A 20-year-old male was referred from a hospital outside the city of Managua (Nicaragua) after suffering trauma to the left arm from a moving vehicle, resulting in a transverse open fracture of the middle third of the humerus type III C according to Gustilo's classification, initially treated with an external fixator and vascular lesion of the brachial artery which could not be repaired. She arrived at our hospital 12 hours after the accident.
Physical examination of the upper extremity revealed an absence of distal peripheral radial and ulnar pulses, a negative Allen test and a decrease in temperature.
We performed a real-time Doppler study with a high-frequency linear B-mode probe that showed flow with attenuated waves in the proximal brachial artery, but not in the middle and distal portions, where there was an absence of colour Doppler, power Doppler and spectral signals, with no flow in the distal arteries (radial and ulnar).
The patient was admitted to the operating theatre where we found a linear wound on the anterior surface of the arm and complete section of the biceps brachii in the middle 1/3, distal and proximal end of the brachial artery knotted with 2-0 silk, with a gap of 8 cm in length, exposed fracture of the middle third of the humerus displaced and forearm with tension, decreased temperature and stiffness.
We kept the limb in warm ischaemia and decided to perform sequential reconstruction of the limb in 2 stages.
First reconstruction time: vascular repair
In collaboration with the Vascular Surgery Department, we proceeded to take a 20 cm long graft from the greater saphenous vein of the left lower limb and transposed 10 cm of graft to the vasobrachial arcade, with end-to-end anastomosis by means of loose stitches with 8-0 nylon under 4.3X magnification. The fracture line is thus exposed.
We therefore achieved revascularisation of the limb 16 hours after the accident.
We also performed an anterior forearm fasciotomy to treat the compartment syndrome associated with the trauma.
Second reconstruction time: internal fixation and coverage
After demonstrating adequate perfusion of the tissues in the area of the injury and distal to it, and 48 hours after vascular repair, we performed internal fixation of the humerus fracture with an endomedullary nail 8 mm in diameter and 24 cm in length, with distal and proximal blocking.
Once the possible reconstruction options for covering the neurovascular structures and the fracture line had been evaluated, we decided to transpose the ipsilateral latissimus dorsi muscle-cutaneous flap.

With the patient in the right lateral decubitus position, we delineated the flap area with a length of 22 cm x 11 cm width; in order to restore elbow flexion function, we took only the lateral portion of the latissimus dorsi muscle on the same side as the injury. The lateral border of the latissimus dorsi muscle is incised to achieve adequate exposure, and the elliptical incision corresponding to the skin component of the flap is continued. We continue the dissection cephalad over the anterior surface of the muscle up to the subscapularis area, performing submuscular dissection in the areolar plane close to the chest wall.

We locate the descending branch of the thoracodorsal artery, first identifying the branches that go towards the serratus muscle, and the circumflex scapular artery, which are ligated and divided so that there is no torsion of the pedicle after transposition.

Once the main pedicle of the flap has been located, we proceed to make the medial cut of the muscle, making sure to include only the tissue necessary to cover the defect.

Incise the axillary area in a zigzag fashion, with distal extension along the lateral border of the latissimus dorsi muscle to transpose the latissimus dorsi flap to the anterior aspect of the arm to provide coverage of the fracture tract and vascular repair saphenous grafts. We finished with direct primary closure of the donor site after placement of a closed drainage system.

Once the flap has been transposed, we fix the coracoid process and the remaining fibres of the biceps muscle belly proximally and fix the bicipital tendon distally with non-absorbable nylon 0 sutures.

The remaining muscle flap and fasciotomy were covered with partial thickness grafts 7 days after transposition of the latissimus dorsi flap, once the distal oedema of the extremity had subsided and the granulation tissue showed no clinical signs of bacterial colonisation.

The patient spent 10 days in hospital with adequate distal perfusion of the tissues, and vascularisation of the superficial and deep palmar arch was demonstrated by 8 MhZ hand-held Doppler auscultation.
The latissimus dorsi flap, with no evidence of venous congestion or arterial insufficiency, provided stable coverage over the humeral fracture tract and over the saphenous vein grafts to the brachial vessels.
The donor area was also uncomplicated, with removal of the closed drainage system at 13 days postoperatively. Graft integration was 100%.
The patient started physical therapy 4 weeks after the initial procedure, with flexion and extension movements of the elbow. After a 6-month follow-up, he has flexion and extension ranges between 60-180 degrees, even with some limitation to full flexion function, which will require more physical therapy to be able to perform strenuous work, since daily tasks, such as dressing and studying, can be performed without difficulty.