Combat extremity Wounds
Combat Extremity Wounds
Improvements in body armor have reduced axial
trauma, but the overall percentage of skeletal
trauma on the modern battlefield has increased.
The severity of the wounds and the amount of
energy absorbed by the limbs with modern
battlefield injuries cannot be overemphasized.”
“.
Journal of Orthopedic Trauma
TLO

Action : The soldier will identify combat
extremity wounds and determine the correct
interventions for these patients

Conditions: Classroom environment with
PowerPoint presentation

Standard: Soldiers will complete a 10
question written exam in less than 5 mins
ELOs

ELO #1: Factors effecting extremity wounds

ELO #2: Early management of extremity wounds

ElO #3: Interventions for extremity wounds
Safety Requirements
 Be
aware of your environment
 Maintain
professional behavior
at all times
( No running with scissors)
Risk factors
LOW
Environmental considerations
 Indoor Classroom
 No
opposing force
Evaluation

The Solider will be evaluated
using a 10 question exam. The
solider will complete the exam in
less than 5 minutes with a
minimal score of 80%
Instructional lead in
This block of instruction will take
place in a classroom setting, using a
PowerPoint presentation and
reference materials.
In actual combat the solider would
encounter enemy fire ,hostile terrain
and host of environmental factors
while weighed down weapons and
equipment
Target
This presentation is designed for
 Line medics/ corpsman

W56, Nurses and physicians attached to
BAS, Forward surgical teams or Shock
platoons.
SAFTY

In the combat zone the provider will need to
conscious of hostile fire, and environmental factors.

Scene safety and BSI should be observed at all times
ELO #1: Factors effecting
extremity wounds

Action: Determine factors effecting
extremity wounds.

Condition: same as TLO

Standards: Same as TLO
ELO#1
Factors affecting Extremity wounds
ELO#1
Factors affecting Extremity
wounds

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 Energy

High-energy sources produce
wounds characterized by violent
tissue destruction. Violent tissue
destruction and contamination
requires radical débridement
Compound Fracture

A compound fracture, also called a open fracture, is
an injury that occurs when there is a break in the
skin around a broken bone. Compound fractures are
generally treated with surgery to clean the site of
injury and stabilize the fracture
Fracture types
Complexity of fracture pattern
Compound
Fracture
Compound Fracture
Compound Fractures
Traumatic Amputations
Though amputations are visually
dramatic, attention must be focused on
the frequently associated lifethreatening injuries.
 Most commonly due to explosive
munitions, with penetration and blast
effects or Parachute Injuries.

Compartment syndrome

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.
Compartment Syndrome
Signs and symptoms

Severe, 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
outcome
Compartment syndrome
Check on learning

High-energy sources produce wounds characterized by violent tissue
destruction

Though amputations are visually dramatic, attention must be
focused on the frequently associated life-threatening injuries

Severe, 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 outcome
 A compound fracture, also called a open fracture, is an injury that
occurs when there is a break in the skin around a broken bone.
ELO #2
Early Management of Extremity
wounds

Action: Determine the management
techniques for extremity wounds

Conditions: Same as TLO

Standards: Same as TLO

"There is no good reason why
wounded soldiers are continuing to
die on the battlefield from extremity
bleeding.“
Capt. Michael J. Tarpey, Battalion
surgeon ,3rd Infantry Division's 1-15 Infantry
Early Management of
Extremity wounds

Control of hemorrhage

Temporary splinting

IV antibiotics

Tetanus prophylaxis
The Tourniquet

Designed for one-handed
application, the tourniquet allows a
soldier to apply the tourniquet to
himself if needed and replaces the
Army's field-expedient method,
where a soldier would use a
bandage and a stick to stop blood
flow from a wound
“There is no pre-hospital
device deployed in this war
that has saved more lives
than tourniquets.”
Col. Holcom , 10th CSH
The Special Operations Forces Tactical
Tourniquet
IMMBOLISATION

It is essential for the provider to immobilize any
fractures prior to CASVAC

Failure to immobilize all fractured extremities could
lead to vascular injuries or compartment syndrome
Transportation cast
ElO #3:
Interventions for extremity wounds

Action: Determine interventions for
extremity wounds

Conditions: Same

Standards: Same
Treatment of fractures

Débridement

Reduction

Fixation

Evacuation
Wound Management
Compound Fractures
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
PULSE LAVAGE
PULSE LAVAGE
High Pressure Irrigation

Irrigation can remove enough wound
bacteria to render the wound noncontaminated but only if the irrigant is
delivered with sufficiently high pressure (
<7 PSI) to mechanically remove bacteria
from the wound surface
Antibiotic beads and spacers
Antibiotic beads and spacers

After 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

Internal fixation is the definitive treatment
for compound fracture.

This procedure is not performed in theater
INTERNAL FIXATION (ORIF)
EXTERNAL FIXATION
Advantages of external
fixation
Technically easy to perform
No soft tissue stripping;
Ease of removing hardware
Disadvantages of external
fixation

Pin tract infections,

Delayed union

Non union , and Mal-union
Technique of Amputation
Tourniquet control is mandatory.
Surgical preparation of the entire limb, because
planes of injury may be much higher than initially
evident.
If a tourniquet was placed in the prehospital
setting for hemorrhage control, it is prepped
entirely within the surgical field.
Fasciotomy
Indications for performing a
Fasciotomy
fasciotomy
Treatment is by fasciotomy and
requires immediate surgical consultation
Technique of Amputation
Indications for performing a
fasciotomy

Greater than a 6-hour delay between injury
and treatment.

Prolonged hypotension and shock.

Massive swelling, either preoperatively,
postoperatively, or during evacuation.

Massive associated soft tissue injury
Postoperative Management
Prevention of hemorrhage
Pain control
Prevention of contracture
EXAM
•
1
Neurovascular status of the extremity should be documented and checked
repeatedly. True or false
•
•
•
2 Name one Advantages of external fixation
•
4 If a tourniquet was placed in the prehospital setting for hemorrhage control, it
is prepped entirely within the surgical field.
True or false
•
4 Fasciotomy is the definitive treatment for what extremity injuries.
•
5 This injuries is Most commonly due to explosive munitions, with
penetration and blast effects or Parachute Injuries.
3 Irrigation can remove enough wound bacteria to render the wound noncontaminated. True or False
Exam
6
It is essential for the provider to immobilize any fractures prior to
CASVAC. True or false
7
These provide local depot administration of antibiotic and maintain
space for subsequent bone graft
8
9
Name the best option for controlling hemorrhage in extremity
injuries
Name a disadvantage of external fixation
10
A fracture that breaks the skin causing a open wound