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© 2007 the American Academy of Orthopaedic Surgeons
Extremity War Injuries: Development of Clinical Treatment Principles
Dr. Ficke is Orthopaedic Consultant to the U.S. Army Surgeon General and Chairman, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Fort Sam Houston, TX. Dr. Pollak is Associate Professor of Orthopaedics and Head, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, and Attending Orthopaedic Traumatologist, R Adams Cowley Shock Trauma Center, Baltimore, MD.
Neither Dr. Ficke nor a member of his immediate family has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Dr. Pollak or a member of his immediate family has received research or institutional support from Synthes, Stryker, and Smith & Nephew, and serves as a consultant to or is an employee of KCI.
The opinions or assertions expressed herein are those of the authors, and do not reflect those of the Army, Navy, Air Force or of the Department of Defense.
Reprint requests: Dr. Pollak, University of Maryland School of Medicine, Suite T3R54, 22 South Greene Street, Baltimore, MD 21201.
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Abstract |
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 Top Abstract Prehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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The AAOS/OTA Extremity War Injuries: Development of Clinical Treatment Principles symposium, held in January 2007, was a follow-up to the first Extremity War Injuries symposium held a year earlier. Discussion focused on four specific areas: prehospital management of extremity wounds, initial débridement, early stabilization, and postoperative wound management during air evacuation. Liberal emergency use of field tourniquets likely is contributing to lower overall mortality and is associated with very low rates of complications. Additional tools for extremity hemorrhage control, such as chitosan-based patches and granular zeolite hemostat, were postulated to be effective. Consensus opinion was that necrotic, devitalized, and contaminated tissue must be removed although objective assessment of completeness of initial débridement is difficult. Definitive open reduction and internal fixation for US and Coalition forces in the theater of operations should be limited to fracture patterns associated with significant perceived risk of delay in treatment. Finally, primary skin closure should be avoided in theater. In addition, because of the time and complications involved in transporting patients to level 4 care facilities, surgeons should consider release of compartments prior to patient transport whenever significant perceived potential for compartment syndrome is present.
The Extremity War Injuries: Development of Clinical Treatment Principles (EWI II) symposium held January 23-24, 2007, was organized to define standardized clinical treatment principles for far-forward care of wounded warriors. As of August 20, 2007, as a result of hostilities, more than 27,400 US casualties have been incurred in Iraq and Afghanistan, and almost 3,300 servicemen and servicewomen have been killed. Many more have been injured or killed as a result of non-battle– related causes.1 The authors of the largest system-wide review of these casualties published to date reported that 26% of these individuals had sustained fractures and that 82% of these were open fractures.2 In the context of such a high volume of severe extremity injuries, definition of treatment principles may improve far-forward surgical decision-making and ultimately improve outcome.
The Extremity War Injuries: State of the Art and Future Directions symposium, held in January 2006, identified a list of prioritized research objectives based on identified gaps between the spectrum of injury being encountered and the existing medical science of injury care. Proceedings of this symposium were published in a special issue of the Journal of the American Academy of Orthopaedic Surgeons.3 Shortly after the symposium, Congressional funding for the Orthopaedic Extremity Trauma Research Program (OETRP) became available, thereby permitting studies to commence based on these prioritized research objectives. Because of the success of the research symposia and the high quality of the research proposals submitted for funding through the OETRP, the American Academy of Orthopaedic Surgeons (AAOS) and the Orthopaedic Trauma Association (OTA) have successfully lobbied to increase Congressional appropriations in this area. In addition, both associations will continue to work with members of Congress and the Department of Defense to obtain future funding to advance the research priorities outlined in the Extremity War Injuries symposia.
The purpose of EWI II was to define treatment principles for the management of extremity trauma in the general context of current military medical facilities and surgical capabilities. EWI II did not attempt to address definitive reconstruction challenges or the challenges associated with care for non-Coalition patients being treated at US military facilities. Planning is under way for a third EWI symposium, Challenges in Definitive Reconstruction, to address some of these additional concerns.
