Reverse sural flap for coverage of a complex Achilles-region injury in a pediatric patient: reconstruction focused on comprehensive rehabilitation

Abstract

Introduction:
Traumatic injuries of the Achilles region and heel in pediatric patients represent a significant challenge, as they involve an area essential for weight-bearing, gait, and functional development. When soft-tissue loss, exposure of deep structures, and associated tendon injury are present, treatment should aim to provide stable, resistant coverage compatible with early rehabilitation. The reverse sural flap is a useful reconstructive alternative for defects of the distal third of the leg, ankle, and heel, as it provides vascularized tissue without the need for microsurgery and offers adequate coverage for areas exposed to partial weight-bearing or friction.

Objective:
To describe the usefulness of the reverse sural flap as a reconstructive option in a pediatric patient with a complex injury of the right Achilles region, emphasizing its role within a comprehensive approach aimed at limb preservation and functional recovery.

Methodology:
We present the case of a 6-year-old female patient who sustained entrapment of the right foot by a motorcycle wheel. On admission, a posteromedial ankle wound measuring approximately 8 × 5 cm was identified, with soft-tissue exposure, severe pain, and limited assessment of mobility. During her clinical course, soft-tissue avulsion of the right Achilles region, near-complete disruption of the Achilles tendon of approximately 95%, and calcaneal physeal fracture-avulsion of approximately 80% were documented. Management was performed in a staged manner, beginning with surgical cleansing, debridement, and temporary wound bed management. During hospitalization, the patient developed influenza respiratory infection, which required postponement of definitive reconstruction due to a temporary anesthetic risk for intubation. Once medical treatment was completed and better clinical and local conditions were achieved, Achilles tendon repair and definitive coverage of the defect with a reverse sural flap were performed.

Results:
After reconstruction, the flap showed favorable clinical evolution, with 2-second capillary refill, preserved temperature, skin color similar to the surrounding tissue, and no signs of congestion, bleeding, or dehiscence. The patient evolved without early surgical complications, tolerated oral intake, and continued with wound care, splinting, and strict positioning measures to protect the flap. She was discharged after 20 days of hospitalization with outpatient follow-up. During subsequent evaluation, rehabilitation and progressive weight-bearing of the limb were indicated, with the goal of gradually restoring foot and ankle function.

Conclusions:
The reverse sural flap represented an appropriate reconstructive option for coverage of a complex Achilles-region injury in a pediatric patient. Its usefulness was based on providing stable and sufficient vascularized tissue to protect repaired deep structures, particularly the Achilles tendon, allowing treatment to be directed toward limb preservation and future gait recovery. This case highlights the importance of integrating reconstructive surgery, postoperative protection, and rehabilitation from the early stages, especially in pediatric traumatic injuries involving functional areas of the foot and ankle.