PMC5404651_01
The right elbow and forearm at initial presentation. Anteromedial view showing an exposed median nerve and brachial artery (arrow) (A). Anterolateral view showing a torn extensor muscle origin (arrowhead) and segmental loss of the radial nerve (B).
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The median nerve and brachial artery were exposed and contaminated (Figure 1).
Anterior (A) and posterolateral (B) appearance of the right elbow and forearm just before the reconstruction. A depressed scar can be seen extending from the anterolateral side of the elbow to the flexor side of the forearm. Note that the patient could not extend the digits or wrist due to loss of the extensor mechanism.
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Muscle strengths in the area innervated by the median and ulnar nerves improved to 2 or 3 on the manual muscle test, but there were no signs of recovery in the extensor muscles (Figure 2).
A 50-cm long latissimus dorsi flap including the gluteal fascia was harvested.
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Caudally, the dissection was continued down to the gluteal fascia across the iliac crest, producing a latissimus dorsi flap that was 50 cm long (Figure 3).
The fascial end of the latissimus dorsi flap, which was confirmed to reach the tendons of extensor digitorum (A), was introduced subcutaneously to the dorsal forearm and sutured to the tendons (B). The arrow indicates the skin paddle of the latissimus dorsi flap.
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The fascial end of the flap was introduced subcutaneously to the dorsal forearm, where it was tightly sutured to the tendinous portion of extensor digitorum, with 15  of flexion at the metacarpophalangeal joints (MPJ) under 90  of flexion at the elbow (Figure 4).
Post-operative pinch motion exercise with wearing an outrigger splint.
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The arm was immobilized in a long arm splint with mild shoulder abduction and the elbow flexed at 90  for 4 weeks; during this time and following period, the patient performed thumb and finger exercises with wearing an outrigger splint (Figure 5).
The right arm at 3 months after the surgery. The wrist was stabilized by tenodesis and thumb and finger flexion was maintained.
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These could contribute to improve grasp and several activities of daily living (Figure 6).