EWI II sessions focused specifically on four separate areas: (1) prehospital management of extremity wounds, (2) initial débridement, (3) early stabilization, and (4) postoperative wound management during the air evacuation process.
The goals of the symposium were to develop consensus-based principles for the treatment of extremity war injuries within the theater of combat operations, to consider development of a process that may lead to formal evidence-based guidelines, and—potentially—to further the development of deployment preparatory courses.
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Prehospital Management of Extremity Wounds |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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The current conflict in Afghanistan and Iraq has been marked by the highest number of US military casualties since the Vietnam War. However, more than 50% of those injured have returned to duty within 72 hours, and survivability is approximately 90%—likely a testament to the effectiveness of the widespread use of body armor, heavily armored vehicles, and organized far-forward surgical and resuscitative care in a cohesive joint-theater trauma system.
Preliminary analysis shows that liberal emergency use of field tourniquets may be contributing to lower overall mortality and has been associated with very low rates of complications such as nerve palsy and compartment syndrome. Evidence suggests that loss of limbs secondary to extended or unnecessary tourniquet application is extremely rare.4 Expert consensus, as defined by the group of symposium attendees, was that the liberal use of tourniquets from the time of initial injury until arrival in the operating room is likely safe and effective for anatomic areas where proximal control of bleeding can be accomplished with this technique. Universal distribution of commercially available field tourniquets was advisable and is underway.
Three additional tools for extremity hemorrhage control were reviewed: chitosan-based hemostatic dressings approved by the US Food and Drug Administration for hemorrhage control (HemCon; HemCon Medical Technologies, Portland, OR); an inert zeolite mineral hemostat that creates a brisk exothermic reaction and encourages rapid concentration of platelet and clotting factors (QuikClot; Z-Medica, Wallingford, CT); and fibrin bandages for intraoperative control of bleeding. These devices were believed to be most effective and applicable for hemorrhage from anatomic areas where proximal control using compression technique (eg, tourniquet) is not feasible.5,6 These areas include the axilla, the proximal brachium, the groin, and the proximal thigh. Although the risk of burn, neurologic injury, and additional tissue damage were described with the use of these modalities, expert opinion was that the potential advantage of reduction in fatal hemorrhage outweighed these risks.
For intraoperative control of hemorrhage in facilities where multiple modalities are available, chitosan-based patches seem preferable due to experience suggesting their efficacy in the context of coagulopathy, hypothermia, and bleeding from large surface areas. Experienced surgeons reported more secondary complications with the use of granular zeolite hemostat associated with the exothermic reaction and decreased efficacy over large surface areas. Fibrin bandages seemed most effective when applied over small surface areas to more discrete bleeding sites.
A factor of great importance in achieving efficacy with any of the hemorrhage-control modalities is training in correct application. Training programs should be developed and validated around any hemorrhage-control adjuncts that are eventually made available for widespread use.
An apparently effective training process has already been established for frontline medics to prepare them for management of exsanguinating extremity trauma, the entity still considered to be a leading cause of preventable death on the battlefield. Medics are trained in nine areas related to tourniquet application postulated to be critical in preventing death on the battlefield:
1) The need for all combatants to carry tourniquets and be trained in their use.
2) The need for tourniquets to be carried on one’s person rather than in an equipment bag.
3) Understanding which wounds are appropriate for tourniquet use.
4) Understanding correct location of tourniquet application in relation to the wound.
5) Understanding when to apply a tourniquet.
6) Understanding when not to remove a tourniquet.
7) Understanding the role of loosening a tourniquet.
8) Understanding how to remove a tourniquet at an appropriate time.
9) Understanding the process of field tourniquet application.
