Managing a Pedicle Groin Flap: An Occupational Therapist’s Role in a Multi Disciplinary Team Approach

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Pedicle groin flaps are often used for reconstruction of extensive soft tissue deficits of the upper extremity following a traumatic injury. Pedicle groin flaps are performed to transfer a muscle with its neurovascular bundle to maintain a stable blood supply to the donor site during the early post-operative period. Portions of the injured upper extremity may be inset (surgically placed) into the abdominal/groin region where there is a vast blood supply to promote a successful surgical outcome.In the early post- operative period, around the clock attention to the patient’s position, as well as utilizing techniques to protect the flap while mobilizing the patient, are critical to the viability of the muscle flap. A multi-disciplinary team, including occupational therapy (OT), is vital during the early mobilization period to promote recovery, and increase a patient’s chances of being discharged home after pedicle groin flap division surgery. This article describes the procedures/treatments implemented to successfully mobilize a patient with a pedicle groin flap and make generalizations for future patients.

A 55 year old male was admitted status post bilateral upper extremity (UE) grade III frostbite after having a seizure and being found down in the snow after several hours. During his first admission, the patient underwent initial bedside debridement of bilateral hands, followed by several additional surgeries, including multiple bilateral hand debridements, a right hypothenar fasciotomy, and amputations through left ring finger and right small finger with Integra (a meshed bilayer wound matrix) placement. Dressing changes were performed by the orthopedic team, nursing, and OT, and daily bilateral UE range of motion (ROM) was initiated by OT on hospital day one. Following patient and family education for daily ROM, positioning, self care and mobility, the patient was discharged home on hospital day thirteen with family assist and outpatient therapy services.

pre-flap

Pre-flap

The patient was re-admitted two months later for further debridements, a left ring finger proximal interphalangeal amputation, right dorsal metacarpal artery flap, insetting of the right first dorsal metacarpal artery rotational flap, split thickness skin grafting, and an abdominal/groin pedicle flap. Following this surgery, several restrictions were put in place by the orthopedic team including bilateral UE non weight bearing (NWB), no right hand digit ROM, and right UE positioning requirements. OT and physical therapy (PT) services were initiated on post-operative day three in order to begin mobilizing the patient. A multi-disciplinary team consisting of OT, PT, orthopedic nurse practitioners (NPs), and nursing was used to mobilize the patient to ensure positioning and flap viability. Pre and post mobilization, the flap site was well observed for appearance, color, drainage, and odor. These observations helped to form the patient’s daily functional mobility goals, as well as adapt the goals based on noted changes.

groin-flap

Groin Flap.
Photo courtesy Coos Hamburger

Table one depicts the patient’s therapy sessions, including the personnel present, activity, flap tolerance, and team plan. In this facility, inpatient orthopedic OT is a position staffed by an occupational therapist who specializes in UE management. Table two depicts the patient’s functional progression from the first to last therapy session, during that hospitalization.

Utilizing dedicated occupational therapists allowed for advanced services to be provided and a skilled individual to be present during all treatment sessions to support the right UE and monitor the tension placed on the flap site. Having a multi disciplinary team approach allowed for real time treatment modifications and adaptations based on patient progress and flap tolerance following functional mobility. On post-operative day eight from his pedicle groin flap, the patient was discharged to acute rehab. With assistance from OT and the addition of a Velpeau sling to optimize UE positioning and to protect the pedicle groin flap, the patient was able to ambulate short household distances and perform light ADLs. The flap was well preserved and allowed the patient to continue with out of bed mobilization once the Velpeau sling was applied. Three weeks post discharge, patient returned for flap division surgery, and was subsequently discharged home.

Velpeau-sling

Velpeau Sling

Safe early mobilization of patients with pedicle groin flaps is possible through utilization of a multi disciplinary team approach, calculated transfer techniques, and in depth observation and management of the flap site. Following pedicle groin flaps an occupational therapist is an essential team member to maintain proper UE positioning and flap viability. Early mobilization and family training performed by occupational therapists assisted the promotion of successful home discharge following flap division surgery. Multiple lessons were learned during the process. A dedicated occupational therapist was instrumental in managing the right UE throughout all sessions to ensure flap preservation. Ongoing communication with the orthopedic team was essential for monitoring patient progress and adjusting therapy sessions as needed. Bed mobility with left side lead allowed for the least amount of tension being placed on the right sided flap. Application and testing of the right UE Velpeau sling prior to discharge ensured continued safe mobilization.

