By COL James Ficke, MD

Since September 11, 2001, U.S. and coalition troops have been actively engaged in the largest conflict since Vietnam. As of January 2008, more than 4,300 U.S. soldiers have died in this conflict, and more than 30,000 have been injured. Of these casualties, approximately 54% sustained open wounds to the extremities and 26% sustained fractures. Of even greater impact, 82% of all of these fractures were open and required urgent, in-theater debridement, often necessitating stabilization.

The cases presented in the Orthopaedic Trauma chapter of the book War Surgery in Afghanistan and Iraq, a Series of Cases, 2003-2007 encompass a thorough survey of typical injuries currently seen in contemporary combat. Leading civilian and military orthopaedic surgeons have collaborated on two annual Extremity War Injury Symposia to identify management principles and challenges faced by surgeons who treat combat injuries. These principles include:

  • Improvement of prehospital care for extremity injuries
  • Initial debridement and stabilization
  • Management of massive bone and soft-tissue defects
  • Treatment and prevention of wound infections
  • Prevention of heterotopic ossification

The following additional comments are warranted.

Civilian (Host National) Care

Often, the only potential for definitive reconstruction rests on the capabilities of the combat support hospital (CSH). Definitive care for a host national patient can be accomplished safely without sophisticated techniques. With minimal additional technology, successful wound management and staged reconstruction may be possible. Early fixation and bone grafting in this situation may be deleterious, however, in the face of inadequate soft-tissue coverage. Although microvascular free tissue transfer is not commonly practiced in theater, alternatives such as pedicle flaps and negative pressure wound therapy (wound VAC) can significantly reduce in-hospital stay, while still permitting appropriate definitive fixation.

External Fixation and Transport

The field external fixator has largely replaced a transportation cast. The disadvantage of casting is primarily related to wound access, weight, and time to apply. In nearly all lower extremity injuries, an external fixator can be safely applied, allowing wound access, comfort, and minimal additional soft-tissue trauma. When periarticular fractures are stabilized with joint-spanning external fixators, these should be placed anteriorly whenever possible in order to facilitate transport.

Extremity Compartment Syndrome

Tibia fractures as a result of blast injury are fairly common, and the chapter on Orthopaedic Trauma demonstrates essential principles in their management. Open tibia fractures lack the abundant soft-tissue envelope of the femur, and complications (eg, infection or compartment syndrome) tend to occur with higher frequency. This necessitates serial examinations and low threshold for performing four-compartment fasciotomy through two incisions. Recent evidence for incomplete release demonstrates the imperative for long incisions, release from 5 cm below the knee joint distally to the musculotendinous junction, and assurance of release of all four compartments. This is best accomplished for the deep posterior compartment by the ability to directly touch the posteromedial fibula from the medial incision, and performing an “H” between the separate longitudinal releases of the anterior and lateral compartments, directly visualizing the intermuscular septum with the horizontal incision.

Some surgeons would disagree that simple bulging of muscle confirms the diagnosis of compartment syndrome. More importantly, muscle viability and contractility must be assessed, and complete release ensured. Additionally, a fasciotomy with normal muscle should not be criticized; rather, the dire consequences of missed compartment syndrome far outweigh an occasional fasciotomy without compartment syndrome. In the face of evolving compartment status, ongoing resuscitation, or significant coagulopathy, delaying evacuation to ensure limb viability is justified and preferable to delaying fasciotomy.

Amputation

The overall amputation rate in the present conflicts in Southwest Asia appears to remain fairly constant and is more related to immediate nonreconstructible trauma than to any other cause. The principles of open-length preserving amputation include removing clearly devitalized tissue (skin, fat, muscle, and bone) and leaving the wound open (Figure 1). Wound debridement is more important than formal flaps. The ideal incision follows the lines of injury, thus providing greater latitude in the definitive care decision process. Loose approximation to prevent skin retraction may have the same effect without increasing the infection rates. At present, formal skin traction is rarely used. An open circular amputation does not preserve length, and leads to unnecessary challenges in healing and rehabilitation of the residual limb. For these reasons, open circular amputation is no longer recommended.


Figure 1. Distal leg wound at presentation (top). Postoperative view of wound; the irregular soft-tissue margins are intentional (bottom).

For more, see Consensus Statement on Length-Preserving Amputations

Pelvic Stabilization

Pelvic ring injuries need to be assessed early for stability, and stabilized as part of the damage control and resuscitation process. This is one of the critical roles an orthopaedic surgeon plays in lifesaving hemostasis. A contained retroperitoneal hematoma can be controlled with external fixation. Use of a pelvic binder, although often effective in short term, is not advisable for prolonged transport. Packing can result in hemodynamic stability (as in the case presented). Early or prophylactic fasciotomies should be considered in the face of massive resuscitation and unclear clinical picture. Recent evidence suggests that delayed fasciotomy is associated with increased mortality and amputation rates. However, more rigid analysis of clinical outcomes data is required.

The present practice of lower extremity, four-compartment fasciotomy through two separate wide incisions (including release of the entire extent of the muscle) appears to be most preventive of additional muscular injury. It should be emphasized that the vast majority of fractures should not be definitively internally fixed in theater. Femoral neck fractures, however, are one of the very few strong indications for definitive internal fixation in the combat zone. The risk of osteonecrosis of the femoral head outweighs the infection risk in this injury, and pinning with reduction can be safely performed if fluoroscopy is available. Intra-articular foreign bodies constitute a contaminated joint and mandate open debridement.

The 13 cases in the Orthopaedic Trauma chapter of War Surgery in Afghanistan and Iraq, a Series of Cases, 2003-2007 catalog a wide diversity of extremity trauma, as well as their spectrum of severity. Principles of surgery are learned with practice and study, a comprehensive review is not in the scope of this book. However, wound debridement, soft-tissue coverage, and consideration of the necessary differences between care of host national patients who often require prolonged and definitive management versus damage control stabilization and transport of U.S. patients are well described. A deployed surgeon of any discipline must know the technique for fasciotomy and the indications for the procedure, as well as be able to anticipate and prevent the drastic consequences of compartment syndrome.

References

  1. DefenseLINK Casualty Report. Available at: http://www.defenselink.mil/news/casualty.pdf. Accessed May 25, 2006.
  2. Owens BD, Kragh JF, et al. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma. 2007;21:254–257.
  3. Pollak AN, Calhoun J. Extremity war injuries: State of the art and future directions. Prioritized future research objectives. J Am Acad Orthop Surg. 2006;14:S212–S214.
  4. ALARACT-106/2007. Management of OIF/OEF Casualties Requiring Extremity Fasciotomy. Washington, DC: Department of the Army Military Operations/Department of the Army Surgeon General; 2007.

Reprinted with permission from [Chapter VII, Orthopaedic Trauma|http://www.bordeninstitute.army.mil/published_volumes/war_surgery/Atlas_chap7_FINAL.pdf], in [War Surgery in Afghanistan and Iraq, A Series of Cases 2003-2007|http://www.bordeninstitute.army.mil/published_volumes/war_surgery/war_surgery.html], edited by Nessen CS, Lounsbury DE, Hetz SP. Published by the Office of the Surgeon General, United States Army, Falls Church, Va., and Borden Institute, Fort Detrick, Md., 2008.

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