally based radial artery
forearm flap is a useful option for repair, having the advantage
of a single operative field, short duration of operation, and
good coverage (Figures 17 and 18). Sometimes the radial
flap is not available and it is therefore necessary to use
Figure 15: Extravasation ulcer excised and bed prepared for grafting
Figure 16: Extravasation ulcer covered with skin graft
Figure 17: Adriamycin extravasation, 2 weeks debridement of all
necrotic tissues done
Figure 18: The defect in Figure 17 reconstructed with distally based
radial artery forearm flap the donor and recepient site of flap are
available locally

Section 3
  Types of Wounds and their Management
346
Figure 19: Chronic extravasation ulcer in the upper arm
Figure 20: Local limberg flap used to cover the defect in a chronic
extravasation ulcer. Note that the treatment was not just limited to
covering the defect but it also entailed excision of chronic fibrotic
necrotic tissue which had resulted in flexion contracture at the elbow.
A satisfactory functional gain is also achieved thereby
Figure 22: Secondary extensor tendon reconstruction were also
done after giving a free flap cover over dorsum of hand
Figure 21: Free radial artery forearm flap from contralateral forearm
used to reconstruct an extensive dorsum of hand extravasation
microsurgical flaps such as a free contralateral radial forearm
flap, free serratus flap, free anterolateral thigh flap or gracilis
muscle and skin graft (Figures 18 to 22). The possibility of
free tissue transfers in such cases should be considered only
after establishing that no vascular compromise to the limb
may ensue if the recipient vessel is used to perfuse the flap
and that its inadvertent loss may not be detrimental. This is an
important consideration knowing that perivascular anatomy
may undergo extravasation damage (Figure 5).

It is, therefore, comprehended that the approach to an
extravasation ulcer must be similar to that to ulcers caused
by radiotherapy. Extravasation lesions, like radiation ulcers,
are notable because they progress rather than resolve
spontaneously, they involve peripheral structures, they reduce
vitality of tissues not apparently involved in the lesion, they
are deep, and often affect structures of functional importance.
Because of these clinical characteristics, the indication for the
use of the grafts is notably reduced. The use of flaps with their
own vasculature allows clearing of the area, reintegration
of the tissue, and supplies sufficient covering to protect the
deep layers. This technique is therefore the first choice for
the resolution of these ulcers. Once extravasation ulcers are
established, the intervention must be done quickly to prevent
the damage becoming chronic with possible functional

Chapter 29
Chemo-Extravasation: Medical and Surgical Management 
347
compromises (Figure 23). A specific single technique to treat
these ulcers does not exist, and there are a number of techniques
from which a choice can be made based on surgical preference
and clinical evaluation in each case. It should not be forgotten
that extravasation ulcer per se is an entirely new disease entity
and that the treatment options are still evolving.23
Acknowledgment
This chapter is dedicated to the memory of Dr Himesh Gupta,
Pediatric Surgical Oncologist and Vascular Access Specialist,
whose illustrious carreer was cut short in a fatal car accident,
on 22nd April, 2011.
References
1. Schrijvers DL. Extravasation: a dreaded complication of
chemotherapy. Ann Oncol 2003;14(Suppl 3):iii26–iii30.
2. Luedke DW, Kennedy PS. Histopathogenesis of skin and
subcutaneous injury induced by adriamycin. Plast R constr
Surg 1979;53:463-5.
3. Schulmeister L. Extravasation management. Semin Oncol
Nurs 2007;23:184-90.
4. Larson DL. Treatment of tissue extravasation by antitumor
agents. Cancer 1982;49:1796-9.
5. Seyfer AE, Solimando DAJ. Toxic lesions of the hand associated
with chemotherapy. J Hand Surg [Am] 1983;8:39-42.
6. Thakur JS,Chauhan JS, Diwana VK. Extravasational side
effects of cytotoxic drugs. Indian J Plast Surg 2008;41:145-50.
Figure 23: Good functional result achieved
7. Wengström Y, Margulies A. European Oncology Nursing
Society Task Force: European Oncology Nursing Society
extravasation guidelines. Eur J Oncol Nurs 2008;12:357-61.
8. Polovich M, Whitford JM, Olsen M. Chemotherapy and
biotherapy guidelines and recommendations for practice, edn
3. Pittsburg, PA: Oncology Nursing Society; 2009.
9. Langer SW. Treatment of anthracycline extravasation from
centrally inserted venous catheters. Oncol Rev 2008;2:114-6.
10. Mouridsen HT, Langer SW, Tjoernelund J, et al. Anthracycline
extravasation in breast cancer patients. Effective treatment
with dexrazoxane in three multicenter trials [abstract]. Eur J
Cancer 2008;(Suppl)6:197.
11. Bertelli G,Dini G, Forno B G, et al. Hyaluronidase as an
antidote to extravasation of vinca alkaloids. Clinical results. J
Cancer Res Clin Oncol 1994;120:505-6.
12. Laufman LR, et al. Liposomal doxorubicin extravasation.
Commun Oncol 2007;4:464-5.
13. Damert HG, Lenz-Scharf O, Altmann S, et al. [Soft-tissue
defects on the dorsum of the hand by extravasation of the
cytostatic agents: surgical options of treatment]. Handchir
Mikrochir Plast Chir. 2007;39:409-13.
14. Scuderi N, Onesti MG. Antitumor agents: extravasation,
management, and surgical treatment. Ann Plast Surg.
1994;32:39-44.
15. Heitmann C, Durmus C, Ingianni G. Surgical management
after doxorubicin and epirubicin extravasation. J Hand Surg
[Br] 1998;23:666-8.
16. Gault DT. Extravasation injuries. Br J Plast Surg 1993;46:91-6.
17. Steiert, U. Hille, W. Burke Journal of Plastic Reconstructive
and Aesthetic Surgery (2010) xx, 1e8.
18. Napoli P, Corradino B, Badalamenti G, et al. Surgical treatment
of extravasation injuries. J Surg Oncol 2005;91:264e8.
discussion 268e9.
19. Telisselis P, Heers G, Plock B, et al. Emergency open surgical
treatment of extravasations of cytostatic agents in the upper
extremity. Handchir. Mikrochir. Plast. Chir; 2009 Nov 3.
20. Kjarkegaad K, Chenoufi H, Daugaard S. Fluorescence
microscopic demonstration and demarcation of doxorubicin
extravasation. Cancer 1990;65:1722-6.
21. Larson DL. Alterations in wound healing secondary to infusion
injury. Clin Plast Surg 1990;17:509-17.
22. Sonneveld P, Wassenaar HA, Nooter K. Long persistence of
doxorubicin in human skin after extravasation. Cancer Treat
Rep 1984;68:895-6.
23. Larson DL. What is the appropriate management of tissue
extravasation by antitumor agents? Plast Reconstr Surg
1985;75:397-9.
24. Francesco D’andrea. Surgical treatment of ulcers caused by
extravasation of cytotoxic drugs, Scand J Plast Reconstr Surg
Hand Surg 2004;38:288-2.

• History of Ballistic Injury
• Pathophysiology
• Wounding Mechanism


– Tissue Crushing


– Tissue Cavitation (Stretch)

• Management


– Circulation


– Disability


– Exposure
INTRODUCTION
Gunshot injuries occur when someone is shot by a bullet or
other sort of projectile from a firearm. Peace time gunshot
injuries occur in a variety of different situations—criminal and
terrorist incidents (including shots fired by law enforcement
agents), attempted suicides as well as unintended firearm
‘accidents’ (both civilian and amongst the armed forces).1
Gunshot injuries are a major problem worldwide from the
medical and economic perspectives and are associated with
profound morbidity and significant mortality.
History of Ballistic Injury
The origins of gunpowder manufacture are uncertain.
Although it is historically recognized that the Chinese
invented gunpowder in the thirteenth century, it is believed
that the Muslims of Moorish Spain used combustible powder
in the twelfth century. The use of gunpowder as a propellant
for projectiles began in the early 1300s. Originally, black
powder—a mixture of sulfur, charcoal, and saltpeter
(potassium nitrate) – was used in cannons and then it was used
in a crude type of hand cannon for more than five centuries
until the mid-1800s, when smokeless powder was developed.
Single-based propellant was developed in France in 1885,
and double-based propellant was developed in England
in 1889.

The earliest weapons were muzzle-loaders, in which
powder and projectile were introduced through the muzzle by
a ramrod. Spiral grooves cut on the inside of the gun barrel
(rifling) imparted a spin to the emerging bullet and were first
used in the early 1500s in sporting rifles only, not in military
guns. The introduction of breech loading led to rapid progress
in the development of weapons and ammunition. Over
time, different types of firearms and ignition systems were
developed.
Pathophysiology
The gunshot wounds may vary in size, depth and severity. The
variation in any gunshot wound depends upon a multitude of
factors, viz. 1. characteristics of the bullet, i.e. mass of bullet,
its velocity, whether it fragments or deforms, 2. tissue through
which it travels, 3. the orientation of the bullet between gun
muzzle and body. For any projectile to hit a critical anatomical
structure the result may be fatal. In general, if the missile yaws
early in the path through the tissue then the wound caused
is more severe. The severity is increased if the projectile
fragments and is travelling at a high speed.

It may be surprising but it is a fact that civilian bullets
are more damaging than military bullets fired from identical
configuration. The military bullets by rule are covered with
complete metal jacket (till the tip) unlike civilian bullets, thus
Gunshot Wounds
Deepak Nanda, Thakur Thussu
30
Chapter

Chapter 30
Gunshot Wounds 
349
civilian bullets fragment and deform much more causing more
damage. Military bullets are designated to disable the enemy
sufficiently so that he is incapable for active combat but not to
kill as an injured combatant uses up more enemy resources to
take care of the injured combatant.
WOUNDING MECHANISM2
As mentioned before the characteristics determining the
nature of wound depends upon both the projectile and
tissue characteristics like elasticity, density and anatomic
relationships which influence the outcome of the wound. The
severity of the wound is further affected by the fact whether
the bullet fragments or deforms to a mushroom shaped end as
in case of hollow point (soft part bullet). The projectile bullet
has some characteristics like the mass, shape, construction
and characteristics which are affected by the weapon like
longitudinal and rotational velocity.
Major mechanisms of wounds are:
• Crushing of tissue at the impact point of the projectile
which forms a permanent cavity.
• Radial stretching of projectile path walls forming a
temporary cavity.
Tissue Crushing
Crushing is caused at impact, i.e. when the projectile strikes
the tissue. This creates a permanent cavity. The size of the
cavity is related to the yaw of the projectile. The yaw of any
projectile is the angle between the projectile’s long axis and
its path of flight. If the bullet (projectile) is travelling with its
long axis parallel to its flight path then the yaw is supposed
to be 0 degrees. Then the permanent cavity it creates is in the
form of a tube which has a diameter approximately as wide as
the bullet. If the bullet yaw is at 90°, i.e. the long axis of the
projectile strikes the tissue at 90° then the amount of cavity
is more, up to three times than at 0° yaw. Even at 0° yaw the
soft point or hollow point bullets create more injury because
on impact the tip of the bullet deforms into a mushroom
shape causing more injury because of the widened tip. If the
mushroomed diameter of a bullet is 2.5 times greater than the
initial diameter of the bullet then it causes a crush which is
6.25 times greater than the amount it would have caused if
the bullet was un deformed. If a projectile or bullet fragments
then also the crush increases because the surface area of a
bullet increases and more tissue tends to be crushed. Bullets
usually fragment when they strike a major bone in their path.
When a projectile from a large bore gun (high velocity) strikes
a bone it results in a comminuted fracture of the bone and
bone fragments can act as secondary missiles and crush further
tissue. Majority of hand guns do not have enough power for
the bullet to fragment bone and usually are embedded near the
bone without any exit wound.

