Armed Conflict Injuries to the Extremities (eBook)

Alexander Lerner is working at the Rambam Medical Center in Haifa, Israel, which is specialised in the treatment of military and civilian casualties. He is an orthopaedic surgeon, member in a number of international learned societies, has lectured worldwide and has heavily published in international journals.

Dedication 6
Foreword 8
Preface 10
Portraits of the Editors 12
Acknowledgments 14
Contents 16
1: Organization of Urgent Medical Aid, Including Mass Casualty and Triage 18
1.1 Introduction 18
1.2 Surge Capacity 18
1.3 Leadership 19
1.4 Hospital Incident Command System 21
1.5 Blood Product Management and Planning 22
1.6 Communication/Information Systems 22
1.7 Characterization of Injuries 23
1.8 Triage 24
1.8.1 Triage – A Brief History 24
1.8.2 Tactical Combat Casualty Care and PHTLS in the Military 25
1.8.3 U.S. Military Triage and Underlying Principles 26
1.8.4 Triage – Practical Application 27
1.8.5 The Evacuation Chain 29
1.8.6 Summary 32
1.8.7 Initial Assessment and Life Support 32
1.9 Conclusion 35
References 36
2: Wound Ballistics and Tissue Damage 38
2.1 Introduction 38
2.2 Bullet and Projectile Ballistics 38
2.2.1 Material Contamination 43
2.2.2 Lead Toxicity 43
2.3 Blast Mechanisms and Tissue Damage 43
2.3.1 Heterotopic Ossification 47
References 48
3: Damage Control Orthopaedics 51
3.1 The Origin of Damage Control in Trauma 51
3.2 Damage Control and Hemorrhage 51
3.3 Resuscitation 55
3.4 The Evolution of Damage Control Orthopedics 57
3.5 Trauma and the Inflammatory Cascade 58
3.6 Long Bone Fixation in Damage Control 59
3.7 Damage Control and Pelvic Ring Injuries 61
References 64
4: Crush Injury of the Limbs and Acute Mechanical Muscle-Crush Compartment Syndrome 66
4.1 Introduction 66
4.2 History of MMCI 66
4.3 Acute Mechanical Muscle-Crush Compartment Syndrome 66
4.3.1 Pathology and Pathophysiology 66
4.3.2 Diagnosis 67
4.3.3 Management 67
4.3.3.1 General 67
4.3.4 Local 67
4.3.4.1 Open High-Energy Injury Crush Wound and Open MMCI (OCW) 67
4.3.4.2 Closed MMCI – Acute Mechanical Muscle-Crush Compartment Syndrome 68
References 69
5: Anesthesia and Intensive Care of the Patient with Severe Extremity Trauma 71
5.1 Preoperative Evaluation and Treatment 71
5.1.1 Evaluation of Underlying Medical Conditions 71
5.1.2 Determination of Surgery Urgency 72
5.1.3 Preoperative Fasting 72
5.1.4 Laboratory Testing 73
5.1.5 Imaging Studies 73
5.2 Anesthetic Techniques 74
5.2.1 General Anesthesia 74
5.2.1.1 Endotracheal Intubation 74
5.2.1.2 Rapid Sequence Induction 75
5.2.1.3 Cervical Spine Injury 75
5.2.1.4 Laryngeal Mask Airway 75
5.2.2 Sedation 75
5.2.3 Regional Anesthesia 76
5.2.3.1 Spinal Anesthesia 77
5.2.3.2 Epidural Anesthesia 77
5.2.3.3 Peripheral Nerve Blocks 77
Nerve Blocks for the Upper Extremity 77
Nerve Blocks for the Lower Extremity 78
5.3 Intraoperative Management 79
5.3.1 Monitoring 79
5.3.2 Body Temperature Regulation 79
5.3.2.1 Patient Warming Techniques 80
5.4 Hemodynamic Stabilization 80
5.4.1 Hypovolemic Shock 80
5.4.2 Cardiogenic Shock 80
5.4.3 Obstructive Shock 81
