In 18 cases the authors used a free tissue transfer during the first 24 hours of the treatment of a complex trauma of the upper limb involving osteoarticular and neurovascular loss combined with loss of skin cover. The various flaps include: lateral arm flap (8 cases), latissimus dorsi flap (4 cases), toe to hand transfer (4 cases), radial forearm flap (2 cases). The series includes 2 failures salvaged without further sequelae by means of a groin flap. With regard to complex one-stage reconstructions, particularly those requiring replacement of bone, the outcome is improved if the selected method permits early mobilisation and complete cover. Free transfers are to be compared with loco-regional flaps which are more reliable but suffer limitations such as a small cutaneous element and, frequently, involvement of the pedicle in the mechanism of the trauma. For the severe cases in this series, only free tissue transfers provided the adequate, immediate cover required to save the traumatised limb.