Fragmented bullets and other secondary missiles (bone
fragments, coins, dental fillings, teeth, etc.) increase the
severity of the wounds and may cause multiple perforations
which weaken the tissue. More weakened tissues create focal
points of stress which we call stress risers. With multiple stress
risers the tissue is vulnerable to more temporary cavitation or
stretch.

The shorter the barrel length the lower is the speed of the
bullet as shorter time is available for bullet acceleration by
expanded gases created by burning gun powder. When bullet
speed is too low, mushrooming effect is not seen even in the
soft or hollow point bullets. Military full jacket bullets do not
mushroom; they either stay intact or fragment even if fired
at very high velocity. They fragment only when they strike a
hard object like bone.
Tissue Cavitation (Stretch)
The yaw of a bullet is taken care of by the rifle of the bone.
The rotation of bullet due to rifle takes care of the yaw and
if a bullet is fired from a proper weapon the yaw generally
is between 0° to 3° when it is travelling through air. This
yaw cannot be maintained once the bullet hits the tissue as
the resistance of the medium changes. If the bullet does not
deform or impact then the yaw generally changes 180° with
the base of the bullet travelling forward. The damage to tissue
is more as the base is more in diameter but is less than when
the bullet is travelling at 90° yaw in which case the damage to
the tissue is maximum.

As the bullet passes through tissue it moves tissue radially
away from its path. As it keeps moving its wounding potential
is decreased. When tissue is moved away radially from the
path of the bullet, there is temporary cavitation. The maximum
size of this cavitation is created a few milliseconds after
the bullet passes through and the path is very irregular and
unpredictable as the force follows the path of least resistance.

Small handguns produce temporary cavitation of negligible
significance (excepting in tissue like brain and liver) but bigger
hand guns and rifles induce significant temporary cavitation of
10 to 25 cm in diameter. Depending on the tissue, this much of
cavitation can cause significant damage.

Tissue with fluid density and less elasticity (brain,
liver and spleen) and fluid filled organs like heart, bladder,
gastrointestinal tract and dense tissue like bones may be more
severely damaged by temporary cavitation force. Tissues
which have a high elasticity like skeletal muscles, tissue with
low density/high elasticity like lungs are less damaged by
these forces. Although cavitation force has devastating effect
on tissues like brain, liver and spleen the effect in peripheral

Section 3
  Types of Wounds and their Management
350
tissues is often exaggerated. Most cases of vessel injury in
limbs is attributed to cavitation force, which is more likely
to be from the fact that secondary missiles fragment. Like all
blunt traumas the effect of the force is more on the mobile
side if one side is fixed and the other is mobile. Vessel injury
attributed to cavitation force can be most common at the
origin of the vessel.

If a high velocity bullet does not deform, fragment or hit
a bone, it passes through the tissue without causing much
severity specially if it is passing through extremities but causes
more damage when passing through chest and abdomen as
thicker tissue gives more tissue for the projectile to yaw and
cause more damage.

A bullet of similar diameter, if one is heavier and larger,
causes more damage and greater severity of wound. A
projectile is at its maximum velocity when it hits the tissue so
from a small wound at that point, only fragmentation or a yaw
of 90° causes its wounding severity. Bullets are not sterilized
by the heat of firing so they carry the bacteria from the body
surface or organs like colon deeper into the wounds.

A physician treating gunshot wounds should be familiar
with the mechanism of injury so as to treat a wound more
efficiently.
MANAGEMENT3
Make sure of your patient’s safety:

• If a victim is shot by accident make sure the firearm is
cleaned of ammunition.

• If a victim is subject of crime, make sure the criminal is
no longer at the scene.

• Do not move the victim unless it is an absolute necessity.

• Try to see that victim reaches medical facility within the
golden hour period.

• A (airway), B (breathing), C (circulation) and D
(disability) are the critical things to be noted.

• If the patient is unconscious make sure the airway is not
obstructed. If the tongue is the guilty factor then turn
patient to side. If the patient is no taking regular breaths
start CPR.
Circulation
Feel for the pulses—if feeble or absent, start fluids, control
bleeding by direct pressure.
Disability
If the patient cannot move his hands or legs then suspect spinal
cord injury and patient is not to be moved unless fully supported,
only when required. Any other deformities of limbs like fracture,
dislocation should be stabilized before moving a patient.
Exposure
Full exposure is required so that wounds other than the
obvious are not missed.

Control of bleeding is the single most important thing one
can do to save gunshot victim. Applying direct pressure with a
pad is the best way to control bleeding, if pads are not available
even fingers and hand can be used. Pressure points in arm like
elbow, arm pit and groin, popliteal fossa for lower limb can
be used to control bleeding. Treatment for shock due to blood
loss should be started as soon as possible. Applying pressure
to the torso is difficult to control bleeding as ribs do not allow
one to put adequate pressure. Then chemical hemostats like
Celox can be used, if available.

In the chest and back, the wounds may be sucking chest
wounds where air is sucked in and out during each breath.
For such wounds an air tight bandage is applied on three sides
leaving one side open which will help the chest to achieve
usual negative pressure.

Low velocity gunshots cause tissue damage by laceration
and cutting tissues but high velocity gunshots transfer more
kinetic energy to the abdominal viscera.

Investigations
for
intraperitoneal
hemorrhage
and
potential hollow viscous injury include focussed assessment
sonography in trauma (FAST). In experienced hands with
proper equipment its accuracy rate is similar to diagnostic
peritoneal lavage (DPL) or computed tomography. The
advantages are that it is simple, noninvasive, accurate, rapid
and in expensive. After the initial scan, a second control scan
should be ideally done after a 30 minutes interval. DPL is the
second fastest method to identify hemorrhage or potential
for hollow viscous injury, however, it is invasive and has
approximately 98 percent sensitivity for intraperitoneal bleed,
free aspiration of blood, gastrointestinal contents, vegetable
fibers or bile in DPL mandates use of laparotomy. CT is time
consuming and expensive and should be used only in patients
who are hemodynamically stable with no apparent indication
of laparotomy.

Most gunshot wounds of the abdomen are managed by
exploratory laparotomy as incidence of intraperitoneal injury
approaches 90 percent. Gunshot injury to the abdomen most
commonly involve the small bowel (50%), colon (40%),
liver (30%) and abdominal vascular structures (25%). Early
diagnosis and timely treatment of extremity vascular injuries
are essential if limb salvage and limb function are to be
optimized. Careful and repeated clinical examination and
ankle/brachial Doppler indices are pivotal for early diagnosis.4

As far as wounds of chest and torso are concerned, applying
direct pressure to wounds is not ideal to stop bleeding. Ideally
the wound should be sealed with air tight material with air
tight bandages on three sides with the fourth side open. This
allows chest to achieve its usual negative pressure by acting
like a valve. Direct pressure helps in controlling bleeding in

Chapter 30
Gunshot Wounds 
351
face, neck, scalp and limbs. Gunshot injuries to face may
require reconstruction for facial defects created because of
loss of tissue (bone and soft tissue).

This may require local, distant flap or free tissue transfer.
Summary
Gunshot injuries to any part of the body is always present as
a life-threatening situation because of severe bleeding which
can compromise airway, and circulation also. Therefore,
the primary management is following the steps of ABCD
steps of ATLS management. The control of bleeding at any
site is always by direct pressure after exposure of the area.
Reconstruction of any defects can be done secondarily once
the patients stabilizers.
References
1. Naidoo SR. Ballistic trauma, overview and statistics.
2005;5:271-83.
2. Jeremey J, Hollerman, et al. Gunshot wounds: bullets, ballistics
and mechanisms of injury. AJR.1990;155:685-90.
3. Fackler ML. Civilian gunshot wounds and ballistics: dispelling
the myths. Emerg Med Clin North Am. 1998;16:17-28.
4. Modrall JG, et al. Diagnosis and management of penetrating
vascular trauma and the injured extremity. Emerg Med Clin
North Am. 1998;16:129-44.

• Vascular Basis of Reconstruction
• Surgical Modalities
• Flap Selection
• Preoperative Evaluation

– Investigations
• Flap Planning

– Common Flaps and Practical Tips
• Postoperative Care
INTRODUCTION
Nonhealing wounds are those which do not heal by conservative
therapy within six weeks time. The cause of chronicity
varies depending upon the genesis of wounds, its depth,
the involvement of underlying structures and wound care.
However, the basic reason is inadequate circulation. Many a
time’s improper primary handling leads to the complication.
Therefore, all these factors must be kept in mind while
assessing the wounds to plan the future course of management.

The etiologies in order of frequency are trauma, infection,
postoperative dehiscence, electrical burn, secondary to
varicose vein, trophic changes following spinal injury or
peripheral nerve involvement. Majority of the road traffic
accident victims with bony and soft tissue injuries attend in
orthopedics. Their main emphasis remains maintenance of
skeletal structure. The soft tissue remains under assessed and
either sutured under tension or left open. Sometimes, foreign
bodies are not adequately cleaned. Later after few weeks or
months the patients are referred to reconstructive surgeon.
This leads to enormous functional, sociopsychological and
economical burden to the patient. Therefore, many a times
such situation can be avoided if a combined team approached
is adopted during the primary management.

Whatever may be the reason, a nonhealing wound is
assessed by what tissue constituents are lost and what
structures are exposed. The final dimension is found after
wound debridement. The structures exposed could be bones
and joints, tendons, hard wear used for fixation of bones
or their may be bony gap to be reconstructed later. The
reconstructive requirement varies with the dimension of the
wound, contour, site and whether in nonweightbearing or at
weightbearing area of the lower limb. Local tissue is always
preferred and therefore, condition of the adjacent region is
evaluated. It is of paramount importance as locoregional flaps
of different constituents can be planned depending upon the
requirement of the wound. Nowadays, the resurfacing can be
done with combination of tissues constituents as their vascular
basis and rationality is better understood.
Vascular Basis of Reconstruction
There are three major vascular axises in the lower limb below
knee, namely: anterior tibial, posterior tibial and peroneal.
Several perforators arise from them which course either
through muscles or through septa to reach the deep fascia.
Therefore, they are named as musculofascial or septofascial
perforators. They fan out on the under surface of the deep
fascia to form the subfascial plexus. Then they perforate the
fascia to form the suprafascial plexus.