5.4.4 Distributive Shock 81
5.4.5 Fluid Resuscitation 81
5.4.5.1 Crystalloid Solutions 82
5.4.5.2 Colloid Solutions 82
5.4.6 Inotropes and Vasopressors 82
5.4.7 Hypocalcemia 83
5.4.8 Glycemic Control 83
5.4.9 Resuscitation Goals 83
5.5 Postoperative Analgesia 83
5.5.1 Regional Techniques 83
5.5.2 Systemic Analgesia 83
5.6 Intensive Care 84
5.6.1 General Considerations 84
5.6.1.1 Some Issues to Consider 84
5.6.2 Rhabdomyolysis 85
5.6.2.1 Signs and Symptoms 85
5.6.2.2 Laboratory and Diagnostic Tests 85
5.6.2.3 Monitoring 85
5.6.2.4 Management 86
5.6.2.5 Outcome 86
5.6.2.6 Prevention 86
5.6.3 Thrombo-Embolic Complications 86
5.6.3.1 Deep Vein Thrombosis (DVT) 87
5.6.3.2 Clinical Significance and Complications 87
Local Complications (Limb Threatening) 87
Systemic Complications (Life Threatening) 87
5.6.3.3 Diagnosis 87
5.6.3.4 Management 87
Treatment Goals 87
Acute 88
Systemic Anticoagulation (Heparin or LMW Heparin) 88
5.6.3.5 Thrombolysis 88
Chronic 88
5.6.3.6 Pulmonary Embolism (PE) 88
5.6.3.7 Management 89
5.6.3.8 Outcome 89
5.6.3.9 Thrombo-Prophylaxis – DVT and PE Prevention 90
Primary Prevention 90
Secondary Prevention 90
Screening for DVT 90
5.6.4 Fat Embolism (FE) and Fat Embolism Syndrome (FES) 90
5.6.4.1 Laboratory and Diagnostic Tests 91
5.6.4.2 Management 91
5.6.4.3 Outcome 91
5.6.4.4 Prevention 92
5.6.5 Critical Illness Polyneuropathy 92
5.6.5.1 Workup 92
5.6.5.2 Management 93
5.6.5.3 Prognosis 93
5.6.5.4 Prevention 93
References 93
6: Hemotransfusion in Combat Trauma 95
6.1 History of Blood Transfusion for Combat Injuries 95
6.2 Currently Available Blood Products 96
6.3 Role of Coagulopathy in the Outcome of Trauma Patients 97
6.4 Preemptive Therapy of Coagulopathy 98
6.5 Northern Israel’s Experience in Handling Massively Bleeding Trauma Patients 99
6.5.1 The Threshold of Blood Product Transfusion 99
6.6 Massive-Transfusion Protocols 102
6.7 Use of Activated Recombinant Factor VIIa (rFVIIa) and Antifibrinolytic Drugs 102
6.8 Thromboelastography 104
6.9 Conclusions 105
References 106
7: Diagnostic Imaging in Combat Trauma 108
7.1 Blast (Explosive) Injury 108
7.1.1 Primary Injuries 108
7.1.2 Secondary Injuries 109
7.1.3 Tertiary Injuries 109
7.1.4 Quaternary Injuries 109
7.2 Bone and Soft Tissue Injuries 110
7.2.1 Limb Fractures and Traumatic Amputation 112
7.3 Arterial Injury 113
7.4 Types of Vascular Injuries 114
7.4.1 Hematoma 114
7.4.2 Pseudoaneurysm 116
7.4.3 Arterio-Venous Fistula (AVF) 118
7.4.4 Arterial Embolization 119
7.5 Clinical Signs of Arterial Injury 119
7.6 Imaging Modalities in Arterial Injury 119
7.6.1 Doppler Sonography 119
7.6.2 Magnetic Resonance Angiography (MRA) 120
7.6.3 Conventional Angiography (CA) 120
7.6.4 CT Angiography (CTA) 120
7.6.4.1 CTA Signs of Vascular Injury in the Extremities 121
7.6.4.2 Pitfalls 121
7.6.4.3 CTA Technique 124
7.6.5 Endovascular Treatment 125
7.6.5.1 Percutaneous Transcatheter Embolization 125
7.6.5.2 Stent/Stent Graft 126
7.7 Conclusions 126
References 126
8: Tissue Debridement 128
8.1 Introduction 128
8.2 Tissue Damage Evaluation 128
8.3 Goals of Debridement 129
8.3.1 Timing of Debridement 129
