Staged Upper Extremity Reconstruction with a Pedicled Parascapular Flap and Bone Graft after a Devastating Airport Accident: Case Report

The author described multiple staged reconstruction procedures for the treatment of a severe injury to the upper extremity of a 21-year-old patient. An airplane propeller hit the patient at his left upper arm and shoulder, causing a massive soft-tissue injury including nerves and shoulder girdle muscles. There was a partial disarticulation of the glenohumeral joint and a segmental fracture of the humerus with bone loss. After serial wound debridements, the proximal half of the humerus was covered only by a thin layer of the remaining deltoid and was skin grafted. The patient was referred 9 months after injury, presenting with a subluxated shoulder and an unstable pseudoarthrosis of the humerus. The neurologic examination revealed a complete deficit of the radial nerve below the elbow. The triceps and biceps were functioning normally with the humerus stabilized with a Sarmiento brace. The proximal half of the humerus was quite palpable through the skin grafted area.

A decision was made for tendon transfer (PT to ECRB, FCU to EDC, and PL to EPL) instead of radial nerve repair, because of the elapsed time between the injury and patient referral. After surgery, the patient became very motivated and asked for treatment of the pseudoarthrosis of the humerus because he did not want to depend on the brace for his lifetime. There were two major problems to consider in this case: poor soft tissue coverage (skin graft) of the proximal half of the humerus and a large segmental bone defect. It was decided to use a pedicled parascapular flap prior to the bone grafting and plating in order to improve the quality of the soft tissue coverage. The parascapular flap was elevated in the same way as it is in a free flap procedure. The flap was mobilized to the anterior aspect of the humerus between the teres major and minor. Six months after this procedure, the patient underwent another procedure to correct the bone defect. The author utilized a corticocancellous structural bone graft combined with a cancellous bone graft from the iliac crest to fill both segmental defects of the humerus. A long LCP plate was used for fixation, and the patient was immobilized in a custom-made thoracobrachial orthosis for 3 months.

After 8 months follow-up, the patient regained full active range of motion of the elbow without the brace, and the x-rays demonstrated a solid consolidation of the pseudoarthrosis with good bone-graft integration.