In the proximal 2/3rd of the limb the musculofascial
perforators dominate and in the distal 1/3rd, the septofascial
perforators dominate as the muscle belly continues with
the tendon. The suprafascial plexus anastomose with the
subcutaneous and then subdermal-dermal plexuses. Thus, the
continuity of all these segments of network is maintained. The
Reconstructive Modalities
of Non-healing Wounds
of Lower Limb
V Bhattacharya, PS Barooah, S Bhattacharya, NK Agrawal
31
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Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
353
plexus formed by the adjacent perforators freely communicate
with each other providing a dense vascular arcade. Therefore,
starting from muscle to skin any constituent alone or in
combination can be transferred as a flap to resurface a defect.
Surgical modalities
The flaps can be of different constituents namely, muscle or
musculocutaneous, fasciocutaneous, sural neurocutaneous,
adipofascial, adipofascial extension of fasciocutaneous flap,
fascial, split fascial, fasciocutaneous extension of adipofascial
flap, expanded fasciocutaneous flap to avoid SSG at the donor
site, tenosynovial flap from the peroneus longus and brevis
muscle. They can be either antegrade flap based on proximal
perforators or retrograde based on distal perforators. All the
flaps can be transferred to the defect in different ways—V-Y
advancement (Figures 1A to E), transposition, rotation, hinged,
tunneled, propeller flap, skeletonized perforator flap and
interpolation flap. Donor site management is also of important
significance. Either it is skin grafted or primarily sutured.
Flap Selection
Selections of an appropriate flap are a major issue as it varies
with the location, nature of defect and future outcome. In
weightbearing areas of foot and sole fasciocutaneous flap is
preferred. The adipofascial and fascial flaps are not preferred
as they will not withstand the pressure and routine wear and
tear during ambulation. In nonweightbearing areas, all types
of flap can be applied. If it is a contour defect, then thicker
flaps (muscle/myocutaneous/fasciocutaneous) are indicated,
e.g. on the proximal tibia and calf area. If it is a shallow
detect, adipofascial flap fulfills the requirement. If the defect
is over shin or distal third of leg, fascial or split fascial
flaps are also indicated. The selection of procedure in this
manner will prevent the necessity of secondary debulking
procedures.

Many a times it will also obviate the use of SSG to the donor
site which can be closed primarily with a linear scar only, e.g.
in adipofascial, fascial and split fascial flaps. Gastrocnemius
and soleus muscle or musculocutaneous flaps can be used for
defects at the upper 2/3rd of the leg. However, it is not preferred
to sacrifice a functional muscle unit in an already traumatized
limb.

Although these are relatively simple procedures of
reconstruction demanding less technical skill as compared
to free tissue transfer by microsurgery, however, one should
realize that meticulous planning and delicate tissue handling
is necessary for the success. Therefore, surgeon should be
well trained and acquainted with the finer details keeping in
mind the vascular basis.
Preoperative evaluation
Consists of clinical evaluation of the defect and the availability
of healthy tissue of required dimension for reconstruction.
While analyzing a wound one should keep in mind its
dimension after debridement. The wound is prepared with
Figures 1A to E: V-Y advancement flap for mid-leg defect
A
B
C
E
D

Section 3
  Types of Wounds and their Management
354
regular antiseptic lotion/saline to make it free of infection.
The flap is planned either from the adjacent area or from the
neighboring zone. This is decided by examination of the tissue
and investigations. The tissue feeling of the surgeon comes
by experience which helps in deciding the condition of the
donor site.
Investigations
They are directed to:
• The defect in the form of wound culture and radio-
diagnosis to evaluate the condition of the bone. If there is
devitalized soft tissue, sequestrum or foreign body, it needs
to be removed. Otherwise they will pose problem with the
flap healing and thereafter.
• Assess the vascularity, specially the integrity of the
perforators. In many occasions, the perforators adjacent to
the defect is also damaged although apparently the tissue
may look healthy. The tissue may be indurated indicating
damage to one or more segments of the vascular network.
In all such situation the flap may not survive. Hence, the
flap may be harvested from the neighboring healthy areas
safely.
Assessment of perforator can be done by:
• CT angiography
• Color Doppler
• Audio Doppler.

By far audio Doppler is the most commonly used practical
method to locate the perforators, on which the flap is planned.
CT angiography provides clear picture of the whole vascular
tree including caliber, site and direction of the perforators.
Color Doppler, in addition, provides the caliber of their
internal diameter. It is important as the perfusion pressure is
directly proportional to their internal diameter. The perfusion
pressure ultimately decides the dimension of the flap that is
perfused by incorporating these perforators.
Flap planning
Every flap requires a meticulous planning in accordance with
the dimension of the defect and dynamics of tissue transfer. One
should always do a “planning in reverse”. In experienced hand it
takes few minutes. One should realize that the transfer of tissue
varies significantly depending upon the constituent of flap,
mode of transfer, vascularity and pliability of tissue. Ultimately
the flap should be appropriate to the need of the defect.
Common Flaps and Practical Tips

a. In case of composite flap, e.g. fasciocutaneous, the
margins are incised 1 cm beyond the prior flap marking
done after “planning in reverse”. The incision should be
bevelled especially where multiple tissue constituents
are incorporated. This allows all the layers to fall in one
plane at the margin. Subsequently, they are kept together
as one unit by interrupted 3/0 chromic catgut stitches.
This prevents shearing movement between individual
tissue planes while dissecting and transfer of the flap.
Thus, the composite vascular network is preserved
allowing free flow of blood without interruption.

  From the initial suspicion about their clinical utility
to a standard technique in the armamentarium of a
reconstructive surgeon, fasciocutaneous flaps have
come a long way. Constituent wise, fasciocutaneous
flaps are those, which include skin, subcutaneous tissue
and the deep fascia. The majority of moderate size
defects extending from knee to sole can be reconstructed
by these procedures. In contrast to earlier beliefs,
fasciocutaneous flaps have a definite vascular system, a
suprafascial plexus and a subfascial plexus anastomosing
with the subcutaneous and subdermal plexi. Direct
cutaneous, musculocutaneous and septocutaneous
perforators contribute to these plexi. For defects from
knee to upper two-third of leg, antegrade flaps either
based on the perforators arising from posterior tibial
artery (on medial side) or flaps from anterolateral aspect
based on the perforators of the peroneal artery are used.
These flaps are transposition-cum-rotation in nature
(Figures 2A and B). The defects at lower third of leg to
midsole will require retrograde flaps based on the lower
perforators of the above mentioned vascular trunks
(Figures 3A to F). It is essential to incorporate two
Figures 2A and B: Antegrade fasciocutaneous flap for middle-
third defect
A
B

Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
355
to three sizeable perforators in the pedicle, to ensure
necessary blood supply, irrespective of the nature of the
flap. That is how a non-conventional long flap can be
designed with safety.

b. Adipofascial flaps are usually defect based hinged
flap. Two aspects need care: (1) The donor site skin is
undermined with two to three fat globules under the
dermis to protect the subdermal plexus. This prevents
marginal desquamation of the sutured donor site, (2) It
should be a gentle hinge to prevent kinking. A temporary
rubber catheter at the base of the flap is a simple measure
to achieve safety. An adipofascial flap has several
advantages, e.g. minimal donor site morbidity, greater
mobility, more refined reconstruction, it provides a
good gliding surface for the tendons and avoids hair
bearing skin transfer. The adipofascial flap is comprised
of subcutaneous tissue and deep fascia. When the skin
is removed from the fasciocutaneous flap, it becomes an
adipofascial flap. Thus, it will incorporate two plexuses
less than that of a fasciocutaneous flap, i.e. dermal and
subdermal plexuses, and only the vascular networks
associated with the deep fascia and the subcutaneous
tissue supply this flap. A skin graft is applied on the
subfascial surface of the transferred flap as the flap is
usually hinged, and the donor site is closed primarily.
We prefer the skin graft on the subfascial surface of
the flap which has rich vascularity. Such flaps can be
either antegrade based on proximal perforators (Figures
4A to C) or retrograde based on distal perforators
(Figures 5A to D). The adipofascial flap is the flap of
choice on many occasions as it has several advantages
namely: (1) it provides well vascularized tissue over
exposed structures, (2) it is a thin flap and thus, does
not look bulky, (3) dissection is easy, (4) it is reliable
and durable, (5) postoperative management is simple,
(6) it provides a good gliding surface for tendons,
Figures 3A to F: Defect over heel extending up to midsole reconstructed by retrograde fasciocutaneous
flap based on the lower posterior tibial perforators
A
B
E
F
D
C

Section 3
  Types of Wounds and their Management
356
(7) there is minimal donor site morbidity with a linear
scar, (8) nonhairy tissue is transferred, (9) no major
vascular trunk is sacrificed, (10) this does not require
any special training or setup, (11) it can be transferred in
various ways, and (12) the option for free flap remains
open.

c. Although
one
should
incorporate
predopplered
perforators at the base of the flap, one need not always
visualize them during dissection.

d. In case of propeller flap or skeletonized perforator flap,
a small cuff of tissue should be preserved around the
perforators to provide additional safety. With specific
knowledge of perforators, the fasciocutaneous flap from
the calf area can be transferred to the distal defects in
a single stage based on skeletonized distal perforators.
The flaps are marked and dissected proximal to the
defect skeletonizing the distal perforators under loupe
magnification and transferred to the distal defect in a
single stage (Figures 6A to E). Similar principle can
be adopted for proximal defect based on proximal
perforators. An incision is made on one side of the
proposed flap and is dissected in the subfascial plane
Figures 4A to C: Antegrade adipofascial flap for exposed tibial tuberosity
Figures 5A to D: Retrograde adipofascial flap for exposed tendo-Achilles
A
B
C
A
B
C
D

Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
357
Figures 6A to E: Single stage reconstruction for lower third defect
by skeletonized distal peroneal perforator flap
A
B
C
D
E
towards the axial vessel until the perforators are
found. The presence and position of the perforators
are confirmed at the distal leg from the respective
malleoli. After confirming the perforator’s position,
the incision is completed all around and dissection is
completed to make it an island flap. The perforators are
totally skeletonized under loupe magnification. Then
the flap is transposed to the defect. The survivability
of these unconventional flaps can be explained in
three ways: (1) Adequate perfusion pressure through
the incorporated perforators. This also proves the
importance of the perforators, (2) These perforators
form rich supra- and subfascial plexus at the level of
deep fascia intercommunicating with the supply of
adjacent perforators, (3) These fascial plexuses are
orientated axially, thus making the flap behave like an
axial flap. Hence, it is not only the rich plexus of vessels

Section 3
  Types of Wounds and their Management
358
associated with the fascia, but also their orientation that
is responsible for survival of flaps of 3:1 length: breadth
ratio or more. This is also the basis of perfusion of island
flaps. The prime advantages of these flaps are: (1) Greater
flexibility in rotating the flap with enhanced reach
compared to the peninsular flap, (2) The procedure is
completed in a single stage. However, careful dissection
is necessary in handling the flap and the perforators.
Excessive manipulation may result in perforator spasm
or even their avulsion. Kinking, torsion or pressure
due to hematoma may be detrimental. Even though
skeletonization of a perforator allows the flap to move
freely 180° on either side, care must be taken to avoid
kinking and torsion of the vessels by not over-stretching
the flap while insetting. With such careful handling,
these flaps have proved to be very useful for resurfacing
defects especially of the distal leg and foot.

e. Distally based fasciocutaneous or musculoneuro-
fasciocutaneous sural flaps with neuroadipofascial
pedicled is one of the popular flap for reconstruction of
distal limb defect. The flap is perfused by two sources:
neurocutaneous arteries from the supramalleolar
vascular network as well as distal septocutaneous
perforators of the peroneal artery. The proximal edge
of the flap is usually about 8 cm from the popliteal
crease, and the lateral edges do not extend beyond the
lateral border of fibula and medial border of the tibia.
Incision is made up to the fascia and the dissection is
continued underneath it preserving the sural nerve.
The flap is transferred to the defect as an island flap
with neuroadipofascial pedicle (Figures 7A and B).
The constituents of the pedicle are sural nerve, median
superficial sural artery, its accompanying arterial
branches and the lesser saphenous vein. The distal
dissection is up to 5 cm above the lateral malleolus to
avoid injury to the perforators. That is the pivot point
of the flap. Flap is used to resurface the Achilles tendon
injuries and concomitant complex soft tissue defects,
heel defects, defects around ankle and the distal tibia.

