The Use of a Flexor Carpi Ulnaris Muscle Flap in
the Treatment of an Infected Nonunion of the
Proximal Ulna
A Case Report
ROY A. MEALS, M.D.
Multiple efforts had failed to heal an infected non-
union of the proximal ulna. A flexor carpi ulnaris
muscle pedicle flap was used to improve blood
supply and soft-tissue coverage at the nonunion
site. The muscle flap and applicationof the princi-
ples of nonunion treatment promoted bone healing
and restoration of useful elbow function.
Infected nonunions of fractures pose mul-
tiple problems, more so when the fracture is
intraarticular. When such an injury occurs at
the elbow the function of the entire upper
limb,can be severely restricted. This report
describes the successful resolution of an in-
fected, intraarticular nonunion of the proxi-
mal ulna, the treatment of which included
providing well-vascularizedsoft-tissue cover-
age with a flexor carpi ulnaris muscle flap.
CASE REPORT
A 64-year-old woman fell down three steps,
sustaining a closed comminuted fracture of her
left, nondominant proximal ulna and a disloca-
tion of the adjacent radiocapitellar joint (Fig. 1).
The ulnar fracture was fixed the same day by a
Rush rod passing through the olecranon into the
medullary cavity of the ulnar shaft and by two
From the Division of Orthopaedic Surgery, UCLA
School of Medicine, Los Angeles, California.
Reprint requests to Roy A. Meals, M.D., Division of
Orthopaedic Surgery, UCLA School of Medicine, 10833
LeConte Avenue, Los Angeles, CA 90024.
Received August 28, 1987.
168
circlage wires securing the coronoid process to the
remaining ulna. The radial head was manually
reduced. Postoperatively, the radial head was
noted to be subluxed anteriorly, and this was ex-
cised two months after injury. A bone graft from
the radial head was packed around the fracture
site in the ulna. Four months later the ulna had
not healed. The original hardware was removed,
and a tension band fixation along with an iliac
cancellous bone graft was placed. Postoperatively,
the Kirschner wires migrated through the skin,
necessitating their removal. Eight months after
the injury, tension band wiring was repeated and
further bone graft was added. One month later
these K-wires had also penetrated the skin. The
pins were left in place. Then over several months
the injury site received 1600 hours of noninvasive
electrical stimulation that did not alter the appear-
ance of the nonunion. Eighteen months after in-
jury the elbow became acutely swollen and tender.
Staphylococcus aureus was cultured from the pin
tracts, and the patient was started on oral antibi-
otics. The hardware was removed one month
later, and the wound was allowed to close by sec-
ondary intention.
Upon presentation to the author's institution
20 months following the injury, the patient was
wearing a hinged elbow orthosis and had a drain-
ing sinus over the nonunion site. She could nei-
ther change the dressing nor apply the orthosis
herself, necessitating thrice weekly visits to her
doctor's office. The loss of function related to the
fracture and the orthosis had forced her to move
out of her apartment into a convalescent home.
With pain, the elbow flexed from 30" to 90", and
the forearm rotated only from 45" to 80' of pro-
nation. Shoulder motion was full, and neurovas-
cular status to the hand was intact. The skin over
Number 240
March. 1989
FIG. 1. Roentgenographic appearance of an
acute fracture-dislocation of the left elbow of a
64-year-old woman.
the posterior aspect of the proximal ulna was in-
durated, multiply scarred, chronically inflamed,
and fixed to the immediately underlying bone.
Fluid cultured from the draining sinus grew S.
aureus. Roentgenograms showed a slightly hyper-
trophic nonunion of the ulna at the level of the
coronoid with the coronoid united to the distal
fragment (Fig. 2). The olecranon fragment ap-
peared sclerotic With respect to surrounding bone
density. A bone scan showed increased activity of
the left elbow, but no determination regarding
vascularity of the olecranon fragment could be
made.
Under general anesthesia and pneumatic tour-
niquet control, the infected nonunion was ap-
proached through one of the previously used pos-
terior longitudinal incisions. All synovial mem-
brane and granulation tissue was sharply removed
from the nonunion site and the bone ends vigor-
ously debrided. Some bleeding was noted from
the nonunion site of the proximal fragment. The
wound was left entirely open. The patient was
placed in a long-arm splint spanning the elbow
Infected Proximal Ulna Nonunion 169
medially and laterally while allowing complete
posterior access to the wound. Postoperatively,
the limb was elevated by an overhead pulley and
counterbalance arrangement, intravenous antibi-
otics were administered, and thrice daily dressing
changes and wound packings were performed.
The patient remained afebrile. One week fol-
lowing the initial debridement the wound was
cleanly granulating and no drainage was noted.
Again under general anesthesia the granulation
tissue was curetted. Multiple small drill holes were
placed in the olecranon fragment to facilitate in-
growth of granulation tissue. Through a longitu-
dinal incision along the ulnar border of the fore-
arm, the flexor carpi ulnaris was transected at the
wrist flexion crease and fully mobilized proxi-
mally to within 7 cm of the medial epicondyle
where the muscle's neurovascular pedicle was vi-
sualized but not disturbed. The muscle measured
approximately 5 cm wide, 1 cm thick, and 20 cm
long. Without exerting traction on the vascular
pedicle, the muscle was folded on itself, fully cov-
ering the nonunion site with the transected end of
the muscle resting posteriorly on the distal triceps.
The donor site in the middle and distal forearm
was closed primarily, and the muscle overlying
the nonunion site was covered with split thickness
skin graft. The elbow was splinted. No further
drainage was noted. Oral antibiotics were contin-
ued for three weeks postoperatively.
Six weeks after the muscle flap placement the
patient was again placed under general anesthesia.
The lateral margin of the muscle flap over the
nonunion site was reflected up sufficiently to ex-
pose the dorsolateral surface of the fracture frag-
ments but without disturbing the majority of the
adhesions between the fracture fragments and the
muscle flap. The fracture site was debrided and
irrigated again. Autogeneic iliac crest cancellous
bone graft was packed in the nonunion site, the
fracture fragments secured with a contoured 3.5-
mm neutralization plate, and the muscle flap with
overlying skin graft closed over the bone graft and
plate. Perioperative antibiotics were given for two
days and then discontinued. The wound healed
primarily. Active and gentle passive motion exer-
cises were begun two weeks postoperatively. The
patient was released to unrestricted self-care and
light household activities six weeks later. Five
months postoperatively the bone graft was com-
pletely consolidated and the fracture fragments
had united (Fig. 3). She exhibited a 25"-110"
painfree elbow range of motion with full forearm
rotation. She made no complaint about any di-
minished wrist flexion power. The hardware grad-
ually became palpable with associated tenderness
of the overlying skin. The plate and screws were
therefore removed one year following placement.
 Clinical Orthopaedics
170 Meals and Related Research

