Background
Severe crush injuries to forearm pose a unique problem in presence of an uninjured hand. Replantation of hand to elbow is an option but severely limits the function.
Methods
Presenting a case of young left-hand dominant worker, with severe crush injury of left forearm involving skin, soft tissue, neurovascular structures, and bones. But the hand was relatively undamaged. Three-stage reconstruction was planned - 1: After below elbow amputation, left hand was recovered from the crushed forearm and ectopic replantation was done on the left distal leg. 2: Neo-Forearm Reconstruction: A Free fibula flap was harvested along with functioning hemisoleus muscle, FHL muscle and skin. Simultaneously,a chimeric functioning Vastuc lateralis muscle and ALT flap were used to reconstruct the entire forearm unit. 3: The ectopically banked hand was returned to the reconstructed neo-forearm and tendon, nerve repair was done.
Results
After 1 year follow up, there is some protective sensation in hand, grip strength - 2 pounds, DASH score - 21, he can use it as an assistive hand. He has key pinch, grasp, hook grip and good elbow strength. He can hold large objects, can stabilize a pen between fingers and thumb and can write using the proximal muscles. Total active ROM of fingers is 100 degrees and for thumb is 50 degrees.
Discussion
Our case was a complex reconstruction problem where a neo forearm was created to mimic the function of forearm muscles. The outcome after the procedure are better than ectopic replantation with subsequent replantation on a suboptimal stump.
Conclusion
Consensus on indications of ectopic banking is still debatable. With addition of our technique, of ectopic-replantated hand, followed by reconstruction of neo-forearm and hand-replantation onto reconstructed neo-forearm which, being a novel concept, the horizon of reconstruction paradigm would be broadened.