The consensus opinion of participating experts was that compressible hemorrhage was ideally managed from injury to operating room with a well-applied tourniquet. There is good evidence that universal distribution of a commercially available field tourniquet is safe and effective.4,7-11 The most influential factor in effectiveness appears to be training in the correct application. Experience suggests that noncompressible hemorrhage (eg, axillary, groin, extremely proximal thigh) can be effectively managed with field application of hemostatic dressings. The US Army currently uses chitosan, whereas the US Navy and Marines use granular zeolite hemostat. Careful analysis is necessary to further define the relative efficacy of each of these modalities. Regardless of material, currently available evidence suggests that reduction in fatal hemorrhage outweighs the risks of burns, neurologic injury, or additional tissue damage associated with the use of these adjuncts.4,7-11
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Concepts of Initial Débridement |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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Extremity war injuries, particularly those sustained secondary to blast mechanisms, are associated with a high degree of contamination and tissue injury requiring expert débridement to reduce the risk of infection and associated complications. Improvised explosive device (IED) blast injuries may be associated with propulsion of contaminants along tissue planes to areas far from the actual area of skin disruption. Current débridement practices in these high-energy injuries include a thorough excision of all devitalized tissue, often requiring serial surgical procedures.
In practice, determination as to which wounds require formal débridement, where the zone of injury begins and ends, and how much tissue should be removed remain challenging. When adequate débridement results in insufficient residual tissue to allow limb function, primary amputation may be indicated. Amputation occasionally occurs as a direct result of the initial trauma, but it also may be indicated after surgical débridement as a result of local or systemic factors. Systemic indications to proceed with primary amputation include patient inability to tolerate the physiologic challenge associated with limb salvage. Guidelines for acute amputation based on physiologic parameters are lacking. Rising serum lactate (suggesting worsening shock), massive uncontrollable local hemorrhage, and extended warm ischemia time are indications for considering amputation, but the ultimate decision is often more subjective. Individual trauma surgeon training and experience play critical roles in this early decision making, and rigorous review of outcomes is needed to provide better objective indicators for primary amputation in the wartime environment.
Extrinsic and intrinsic factors affect the decision to proceed with secondary wound débridement in theater. Extrinsic factors include capability of evacuation, time to next surgical or definitive care facility, and current patient load. Those more intrinsic to the patient include local factors within the wound itself, such as contamination, location, and risk of complications. Systemic factors such as sepsis, perfusion, and overall patient nutrition also must be considered. Techniques for more objective assessment of wound viability, adequacy of débridement, and timing of safe closure must be developed with further research.
Consensus opinion was used to describe best practices with respect to early initial wound débridement. Education of deploying surgeons was considered to be an important factor in improving technical proficiency with complex débridement, particularly early in the course of an individual surgeon’s deployment. Specific techniques of débridement vary, and little evidence exists to compare the efficacy of specialty equipment or the validity of specific endpoints. Complete assessment of the zone of injury is often difficult after blast injury. In these situations, repeat débridement performed several days after injury was considered to be valuable.
Consensus opinion was that necrotic, devitalized, and contaminated tissue must be removed but that objective assessment of completeness of débridement is difficult. Contractility, color, consistency, and capacity to bleed are all important putative indicators of viable tissue, but a great deal of experience is necessary to define nonviable tissue.
Surgeons face difficult decisions with regard to which wounds require formal débridement and when to perform débridement. Often after blast injuries, many very small wounds are present. Experienced surgeons described techniques to assist in this decision-making process. A palpable cavity beneath the surface, serous or sanguineous drainage with pressure on the wound, puncture wounds whose local exploration demonstrates depth of penetration, and wounds involving a fracture, joint, or major vascular structure all warrant surgical débridement. Jagged metal, such as IED shrapnel fragments, often lacerate nerves and vessels, creating wounds that behave differently from typical low-velocity gunshot wounds seen in civilian settings. Even superficial wounds should be cleaned with a surgical scrub brush. Wound débridement in the face of fracture requires formal extension of wounds and delivery of bone ends, inspection of tissues within the zone of injury, and removal of fragments lacking periosteal attachments. Low-pressure pulse irrigation appears to be valuable in the débridement of high-energy extremity war injuries, but no clear statement can be made as to the ideal type or volume of irrigation fluid.
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Early Stabilization |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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External fixation is valuable and is frequently used for temporary fracture management until definitive treatment can be provided outside the theater of combat operations. As with issues of débridement and hemorrhage control, decisions regarding optimal utilization of external fixation in the treatment of combat-related injuries require consideration of both systemic and local factors.
