Vascularized Proximal Phalanx Transfer for First Ray Reconstruction Following High-Energy Gunshot Injury: A Case Report.

Abstract

High-velocity gunshot wounds (GSWs) to the foot can result in complex bone and soft tissue loss, particularly when involving the first ray. Reconstructive options are limited, and reports describing first metatarsal reconstruction after firearm injury are scarce.  A 24 year-old male sustained a high-energy rifle injury with destruction of the distal first metatarsal head, proximal phalanx, and medial neurovascular bundle. Following multiple debridements, an antibiotic cement spacer was placed to maintain the defect space. Definitive reconstruction was later performed using a rotational flap and a vascularized proximal phalanx graft from the ipsilateral great toe. The patient progressed to full weight-bearing, achieved pain-free ambulation, and demonstrated radiographic union.  This case highlights a successful reconstruction strategy that avoids free tissue transfer and may serve as a viable option for managing complex medial forefoot defects after high-energy trauma.