Excision and grafting of a chronic ulcer over the elbow

Presentation

The patient presented with a chronic ulcer over the point of the elbow which had not healed with dressings. An ulcer here sits over a bony prominence with very little soft tissue beneath it, and it is loaded every time the patient leans on the arm — so the wound is re-injured as fast as it heals, and the elbow ends up held flexed to avoid the pressure.

An ulcer over the olecranon with slough and devitalised tissue in its base and a fibrotic margin. Surrounding skin was intact and the elbow was passively mobile, indicating the stiffness was protective rather than a fixed joint contracture.

Procedure

The ulcer was excised with its fibrotic margin down to bleeding tissue, and the defect resurfaced. As over the tibia, the excision is what decides the result: a chronic ulcer margin is poorly vascularised, and resurfacing sutured onto that margin fails for the same reason the ulcer never healed. Over the elbow there is the additional problem of pressure, so the reconstruction has to tolerate being loaded once the patient starts using the arm.

1. AssessmentUlcer assessed; excision and resurfacing planned
2. OperationUlcer and fibrotic margin excised to healthy tissue; defect resurfaced

Outcome

The ulcer was excised and the defect resurfaced in a single stage. Healing, elbow movement and recurrence are placeholder and await the surgeon’s follow-up records.

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