FIGS.2A-2C. The appearance of the infected

nonunion of the proximal ulna 20 months follow-
ing injury. (A) Scarred skin and draining sinus.
(B) A lateral roentgenogram. (C) An anteroposte-
rior roentgenogram.

The patient's elbow remained free of pain with the coverage and local blood supply for the com-
above-noted motion and without evidence of in- monly encountered infected nonunions in
fection. Shortly after hardware removal oat cell the tibia. In planning the definitive treatment
carcinoma was diagnosed and the patient died
several months later. for this patient, it was noted that the olecra-
non fragment was probably hypovascular
DISCUSSION and the overlying skin was definitely inade-
quate to cover any hardware necessary to
Nonunions, and particularly infected non-
unions, of fractures around the elbow, are
rare. ',2,4,9~'0~12When present, however, their
effects on upper limb function can be devas-
tating. The principles of treatment for in-
fected nonunions are well e~tablished.~,'~ De-
bridement and open packing promote clear-
ance of the infection. Rigid fixation of the
fragments allows revascularization and heal-
ing. Depending on the specific case, ap-
proaching either the nonunion or the infec-
tion primarily may take precedence. In either
case rigid fixation is required to allow mobi-
lization and rehabilitation of adjacent joints.
Muscle and myocutaneous pedicle flaps as FIG. 3. Roentgenographic appearance of the
well as free flaps have been used to improve ulna eight months after staged reconstruction.
Number 240
March, 1989 Infected Proximal Ulna Nonunion 171

I OLECRANpN ! I

FIGS.4A-4D. The dorsal aspect of right elbow and proximal forearm of a cadaver dissection, clarified
with a line drawing. (A) and (B) The vascular pedicle enters the flexor carpi ulnaris 5 cm distal to the
elbow joint. (C) and (D) When the flexor carpi ulnaris flap is reflected proximally without distorting the
vascular pedicle, as much as 14 cm of muscle is available for coverage around the elbow.

provide rigid internal fixation. Thus, a
method of improving soft-tissue coverage
and local blood supply was sought.
Flaps of skin, with and without underlying
fascia, and flaps of muscle have been taken
from the chest and abdominal walls to cover
elbow defect^.^.^^'^^' These distant flaps re-
quire attachment of the limb to the trunk for
several weeks; following flap division the
transferred tissue is parasitic on the local tis-
sues rather than bringing its own enhanced
blood supply to the area. A distant, free flap
of muscle with or without skin or bone
would enhance local blood supply, providing
that the required vascular anastarnoses re-
mained patent and the flap survived.
Use of a local flap would preclude both
tethering the limb to the trunk and vascular
anastamoses, yet would provide additional
vascularity to the problem area. Two upper
limb muscles that might be expendable and
that can provide highly vascularized cover-
age around the elbow are the brachioradidis
and the flexor carpi u l n a r i ~ .The
~ . ~ size and
location of the deficit to be covered and the
donor site morbidity need to be carefully
considered before choosing the muscle for
use. A preoperative cadaver dissection for
this case indicated that the flexor carpi ul-
naris would serve well (Fig. 4). The flexor
carpi ulnaris is the strongest wrist flexor and
ulnar deviator, and it should not be sacri-
ficed without forethought to the overall
function of the limb. In difficult coverage
problems around the elbow, as in muscle im-
balances of the wrist and hand, the benefit of
the flexor carpi ulnaris in its new position
must outweight the loss of powerful wrist
flexion and ulnar deviation.
A chronic infection of bone can never be

172 Meals
considered cured because retained bacteria
may remain quiescent for years before reac-
tivating symptoms. A long-term follow-up
evaluation of the patient reported here was
not possible, but the treatment described
achieved its intermediate goal of providing
the patient a functional, pain-free limb and
relieving her of drainage and orthotic use.
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3. Fisher, J.: External oblique fasciocutaneous flap for
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M d Related Resaarch
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