  Advantages of this flap are: (1) Long pedicle enables a
great arc of rotation, (2) No sacrifice of any major artery,
(3) Surgical procedure is relatively short, (4) Donor site
can be primarily closed for smaller flaps, (5) Suitable for
patients even with an external fixator.

f. Adipofascial extension of fasciocutaneous flap is a
useful method to fill the moderate size contour defects.
Fasciocutaneous flap with adipofascial extension is a
technique utilizing principles of both fasciocutaneous
flap and adipofascial flap for moderate size contour
defect fulfilling the requirements. In selective situation
where there is contour defect of moderate size with
uninfected bed, a fasciocutaneous flap with adipofascial
extension is a suitable choice (Figures 8A to D). To
raise the adipofascial extension a lazy ‘S’ skin incision
is made from the middle of the distal margin of the
proposed fasciocutaneous part. The skin is undermined
keeping two globule of subcutaneous fat to protect
the subdermal plexus. The distal incision is deepened
through the subcutaneous tissue and deep fascia.
The required adipofascial flap is raised by dissecting
between deep fascia and muscle tills the distal margin
of the fasciocutaneous unit. Then the two lateral skin
incision of the fasciocutaneous flap are given and the
flap is elevated in continuity up to the required length.
The adipofascial extension part is gently folded under
the distal fasciocutaneous unit and secured by few
marginal catgut stitches. The flap is then transferred to
the defect and skin margins are sutured. The donor site
of the adipofascial extension is closed primarily with a
drain and that of the fasciocutaneous unit is skin grafted.

g. Fascial flaps are chosen for noncontoured defects, e.g.
over shin of tibia, exposed tendo-Achilles, distal tibia,
etc. A fascial flap of a smaller dimension can be used
as a random pattern defect based hinge flap. When one
or two sizable perforators are incorporated in the base,
larger flaps can be safely used. A skin graft is applied
on the subfascial surface of the transferred flap and the
donor site is closed primarily. For reconstruction of
moderate size defects, a turnover fascial flap is a simple
and reliable method. The flap is horizontally hinged with
Figures 7A and B: Sural neurofasciocutaneous flap for heel defect
A
B

Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
359
a vertical base for midtibial defect (Figures 9A to E). The
flap is distally based and hinged for defect on the distal
leg, around the ankle and tendo-Achilles (Figures 10A
to E). Audio Doppler study and prior marking of the
perforators are useful for planning. However, it is not
necessary during dissection to visualize the perforators
incorporated at the base of the flap. The maximum safe
length of the distal perforator based flap is 14 cm. In
case of a random flap the length is about 8 to 10 cm
depending upon the length of the base. The fascial
flap can be considered as the flap of choice on many
occasions as it has several advantages namely:

• It provides a well vascularized tissue over exposed
structures.

• It is a single stage procedure.

• It is a thin flap, which ideally fulfills the requirement.

• Dissection is easy and operating time is less.

• It is reliable and durable.

• It provides a good gliding surface over the tendons.

• It can be easily tailored according to type and location
of the defect.

• It can be transferred in various ways.

• Postoperative management is simple.

• There is minimal donor site morbidity with a linear
scar only.

• No major vascular trunk is sacrificed.

• It does not require any special training or setup.

• Nonhairy tissue is transferred.

• The option for free flap remains open. This procedure
provides gratifying results in majority of moderate
dimension lower limb defects at nonweight-
bearing areas. It meets most of the requirements of
reconstruction in a single stage. Therefore, whenever
feasible this simple method is justified. The only
prerequisite is availability of the healthy tissue
of required dimension adjacent to the defect and
undamaged perforators.

h. A distally based tenosynovial sheath of peroneal
tendons is used as a flap with skin graft to cover
the exposed tendo-Achilles. The flap has a reliable
blood supply being perfused by a constant sizeable
musculofascial perforator. The flap is used to cover the
exposed Achilles tendon, the malleoli and anterior ankle
defect. The flap is thin, provides good gliding surface,
and has minimal donor site morbidity, is technically
simple and easily accessible. This flap has proved to
be durable and another very versatile technique to
cover the tendo-Achilles and tendons around the ankle
(Figures 11A to E). The peroneus longus arises from
the upper two-thirds of the lateral surface of the fibula.
It overlaps the peroneus brevis which arises from the
lower two-thirds of the same surface. Both the muscles
descend with the longus being superficial to reach the
posterior surface of the lateral malleolus. These tendons
are enclosed by a common tenosynovial sheath, which
is the main constituent of the flap. The flap is transferred
to the defect, either by transposing or by tunneling it
subcutaneously. The retrograde tenosynovial flap, being
a tendon sheath, meets all the criterias of tendon cover
and hence is the appropriate choice. Being deep to the
deep fascia, the flap tissue remains protected in trauma
of moderate severity. Apart from resurfacing, the inner
lining provides functional synovium which helps in
gliding and simultaneously enhancing nutrition to the
tendon to promote tendon healing.

i. The SSG should be thin and perforated when applied
over adipofascial flap, fascial flap, split fascial flap or
tenosynovial flap.

j. Whenever a flap is moved more than 90° over a pivot point,
acute twist should be prevented. This can be achieved by
raising a little longer flap or by narrowing the pedicle
towards the perforators along the main vascular axis.

k. Avoid suturing under tension by adequate dissection
and transfer.
Figures 8A to D: Adipofascial extension of fasciocutaneous flap for contour defect at knee
A
B
C
D

Section 3
  Types of Wounds and their Management
360

l. A drain under the flap and firm dressing prevents
hematoma and adds to the well being of the flap.
m. Low molecular dextran infusion, during flap dissection
and for two days postoperatively, as an adjuvant therapy,
is beneficial.
PostOperative Care
It is as important as surgery. The flap needs to be inspected
everyday, at least the distal most part. The things that are to
be ensured are:
• Light dressing.
• Avoid pressure over pedicle.
• Limb to be kept elevated by 20 to 30°.
• Stitches are removed around 10 to 12 days.
Instructions to the Patient during Follow-up
• Keep the flap clean to prevent infection
• Keep it moist by use of moisturizer
• Protect from trauma
• Inspect twice a day
• Explain that different types of sensations will appear after
at least six months starting with protective sensation.
Therefore, till then one has to be careful.
• Use soft sole shoes in case of flaps on the ankle, dorsum of
foot, on the heel and sole.
Figures 9A to E: Random pattern fascial flap for
mid shin defect with 6 months follow-up
A
C
B
D
E

Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
361
• Visit for monthly check-up for first six months and three
monthly for two years.
During Evaluation
• The functional and aesthetic aspect is considered both for
the recipient and donor sites.
• Hospital stay is calculated.
• Expenditure in calculated.
Conclusion
Chronic nonhealing wounds of lower limb of different
etiologies pose significant challenge to the reconstructive
surgeons. It is important to choose the appropriate procedure
of resurfacing keeping in mind the nature and location of the
defect. Adequate understanding of vascularity and meticulous
execution is the key to the long-term success. The loco-
regional flaps of different constituent are of enormous value
and popular in managing moderate size defects.
Figures 10A to E: Predopplered posterior tibial
perforator based fascial flap for lower third defect
with 6 months follow-up
A
C
B
D
E

Section 3
  Types of Wounds and their Management
362
Figures 11A to E: Post-traumatic exposed tendo-
Achilles resurfaced with retrograde tenosynovial
flap and split skin graft
ACKNOWLEDGMENT
The authors like to acknowledge Dr Shipra Bhattacharya,
PhD (English) for correcting the manuscript.
Bibliography
1. Bhattacharya V, Arora R. Fasciocutaneous flap with
adipofascial extension in contour defects of leg. Ind J Plast
Surg 2002;35:70.
2. Bhattacharya V, Deshpande SB, Watts RK, et al. Measurement
of perfusion pressure of perforators and its correlation with
their internal diameter. Br J Plast Surg. 2005;58:759-64.
3. Bhattacharya V, Goyal Sunish, Adil BS. Reconstructive
implications of adipofascial flaps in limb defects. Eur J Plast
Surg 2007;30:169-75.
4. Bhattacharya V, Reddy Ganji Raveendra, Goyal Sunish, Bashir
Sheikh Adil. Distally based tenosynovial sheath flap of peroneal
tendons for exposed tendo-Achilles: Preliminary report of five
cases. Journal of Plastic, Reconstructive and Aesthetic Surgery
2007;60:1204-7.
5. Bhattacharya V, Reddy Ganji Raveendra, Goyal Sunish,
Kumar Umesh. Skeletonised retrograde distal perforator
island fasciocutaneous flaps for leg and foot defects. Journal of
Plastic, Reconstructive and Aesthetic Surgery, 2007;60:892-
7.
A
B
C
D
E

Chapter 31
Reconstructive Modalities of Non-healing Wounds of Lower Limb 
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6. Bhattacharya V, Watts RK. Ipsilateral fasciocutaneous flaps for
leg and foot defects. Ind J Plast Surg. 2003;36:30-5.
7. Bullocks JM, Hickey RM, Basu CB, Hollier LH, Kim JY.
Single-stage reconstruction of Achilles tendon injuries and
distal lower extremity soft tissue defects with the reverse sural
fasciocutaneous flap: Journal of Plastic, Reconstructive and
Aesthetic Surgery. 2008;61:566-72.
8. Carriquiry C, Costa A, Vasconez LO. An anatomic study of the
septocutaneous vessels of the leg. Plast Reconstr Surg. 1985;
76:354-61.
9. Cormack GG, Lamberty BGH. The fasciocutaneous system
of vessels. The Arterial Anatomy of Skin Flap. Churchill
Livingstone, 1986.
10. Enrique Vergara-Amador. Distally-based superficial sural
neurocutaneous flap for reconstruction of the ankle and foot
in children: Journal of Plastic, Reconstructive and Aesthetic
Surgery. 2009;62:1087-93.
11. Haertsch PA. The blood supply to the skin of the leg. A post-
mortern investigation. Br. J. Plast Surg. 1981;34:470-7.
12. Lee S, Estella CM, Burd A. The lateral distally based
adipofascial flap of the lower limb. Br J Plast Surg. 2001;54:
303-9.
13. Lees V, Townsend PLG. Use of pedicled fascial flap based on
septocutaneous perforators of the posterior tibial artery for
repair of distal lower limb defects. Br J Plast Surg. 1992;45:141.
14. Lucian Fodor, Zvi Horesh, Alexander Lerner, et al. The distally
based sural musculoneurocutaneous flap for treatment of
distal tibial osteomyelitis: Plastic and Reconstructive Surgery.
2007;119:2127-36.
15. Ponten BC. The fasciocutaneous flap: its use in soft tissue
defects of the lower leg. Br J Plast Surg. 1981;34:215.
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Plast Surg. 1987;40:113-41.

