Dear Sir, A 5 year old girl was brought to the plastic surgery outpatient clinic for the treatment of a discharging sinus within a circumferential scar in the right arm of 6 months duration. The scar was found to be unstable with firm consistency and multiple discharging sinus within the scar. The rest of the limb was clinically normal [1]. The scar and the sinus history dates back to 9 months where the girl had sustained fracture of the arm managed by a local bone setter. The parents noticed the scar and the sinus after the removal of wooden sticks used for immobilization. The radiograph showed united fracture shaft of humerus with no evidence of osteomyelitis. The blood parameters were normal. Considering the clinical and radiological bone union with a discharging sinus in the circumferential scar, we had planned for exploration, excision of the unstable scar and soft tissue cover by multiple Z plasties. Interestingly, on exploration we found a very unusual rubber band embedded circumferentially (Fig. 1) inside the scar along the subcutaneous plane which could be the reason for the discharging sinus. Thorough wound debridement, removal of the band and soft tissue cover was done. The girl was comfortable in the post-operative period and was discharged. The wound healed and the girl was symptom free since then.There has been few literature studies which described unsual foreign bodies tied circumferentially in the limbs for various reasons which later cause serious constriction bands, ulcers, discharging sinus and compartment syndrome [2][3][4]. These circumferential constricting foreign bodies produce inherent heat on stretching and coolness on relaxing. This thermodynamics makes the rubber band gradually breach the skin and remain in the planes of the limbs depending upon the place and its position. Our case is an unsual presentation of the rubber band tied around the arm during native treatment of bone fracture causing superficial skin necrosis, circumferential scar and discharging sinus. We propose this short communication as rubber band syndrome in the arm and suggest clinical suspicion in all native treated wounds, bone fractures and non allopathic treatments with circumferential scar and discharging sinus.

Soft tissue reconstruction of distal third leg, heel and ankle region is a challenging problem because of poor vascularity and limited mobility of skin. The reverse sural artery with ideal flap thickness, minimal donor site morbidity, lack of functional muscle loss, short recovery time, wide arc of rotation and safe vascularity makes it a preferable flap for covering such defects. AIMS AND OBJECTIVES: To study various modifications of distally based reverse sural artery flap to suit the defects and for better survival of flaps. RESULTS: It is a retrospective study conducted in our institute to cover the distal leg and foot defects.60 cases of distal leg defects exposing vital structure who underwent reverse sural artery flap coverage were included in the study .5 of the 60 flaps had complete flap necrosis and another11 flaps had partial necrosis.73.4% of the flaps survived during the follow up period of 1 years with good functional outcome. CONCLUSIONS: Reverse sural artery flap with its modifications is a good flap for the defects of distal leg, heel and ankle defects. KEY WORDS: Reverse sural artery flap, modifications, distal leg defects. Mesh terms: Reverse sural artery flap, modifications, distal leg defects. INTRODUCTION:Soft tissue reconstruction of the lower third leg, ankle and foot region is a challenging problem. The major problem is the poor vascularity and limited mobility of the skin. Tendon, bone and hardware are frequently exposed because of the thinness of subcutaneous tissue making possibility of skin grafting a poor option. A durable flap with good skin texture, reliable vascularity, good arc of rotation, ease of dissection with minimum donor site morbidity is the most desired option for covering such defects.The different local flaps for hind foot defects including dorsalis artery flap 1 , abductor hallucis and abductor digiti minimi muscle flaps 2,3 have inadequate tissue and limited arc of rotation thereby limiting their frequent use. Medial plantar artery flap is an excellent option for weight bearing heel but its involvement in trauma frequently precludes its use.Locoregional flaps for lower leg and ankle defects such as the peroneal artery flap, anterior tibial artery flap and posterior tibial artery flap 4-6 have the disadvantage of sacrificing a major artery in already traumatized limb. Supramalleolar flap 7 is another option but its reliability is questionable in compromised vascularity. Morbidity and operative times are increased in technically demanding microvascular surgeries 8,9 . Ideal flap thickness and quality, minimal donor site morbidity, the lack of functional loss, short recovery time , the wide arc of rotation and safe vascularity are the significant advantages of the reverse sural artery flap.Masquelet et al 10 Introduced the sural flap in 1992 with concise description of relevant anatomy and the surgical procedure. After the work of Masquelet et al distally based sural fasciocutaneous flap has become a mainstay in the reconstruction of the lower leg, ankle and ...

AIMS: Distal leg defects are very difficult to cover because its structure its vicarious blood supply paucity of the muscles. Peroneus brevis muscle type 2 muscle long & slender to cover small & medium size defects. Prospective study conducted in Victoria hospital to cover the post traumatic distal leg defects. 20cases of distal leg defects exposing vital structure which require the flap cover. 16 patients are male, patients ranging from 18yrs to 65yrs. RESULTS AND CONCLUSIONS: 18 flaps survived. 2cases flap loss 2 cases graft loss. No functional deficit noted, less donor defect. Ideal flap for the small & medium size defects of distal leg.

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