8.4 Wound Irrigation 130
8.4.1 Local Antiseptics 130
8.4.2 Local Antibiotics 130
8.4.3 Surfactants 130
8.4.4 High-Pressure Pulsatile Lavage (HPPL) 131
8.5 Debridement Technique 131
8.6 Fasciotomy 133
8.7 Repeated Debridement 137
8.8 Management of Retained Bullets, Shells, and Shrapnel in the Limbs 138
References 143
9: Primary External Fixation 146
9.1 Introduction 146
9.1.1 Important Advantages 147
9.1.2 Disadvantages 147
9.2 Unilateral External Fixation 147
9.2.1 Unilateral External Fixation Application Technique 148
9.2.2 Half-Pin Choice 149
9.2.3 Introduction of Half-Pins to the Bone 151
9.3 Specific Anatomical Locations 155
9.3.1 Femoral Bone Fractures 155
9.3.2 Tibial Bone Fractures 156
9.3.3 Humeral Bone Fractures 156
9.3.4 Forearm Bone Fractures 157
9.4 Small Bone External Fixation Frames 157
9.5 Multiplanar Configurations of Fixation Frames 158
9.6 Transarticular Bridging 158
9.7 Limb Suspension in the Early Post-traumatic Period 159
9.8 Hybrid Frames (Modular Combinations in Various Types External Fixation Devices) in Primary Fractures Stabilization Set 161
References 174
10: Prevention of Infection and Antibiotic Use in the Management of Armed Conflict Injuries to the Extremities 176
10.1 Background 176
10.2 The Nature of the Problem 176
10.3 The Wound Microenvironment 177
10.4 Epidemiology of Combat-Related Wound Infections Caused by Multidrug-Resistant Organisms 177
10.5 Combat-Related Extremity Injuries and Open Fractures 178
10.6 Prevention of Infections Associated with Combat-Related Extremity Injuries 179
10.7 The Use of Antibiotics in the Management of Combat-Related Extremity Injuries 180
References 183
11: Vascular Trauma to the Limbs 185
11.1 Incidence of Vascular Trauma in Armed Conflicts 185
11.2 Methods of Hemorrhage Control 186
11.3 Tourniquets 186
11.4 Evacuation Methods of Casualties with Vascular Injuries 186
11.5 Triage in Emergency Room 187
11.6 Vascular Injury Imaging 187
11.7 Priority in the Operating Room 188
11.8 Mechanisms of Vascular Injury 188
11.9 Methods of Vascular Repair 189
11.10 Endovascular Methods 190
11.11 Temporary Shunt 190
11.12 Compartment Syndrome and Fasciotomy 191
11.13 Arterial Versus Venous Injury 192
11.14 Amputation 192
References 193
12: Peripheral Nerve Injury 195
12.1 Introduction 195
12.2 Definitions 195
12.2.1 Low-Velocity Injury 195
12.2.2 Medium Velocity Injury (The Usual “Low Velocity” of Firearm Injury) 195
12.2.3 High-velocity Injury 195
12.3 Nerve Injury Mechanism 195
12.3.1 Indirect Nerve Trauma 195
12.3.1.1 Nerve Trauma When a Blast Throws the Victim 195
12.3.1.2 Nerve Stretching Due to a Displaced Fracture 196
12.3.1.3 Shock Waves to the Adjacent Tissues Produced by a Penetrating Missile 196
12.3.1.4 Heat 196
12.3.2 Direct Nerve Trauma 196
12.3.2.1 Low-Velocity Injury 196
12.3.2.2 Medium-Velocity Injury 197
12.3.2.3 High-Velocity Injury 197
12.3.2.4 Iatrogenic Injury 197
12.4 Treatment Guidelines 197
12.4.1 Emergency Procedure Scheduled for a Concomitant Lesion 197
12.4.1.1 Nerve Continuity 197
12.4.1.2 Nerve Disruption 197
12.4.2 No Other Lesion Requiring an Emergency Procedure 200
