Reconstruction of a severe open distal humerus fracture and intercondylar fracture with complete loss of 13 cm humeral bone by using a free vascularized fibular graft

Background: Segmental bone defects resulting from traumatic injuries are complicated problems with significant long-term morbidity. Vascularized bone grafts, by definition, are placed with their vascularity intact, and thus are immediately viable. Case: A 46 years old man referred to Sanglah Hospital after roadway accident and subsequently fell to the valley. Open wound Ø 5x2 cm (already stitched), bone loss 13 cm length, tenderness over the arm and elbow, radial artery and ulnar artery palpable, O2 saturation 98%, no paresthesia, no active ROM elbow flexion and extension, active ROM wrist 80/70 , active ROM MCP-IP 90/45, and patient can do a thumb extension. Already done the free vascularized fibular graft, and stabilized with 3.5 mm reconstruction plate and screwing for intercondylar fracture. Then checked with angiography for vascular viability. Discussion: Management of bone defects after severe open fractures of the distal humerus encompasses many technical difficulties. In these cases, appropriate osteosynthesis may not always feasible, and bone grafting should be considered for the restoration of normal elbow anatomy. Vascularized bone transfers are more efficient than conventional corticocancellous interposition grafting for the management of massive bone loss (>6 cm). The free osteocutaneous fibula flap is a composite tissue transfer suitable to address combined defects. Clinical monitoring and early detection of anastomoses failure can be done within hours after the surgery by evaluating the skin paddle viability. Conclusion: The surgeon should decide elbow reconstruction in severe injuries that compromise several structures and create tissue defects by careful evaluation. The kind of lesion and mechanism of trauma are not necessarily the most important factors for planning treatment. The free osteocutaneous fibular graft should be further considered as a reconstructive option for the treatment of metaphyseal or juxtaarticular complex defects of the elbow joint.