• Surgical Anatomy
• Reconstruction of Foot Defects

– Weight Bearing Heel and Midplantar Area

– Non-weight Bearing Heel, Malleoli and
Achilles Tendon Area

– Distal Plantar Area

– Extensive Foot Defects
• Sensory Recovery of Sole after ­Reconstruction
Introduction
Human foot supports the body in upright position and provides
the vital interface between body and ground during locomotion.
For the foot to subserve these functions it must have the
arches, joints, skin and sensation intact. Reconstruction of
foot defect has always been challenging owing to the unique
skin requirement and stress of ambulation taxing the result of
reconstruction. Moreover sensation is a prime requirement for
any reconstructive modality to be successful.
Surgical anatomy
Skin of the sole is unique as epidermis has thickest stratum
cornium and deep epidermal ridges firmly attach it to the
dermis. On the contrary the dorsal skin is thin and mobile
facilitating easy gliding of extensor tendons. The subcutaneous
tissue is minimal on the dorsum. The subcutaneous tissue
is well developed in the sole and is compartmentalized by
fibrous septae. These fat cushions act as buffer against vertical
pressure and the fibrous septae prevent shearing by tethering
the skin to the underlying bone. Deeper to the subcutaneous
fat layer is plantar aponeurosis, a tough triangular structure
which fixes and adds stability to the sole skin and maintains
the longitudinal plantar arch. The intrinsic muscles of the sole
lie deep to the aponeurosis and are arranged in four layers.
From reconstructive point of view the muscles of the first layer
are important as the neurovascular bundle lie either deep to or
in between them. The foot is perfused by the vessels of all
the three compartments of the leg, i.e. anterior tibial, posterior
tibial and peroneal arteries and they from a rich anastomosis
around the ankle. The principle supply to the dorsum is from
the anterior tibial artery which gives out anterior medial
malleolar and anterior lateral malleolar branches at the ankle
and continues as dorsalis pedis artery. Dorsalis pedis artery
gives lateral tarsal, medial tarsal, arcuate and first dosal
metatarsal arteries. The dorsal arterial network is classically
formed by lateral tarsal and arcuate arteries. The second to
fourth dorsal metatarsal arteries arise from the lateral arcuate
arteries. The terminal branch of dorsalis pedis artery, the first
dorsal metatarsal artery merits a special mention owing to its
variation of course. The artery can course dorsal to, within
or deep to the first interosseous space. The primary supply
to the sole is the posterior tibial artery which courses into
the foot deep to the flexor retinaculum. It gives the calcaneal
branch which pierces the retinaculum and supplies the skin
over the tendo-Achilles and heel. In the sole the posterior
tibial artery courses under the abductor hallucis and divides
into the lateral and medial plantar arteries. The former is the
dominant among the two, run lateral to the lateral plantar
nerve coursing between flexor digitorum brevis and flexor
digitorum accessorius and ultimately joins the dorsalis pedis
Foot Defects
Sameek Bhattacharya, Ashish Rai
32
Chapter

Foot Defects 
Chapter 32
365
artery to form the plantar arch. The medial plantar artery runs
lateral to the nerve coursing between the abductor hallucis and
flexor digitorum brevis. The cutaneous blood supply of the
sole has been demarcated in four arterial zones by Hidlago.1
These are:

Zone 1: proximal plantar area

Zone 2: midplantar area

Zone 3: lateral foot

Zone 4: distal foot.

Zone 1 extends till half way between heel and metatarsal
heads and is supplied by the proximal plantar subcutaneous
plexus (PPSP). The PPSP is a rich plexus of the dorsalis
pedis arterial branches which wrap around the sides of
the foot anastomoting with the branches of lateral plantar,
medial plantar, medial calcaneal artery and lateral calcaneal
arteries. Zone 2 overlies distal two-third of plantar fascia and
is supplied proximal to distal by PPSP, medial and lateral
plantar arteries and branches of plantar arch. Zone 3 overlies
the lateral aspect of middle one-third of plantar fascia and
is supplied by branches of dorsalis pedis and lateral plantar
artery. The part of forefoot distal to plantar fascia is designated
as zone 4 and is supplied by platar metatarsal arteries from
the platar arch. The musculocutaneous perforators to the sole
emerge mainly from abductor hallucis and abductor digiti
minimi. Medial plantar nerve a branch of tibial nerve courses
through the tarsal tunnel and lies deep to abductor hallucis and
divides into medial and lateral division. The medial division
courses suprafacially medial to plantar fascia and supplies the
instep skin curving around the edge of the fascia. The lateral
division courses sub-fascially and gives webspace branches.
The lateral plantar nerve also a branch of tibial nerve courses
under the flexor digitorum brevis. It divides into a deep motor
division and a superficial sensory division which supplies the
lateral one-third of sole and the last webspace.
Anatomical Consideration in Planning
­Reconstructive Procedures
The plane of dissection of any flap in sole can be subfascial
or suprafascial. If a fasciocutaneous flap is raised the plane
is superficial to oscalci and flexor digitorum brevis including
either the medial or lateral plantar artery. On the other hand
a musculocutaneous flap is raised deep to flexor digitorum
brevis and lateral or medial plantar artery. The skin flaps are
raised in the suprafacial plane superficial to plantar fascia
which are supplied by ppsp which supply the flap via dorsal
circulation by the wrap around branches of dorsal pedis artery.2
While raising a skin flap care must be taken in the medial
side because the branches of the medial plantar nerve courses
obliquely. But it is safe on the lateral side as the lateral plantar
nerve branches course vertically. While planning incisions
on the sole the cutaneous nerve territories must be respected.
The oblique line anterior to the heel is distal to the medial
calcaneal nerve territory and the flaps should not be laterally
based. The longitudinal incision bisects the medial and lateral
plantar nerve territory. The skin overlying the plantar fascia is
nerve free zone as the nerve branches emerge from the sides
of the fascia. The distal incision line is 3 cm proximal to the
metacarpal heads and respects the webspace branches and
keeps the toes sensate.2
Reconstruction of foot defects
The ideal end point of foot reconstruction is restoration of
sensation, stability and appearance. Reconstruction of foot
is always challenging because the sole skin is unique and
cannot be substituted and restoration and preservation of
sensation is an important factor. Moreover any reconstructive
effort faces the stress of ambulation and weight bearing.
Before planning the reconstructive options it is important to
evaluate the defect. It is imperative to assess extent of the
defect, the structures exposed, skeletal and arch integrity,
vascular status, sensation and chronicity. The extent of the
defect especially in case of traumatic defects is best assessed
by Hidalgo’s classification.

Type I:
Limited soft tissue injury

Type II: Major soft tissue loss with or without distal
amputation

Type III: Major soft tissue loss with an open fracture of
the ankle, calcaneus or distal leg.

The extent of the defect should be evaluated in relation to
the weight bearing areas of the foot. The nature and urgency
of reconstruction also depends upon the structures exposed.
Exposure of vital structures like tendon, nerves and vessels
needs emergent attention. As a rule more distal foot defect
need free flaps and proximal defects can be managed by local
or regional flaps. The timing of reconstruction is generally
governed by the condition of the wound and its chronicity.
Fresh traumatic wounds can be debrided and reconstructed
either immediately or secondarily. Subacute wounds can be
grafted and definitive reconstruction can be done later in a
stable and non-infected setting. Chronic wounds especially
of the weight bearing sole needs additional assessment
of sensation, arches, bony abnormalities and gait before
embarking on reconstruction.

Reconstruction options of the foot are grouped in four
functional zones:1
1. Weight bearing heel and midplantar
2. Non-weight bearing heel and distal malleoli and Achilles
tendon area
3. Distal plantar
4. Extensive foot defects

Types of Wounds and their Management
Section 3
366
Reconstruction Options of Weight Bearing
Heel and Midplantar Area
The best reconstructive modality for this area are local flaps
which utilizes sensate like tissues.
Skin Flaps
The vascular basis of skin flaps of the sole is the proximal
plantar subcutaneous plexus, which is fed by wrap around
branches of dorsalis pedis artery. The flaps are sensate supplied
by lateral or medial plantar nerves. The flap is generally
medially based, extends laterally just short off the lateral edge
of plantar fascia and distally extends 3 cm proximal to the
metatarsal heads. The flap is elevated superficial to the plantar
fascia and rotated posteriorly to cover heel defect.3,4
Medial Plantar Artery Based Flap
This is fasciocutaneous flap based on the medial plantar artery
and its fasciocutaneous perforator to the instep skin. The flap
centered on a line joining the center of the heel and the medial
sesamoid of great toe. This line corresponds to the medial edge
of the plantar aponeurosis and the perforators emerge along it.
Proximally the skin paddle is till the heel crease and the distal
extent till 3 cm proximal to the metatarsal heads. The flap is
marked as an island and the dissection commences distally and
the medial plantar artery is identified, divided and included in
the flap. The dissection courses proximally in a fasciocutaneous
plane including the septum between abductor hallucis and
flexor digitorum brevis along with the fasciocutaneous
perforator. After the whole island is elevated the medial plantar
artery is dissecting till its origin from posterior tibial artery.
This flap is made sensate flap by including the branch to the
instep skin by dissected intraneurally from the medial plantar
nerve. The flap is interpolated posteriorly to cover the defects
on heel (Figures 1 and 2).2,5
Lateral Plantar Artery Based Flap
This flap is based on the fasciocutaneous and musculocutaneous
perforators of lateral plantar artery. The flap is planned on a line
joining the calcaneum and the base of the 5th metatarsal which
corresponds to the course of the lateral plantar artery. The flap
is marked as penisular flap with base at the medial border of
heel. The dissection commences laterally dividing the proximal
attachment of the plantar aponeurosis and the flap is elevated
deep to flexor digitorum brevis. As the dissection courses
medially the perforating branch of the lateral plantar artery are
identified and preserved. Distally the distal attachment of flexor
digitorum brevis and plantar aponeurosis and the lateral plantar
artery are divided and included in the flap. The flap is sensate as
Figure 1A: Heel ulcer with flap marking
Figure 1C: Instep island flap inset into defect
and donor area skin grafted
Figure 1B: Instep island flap intraneuronal dissection

Foot Defects 
Chapter 32
367
the medial plantar nerve is included in it. This flap is transposed
posteriorly to cover heel defects.2
Reverse Sural Artery Flap
This flap has been described in detail in the previous chapter
already. It is an important reconstructive option for heel
defects (Figures 3A and B).
Rotation Flap
The flap is based on calcaneal branch of posterior tibial
artery which emerges at the proximal attachment of plantar
aponeurosis at the medial tubercle of calcaneum which
pierces the plantar aponeurosis and courses posterolaterally
and supply anterior heel and midplantar area. The flap is
planned as a rotation flap with base centered on a point distal
to medial tubercle, elevated deep to plantar aponeurosis and
moved posteriorly to cover heel defect.2
Heel Advancement Flap
The flap is based on calcaneal branch of posterior tibial artery.
This flap is planned as an advancement flap by a fish mouth
incision. The dissection is deep to flexor digitorum brevis and
the flap freed by elevating it 6 to 8 cm distal to the plantar
end of the calcaneum. The skin over the tendo-Achilles is
mobilized down to stitch to the posteriorly mobilized flap.
Figure 2B:  Free instep flap for coverage of defect
Figure 2A: Heel avulsion
Figure 3A: Marjolin ulcer heel
Figure 3B: Postoperative picture of same patient after excision of
ulcer and cover by reverse sural artery flap

Types of Wounds and their Management
Section 3
368
Local Muscle Flaps
Flexor digitorum brevis: This is a type III muscle with vascular
pedicle from medial and lateral plantar arteries entering
the proximal one-third of the belly. The musculocutaneous
perforator perfuse the instep skin. The muscle is exposed by a
midplantar incision and the distal attachment and the medial
and lateral plantar are divided. The pedicle is dissected till the
posterior tibial artery and the muscle is mobilized proximally
and reflected posteriorly on its origin to cover heel defects.6,7

Abductor hallucis: The neurovascular pedicle from the
medial plantar artery is 1 cm distal to its origin. The muscle is
exposed by a convex incision over the medial side of the foot.
The insertion is divided and the muscle is reflected back on its
origin to cover small and medial defects on the heel.6

Abductor digiti minimi: This muscle is used to cover small
and lateral defects of the heel.
Distant Pedicle Flaps
The pedicled options from a distant site are cross leg, cross
foot and ipsilateral gluteal or thigh flap.
Skin Graft
For small defects with intact soft tissue padding can be
closed by skin grafting. Full thickness scores over the split
thickness grafts as the former is more durable and has better
reinnervation. Split thickness graft can be harvested from the
instep area of the same or opposite foot which is more resilient
than grafts from thighs.
Posterior Non-Weight bearing Heel, Malleoli
and Achilles Tendon Area
The various reconstructive options available are:
Lateral Calcaneal Artery Flap
This flap is based on 4 to 5 calcaneal branches of peroneal
artery which are given out 3 cm below the fibular styloid, run
posteroinferiorly supplying the skin over lateral, posterior and
inferior surface of the calceneum. The venous drainage is via
short saphenous vein.

