A 40-year-old male was a driver of a car that overturned in a road traffic accident. He sustained a Gustilo IIIB open fracture dislocation of the right olecranon with degloving injury and 10 cm segmental loss of the right ulnar nerve (). Initial management included multiple wound debridement and external fixation. 11 days after injury, internal fixation of the olecranon was performed. The ulnar nerve gap was bridged with a 3-cable sural nerve graft (). A free ALT musculocutaneous flap was used to cover the elbow. The nerve grafts were buried in the forearm flexor/pronator muscle mass and covered with vastus lateralis muscle. The affected limb was immobilized in extension for 7 days. Despite using a flap with very well vascularised muscle, due to the severity of the injury and degree of comminution, he later developed septic arthritis and osteomyelitis necessitating removal of the implants. Heterotopic ossification developed subsequently. At latest review at 9 years 2-point discrimination was 7 mm, he had regained full hand function (intrinsic muscle power 4/5) and active range of motion at the elbow was 45° (range, 45° to 90°) (). He declined further surgery.
Case 4. A 35-year-old male sustained loss of anterior elbow soft tissue in a workplace accident. This exposed underlying tendons, vessels, and nerves. The large defect was resurfaced with a free ALT fasciocutaneous flap with a cuff of vastus lateralis muscle (). In 12 months postoperatively, the patient has excellent contour and 110° ROM.