Purpose: Reconstruction of long bones with significant loss of bone stock is a major challenge particularly if the gap is greater than 5 cm. Complementary bone resection is often necessary. A conventional cancellous graft may be used when loss of bone substance is not too extensive, but when the defect extends over several centimeters a vascularised bone graft with a microanastomsed fibular graft may be indicated. This technique is widely used for the lower limb but rarely applied for the forearm. The purpose of this work was to examine the modalities and report our experience.

Material and methods: This retrospective study included six microvascularised free fibular grafts performed to reconstruct the forearm bones after massive loss of bone stock. The mean age of the five men and one woman was 34 years. Bone loss (mean 10 cm, range 6 – 18 cm) involved the radius in five cases and the ulna in one. All six patients were victims of crush injuries with open fractures and expulsion of part of the forearm skeleton. Initial treatment included debridement, wound closure, and temporary external fixation. The fibular graft was performed eight weeks (mean) after trauma in five patients and six months after trauma in the sixth patient who also had multiple autologous cancellous grafts which left a nonunion of the ulna and an 18 cm defect. The Meyer method using a saphenous loop was used for vessel anastomosis in five cases. A vascularised fibular bypass was used in one. Osteosynthesis was achieved with screw or plate fixation.

Results: Bone healing was achieved in all patients four to six months after grafting. Mean follow-up was three years (range 1–5). There were no secondary fractures. Mean flexion-extension of the elbow was 100° at last follow-up. Mean pronation-supination was 100°.

Discussion and conclusion: Free fibular transfer enabled reconstruction of the forearm skeleton after massive bone loss. The vascularised graft shortened time to bone healing for these extensive defects with a mechanical quality superior to that obtained with conventional non-vascularised grafts. These vascularised grafts can be indicated for infected nonunion because the vascularised graft favours antibiotic diffusion.

Purpose: Crush injury of the upper limb often causes bone and soft tissue damage leading to a paralytic hand. We report our experience with reactivating wrist and finger flexion using a neurotised latissimus dorsi transfer in patients with volkmann syndromes of the forearm.

Material and methods: Mean patient age was 25 years and mean follow-up was three years. The surgical procedure consisted in a free latissimus dorsi flap with arterial suture onto the ulnar artery and neurotisation using the largest median nerve branch innervating the finger flexors. The muscle was fixed proximally on the medial epicondyle; the distal fibrous lamina was divided for suture to the deep flexor tendons. Mobilisation started 21 days after surgery.

Results: The four-month electromyogram demonstrated reinnervation of the latissimus dorsi. The patient recovered thumb-index opposition with flexion of the long fingers enabling daily life activities. All patients required occupational reclassification but stated they were satisfied with the operation. Flexion of the fingers and wrist was active and was not obtained by tenodesis.

Discussion and conclusion: Volkmann syndrome leaves serious sequelae after crush injury to the forearm. The usual surgical techniques enable reduction of claw fingers by distention but do not, due to muscle necrosis, enable proper function. The free latissimus dorsi transfer method improves trophicity of the forearm and, by neurotisation, enables active hand flexion. Because the nervous pedicle of the flap is short, recovery is rapid, avoiding degeneration of the transferred muscle.