EXTREMITY INJURIES IN
THE BATTLEFIELD
CDR JOHN P WEI, USN MC MD
4th Medical Battallion, 4th MLG
BSRF-12
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
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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 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
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attention must be focused on associated lifethreatening injuries
commonly due to explosive munitions, with
penetration and blast effects (parachute
Injuries)
COMPARTMENT SYNDROMES
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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
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If untreated surgically, can lead to
neurovascular compromise and ischemia
resulting in gangrene
COMPARTMENT SYNDROME
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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
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Control of hemorrhage
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Temporary splinting
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IV antibiotics
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Tetanus prophylaxis
COMBAT APPLICATION
TOURNIQUET
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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
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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
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Débridement
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Reduction
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Fixation
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Evacuation
WOUND MANAGEMENT
FRACTURES AND WOUND
MANAGEMENT
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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 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
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 OF
FRACTURES
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Internal fixation is the definitive treatment for
compound fracture
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This procedure is not performed in theater
due to risk of contamination and infection
EXTERNAL FIXATION OF
FRACTURES
EXTERNAL FIXATION OF
FRACTURES
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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
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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
SUMMARY
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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