From Shrapnel to Stability: A Reverse Perforator Flap for Definitive Elbow Coverage Seven Decades Post-Trauma. A Case Report.
Alvise Montanari, Cesare Tiengo, Alfio Luca Costa et al.
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Case in brief
A man injured by shrapnel at age four sustained a severe right elbow fracture and complete ulnar nerve transection, leaving ankylosis and chronic dysfunction. Decades later, recurrent ulceration and unstable scarring developed over the olecranon, with suspected chronic osteomyelitis. Antibiotics and scar revision with lipofilling did not prevent recurrence. After surgery was initially delayed because of cardiac conditions, he underwent fistulectomy and extensive bone debridement, followed by coverage with a reverse-flow perforator flap based on the posterior interosseous and radial recurrent arteries. Healing was successful, with no recurrence at five-year follow-up.
What made this case unusual
Recurrent olecranon ulceration emerged decades after the original wartime injury, and definitive coverage required a reverse-flow perforator flap in the challenging elbow region.
Diagnostic / clinical pearl
When ulceration over a chronically scarred elbow recurs despite conservative measures and scar revision, definitive management may require fistulectomy and extensive bone debridement with robust soft-tissue coverage.
Why it matters
The case illustrates that complications of severe trauma can persist or reappear across a lifetime, including in elderly patients with significant comorbidities.