The flap is planned with the base 1 cm superior to the
maximum convexity of the lateral malleolus extending from
the lateral border of tendo-Achilles and the posterior border
of lateral malleolus. Distally the flap extends with an anterior
inclination till the lateral border of the heel. The flap can be
extended by delay. The extended version curves anteriorly and
run parallel to the peroneus longus tendon till the base of the
5th metacarpal.

This flap can cover defect of 3 to 4 cm over the posterior
heel, lateral malleolus and tendo-Achilles8 (Figures 4A to C).
Supra Malleolar Flap
This flap is based on the anterior perforating branch of peroneal
artery which pierces the intermuscular septum 5 cm superior to
the lateral malleolus and divides into the superficial and deep
Figure 4B: Lateral calcaneal artery flap raised to cover the defect
Figure 4A: Supra calcaneal defect

Foot Defects 
Chapter 32
369
branch. The superficial branch is fasciocutaneous perforator
which courses anterosuperiorly perfusing cutaneous area of
8×16 cm over anterior leg. The flap is planned with base
centered over the groove between extensor digitorum and
peroneous longus 5 cm proximal to the lateral malleolus.
The flap paddle is 8×16 cm with the lateral limit being the
lateral border of fibula. The flap is elevated subfascially
commencing medially. The pedicle length can be increased
by dividing the anterior perforating branch and basing the
flap on the anastomosis between the deep branch and the
dorsalis pedis artery. It can be elevated either as a penisular
or island flap or adipofascial flap (Figures 5A to C). It is a
reliable modality to cover defects over the either malleoli and
lateral side of heel (Figures 5A to C).9
Dorsalis Pedis Artery Flap
This flap is based on the dorsalis pedis artery and first dorsal
metatarsal artery. The flap is planned with the base at the
lower border of the inferior limb of extensor retinaculum
and extending distally just short of the first webspace. The
whole dorsal skin within this limit can be elevated based
on the dorsalis pedis artery. The dissection commenses
medially elevating the flap over extensor hallucis longus and
progressing laterally over the extensor digitorum longus.

The flap is dissected proximally and islanded proximally
and the pedicle is lengthened by dividing the inferior band of
Figure 4C: One month postoperative picture of the same patient
Figure 5A: Ankel defect
Figure 5B: Ankle defect with adipofascial turnover
Figure 5C: Postoperative picture of same patient

Types of Wounds and their Management
Section 3
370
extensor retinaculum. The flap is used to cover defects over
tendo-Achilles, both malleoli and posterior heel.9,10
Dorsal Metatarsal First Webspace Flap
The flap is based on the first dorsal metatarsal artery which
perfuses a longitudinally oriented skin overlying the first
webspace innervated by deep peroneal nerve. The pedicle
is dissected till the dorsalis pedis artery to cover defects of
posterior heel.
Extensor Digitorum Brevis Muscle Flap
This type II muscle is supplied by lateral tarsal artery and is
used to cover defect over tendo-Achilles and malleoli. The
muscle is exposed by giving an incision from the origin
of dorsalis pedis artery to the midtarsal level laterally. The
tendon is divided and the muscle is reflected proximally. The
reach is increased by tracing the lateral tarsal artery till its
origin from dorsalis pedis artery.6,11
Reconstruction Options of Distal Plantar
Area
The reconstruction goal is to provide durable cover over the
weight bearing metatarsal heads. Distally based options are
available with both lateral and medial plantar and dorsalis
pedis pedicle.2,12,13 These flaps provide local and like tissue
but have the disadvantage of being insensate. Toes especially
the first and fifth can be filleted to provide sensate cover of
the forefoot. Loss of toes does not entail significant loss of
function (Figures 6 and 7).14
Reconstruction of Extensive Foot Defects or
Type III Foot Injury
Extensive soft tissue loss with open fracture and devasculariza-
tion present a significant reconstructive challenge and decision
making. It is difficult to predict whether salvage or amputation
is the appropriate option. Gross devascularization, plantar
avulsion, class III fracture with bone loss, open fracture of the
ankle and calcaneal crush are associated with poor prognosis
for salvage and many of the cases landup with amputation.
With the advent of microvascular technique significant number
of mutilated feet can be salvaged. Thorough debridement
and skeletal stabilization is followed by free tissue transfer
for cover. Free flap cover is indicated for extensive and
three dimensional defects with compromised local tissues,
osteomyelitis and after failed local flaps. As cover of choice
muscle flaps scores over skin and fasciocutaneous flaps
because it adheres to the underlying bones, eliminates dead
Figure 6A: Forefoot sole ulcer
Figure 6B: Forefoot sole ulcer with distally based instep flap marking
Figure 6C: Same patient with distally based instep flap

Foot Defects 
Chapter 32
371
Figure 7A: Forefoot defect
Figure 7B: Distally based dorsal metatarsal artery flap
for same defect
space and is mandatory for osteomyelitis, open ankle fractures
and grossly infected wounds. The options of choice in most
cases are latissimus dorsi, gracilis and rectus muscle flaps.
The muscle is harvested with its investing fascia for firm inset
and is stitched to the defect in stretched state excising the
redundant part. The muscle is covered with a thick split skin
graft.14,15

In case the foot needs to be amputated efforts must be made
to use fillet flap from the foot to provide sensate cover to the
stump.16

Local fasciocutaneous or muscle flaps of the leg can
be used to cover defects of ankle and proximal foot. The
Figure 7C: Distally base dorsal metatarsal artery flap postoperative
fasciocutaneous flaps are raised as distally based or medially
based cross-leg flap based on the fasciocutaneous perforators
(Figures 8 to 10). The retrograde blood flow is through an
intact distal anastomosis between peroneal, anterior tibial and
posterior tibial artery. Retrograde flaps based on peroneal and
posterior tibial artery are used to cover defects of ankle, heel,
and proximal dorsal foot defects.17 The retrograde anterior
tibial artery fasciocutaneous flap is also used to cover wounds
over the same areas. But the dissection is tedious and it entails
sacrifice of one of the three major arteries of the leg. The
reverse sural flap is another leg flap that is useful for ankle
and heel defects. This is a neurofasciocutaneous flap based
on the sural artery which courses with the sural nerve and
receives retrograde flow from a peroneal perforator 5 cm
above the lateral malleolus. The artery is first subfascial but
get subfascial at midcalf level. The venous congestion often
seen with this flap can be minimized if the flap is delayed by
ligating the proximal lesser saphenous vein and sural artery.
While insetting the flap care should be taken to avoid kinking
of the pedicle.18 The supramalleolar flap and perforator based
propeller flap can be used for lateral malleolar, anterior ankle,
and dorsal foot defects.19

In the lower leg muscles are poor options for pedicled flaps
as most of them have segmental arterial. That is why only
a part of the muscle can safely be transferred by preserving
minor pedicles along with the accompanying major artery.
This option should be exercised only if all three arteries are
patent with excellent retrograde flow.

The extensor hallucis longus, extensor digitorum longus,
and peroneus tertius muscle can cover small defects over
lateral malleolus. The peroneus brevis muscle can be used for
defects over tendo-Achilles and medial malleolus.1,20

Types of Wounds and their Management
Section 3
372
Sensory Recovery of Sole after
­Reconstruction
The durability of reconstruction in foot especially sole primarily
depends upon the restoration or recovery of sensation. Pain
is the first sensation to be restored followed by touch and
heat sensation. The recovery starts from the periphery and
extends to the center of the reconstructed area. The quality of
recovery is better in case of muscle with skin graft than skin
and fasciocutaneous flap. Moreover the sensation is better in
cases of thicker grafts. The recovery time ranges from two
weeks to nine months.21 Although sensation is a major factor
breakdown of flap is also attributed to skeletal deformity, gait
abnormality and wobbly and bulky skin flaps.
Figure 8A: Avulsion medial side of foot with exposed ankle joint
Figure 8B: Primary debridement followed by cover with distally
based fasciocutaneous flap
Figure 9B: Cover given with cross leg fasciocutaneous flap
Figure 9A: Avulsion injury dorsum of foot

There are a number of modalities to restore sensation either
as a primary procedure or secondarily in case sensation does
not recover in time. Neurosensory flaps like tensor fascia lata
flap with femoral cutaneous nerve are used primarily and
coapted to calcaneal nerve to provide sensation. Neurovascular
island flap from the great toe is used secondarily to provide
sensation to the weight bearing part of the reconstructed sole.
Sensation in a muscle flap with skin graft can be restored by
anatomizing sural nerve to the motor nerve of the muscle or
by interposing superficial peroneal nerve between the muscle
and the skin graft.22

For best result after foot reconstruction it is important to
contour the weight bearing skeleton to remove any abnormal
pressure points, tailor the flap to the defect avoiding any