Damage control orthopaedics is the use of external fixation to provide temporary stabilization of extremity injuries to mitigate systemic consequences of long bone injury in the context of physiologic instability that precludes safe, definitive treatment.12 In the combat scenario, external fixation for damage control is also frequently employed for safe transport to a cleaner and more stable treatment environment.
When such temporary techniques are used, pin placement decisions should be made while considering likely definitive treatment options. Because the combat surgeon who employs temporary stabilization techniques and deploys the initial fixator is rarely the same surgeon who will be providing definitive treatment, extra care must be taken to preserve approaches and hardware placement possibilities for as many definitive treatment options as possible.
Given the logistical challenges associated with complex definitive fixation in theater and the difficulty of ensuring as sterile an operating environment as possible in more traditional hospitals, the role in theater of definitive open reduction and internal fixation of fractures in injured US service personnel has been limited. Logistical challenges are varied and include implant selection and availability, radiologic support, including fluoroscopy, and surgeon and staff familiarity with more complex reconstructive procedures. Most limiting, and perhaps least controllable, is the unknown timing and frequency of mass causality events in the theater of combat operations, which preclude obligating an operating room and team to a nonemergent reconstructive procedure. Issues of maintenance of sterility include the frequent presence of more than one patient in the operating room simultaneously as well as difficulties in limiting transmission of multidrug-resistant bacteria during procedures.
Given these limitations, consensus opinion concluded that definitive open reduction and internal fixation within the theater of combat operations should be limited to fracture patterns associated with significant perceived risk of delay in treatment and the absence of effective means of achieving reduction and temporary stabilization. Such injuries include displaced femoral neck or peritrochanteric fractures and displaced talar neck fractures.
With any of these injuries, consideration should be given to surgeon and staff expertise with the necessary surgical procedure, availability of implants and resources, and the logistics of transfer to the next level of care, where the procedure might be more safely and expertly performed.
Current techniques of temporizing external fixation are less effective in stabilization of very proximal appendicular skeletal injuries, including fractures and fracture dislocations about the hip and shoulder girdles. Definitive open treatment of these injuries in theater before transport to Landstuhl Regional Medical Center (LRMC) or the continental United States may be less avoidable.
After initial external fixation of skeletal injuries, infection rates seem to increase with intramedullary nailing in proportion to the length of time the frame has been in place.13 When temporizing techniques are used, conversion to definitive treatment should not be unduly delayed. Reconstruction of complex bony defects, however, requires specialized resources and training and is typically accomplished by fellowship-trained orthopaedic trauma specialists at designated tertiary care facilities. The austere conditions of level 2 or 3 facilities typically do not lend themselves to such complex reconstructive procedures.
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Postoperative Wound Management During Air Evacuation |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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In the current chain of evacuation of injured warriors from the theater of combat operations, patients are flown from Iraq or Afghanistan to LRMC in Germany, the military’s only level 4 facility and the largest tertiary care US military medical facility outside the United States. Timing of transport to LRMC is variable but often commences within 24 hours of injury, depending on transport availability and patient condition.
This flight time from Iraq to Germany is approximately 6 hours, and additional time is necessary to load and unload patients from the aircraft on either end. During this time, access to an operating room for repeat evaluation or repeat surgical débridement of a limb is not possible. Surgeons must recognize these challenges, and they should have a low threshold for release of compartments prior to patient transport whenever any suspicion of potential for compartment syndrome is present. Prolonged recumbence, relative immobilization, and ongoing fluid resuscitation all may contribute to impaired limb perfusion. No primary skin closures should be performed in theater, and bulky dressings should be used to assist in collecting the substantial drainage that may occur from wounds during transport.
Space constraints in flight, as well as noise, staffing, and environmental conditions, preclude routine dressing changes, wound management, and any type of surgical procedure. Patients, therefore, routinely undergo serial débridements at 48- to 72-hour intervals along the evacuation chain. For wounds initially débrided at level 2 facilities, a second débridement at a level 3 facility before evacuation from theater is often necessary. Almost all injuries undergo surgical exploration and redébridement at LRMC prior to transport to the continental United States.
