Thumb salvage with skin grafted medial femoral corticoperiosteal free flap

A 23-year-old man suffered a severe crush injury with fracture of his left thumb base phalanx and destruction of his extensor pollicis longus tendon. Immediate plate stabilisation and soft tissue coverage was performed; however, a recalcitrant pseudarthrosis developed in this compliant non-smoker despite three revisions with avascular iliac crest grafts for interphalangeal joint arthrodesis, corticocancellous bone application and hardware exchange. An attempt to improve thumb vascularity and soft tissue cover with a pedicled Foucher flap as well as through extracorporeal shock wave therapy failed. Bone healing and subsequent thumb salvage were finally achieved with a free vascularised medial femoral condyle(MFC) bone flap, which was covered directly with a full-thickness skin graft. Both bony and soft tissue healing went well and after 3 months the patient returned to work. This case demonstrates that skin grafting the periosteal surface of the MFC flap is safe and results in a thin skin-bone compositae transplant which also might be very useful for indications other than hand surgery. (C) 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.