From Shrapnel to Stability: A Reverse Perforator Flap for Definitive Elbow Coverage Seven Decades Post-Trauma. A Case Report

This case report details the lifelong sequelae and complex management of a shrapnel injury sustained by a 4-year-old male during a 1943 World War II bombing. The initial trauma caused a severe right elbow fracture and complete ulnar nerve transection, resulting in ankylosis and chronic joint dysfunction. Decades later, the patient developed recurrent ulcerations and scar instability over the olecranon. A suspected chronic osteomyelitis was initially managed conservatively with antibiotics and scar revision with lipofilling. However, ulceration recurred, ultimately necessitating aggressive surgical intervention, initially postponed for the patient's heart conditions. This involved fistulectomy, extensive bone debridement, and definitive coverage with a reverse-flow perforator flap based on the posterior interosseous and radial recurrent arteries. The procedure achieved successful healing with no recurrence at five-year follow-up. This case underscores that chronic complications from wartime trauma can manifest over a lifetime. It highlights the necessity of a definitive surgical approach, combining radical debridement with robust soft tissue reconstruction, even after long periods of quiescence. For elderly patients with complex comorbidities, this pedicled flap provides a reliable, single-stage reconstructive option in the challenging elbow region.