Seven patients with traumatic quadriplegia were treated for either an olecranon pressure sore or chronic olecranon bursitis at one institution between 1989 and 1998. Treatment involved excision of all necrotic and infected tissue (including infected bone) followed by coverage. This included a pedicled cross-chest fasciocutaneous flap in two patients and a lateral arm fasciocutaneous rotation flap and skin grafting of the donor site in four. One patient underwent debridement and primary closure of an uninfected olecranon bursa. Three of seven patients had recurrent breakdown, two in the rotation flap group and one of the two chest flaps. All three were successfully treated with additional surgery. The chest flap was converted to a lateral arm flap and the lateral arm flaps were advanced. No flaps were lost due to circulatory compromise, despite the fact that six of seven were smokers. Staphylococcus aureus was isolated from all but one wound. Postoperative elbow mobility was comparable to preoperative values.
Chronic bursitis and pressure sores about the olecranon are some of the most challenging problems in upper extremity soft-tissue reconstruction. The location of the wound on a pressure surface, the need for motion, the presence of a large bursa, and poor local soft-tissue quality all contribute to a high recurrence rate after most forms of treatment. These factors are compounded in quadriplegic patients due to the use of the forearm in transfers and lack of sensory feedback. The authors present an impressive record of successful treatment using a lateral arm fasciocutaneous rotation flap described by Lazarou and Kaplan in 1993. This method has the advantages of adequate random circulation, sensate coverage in C6 and lower levels of injury and preservation of all muscle units and circulatory integrity in a severely compromised extremity. The flap can be advanced in cases of recurrence, which makes it a valuable workhorse in the treatment of this most challenging problem. The authors stress the importance of patient education and close follow-up in preventing recurrence, even after successful flap closure.
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