Table 1

Objective Assessment
Session 1 – POD 3 Personnel: Entire multi disciplinary team present.
Activity: Transferred out of bed (OOB) to chair with left side lead, sat in semi-recumbent position (due to flap restrictions) in recliner for 10 minutes, ambulated 15 feet, then transferred back to bed with left side lead. Continued with left UE ROM exercises, using left hand for light activities of daily living (ADLs), and orthopedic NPs approving left UE palm weight bearing to assist with mobility.
Flap tolerance: Following mobility flap was darker reddish-purple, but resolved after return to bed.
Team Plan: Discussed OOB tolerance and flap response with orthopedic team. Patient allowed to increase seated time to 20 minutes next session.
Session 2 – POD 4 Personnel: OT, PT, and nursing carried out similar treatment session.
Activity: Increasing OOB seated time in semi-recumbent position to 20 minutes.
Flap tolerance: Flap appearance following mobility was darker reddish-purple.
Team Plan: Discussed OOB tolerance and flap response with orthopedic team. Based on continued flap response with prolonged upright sitting, patient was restricted to OOB ambulation only, no sitting in chair.
Session 3 – POD 5 Personnel: OT, PT, and nursing present.
Activity: Transferred OOB, ambulated 15 feet, and then transferred back to bed
Flap tolerance: Flap appearance following mobility was darker reddish-purple.
Team Plan: Orthopedic NPs were updated following session with patient progress and flap appearance.
Session 4 – POD 6 *Prior to initiating mobility, flap was noted to have increased drainage, orthopedic NP notified and assessed flap to clear patient for continued mobility.
Personnel: OT, PT, and nursing present. Activity: Carried out identical treatment session as the one prior
Flap tolerance: Flap appearance following mobility was darker reddish-purple.
Team Plan: Orthopedic NPs were updated following session with patient progress and flap appearance. As patient was approaching discharge, orthopedic team expressed concern for right UE stabilization to reinforce flap viability. Discussed plan with inpatient orthopedic OT.
Session 5 – POD 7 Personnel: OT and PT present.
Activity: Inpatient orthopedic OT fabricated right UE Velpeau sling using two 4” ace wraps to maintain stable right UE positioning throughout mobility. Transferred patient OOB, ambulated household distances in the halls, and then transferred back to bed.
Flap tolerance: Flap appearance following mobility was darker reddish-purple, but returning to baseline within 2-3 minutes; faster than previous sessions.
Team Plan: Orthopedic NPs were updated following session with patient progress and flap appearance. Velpeau sling provided sufficient stabilization for the patient to be successfully discharged to rehab as evidenced by the flap response. Importance of maintaining Velpeau sling to protect flap during mobilization activities reviewed with patient, and included in OT discharge instructions to promote communication and proper hand off to the rehab facility.

 

Table 2

Session 1 Session 5
Bed Mobility Min-Mod assist x 3 Min assist x 2
Transfers Min assist x 3 Contact guard assist x 2
Ambulation Min assist x 3 for 3-4 steps, then 15 ft. Min assist x 2 for short community distances
Upper Body Dressing Max assist Min-Mod assist
Feeding Max assist Mod assist

 

References:

  1. Sabapathy, R., & Bajantri, B. Indications, Selection, and Use of Distant Pedicled Flap forUpper Limb Reconstruction. Hand Clinics. 2014; 30(2): 185-199.
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About Author

Kate Heyman, MS, OTR/L

Kate Heyman, MS, OTR/L is an Advanced Occupational Therapist with over 6 years of experience in the acute care setting. She has treated multiple patient populations including cardiac, medicine, neurology, neurosurgery, surgical, vascular, transplant, orthopedic, neurotrauma, and multi trauma. Kate consistently treats patients in the ICU setting including patients who are on a ventilator and extracorporeal membrane oxygenation (ECMO). She also maintains competencies to treat patients with ventricular assist devices (VADs). Her interests include liver transplantation, multi trauma, and critically ill patients.

Wendy Thornton, OTR/L

Wendy Thornton, OTR/L is an Advanced Occupational Therapist with more than 20 years of experience in the field of Occupational Therapy. Recently, her focus has been on upper extremity management. Wendy also has experience in Outpatient, Acute and Subacute rehab, Home Health, Hospital Based Preschool, and Early Intervention. Her interest and focus lies in direct patient care throughout the acute hospital stay, including patient, family and caregiver education and discharge planning. For several years Wendy held the position of inpatient orthopedic OT which focuses on splinting and bracing management of a variety of patient populations in the acute hospital setting. She recently transitioned to outpatient orthopedic splinting.

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