Staged limb salvage after an infected full-thickness shoulder-girdle flame burn with osteoarticular exposure in an elderly patient

Rationale: In extensive shoulder-girdle burns, the critical question may not be flap selection itself, but whether meaningful limb salvage remains justified, particularly in an elderly, frail patient with a delayed infection but preserved distal neurovascular function. Patient concerns: A 73-year-old woman with diabetes, hypertension, and cachexia (body mass index, 16.9 kg/m 2 ) was transferred approximately 3 weeks after a flame burn. She presented with an extensive infected wound extending from the neck base to the distal third of the left arm. Diagnoses: The burn extended through deep soft tissues to the shoulder capsule, rotator cuff, proximal humerus, scapula, and acromioclavicular and glenohumeral regions, consistent with a fourth-degree injury. Cultures grew Escherichia coli and Acinetobacter baumannii . No injury to the brachial plexus and major vessels was identified. Sepsis could not be retrospectively classified. Interventions: Following systemic and nutritional optimization, culture-directed antibiotics, 6 serial debridements, and negative-pressure wound therapy at −125 mm Hg, the infection was clinically controlled. Four weeks after admission, the defect was reconstructed with a 20 × 15 cm ipsilateral pedicled latissimus dorsi myocutaneous flap and skin grafting. Outcomes: The flap survived completely without significant donor-site complications. At 3.5 years, the wound remained healed without recurrent drainage, ulceration, or further surgery. Active shoulder motion remained markedly limited, whereas passive shoulder motion and distal upper-extremity function were near those of the contralateral side. The patient remained independent in daily activities, with a disabilities of the arm, shoulder and hand score of 28/100. Lessons: Preserved distal neurovascular function and realistic residual-limb utility may justify staged salvage despite severe shoulder destruction. The favorable outcome reflects careful patient selection, stabilization, debridement, infection control, and durable vascularized coverage rather than the superiority of a specific flap or a general recommendation to delay reconstruction.