CDR JOHN P WEI, USN MC MD4th Medical Battallion, 4th MLG

BSRF-12

EXTREMITY INJURIES IN THE BATTLEFIELD

Improved body armor has reduced axial trauma

Skeletal trauma on battlefield has increased

Severity of wounds and energy absorbed by injured limbs much greater

INTRODUCTION

Factors effecting extremity wounds

Early management of extremity wounds

Interventions for extremity wounds

FACTORS IN EXTREMITY INJURIES

FACTORS IN EXTREMITY INJURIES

• Energy 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 débridement of devitalized tissue

FRACTURE TYPES

COMPOUND FRACTURE

Compound 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 INJURIES

•Initiate basics of trauma life support: airway, breathing, circulation

•Assess for life threatening injuries•Control hemorrhage•Intubate for airway control if needed•Begin resuscitation•Secondary survey of extremities•Complete neurologic and vascular examination

EXTREMITY INJURIES

Concomittant vascular injuries require urgent surgical repair in addition to orthopedic fixation

TRAUMATIC AMPUTATION

attention must be focused on associated life-threatening injuries

commonly due to explosive munitions, with penetration and blast effects (parachute Injuries)

COMPARTMENT SYNDROMES

• Caused 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 SYNDROME

Severe, constant pain in affected limb, pain on muscle palpation, passive stretch, and active contraction

Paresthesia and loss of distal pulses are late signs and indicate poor outcome

Can measure compartment pressures (if > 25 mm Hg)

FASCIOTOMIES•Need to perform complete fasciotomy in all 4 compartments•All fascial envelopes opened completely from knee to ankle•Less frequently, fasciotomies of upper extremities, thighs, and buttocks are performed

FIELD MANAGEMENT OF EXTREMITY WOUNDS

• Control of hemorrhage

• Temporary splinting

• IV antibiotics

• Tetanus prophylaxis

COMBAT APPLICATION TOURNIQUET

• One-handed application• Tourniquet can be applied by soldier to

himself if needed• Controls hemorrhage from extremity wounds

until evacuated to higher level of care

IMMOBILIZATION OF EXTREMITY INJURIES

• Essential to immobilize any fractures prior to CASVAC from field

• Failure to immobilize fractured extremities could • lead to vascular or neurologic injuries or

increased bleeding

TREATMENT OF FRACTURES

Débridement

Reduction

Fixation

Evacuation

WOUND MANAGEMENT

FRACTURES AND WOUND MANAGEMENT

• Treat by irrigation and debridement as soon as feasible to prevent infection

• Neurovascular status of the extremity should be documented and checked repeatedly

• Biplanar radiographs should be obtained

PULSE LAVAGE

High pressure irrigation can remove enough wound bacteria to render the wound non-contaminated but only if the irrigant is delivered with sufficiently high pressure ( <7 PSI) to mechanically remove bacteria from the wound surface

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 FRACTURES

• Internal 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

required• Ease of removing hardware• Less risk of infection

 EXTERNAL FIXATION OF FRACTURES

• Pin tract infections• Delayed union• Non union or mal-union

AMPUTATION IN FIELD

•Surgical preparation of the entire limb•Only amputate nonviable and ischemic tissue•Completion amputation through wound preferrable•Ligate major arteries and veins•Debride bony stumps•Dress wound in open manner with VAC dressing•Definitive revision of wound at later time

• Treatment of extremity injuries begins with ABC of trauma protocol

• Control hemorrhage• Stabilize vital signs• Evaluate neurologic and vascular status• Stabilize fracture• Debride wound• Fasciotomy if indicated• Casevac to next level of care

SUMMARY