CDR JOHN P WEI, USN MC MD4th Medical Battallion, 4th MLGBSRF-12EXTREMITY INJURIES IN THE BATTLEFIELD

Improved body armor has reduced axial traumaSkeletal trauma on battlefield has increasedSeverity of wounds and energy absorbed by injured limbs much greater

INTRODUCTIONFactors effecting extremity woundsEarly management of extremity woundsInterventions for extremity wounds

FACTORS IN EXTREMITY INJURIES

FACTORS IN EXTREMITY INJURIESEnergy level (height of a fall / speed of car / caliber of bullet) Degree of contamination (soil, broken glass, shrapnel) Degree soft tissue injury (crushed / avulsed) Complexity of fracture pattern (number of bony pieces) Vascular injury

HIGH ENERGYHigh-energy sources produce wounds characterized by violent tissue destruction

Violent tissue destruction and contamination requires radical dbridement of devitalized tissue

FRACTURE TYPES

COMPOUND FRACTURECompound fractures (open fracture) : injury occurs with break in skin around broken bone

Compound fractures require surgery to clean the site of injury and stabilize the fracture

COMMINUTED COMPOUND FRACTURE

COMPOUND FRACTURES AFTER IED BLAST

MANAGEMENT OF EXTREMITY INJURIESInitiate basics of trauma life support: airway, breathing, circulationAssess for life threatening injuriesControl hemorrhageIntubate for airway control if neededBegin resuscitationSecondary survey of extremitiesComplete neurologic and vascular examination

EXTREMITY INJURIESConcomittant vascular injuries require urgent surgical repair in addition to orthopedic fixation

TRAUMATIC AMPUTATIONattention must be focused on associated life-threatening injuriescommonly due to explosive munitions, with penetration and blast effects (parachute Injuries)

COMPARTMENT SYNDROMESCaused especially by crush injuries, electrical burns, circumferential scars, tight casts, hematoma in compartment, snake bites, and anything else that can increase pressure in a compartment

If untreated surgically, can lead to neurovascular compromise and ischemia resulting in gangrene

COMPARTMENT SYNDROMESevere, constant pain in affected limb, pain on muscle palpation, passive stretch, and active contractionParesthesia and loss of distal pulses are late signs and indicate poor outcomeCan measure compartment pressures (if > 25 mm Hg)

FASCIOTOMIESNeed to perform complete fasciotomy in all 4 compartmentsAll fascial envelopes opened completely from knee to ankleLess frequently, fasciotomies of upper extremities, thighs, and buttocks are performed

FIELD MANAGEMENT OF EXTREMITY WOUNDSControl of hemorrhage

Temporary splinting

IV antibiotics

Tetanus prophylaxis

COMBAT APPLICATION TOURNIQUETOne-handed applicationTourniquet can be applied by soldier to himself if neededControls hemorrhage from extremity wounds until evacuated to higher level of care

IMMOBILIZATION OF EXTREMITY INJURIESEssential to immobilize any fractures prior to CASVAC from fieldFailure to immobilize fractured extremities could lead to vascular or neurologic injuries or increased bleeding

TREATMENT OF FRACTURESDbridement

Reduction

Fixation

Evacuation

WOUND MANAGEMENT

FRACTURES AND WOUND MANAGEMENTTreat by irrigation and debridement as soon as feasible to prevent infection Neurovascular status of the extremity should be documented and checked repeatedlyBiplanar radiographs should be obtained

PULSE LAVAGEHigh pressure irrigation can remove enough wound bacteria to render the wound non-contaminated but only if the irrigant is delivered with sufficiently high pressure (

ANTIBIOTIC BEADS AND SPACERSAfter fracture stabilization has been completed, bone defects may be filled with antibiotic-impregnated methacrylate beads. these beads provide local depot administration of antibiotic and maintain space for subsequent bone graft

INTERNAL FIXATION OF FRACTURESInternal fixation is the definitive treatment for compound fracture

This procedure is not performed in theater due to risk of contamination and infection

EXTERNAL FIXATION OF FRACTURES

EXTERNAL FIXATION OF FRACTURES Technically easier to perform in field conditions No soft tissue dissection or extended exposure requiredEase of removing hardwareLess risk of infection

EXTERNAL FIXATION OF FRACTURESPin tract infectionsDelayed unionNon union or mal-union

AMPUTATION IN FIELD

Surgical preparation of the entire limbOnly amputate nonviable and ischemic tissueCompletion amputation through wound preferrableLigate major arteries and veinsDebride bony stumpsDress wound in open manner with VAC dressingDefinitive revision of wound at later time

Treatment of extremity injuries begins with ABC of trauma protocolControl hemorrhageStabilize vital signsEvaluate neurologic and vascular statusStabilize fractureDebride woundFasciotomy if indicatedCasevac to next level of care

SUMMARY

Orthopedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts.. The spectrum of injuries include open fractures, amputations, neurovascular, and soft-tissue injuries. 85% will receive treatment beyond local wound care prior to arrival at a military medical center.

Though amputations are visually dramatic, attention must be focused on the frequently associated life-threatening injuries. Most commonly due to explosive munitions, with penetration and blast effects or Parachute Injuries. Involve a large zone of injury with a high degree of contamination, which may affect the level of amputation and/or surgical intervention. Battle casualties who sustain amputations have the most severe extremity injuries.

Historically, one in three patients with a major amputation (proximal to the wrist or ankle) will die, usually of hemorrhage .

These high-energy sources produce wounds characterized by violent tissue destruction. Violent tissue destruction and contamination requires radical dbridement. This combination of high-energy injury, massive evolving tissue destruction, and widespread contamination and increased zone of injury. This evolving zone of injury respects no tissue planes, anatomic boundaries, or normal physiologic rules. .The result of such trauma is open, complex wounds with severe bone fragmentation.The Casualty exposed to blast and high velocity weapons will often present with multiple fracture types.

Debridement and irrigation is the most commonly performed procedure due to the contaminated nature of these combat injuries .According to the trauma registry There were no infections among evacuated patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days.

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Longitudinal incisions to obtain exposure. Fascia incised longitudinally to expose underlying structures and compartment release. All foreign material in the operative field must be removedSevere, constant pain in affected limb, pain on muscle palpation, passive stretch, and active contraction, paresthesia loss of distal pulses are late signs and indicate poor outcomeAt risk for ischemic necrosis above 30 mmCombat life savers. 98w, self aid .aid buddy aidTourniquets, direct pressureThe goals of the FST are to Control Hemorrhage and contamination, stabilize any fractures and evacuate to higher echelon for definitive care.High velocity GSW need to be treated like open fractures. generally requires formal operative dbridement and fixation. Begin IV antibiotics as soon as possible and maintain throughout the evacuation chain. Use a broad spectrum cephalosporin (cefazolin 1 g q 8 h) . The two most harmful bacteriaclostridia and streptococciare covered by a 1st generation cephalosporin.Surgical preparation of the entire limb, because planes of injury may be much higher than initially evident Tourniquet control is mandatory. If a tourniquet was placed in the prehospital setting for hemorrhage control, it is prepped entirely within the surgical field.Prevention of hemorrhage: A tourniquet should be readilyavailable at the bedside or during transport for the first weekfollowing injury. Pain control Adequate analgesia should be available and the patient during dressing changesPrevention of contracture : BK amputations are at risk for knee flexion contractures. These contractures are preventable by using a long leg cast.AK amputations are at risk for hip-flexion contractures. Prone positioning and active hip extension exercises willavoid this complication.