Gunshot Injury of the Forearm - Staged Reconstruction for the Session Ballistics and Microsurgery

Introduction: Gunshot injuries often lead to the challenging problem of a complex skeletal defect. The staged reconstruction of a proximal forearm complex injury, including a large defect of the radius, muscle mass loss and radial nerve injury, is described.

Methodology and Material: A 46-year old male patient was referred to our unit 7 months after a proximal forearm gunshot injury that lead to the loss of the proximal third of the radius (length of defect: 6.5 cm), of the extensor muscle mass and of the radial nerve and brachial artery. The brachial artery was reconstructed with a large graft in an emergency basis at the unit initially treated. In our unit the patient was scheduled for a staged 3-step reconstruction. Initially the skeletal defect was reconstructed with the use of a composite flap [free vascularized fibular graft (FVFG) with flexor hallucis longus]. FVFG fixation was accomplished with a T-plate proximally and a DCP plate distally. Skeletal defect reconstruction was followed by an ulnar shortening procedure and a DCP plate fixation to combat a fixed extension deformity of the wrist, and by tendon transfers for the extension of the fingers.

Results: The follow-up period was 6 years. The intervals between the 3 procedures were 5 and 7 months respectively. Graft-host union was achieved at both junction sites at a mean time of 3.5 months in the radius, while the ulnar osteotomy was united 3 months after the procedure. No complications (stress fractures, loss of the soft tissue component of the flap, tendon transfer ruptures) were noted and a very good result was achieved after the staged reconstruction, with elbow flexion-extension, forearm pronation-supination and wrist and fingers extension.

Conclusions: The FVFG constitutes a versatile reconstructive option for the management of large skeletal defects. The graft vascularity allows concurrent transfer of muscle to address associated soft tissue defects. The size and shape of the FVFG matched the radius and after healing of both junction sites and the additional procedures (ulnar shortening osteotomy and tendon transfers) full function of the upper extremity was restored. A detailed preoperative planning and a careful postoperative follow-up were required for a successful outcome.

Acknowledgment Partially funded from the European Commission, Leonardo da Vinci Project Number 2013-1-BG1-LEO05-08711 “Osteosynthesis for Surgical Management of Fractures for Orthopaedic Surgeons and Biomedical Engineers.” This publication reflects the views only of the authors, and the Commission cannot be held responsible for any use, which may be made of the information contained therein.