Evolving concepts in the management of the bone gap in the upper limb. Long and small defects.

Vascularised bone graft is a well accepted technique when dealing with long defects. Its role in refractory nonunion, in small defects and in the growing patient is rarely discussed. In this paper the authors review the different alternatives to deal with bone defects in the upper extremity. The indications of vascularised corticoperiosteal graft for solving small defects harbouring refractory nonunion, and the use of vascularised bone phalanx and metatarsal for complex - but small - defects in the fingers is presented. The ability of the bone to grow and remodel when a living epiphysis is included, and to maintain the cartilage viability when a composite osteochondral graft is transferred are also discussed.