12.4.2.1 High Suspicion of Isolated Indirect Nerve Trauma 201
12.4.2.2 High Suspicion of Isolated Direct Nerve Trauma 201
Low-Velocity Injury 201
Medium-Velocity Injury 203
High-Velocity Injury 203
Other Indications 204
12.5 Discussion 204
References 205
13: Tissue Coverage After War Trauma 207
13.1 General Considerations 207
13.2 Physical Examination 208
13.3 Timing of Soft-Tissue Coverage 208
13.4 General Strategies of Treatment 209
13.5 Negative-Pressure Wound Therapy 211
13.6 Skin Grafts 212
13.7 Flaps 213
Free Flaps 214
Perforator Flaps 215
13.8 Specific Flaps According to Anatomical Area 215
13.9 Complications of Soft Tissue Coverage 219
References 224
14: Definitive Bone Fixation and Reconstruction: Conversion from Temporary External Fixation to Internal Fixation Methods 227
14.1 Introduction 227
14.1.1 The Problem 227
14.1.2 The Civilian Experience: Provisional External Fixation in the Staged Treatment of Musculoskeletal Injuries 227
14.1.3 The Military Experience 228
14.1.4 The Military Paradigm (Echelons of Treatment) 229
14.1.5 Considerations 230
14.2 Wounding Mechanisms in the Combat Environment 230
14.3 Rationale and Timing of Conversion to Definitive Fixation 230
14.3.1 Synopsis 230
14.3.2 The Pin Tract 236
14.3.3 Staged Treatment of Diaphyseal Fracturess 237
14.3.4 Staged Treatment of Periarticular Fractures 239
14.3.4.1 Management of the Fixator at the Time of Reconstruction 240
14.3.5 Ring (“Skinny Wire”) and “Built-up” Fixators 241
14.3.6 Consideration for Primary Definitive Internal Fixation 241
14.4 Conclusions 241
References 242
15: Definitive Skeletal Reconstruction: Conversion to the Ilizarov Method 244
15.1 Introduction 244
15.2 Conversion from the Unilateral Tubular Fixator to Ilizarov Circular Frame 245
15.3 Preserving Bone Alignment During the Conversion Procedure 245
15.4 Ilizarov Frame Assembly Technique for Fracture Reposition and Fixation 248
15.4.1 General Principles 248
15.4.2 Specific Locations 251
15.4.2.1 Femur 251
15.4.2.2 Tibia 254
15.5 Fibular Stabilization in Distal Tibiofibular Fractures 255
15.5.1 Open Reduction and External Fixation 255
15.5.2 Bilateral Lower Limb Injuries 258
15.5.3 Primary Circular/Hybrid Fixation Frame Assembly 258
15.5.4 Hinged Fixation of Extensive Periarticular Injuries 260
15.5.5 Peculiarity of Upper Limb Reconstruction: Methods of Isolated Hybrid External Fixation of the Humerus, Ulna, and Radi 263
15.5.6 Primary Arthrodesis for Joint Destruction 265
15.5.7 Limb Salvage in Severe Bone and Soft Tissue Loss 267
15.5.7.1 Bone Reconstruction by Callotasis (Bone Induction at the Site of Injury) 267
15.5.7.2 Bone Reconstruction Using the Bifocal Technique 270
15.5.8 Acute Temporary Malalignment in Limb Salvage 274
15.5.8.1 Acute Limb Shortening 274
15.5.9 Acute Shortening and Angulation 280
15.5.10 Acute Shortening, Angulation, and Malrotation 283
15.6 Summary 286
15.7 Conclusion 287
References 287
16: War Injuries of the Hand 289
16.1 Introduction 289
16.2 Primary Care of the Wounded Hand 290
16.3 Tourniquet-Related Morbidity 291
16.4 Advanced Primary Management 291
