Immediate reconstruction of bone and skin defects of the humerus with free fibular graft and muscle flap.

The following Case Report describes the immediate reconstruction of bone and skin defects of the humerus with a free fibular graft and muscle flap. A 33-year-old white female sustained a gunshot wound to the left upper extremity with a 3.08 caliber high-powered rifle. The entry wound was on the lateral aspect of her mid-arm. The exit wound on the anteromedial aspect of the upper extremity measured approximately 10 x 15 cm. A segmental loss of the middle of the humerus and a defect of the radial nerve were noted. Within 48 hours after injury, reconstructive surgery was begun. A free vascularized fibula graft, peroneal artery, and concomitant vein were harvested from the left lower extremity, prepared, and inserted "peg in hole" fashion between the humerus fragments. The proximal segment was inserted between two fracture fragments, and the two fragments, including the proximal fibula, were transfixed with a single screw. The graft was revascularized with end-to-side anastomosis of the peroneal vessels to the brachial artery and its concomitant vein. The entire reconstruction was then covered with rotation of the latissimus dorsi muscle flap and a split-thickness skin graft. All wounds and the donor site healed primarily. Post-operative orthopaedic management consisted of maintenance of the external fixator for three months. Postoperative x-rays at 5 months showed healing at both ends of the fibular graft. A history of free fibula transfers and a discussion of the importance of aggressive, early, bony reconstruction using the free vascularized fibula graft are presented.