US Army Orthopaedic Trauma Cases

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The Borden Institute, an agency of the US Army Medical Department Center & School, publishes the Textbooks of Military Medicine series, as well as standalone specialty clinical titles such as War Surgery in Afghanistan and Iraq, a Series of Cases, 2003-2007, a compilation of nearly 100 cases describing the management of acute combat trauma. Presented with vivid surgical photos, the cases encompass the spectrum of trauma that characterizes war today, as well as the medical interventions constantly evolving to treat these wounds.

The cases below are reprinted with permission from the chapter on orthopaedic trauma in War Surgery in Afghanistan and Iraq, a Series of Cases, 2003-2007, and they highlight the innovations and improvisations required of surgical teams working in the forward austere operative environment of war in the 21st century.

Commentary: Orthopaedic Trauma
Since September 11, 2001, U.S. and coalition troops have been actively engaged in the largest conflict since Vietnam. Of the 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.

Blast Injury of the Hand
A male patient presented with blast injuries to all four extremities. His case is an example of using available resources to obtain an acceptable outcome. The surgeons were successful in an austere environment by using basic wound care management and relatively simple medical techniques.

Blast Injury of the Humerus
A blast injury from an improvised explosive device (IED) resulted in a large, lateral arm wound and an open humerus fracture.Open humerus fractures resulting from gunshot wounds or blast injuries are very common. A thorough understanding of these blast injuries, their associated injuries, and the range of options to treat them is important.

Gunshot Wound of the Hand
A soldier suffered a through-and-through gunshot wound to the hand. Hand wounds are very common in the combat theater — hands are unprotected by armor and are therefore exposed to wounding by gunshots, blasts, and thermal mechanisms. Early evaluation and appropriate treatment of these wounds can help preserve function and limit disability.

Gunshot Wound with Loss of the Elbow
An interpreter for Special Operations Forces sustained a gunshot wound to the left elbow, resulting in loss of the proximal ulna. He refused amputation, necessitating highly sophisticated, technically complex surgery in theater. Combat support hospitals are not intended to provide this type of surgery because of the rapid evacuation of the wounded. However, at times, complex surgeries are still necessary and are appropriate in the combat zone.

Hand and Face Blast Injuries - Polytrauma Management
Blast injuries cause severe injuries to multiple body parts. That was the case for this male patient, the driver of a Humvee in a convoy that was hit by a blast from an improvised explosive device (IED). It is crucial that a surgeon not become fixated on any one injury in these situations; Advanced Trauma Life Support principles must be followed.

High-Energy Gunshot Wound to the Forearm
An Iraqi Army soldier sustained a high-velocity gunshot wound that causes an open forearm fracture. These fractures have extensive segmental bone and soft-tissue loss and are a challenging clinical problem. It is important to obtain initial skeletal stabilization with an external fixator to restore the anatomy and prevent further damage to the soft-tissue envelope.

High-Energy Orthopaedic Polytrauma
This case demonstrates the severity of musculoskeletal injuries from high-energy blunt trauma. Priority was given to the patient's potentially life-threatening intra-abdominal injuries, followed by attention to multiple complex extremity injuries. All injuries were promptly treated, and the patient was stabilized for transport to a higher echelon of care.

Open Femur Fracture
A soldier sustained a penetrating blast injury to his left thigh from an improvised explosive device (IED), resulting in an open femur fracture. These are some of the most commonly encountered injuries in the current combat environment. All general and orthopaedic surgeons should have a thorough understanding of extremity anatomy and treatment options for these injuries.

Open Ulna Fracture
A male host national with multiple gunshot wounds required prolonged inpatient and outpatient care. His treatment necessitated operative and postoperative management different from the typical patient treated at a combat support hospital, which is not generally equipped to render definitive repairs and comprehensive follow-up therapy. The surgeons involved managed the patient in accordance with the circumstances.

Penetrating Injury of the Left Foot
This case of an 11-year-old host nation male with a blast injury to the foot demonstrates the effectiveness of secondary intention healing in soft-tissue injuries. In this case, the patient made a good, functional recovery following adequate washout, debridement, and dressing changes.

Tibia Fracture with Compartment Syndrome
A soldier sustained a left tibia fracture from the blast of a vehicle-borne, improvised explosive device (IED). This is a very common injury in the combat environment because the lower extremities are not protected by body armor. He then developed compartment syndrome, which will result in long-term disability if not diagnosed in a timely manner. It is important to remember that physical examination of a trauma patient should be repeated frequently.

Traumatic Below-Knee Amputation
Surgeons in combat operations will see high-energy blast injuries that result in traumatic amputation — in fact, traumatic amputations are common and are the most severe limb injuries seen. This case illustrates the basic techniques of caring for a patient with a traumatic below-knee amputation.

Umbrella Effect of a Landmine Blast
As was the case with this patient, a landmine blast leads to an umbrella effect in which the soft tissues, vessels, and nerves are stripped from the bone. This shredding results in a more proximal injury than may be clinically apparent and requires a reasoned approach to amputation.

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