Osteocutaneous Fibular Flap for Reconstruction of Composite Metacarpal Defects Due to Gunshot Wounds

Abstract

Background: Gunshot wounds of the hand are challenging, as these injuries include bones, tendons neurovascular structures, and soft tissue. The osteocutaneous fibula flap has shown to be an excellent option for treating the composite defects, including bone and soft tissue. In this study, reconstructions of gunshot injuries of the metacarpal bones with a fibular flap are presented.

Methods: Six patients with gunshot injuries to the hand were treated with free fibula flap. All patients had composite defects reconstructed with osteocutaneous fibula flap. Because of the size mismatch between fibula and metacarpal bone, a longitudinally split fibula was used in 2 patients. In 1 patient, the flap was used in a double-barrel fashion to reconstruct 2 metacarpal bone losses. Tendon repairs were performed either primarily or with tendon graft. All patients received hand rehabilitation. Hand function of the patients was evaluated by grip and pinch strength tests and Jebsen hand function test.

Results: All flaps survived with no major postoperative complications. The mean follow-up period was 18 months. Web releasing and an arthrodesis procedure was performed in 1 patient, and tenolysis was performed in 2 others. All flaps adapted well to the recipient area. With respect to routine daily activities, overall hand function measured by grip and pinch strength tests and Jebsen hand function test was considered satisfactory in all patients.

Conclusions: The fibular flap is a good alternative for reconstruction of the injured hand with composite defects, including metacarpal bone and soft tissue. It can be used longitudinally or transversely. Osteotomies can be performed to obtain split fibular flap or double-barrel fibular flap according to the bone defect.

Keywords: Gunshot Wounds; Hand Injury; Hand Reconstruction; Metacarpal Reconstruction; Osteocutaneous Fibular Flap.

Figure 1

Second case with gunshot wound of the right hand. The preoperative appearance upon arrival. The fourth and fifth rays are amputated; third metacarpal bone is exposed and necrotic (A). Preoperative x-ray showing loss of fourth and fifth rays and bone comminuted fracture of third metacarpal bone (B). Appearance of the in full hand extension of the fingers at 2-year follow-up (C). Postoperative x-ray showing the fibular flap reconstruction of the third ray (D).

Figure 2

Fifth case sustaining from right-hand gunshot wound with composite metacarpal bone defect including tendons (A). Extent of bone defect at preoperative x-ray (B). Appearance of the hand following free fibular flap (C), and excellent bone union and size match of the fibula with the metacarpus at 18 months (D).

Figure 3

Sixth case with left-hand gunshot injury. The appearance of the wound (A), bony defect at the shaft of the second, third, and fourth metacarpal bones (B). Postoperative result following fibular flap. There is no shortening at the reconstructed metacarpal bones (C). Postoperative x-ray of the patient, showing adequate stabilization of the hand (D).

Figure 4

Longitudinally split fibula flap of the fifth case. Reduction of width of the fibular bone enabled size match with metacarpal bones and better adaptation to the bony defect.

Figure 5

Occupational therapy is used complementary to regular physical therapy for better adaptation of the patients to daily life.

Figure 6

Long-term outcome of second case showing opposition with the reconstructed finger (A), flexion (B), grasp (C), and pinching (D) functions at 2-year follow up.