Clinical Examples: Trauma: Reconstruction of Dorsal Metacarpus with Latissimus Free Flap, Iliac Bone Graft and Tendon Grafts

Complex dorsal metacarpal wounds involving composite loss of skin, tendon are challenging in that the palmar tendons and neurovascular structures may be preserved, but lacking a large intercalated skeletal framework.

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This type of injury in a young woman resulted from a rollover car accident.

After debridement, the index and middle flexor tendons are visible in the base of the wound. The fingers were held out to length with an external fixator constructed from K-wires, suction tubing and methacrylate, and the soft tissue defect was closed with a latissimus dorsi myocutaneous free flap.

After the flap had healed, the patient was brought back for iliac crest bone graft reconstruction of the index and middle metacarpals. A sterile sponge was used to test a template size of the tricortical graft, which spanned from the proximal carpus to the proximal phalanges. Hunter rods were passed through the graft for extensor tendon grafting at the next stage.

The bone graft healed. Subsequent procedures included flap recontouring and extensor tenolysis.

Progression of Xrays: injury; debridement; bone graft; after hardware removal:

As an alternative, reconstruction with free flap, bone graft and primary extensor tendon grafts could have been performed at one setting.

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