Foot Defects 
Chapter 32
373
Figure 10A: Extensive avulsion injury of dorsum foot
Figure 10B: Cover given by whole cross leg flap (medially based)
redundant and wobbly skin. It is also imperative to teach and
correct any gait abnormality and provide protective footwares to
save the reconstructed foot from the daily stress of ambulation.
References
1. Hidalgo DA, Shaw WW. Reconstruction of foot injuries. Clin
Plast Surg.1986;13:663-80.
2. Hidalgo DA, Shaw WW. Anatomic basis of plantar flap design.
Plast Reconstr Surg. 1986;78:627-71.
3. Freeman BS. Plantar flaps used for sole, heel lesions. Tex Med.
1968;64:64.
4. Medial Plantar sensory flap covereage of heel defects. Plast
Reconstr Surg. 1979;64:295.
5. Reading G. Instep Island flaps. Ann Plast Surg. 1984;13:488.
6. Attinger CE, Ducic I, Zelen C. The use of local muscle flaps in
foot and ankle reconstruction. 2000;17:681-711.
7. Hartrampf CR, Scheflan M, Bostwick. The flexor digitorum
brevis muscle island pedicle flap: A new dimension in heel
reconstruction. Plast Reconstr Surg. 1980;66:264.
8. Omokawa S, Yajima H, Tanaka Y, Ryu J. Long-term results
of lateral calcaneal artery flap for hindfoot reconstruction. J
Reconstr Microsurg. 2008;24:239-45.
9. Masquelet AC, Beveridge J, Romana C, Gerber C. The lateral
supramalleolar flap. Plast Reconstr Surg. 1988;81:74-81.
10. Ritz M, Mahendru S, Somia N, Pacifico MD. Reconstr
Microsurg. The dorsalis pedis fascial flap. 2009;25:313-7.
11. Chattar-Cora D, Pederson WC. Experience with the extensor
digitorum brevis muscle flap for foot and ankle reconstruction.
Ann Plast Surg. 2006;57(3):289-94.
12. Cheng MH, Ulusal BG, Wei FC. Reverse first dorsal metatarsal
artery flap for reconstruction of traumatic defects of dorsal
great toe. J Trauma. 2006;60(5):1138-41.
13. Earley MJ, Milner RH. A distally based first web flap in the
foot. Br J Plast Surg. 1989;42:507-11.
14. Georgiade SD, Smith DH. Comparison of free flaps with
pedicled flap for defects of the leg and foot. Plast Reconstr
Surg. 1977;59:492.
15. Zhuang YH, Zheng HP, Lin SQ, Xu DC. Vasculature at the
medial aspect of the foot and clinical application of flaps
based on it for forefoot reconstruction. Plast Reconstr Surg.
2011;127:1967-78.
16. Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin
SL, Germann G. The concept of fillet flaps: classification,
indications, and analysis of their clinical value. Plast Reconstr
Surg. 2001;108:885-96.
17. Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility
of the pedicled peroneal artery perforator flaps for soft-tissue
coverage of the lower leg and foot defects. J Plast Reconstr
Aesthet Surg. 2011;64(3):386-93.
18. Suliman MT. Ann The reverse sural flap: modifications to
improve efficacy in foot and ankle reconstruction. Plast Surg.
2009;63:468.
19. Haddock N, Garfein ES, Reformat D, Hecht E, Levine J, Saadeh
P. Perforator vessel recipient options in the lower extremity: an
anatomically based approach to safer limb salvage. J Reconstr
Microsurg. 2010;26:461-9.
20. Lorenzetti F, Agostini T, Pantaloni M, Lazzeri D. The
versatility of the distally based peroneus brevis muscle flap.
Plast Reconstr Surg. 2011;127:1751.
21. Hattori Y, Chuang DC, Lan CT. Sensory restoration of the skin
graft on a free muscle flap: experimental rabbit study. Plast
Reconstr Surg. 2001;108:132-40.
22. Rautio J. Resurfacing and sensory recovery of the sole. Clin
Plast Surg. 1991;18:615-26.

• Etiology

– Traumatic Wounds

– Burn Wounds

– Postinfective Wounds

– Postsurgical Wounds
• Management

– Cleaning of Wound

– Debridement of Wound

– Tetanus Prophylaxis

– Wound Culture

– Dressings
• Reconstruction of the Wound

– Primary Closure

– Skin Graft

– Local Flaps

– Distant Flaps

– Free Tissue Transfer
• Postoperative Care
INTRODUCTION
Wound involving upper extremity result in considerable
disability, either temporary that causes loss of time from work or
the deformity and loss of function that is permanent disability.
Careful evaluation with preservation of all viable structures
especially in acute wounds is important. So it is important to treat
and prevent complications such as infection, additional tissue
damage, and stiffening. Recent advances in wound dressing,
debridement procedures, and surgical reconstruction allows
treatment of any complicated wound. Surgical management of
wound has always been crucial in wound healing.
ETIOLOGY
The wound is formed by breach in the continuity of skin and
subcutaneous tissue through various mechanisms. The various
causes for wounds in upper limb can be:
Traumatic Wounds
Traumatic injuries are the commonest type. They can be due
to blunt injury, penetrating injury or bite either human or
animal. Blunt injuries can be crush, avulsion, amputation or
degloving (Figures 1A and B). It is diffi cult to predict extent
of injury in initial examination and requires careful evaluation
and exploration of wound. Penetrating wounds are commonly
due to stab, gun shot or glass cut injury. Gun shot wound may
involve a very small entry wound with extensive underlying
tissue destruction to complete destruction of surface soft
tissue as well as underlying structures (Figures 2A and B).
Other wounds are due to human and animal bite. Human bite
may result in serious infection due to presence of aerobic and
anaerobic bacteria. Common animal bite includes dog and
monkey. They result in extensive soft tissue loss due to crush
and avulsion injuries.
Burn Wounds
Burn wounds can result from thermal, electrical, chemical
and radiation. Depending upon depth of wound they can be
divided as superfi cial, partial thickness and full thickness.
Superfi cial wounds (e.g. sunburn) generally are red, painful
and are not included in calculation of total burn surface
area. Partial thickness burns involve dermis and epidermis.
Superfi cial partial thickness burn wound are painful, moist
and red with blisters. Deep partial– thickness appears drier
and paler. Full thickness burns are leather like and white with
thrombosed veins and painless (Figures 3A and B). Thermal
injuries are by far the most common cause of burn in upper
Management of Upper
Extremity Wounds
Durga Karki
33
Chapter

Management of Upper Extremity Wounds
375
Figures 1A and B: (A) Severe avulsion injury through the right wrist; (B) Amputation injury of left hand
Figures 2A and B: (A) Gunshot injury to the left distal forearm with loss of skin, subcutaneous tissue, exposed tendons with fracture radius;
(B) Skeletal stabilization with external fi xator and defect covered with groin fl ap
Figures 3A and B: (A) Mixed deep dermal and full thickness thermal burn right arm and forearm;
(B) Tangential excision and split-thickness skin grafting
A
B
A
B
A
B

Types of Wounds and their Management
376
extremity. Skin of dorsum of hand is thin, so commonly burn
in this area is full thickness as compared to palmar skin which
is thicker and more resistant to full thickness burn. It is crucial
to diagnose vascular compromise in the circumferentially
or severely burned upper extremity. The major electrical
burn wounds involve tissue destruction beyond skin and
subcutaneous tissue into nerve, muscle and bone to varying
degree. The destruction produced by electric burn injuries
is primarily due to the production of heat from current fl ow.
Early decompression with fasciotomies and debridement is
almost always required in upper extremity. Upper extremity is
the most frequent site with chemical burns as it is the exposed
part of body and the part handling these chemicals. Chemicals
can be acids, alkalis or organic compounds. Acids produce
coagulative necrosis whereas alkalies are liquefactive. Organic
compounds produce both contact injuries and systemic
effects. The severity of injury is related to specifi c agent used
involved, its concentration, and the volume and duration of
contact. If injury is suffi ciently deep then consideration is
given to early excision.
Postinfective Wounds
Infection impairs the ability of the wound to heal by several
mechanisms. All phases of wound healing cascade are affected
by infection. Infection decreases tissue PO2 and prolongs the
infl ammatory phase. Signifi cant infection (>105g bacteria)
impairs leukocyte chemotaxis and migration, phagocytosis
and intracellular killing. Depending on the interaction
between the invading microbe and host defenses, the infection
may be localized to the wound or may spread to the adjacent
structures or may become systemic.
Necrotizing Fasciitis
Necrotizing fasciitis is a life threatening, rapidly progressive
infection of the subcutaneous tissue and fascia. Predisposing
factors are diabetes mellitus, alcoholism, intravenous drug
use and immunocompromised individuals. These infections
are caused by Group A Streptococci alone or in combination.
The other majority of these cases are now caused by mixed
infection of aerobe and anaerobe. Necrotizing fasciitis
fi rst appear as cellulitis, but infection rapidly progresses
into the subcutaneous tissue and superfi cial fascia. These
are liquefi ed by necrosis, which is followed by vascular
thrombosis and myonecrosis. The cutaneous vessels are
last to be affected. Treatment requires wide and aggressive
surgical debridement of all necrotic tissue with vigorous
antibiotics and secondary wound closure, often by skin
grafting.
Infection Due to Gas Producing Organism
Organism that cause gas production with tissue necrosis
usually are anaerobic bacteria and thus more often invade
tissue with low oxygen tension such as crush injuries in hand.
The organism most commonly associated with gas productions
in the tissues are the clostridium species but occasionally other
anaerobe like bacteroides, anaerobic streptococci, coliforms
are also responsible. Gas forming infections that lead to
gangrene usually present as swelling, severe pain, ecchymosis
and palpable crepitance in the soft tissue. Radiograph often
demonstrates gas in the soft tissue which requires radical
debridement, high level antibiotics with hyperbaric oxygen.

Diabetic gangrene is usually seen in diabetic patient with
peripheral vascular disease. Gram negative and gram positive
infections occur in such cases.
Postsurgical Wounds
Surgical resection of benign or malignant lesions creates
iatrogenic wounds, which often requires immediate recon-
struction. Immediate reconstruction is particularly required
in upper extremity to protect vital structures. Depending
on the different treatment modalities, such as radiation and
chemotherapy, reconstruction and wound healing can be
affected adversely by these options in cancer therapy.
MANAGEMENT
A primary objective for acute traumatic wounds of upper
extremity is to obtain early closure with good wound healing.
Following injuries, the hand is particularly susceptible to the
development of complications leading to serious disability. For
this reason it is important to protect freshly injured hand most
carefully against complications as such infection, additional
tissue damage, and stiffening. A simple wound such as
laceration of skin and subcutaneous tissue can be cleaned and
closed primarily. When wound involves underlying structures
and is too large to close primarily, it requires adequate
anesthesia, proper instruments and good lighting in operation
theater. A proper evaluation of extent of injury should be
made. In upper extremity, a tourniquet is essential as it offers a
bloodless fi eld which makes viewing of small structures easier.
Cleaning of Wound
Injuries of upper extremity are almost always contaminated to
a certain degree and they should be cleaned properly before
operation is started. Wound and the surrounding skin are

Management of Upper Extremity Wounds
377
cleaned with soap and water. Irrigating a wound with topical
solution does lower the bacterial counts in wounds and result
in a decreased rate of infection.
Debridement of Wound
Debridement involves the removal of devitalized, infected,
necrotic tissue, dirt and foreign body if any from the tissue.
Debridement to bleeding tissues serves as the endpoint.
Multiple operative wound debridement may be necessary
to achieve wound stability. Over the course of serial
debridement, wound cultures may be obtained to assess the
status of bacterial infection.
Tetanus Prophylaxis
Tetanus prophylaxis should be indicated for all patients with
wounds. For clean wounds, if patient has not been immunized
within ten years then tetanus toxoid should be administered.
For highly contaminated wound, tetanus toxoid should be
administered in all cases, and if patient has not been immunized
within fi ve years, tetanus immune globulin is also recommended.
Wound Culture
In open wounds, swab culture and sensitivity is most
commonly used for determining infection and subsequent
use of appropriate antibiotics. Tissue culture is more specifi c
and accurate in determining sensitivity and specifi city. Tissue
culture has advantage, particularly in burn and chronic wounds.
Dressings
Between the stages of wound treatment, multiple dressings are
used to manage exudates and infection. Moist, clean and warm
environment is ideal for successful wound healing. A properly
moistened wound bed allows epithelial cells to migrate and
wound edges to contract. With the use of appropriate dressing
this environment can be maintained. There are four principles
involved in choosing the optimal dressing for any wound. If
a wound is desiccated, it needs to be hydrated. If wound has
excessive exudates, the fl uids need to be absorbed by the
dressing. If a wound has necrotic tissue or foreign debris, it needs
to be debrided. If a wound is infected, it needs to be treated with
antimicrobials. Various types of dressings are available. There
is no single perfect dressing for all wounds. With advances in
technology several dressings, which include nanocrystalline
silver dressing (Acticoat®) and negative pressure therapy, have
a major role in wound management. These dressings can be
used appropriately before defi nite reconstruction is done.
RECONSTRUCTION OF THE WOUND
The reconstruction ladder is a useful way to plan the closure
of any wound systematically (Figure 4) in order to regain
both form and function. It is important to remember that
ladder is only a guideline to reconstruction and sometimes
moving up and down the ladder can result in wound closure.
Reconstruction options start with simple steps and may
become more complex at times for a given defect.
Primary Closure
The fi rst method of treatment is by primary closure of the
wound. If the wound is a clean laceration without any tissue
loss, primary suturing is done in anatomical layers. Primary
repair of injured structures such as skin, nerve, tendon and
blood vessels are the preferred treatment when wound is clean
and injury zone is small. Similarly when extremity is amputated
primary repair is done after skeletal fi xation (Figures 5A to D).

