Reconstruction of Metacarpals of Two Rays with Double Barrel Osteocutaneous Fibular Flap in a Hand Injury with Composite Tissue Loss: A Case Report

Abstract

Free fibula flap has been a workhorse for head, neck, and extremity long bone defects. We discuss the reconstruction challenge in an unusual hand injury case involving the loss of multiple metacarpals and soft tissue with surprising preservation of finger vascularity. The reconstructive goals were addressed with a microvascular osteocutaneous fibula flap transfer with multiple osteotomies to create spitting images of metacarpals and soft tissue defects restored with the skin paddle. The outcome, in terms of functional gain, was sufficient for managing day-to-day activities. We share our experience in reconstructing this unique presentation of a complex hand injury.

Keywords: free fibula flap; metacarpal loss; metacarpal reconstruction.

Fig. 1:

(a) Image of the injured hand following trauma showing composite tissue loss. (b) Radiograph of the injured hand showing loss of 1st and 2nd metacarpals. (c) Clinical image showing stabilisation of 1st and 2nd digits with K-wire.

Fig. 2:

(a) Harvested Osteocutaneous fibula flap with filleted middle segment. (b) Reconstructed hand after flap inset.

Fig. 3:

(a) Follow-up image showing a well-settled flap. (b) Follow-up radiograph showing fibular bone segments resembling metacarpals without bony resorption after six months. (c) Patient holding a book (Power grasp). (d) Patient lifting a bag (hook grip).