Background: Targeted muscle reinnervation (TMR) is a relatively new treatment for neuroma/phantom limb pain and for improving prosthetic functional outcomes. TMR uses coaptation of major peripheral nerves to recipient motor branches to expendable muscle targets.(1,2) This case demonstrates the first application of immediate TMR for acute upper limb amputation at Waikato Hospital. Case: We were presented with a 20-year-old otherwise well, male engineer. The patient suffered a farm machinery accident with multi-segmental crush/avulsion amputation of the non-dominant forearm. Within 3hours from time of injury, the patient was undergoing a multi-specialty team replantation of the limb. Unfortunately, on day 9 following replant, infection was noted. The limb was deemed non salvageable on day 11. Following multi-consultant review, a trans-humeral amputation to allow adequate stump closure and healing was chosen. Treatment/Outcome: The amputation was performed with immediate TMR. Via anterior approach the median nerve was transferred onto the nerve to short head of biceps and the ulnar nerve onto the nerve to brachialis. Via the posterior approach the radial nerve was transferred onto the branches to lateral head of triceps. The patient was discharged day 5 with minimal analgesia requirements. At the 2week follow-up the wound was well healed, without reports of neuroma/phantom limb pain. Conclusion: With established improved outcomes in pain and prosthetic use/function for patients and our positive case experience, we should consider immediate TMR for our patients undergoing upper limb amputation. References 1. Hagiga, A., Aly, M., Gumaa, M., etal. (2023). Targeted muscle reinnervation in managing post-amputation related pain: A systematic review and meta-analysis. Pain practice : the official journal of World Institute of Pain, 23(8), 922–932. 2. Le, E.L.H., Iorio, M.L. & Greyson, M.A. Targeted muscle reinnervation in upper extremity amputations. Eur J Orthop Surg Traumatol 34, 3717–3725 (2024).