If the wound is contaminated, infected skin margins cannot
be approximated so it is better to leave it open, dress with
antibiotic solution followed by delayed primary suturing.
Skin Graft
If the defect cannot be closed primarily then next option is to
reconstruct with skin graft. Wounds involving fi nger tip are
quiet common. Soft tissue injuries, involving tip but without
bone exposure are often treated with skin graft or allowed to
close by secondary intention. Wound involving volar pulp of
Figure 4: Reconstruction ladder

Types of Wounds and their Management
378
fi nger tip which contains large number of sensory end organs,
is diffi cult to replace. If amputated tip is available then after
defattening skin from the tip, it can be used as a full thickness
graft. Otherwise split thickness graft from the instep of foot or
ulnar border of hand can be used. Composite grafts are used in
distal digital amputation especially in pediatric patients.

Wound with avulsion injury with raised skin fl aps is another
important type in upper extremity. It is important to assess
the viability of the fl ap. If the fl ap is viable after debridement
of margins and dead necrotic tissue, it should be secured in
position with loose sutures. Care must be taken not to produce
any tension during suturing of the fl ap as this will inevitably
lead to necrosis of fl ap. When the viability of the skin fl aps is
in doubt, that portion of fl ap is to be removed. Split skin graft
can be harvested from the avulsed skin fl ap and can be used
to cover the wound. Usually skin graft requires meticulous
wound bed preparation.

Infectious wounds like necrotizing fascitis require radical
surgical debridement. All necrotic fat, fascia, and muscle
must be debrided. Repeated debridement is usually required
followed by skin grafting. Gas gangrene wounds also require
early aggressive debridement and intravenous penicillin
therapy. Once the wound is healthy and granulating, skin
grafting is done.

Oncologic resection of benign and malignant lesions of
upper extremity can be reconstructed with skin graft if the
vital structures are not exposed (Figures 6A to C).

Burn wound involving upper extremity can result in major
functional impairment. So successful management of the burned
hand is of signifi cant importance. Second degree superfi cial
burn wounds usually heal spontaneously within a period of
three weeks. Deep second and third degree burn requires early
excision and skin grafting (Figures 3A and B). Early closure of
burn wound is the key to long-term outcome with respect to hand
function. It minimizes edema, decreases pain, and promotes
earlier functional rehabilitation. Exposure of tendons, bones
Figures 5A to D: Complete traumatic amputation at wrist level
(A) Volar aspect; (B) Dorsal aspect; (C) Replanted hand volar aspect;
(D) Replanted hand dorsal aspect
Figures 6A to C: (A) Neurofi bromatosis involving predominantly left
forearm and arm; (B) Postexcision defect; (C) Defect covered by split
thickness skin graft
A
B
C
D
A
B
C

Management of Upper Extremity Wounds
379
and nerves usually seen in electrical burns requires early fl ap
cover in order to save these structures. cracker burn commonly
involves hand. Majority of injuries are superfi cial second
degree burn which can be managed conservatively but cracker
blast injury of the hand is a severe injury leading to split of
web spaces along with amputation of fi ngers. Blast injury hand
is managed with skeletal fi xation, debridement and primary
closure (Figures 7A and B). If bone, tendon and joints are
exposed, the wound should be covered with fl ap.
Local Flaps
Next step of reconstruction ladder is local fl ap. These are indicated
when there is skin and soft tissue loss with exposed joint, bone and
tendons. Local fl aps can be either random pattern, axial pattern or
perforator based. These fl aps can be used as transposition, rotation
or propeller depending upon the site and extent of defect. The
advantage of local fl aps includes similar skin texture and color
match as the surrounding skin and therefore, aesthetically good
result. In majority of patients skin graft covers the donor site.
Figures 7A and B: (A) Cracker blast injury hand; (B) Debridement,
skeletal stabilization and primary suturing
Finger tip is the frequent site of traumatic wound. If the bone is
exposed local fl aps from same fi nger in the form of Atasoy volar
V-Y fl ap, Kutler Lateral V-Y fl ap or Moberg fl ap may be used.
Atasoy volar V-Y fl ap provides vascularized, sensate skin. It is
used to cover defects which are transverse or dorsal oblique in
position with exposed bone. A triangular fl ap is designed with its
apex at the distal fl exion crease and its base adjacent to the defect
and as wide as the nail bed. The fl aps are advanced and sutured
while proximal defect is closed primarily. (Figures 8A and B)
Kutler lateral V-Y fl ap is also used to reconstruct fi nger tip injury
similar to Atasoy V-Y Flap, but includes two lateral fl aps from
both sides and advanced over the tip. Flaps from other fi ngers
or palm to cover the defect includes cross fi nger fl ap, fl ag fl ap,
thenar fl ap or neurovascular island fl ap. Flaps from digits to be
amputated may be used to restore sensation as well as to provide
skin and soft tissue cover. Commonly used local fl ap to cover the
defects over the dorsum of hand or palm include inferiorly based
radial artery forearm fl aps or posterior interosseous artery fl ap.
Radial artery forearm fl ap is based distally on radial artery with
its accompanying venae comitantes. The major disadvantage is
donor site morbidity (Figures 9A to E).

The fi eld of reconstructive surgery has taken a signifi cant leap
forward with the introduction of perforator fl aps. Advantage of
perforator fl aps is that they are safe, reliable and with minimal
donor site morbidity. With the concept of propeller fl ap, based
on a perforator which becomes the pivot point for the island that
Figures 8A and B: (A) Traumatic amputation of the index fi nger tip
and V-Y advancement of volar fl ap designed; (B) Postoperative result
A
B
A
B

Types of Wounds and their Management
380
Figures 9A to E: (A) Soft tissue defect over dorsum of hand with
exposed metacarpal and proximal phalaynx of index and middle fi nger
and injury to extensor tendons; (B) Distally based radial forearm fl ap
marked; (C) Reverse radial forearm fl ap elevated; (D) Flap inset with
skin graft proximally over the pedicle; (E) One week postoperative
A
B
D
E
C
can be rotated to 180 degrees. Primary advantage is closure of
the donor area primarily and also the fl ap design increases reach
of local fl ap, thus increasing their versatility.

Propeller fl aps are based on perforators of ulnar and radial
artery and are used to cover hand, wrist, forearm and elbow
defects (Figures 10A to E).

Management of Upper Extremity Wounds
381
Figures 10A to E: (A) Crush injury to the right hand with loss of
skin, subcutaneous tissue, extensor tendons of thumb with exposed
1st metacarpal; (B) Propeller fl ap outlined and two distal perforators
marked; (C) Flap islanded on single perforator; (D) Flap rotated to
180° closed primarily; (E) Flap inset and donor area is closed primarily
A
C
B
D
E
Distant Flaps
Next in the reconstruction ladder is distant fl aps. Distant fl aps
are fl aps from sites outside of the injured extremity and the
procedure involves keeping the upper limb attached to the
pedicled fl ap for three weeks before it can be divided and fi nal
inset of fl ap achieved. They can be axial fl aps or random fl aps.
Axial Flaps
Most common site of distant axial fl aps is abdomen.

Superfi cial circumfl ex femoral artery (groin fl ap) is used
to reconstruct fi nger, hand, wrist and distal forearm (Figures
11 and 12). These fl aps can be long, and donor sites as wide
as 10 cm can be closed primarily with minimal donor site
morbidity. Flap can be used for ipsilateral and contralateral
extremity.

Superfi cial inferior epigastric artery fl ap is based on superfi cial
inferior epigastric artery branch of femoral artery. These fl aps
are used to reconstruct hand and distal forearm defects.

Posterior intercostal artery fl ap is also used commonly
to reconstruct forearm, elbow and lower arm defects.
Contralateral fl ap may be used to reconstruct hand and distal
forearm. The fl ap is based on posterior intercostal artery.
Random Flaps
Superiorly or inferiorly based abdominal fl aps are also used
for forearm defects. Length and breadth ratio is usually 1.5:1
(Figures 13A to E).

Types of Wounds and their Management
382
Figures 11A to E: Groin fl ap (A) Soft-tissue defect of 1st web space;
(B) Flap elevation based on superfi cial circumfl ex iliac artery and
primary closure of donor area; (C) Flap insetting into defect; (D) and
(E) Three months postoperative showing good hand function
A
C
B
D
E
Muscle or Musculocutaneous Flaps
Pedicled latissimus dorsi muscle fl ap with skin graft is used to
cover arm and elbow defects.
Free Tissue Transfer
Free tissue transfer in reconstruction ladder is one of the
important methods to cover wound of upper extremity.

Management of Upper Extremity Wounds
383
Figures 12A to C: (A) Severe crush injury to the left hand with loss
of skin and soft-tissue; (B) and (C) Groin fl ap cover, three months
postoperatively
This technique has all the advantage of local fl ap along with
transferring tissue from other parts of body by means of
microsurgical anastomosis. Free fl aps can be designed to
include skin, fascia, muscle and bone.

Free microsurgical tissue transfer requires one step
operation of the most complex wound. Now it is recommended
as a fi rst option in complex reconstruction and has therefore
modifi ed the reconstructive ladder.

The advantages of free microsurgical transfer include
reconstruction of complex wounds requiring composite tissue
transfer, areas where local fl ap option is not available or has
failed with limited option left. The disadvantages, on the other
hand, are that it is more complex, time consuming and requires
microsurgical facility. Commonly used free fasciocutaneous or
fascial fl aps includes radial forearm, temporoparietal fascial
and lateral forearm fl ap.

Radial forearm free fl ap has ideal characteristics for hand
reconstruction. This fl ap is based on radial artery and venous
drainage is through concomitant veins of radial artery and also
cutaneous veins (Figures 14A to E).

Muscle fl ap may also be used to reconstruct upper
extremity wounds. In large wounds free lattismus dorsi fl ap is
used. Other fl ap includes free gracilis muscle fl ap.

Composite tissue transfer includes transfer of skin, subcu-
taneous tissue with bone or muscle. Free fi bula osteocu-
taneous fl ap offers best for reconstruction of bone and soft
tissue defect.
POSTOPERATIVE CARE
Early rehabilitation of upper extremity is extremely important
in achieving good outcome. Adequate immobilization favors
wound healing. However prolonged immobilization can
lead to stiffness of the small joints, immobilization should
be maintained where essential for the minimal amount of
time needed and continued movement of other parts. When
immobilization is essential, it should be in the “protective
position”. In protective position, interphalangeal joint
should be in extension, metacarpophalangeal joint in fl exion
and thumb in palmar abduction. The upper limb should be
A
B
C