16.4.1 Reassessment: General and Local 291
16.4.2 Anesthesia 291
16.4.3 Primary Wound Excision 293
16.4.3.1 Skin 293
16.4.3.2 Subcutaneous Tissues and Muscles 293
16.4.3.3 Vascular Structures 293
16.4.3.4 Nerves 295
16.4.3.5 Bone 295
16.4.3.6 Amputation 298
16.5 Delayed Primary and Secondary Surgical Management 299
16.5.1 Wound Closure: General Principles 299
16.5.2 Principles of Skin Cover 301
16.5.3 Management of Bone Injury 301
16.5.4 Management of Nerve Injuries 301
16.5.5 Management of Tendon Injury 302
16.5.6 Amputation 302
16.6 Physiotherapy, Occupational Therapy, and Early Motion 302
16.7 The Hidden Injury: Psychosocial Implications of Hand Injuries 302
References 303
17: Foot Surgery in War Trauma 304
17.1 Epidemiology, Battlefield Stabilization, and Triage 304
17.1.1 Epidemiology 304
17.1.2 Battlefield Stabilization and Triage 305
17.1.3 Interim Wound Management Techniques 307
17.2 Definitive Care Management 308
17.2.1 Initial Assessment and Planning 308
17.2.2 Initial Operative Strategy and Limb Salvage Assessment 309
17.2.3 Follow-on Wound Management 310
17.2.4 Wound Closure 311
17.2.5 Fracture and Bone Defect Management 313
17.2.6 Forefoot Reconstruction 313
17.2.7 Midfoot Reconstruction 315
17.2.8 Hindfoot Reconstruction 316
17.2.9 Combined Injuries 318
17.3 Deformity and Complication Correction Following Limb Salvage 318
17.3.1 Treatment Strategy 318
17.3.2 Nerve Deficit and Neuropathic Pain 319
17.3.3 Stiffness After Foot and Ankle Blast Trauma 320
17.3.4 Chronic Infection and Treatment 320
17.3.5 Posttraumatic Arthritis and Fusions 321
17.3.6 Deformity Correction Following Loss of Tendon Insertion 321
17.3.7 Residual Deformities After Compartment Syndromes and Blast Trauma 322
References 324
18: Limb Salvage Versus Amputation: The Dilemma 327
18.1 Introduction 327
18.2 Limb Salvage 328
18.3 Amputation 329
18.4 Classifications, Scoring, and Decision-Making 329
18.5 Clinical Examples of Lower and Upper Limb Salvage Reconstruction Using the Staged Protocol 330
18.5.1 Lower Limb Salvage 330
18.5.2 Upper Limb Salvage 330
18.6 Conclusion 333
References 341
19: Amputation in Combat Trauma 342
19.1 Introduction 342
19.2 History 342
19.3 General Principles 344
19.3.1 Introduction 344
19.3.2 Level of Care 344
19.3.3 Medical Care 345
19.3.4 Blast Wound Amputation 345
19.3.5 Amputation in Crush Injury 346
19.3.6 Indications for Amputation 347
19.3.6.1 Patient Related 347
General Condition 347
Local/Extremity Factors 347
19.3.6.2 Surgeon and Facility Related 347
19.3.7 Determination of the Level of Amputation 349
19.4 Surgical Technique 349
19.4.1 General 349
19.4.1.1 Hemostasis 349
19.4.1.2 Secondary Examination 349
19.4.2 Wound Care 349
19.4.3 Below-Knee Amputation 350
19.4.3.1 Postoperative Management 352
19.4.4 Knee Disarticulation 352
19.4.5 Above-Knee (Transfemoral) Amputation 352
19.4.5.1 Level of Amputation 353
19.4.5.2 Amputation Technique 356
19.4.6 Hip Disarticulation 356
19.5 Complications 356
19.5.1 Early Complications 356
19.5.1.1 Delayed Hemorrhage 356
19.5.1.2 Skin Flap Breakdown 357
19.5.1.3 Infection 357
