Surgical images: musculoskeletal: Sural neurocutaneous cross-leg flap.

© 2008 Association médicale canadienne A girl presented to the multinational medical unit at Kandahar Airfield with an open lateral malleolus fracture secondary to a blast injury. Serial débridement procedures preceded a vacuum-assisted closure dressing applied for 8 days (Fig. 1). Flap coverage was needed, and because of the location and size of the wound, no local options were feasible. The ipsilateral lesser saphenous vein and sural nerve had been injured, and there was no access to microsurgical expertise. Although currently out of favour, a cross leg flap was chosen in this case. A sural neurocutaneous flap was harvested from the contralateral leg. An external fixator was then applied to hold the legs crossed (Fig. 2). The periphery of the traumatic wound and the sural flap donor site were skin grafted immediately. Although awkward, the leg position was tolerated well by the patient. Twenty-one days after the index surgery the pedicle was divided. Vigorous retrograde bleeding was noted from the severed pedicle. Two days later the flap was trimmed and inset. No necrosis or venous congestion occurred at any time (Fig. 3).