A 24-year-old male presented to us 1 month after sustaining a gunshot injury to the base of his left thumb with large chronic ulcer and loss of the whole first metacarpal bone (Figs. 6.4 and 6.5). The ulcer was completely debrided (Fig. 6.6) and a distally based posterior interosseous skin flap of 12 × 7 cm was planned for skin coverage (Fig. 6.7). The metacarpal bone defect was reconstructed with a free iliac crest flap (Fig. 6.8) anastomosed to the radial artery and to the lateral forearm vein (Fig. 6.9). To cover the whole soft-tissue defect, the posterior interosseous flap was harvested with preserving the fascia and subcutaneous tissues around its pedicle securing its venous drainage (Figs. 6.10 and 6.11).

A 55-year-old patient presented to us with a shrapnel injury to his right thumb resulted in skin defect and 2 cm bone loss from the first metacarpal (Fig. 6.12). The bone defect was reconstructed using a vascularized bone island flap from the second metacarpal bone (Figs. 6.13 and 6.14). A dorso-radial perforator flap of 3 × 6 cm in size was used for coverage of the base of the thumb (Figs. 6.15 and 6.16). The thumb appearance and opposition were restored (Figs. 6.17, 6.18 and 6.19).