19.5.2 Late Complications 358
19.5.2.1 Stump Instability 358
19.5.2.2 Ulceration 358
19.5.2.3 Neuroma 358
19.5.2.4 Heterotopic Ossification 358
19.5.2.5 Phantom Limb Pain 358
19.5.2.6 Contractures 358
19.6 Conclusion 359
References 359
20: Delayed Union and Nonunions 362
20.1 Introduction 362
20.2 Classification 362
20.3 Evaluation 364
20.3.1 Clinical Evaluation 364
20.3.2 Radiologic Evaluation 366
20.3.3 Laboratory Studies 366
20.4 Treatment 366
20.4.1 External Fixation Modalities 367
20.4.1.1 Monofocal Distraction 367
20.4.1.2 Consecutive Monofocal Compression Distraction 368
20.4.1.3 Bifocal Strategy: Acute Shortening and Gradual Lengthening 368
20.4.1.4 Computer-Assisted External Fixation (Hexapod Systems) 368
20.4.2 Internal Fixation 369
20.4.2.1 Plate Osteosynthesis 369
20.4.2.2 Exchange Nailing 371
20.4.2.3 Cage and Grafting for Defect Nonunions 373
20.4.3 Combination Techniques 373
20.4.3.1 Bone Transport 374
20.4.4 Biologic Stimulation 377
20.4.4.1 Central Bone Grafting for Tibial Nonunions 377
20.4.4.2 Electrical Stimulation 377
20.4.4.3 Partial Fibulectomy 378
20.4.4.4 Bone Marrow Injection 378
20.5 Future 379
References 379
21: Osteomyelitis 381
21.1 Introduction 381
21.2 Clinical Evaluation 381
21.3 Principles of Therapy 383
21.3.1 Debridement 384
21.3.2 Local and Systemic Antibiotherapy 385
21.3.3 Bone and Soft Tissue (Temporary) Stabilization 385
21.3.4 Final Bone (Defect) Reconstruction 386
21.3.5 Distraction Osteogenesis Techniques 386
21.3.6 Fibula Transport 386
21.3.7 Vascularized Bone Grafts (VBGs) 388
21.3.8 Titanium Cage 388
21.3.9 The Combined Technique 388
21.3.9.1 Step I 388
21.3.9.2 Step II (IM Nail Insertion/Application of External Fixator and Osteotomy) 388
21.3.9.3 Femur 391
21.3.9.4 Tibia 392
21.3.9.5 Postoperative Care 392
21.3.9.6 Step III (Removal of External Fixator and Static Locking of the Nail) 392
21.4 Complications 392
21.5 Conclusion 392
References 394
22: Chronic Pain Subsequent to Armed Conflict Injuries to the Extremities 396
22.1 Introduction 396
22.2 Neuropathic Pain 396
22.2.1 Definitions 396
22.2.2 Epidemiology 396
22.2.3 Clinical Presentation 397
22.2.4 Diagnosis 397
22.2.5 Management of Post-traumatic Neuropathic Pain 397
22.2.5.1 Pharmacotherapy 397
22.2.5.2 Nerve Blocks 399
22.2.5.3 Peripheral and Spinal Cord Stimulation 399
22.2.5.4 Surgery 399
22.2.5.5 Prevention 399
22.3 Complex Regional Pain Syndrome (CRPS) 400
22.3.1 Epidemiology 400
22.3.2 Pathogenesis 400
22.3.3 Clinical Presentation 400
22.3.4 Diagnosis 401
22.3.5 Management of CRPS 401
22.4 Bone and Joint Pain 402
22.4.1 Overview 402
22.4.2 Diagnosis and Classification 402
22.4.3 Epidemiology 403
22.4.4 Clinical Presentation 403
22.4.5 Management of Bone and Joint Pain 404
22.5 Myofascial Pain Syndrome 404
22.5.1 Overview 404
22.5.2 Epidemiology 405
22.5.3 Clinical Presentation 405
22.5.4 Pathophysiology 406
22.5.5 Management of MPS 407
22.5.5.1 Noninvasive Therapy 407
22.5.5.2 Medications 407
22.5.5.3 Needling and Infiltrations 407
22.5.5.4 Exercise and Physical Activity 408
22.6 Dysfunctional Pain 408
References 408
Index 412