Extremity Fractures and the Mangled Extremity

Abstract

With the ongoing improvements in body armor and ballistic helmets, as well as advances in modern combat casualty care, more and more combat wounded are surviving to be transported for resuscitation and surgical care. As such, the severity of extremity injuries among survivors of combat injuries has increased. Such injuries are rarely encountered in the context of civilian medicine, even at level I trauma centers.

When called upon to serve in a combat zone, it is imperative to recognize the differences in environment, treatment capability, and logistical challenges when attempting to optimize surgical care for those wounded during wartime operations. Timely and appropriate treatment of extremity wounds is essential to patient resuscitation, stabilization, and preservation of future functional capability.

Civilian Translation of Military Experience and Lessons Learned

• George Velmahos 

In this truly practical and exceptionally well-written guide of “what to do with extremity injuries,” Drs. Horne and Robins offer all the important principles of severe extremity trauma management. As expected, they focus on the early stage, which is probably the most important one for the stabilization of the injured victim and determines the eventual preservation of life and limb. Even if injuries in the battlefield may be distinctly different than those of the civilian setting, the medical tenets are astonishingly similar. Let’s list them:

• Careful debridement of dead tissues and removal of foreign bodies are key maneuvers to promote the ultimate healing of tissues. As simple as this rule is, inadequate debridement during the first surgery is extremely common. Surgeons should realize that dead tissue does not become alive again; it only promotes infection and further necrosis.

• Early stabilization of fractures controls bleeding and prevents complications. It can be achieved relatively easily by splints, casts, and external fixators.

• Tourniquets can save limb and life, but to do so, they should be placed expertly, which is not always the case. As simple as the placement of a tourniquet may seem, inadequate training leads to incorrect placement.

• Compartment syndrome is on occasions hard to diagnose, particularly in intubated patients. Increased vigilance, targeted clinical exam, and compartmental pressure monitoring will prevent catastrophes.

• Different scores do not predict the need for amputation and should not be used, definitely not in the acute setting.

On the other hand, there are also important differences between the military and civilian management of these injuries :

• Major civilian extremity injuries are caused typically by blunt trauma, as opposed to penetrating trauma and explosions in the military setting.

• While damage control principles are always applicable, the likelihood of using them in civilian extremity injuries is low. An abbreviated exploration of an extremity is rarely needed, unless dictated by associated, overwhelming, non-extremity injuries, or it happens in a rural, resource-restrained environment. For example, even in a mass casualty scenario, as happened at the Boston Marathon bombing, damage control was not necessary.

• The authors make the point of always trying to salvage the leg, unless it is nearly auto-amputated or a risk for the patient’s life; this advice is based more on emotional than medical reasoning, as the authors want to assure the military patient that everything was done to save the extremity. Although I agree that amputation does not need to be offered hastily, the LEAP studies have repeatedly shown that a well-fitted prosthesis is more acceptable to the patient than a poorly functional extremity, subjected to multiple operations. There are no rules to govern when an amputation should be offered, but the reluctance to remove an obviously failing extremity is far more common than an unnecessary amputation before all possibilities are exhausted. Given the resources of a civilian setting, an amputation can be offered promptly after appropriate work-up and consultations, saving the patient from pain, complications, and financial loss.

War surgery has offered amazing knowledge and experience to the field of trauma. Diagnostic and treatment principles cross over from the battlefield to the civilian arena and vice versa; civilian trauma surgeons have learned a tremendous amount from those who give their lives and those who fight to save them.