Negative-pressure wound therapy is routinely used as a tool in the definitive management of soft-tissue defects once patients return to the United States. Negative-pressure wound therapy also is used within the theater of combat operations on local national patients. The vacuum-assisted wound closure system is also officially approved for use in air evacuation and is being used more frequently. Challenges to its use in flight include difficulties with access to limbs to allow the dressing management necessary to maintain suction. Once suction is lost, a closed anaerobic environment results, and anecdotal evidence suggests that wound conditions may worsen. For these reasons, additional safety testing was necessary before widespread use began of the negative-pressure wound therapy devices during air evacuation.
Pain management, even in a stationary environment, can be challenging in the multiply injured patient. This is compounded by the additional stressors of flight, including decreased partial pressure of oxygen, noise, vibration, immobility, and limited climate control. Options currently available include oral narcotics, regional anesthesia, and flight-approved patient-controlled analgesia devices.
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Future Directions |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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The goal of the EWI II symposium was to define basic treatment principles for delivery of far-forward musculoskeletal care. These principles were based, when possible, on peer-reviewed medical literature. However, given the paucity of published medical evidence to guide prehospital management of exsanguinating extremity hemorrhage, early débridement and stabilization of fractures secondary to blast injury, and postoperative wound management during air evacuation, expert opinion was necessary to formulate treatment principles.
Important next steps in improving consistency and quality of far-forward musculoskeletal care will be the development of formal treatment guidelines and associated educational programs to communicate these principles and guidelines.
The development of formal guidelines requires using a validated process to ensure completeness of the review of the medical literature and extraction of information from that literature using methodology that is standardized, validated, and reproducible. The AAOS uses such methodology in preparing all of its guidelines. These methods are based on the processes for preparing a systematic review and are common in evidence-based medicine. The handbook of a leading organization in evidence-based medicine (Cochrane Collaboration) offers an in-depth look at these processes.14
The development of educational programs can be based on treatment principles outlined in this symposium. Opportunities for programs include revision of the existing Emergency War Surgery manual15 and development of military-specific trauma training programs involving all three relevant services. Consideration also should be given to developing civilian courses to help prepare a broader spectrum of surgeons for the possibility of IED-type blast injuries occurring within the United States. In addition to these educational programs, another EWI symposium is necessary and is planned to define principles of definitive treatment for high-energy extremity war injuries.
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Summary |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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The EWI II symposium was convened to define basic treatment principles for delivery of far-forward musculoskeletal care. The four specific areas of focus were the prehospital management of extremi-ty wounds, initial débridement, early stabilization, and postoperative wound management during the air evacuation process. Liberal emergency use of field tourniquets is likely contributing to lower overall mortality and is associated with a very low rate of complications. Adjuncts for extremity hemorrhage control (eg, chitosan-based patches, granular zeolite hemostat, fibrin bandages for intraoperative control of bleeding) were postulated to be effective. Consensus opinion was that obviously necrotic, devitalized, and contaminated tissue must be removed although objective assessment of completeness of débridement in the context of more equivocal clinical findings is difficult. Further, the education of surgeons to be deployed is an important factor in improving technical proficiency with complex débridement. In theater, definitive open reduction and internal fixation should be limited to fracture patterns associated with significant perceived risk of delay in treatment and the absence of effective means of achieving reduction and temporary stabilization (eg, displaced femoral neck fracture, peritrochanteric fracture, and talar neck fracture). Because of the time and complications involved in transporting patients to level 4 care facilities, surgeons should consider release of compartments prior to patient transport whenever the potential for compartment syndrome is perceived to be high. Important next steps in improving far-forward musculoskeletal care are to develop formal treatment guidelines and associated educational programs to communicate these principles and guidelines.
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References |
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TopAbstractPrehospital Management of...Concepts of Initial DebridementEarly StabilizationPostoperative Wound Management...Future DirectionsSummaryReferences |
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Citation numbers printed in bold type indicate references published within the past 5 years.
- Defense Casualty Report 20 August 2007. Available at: http://www.defenselink.mil/news/casualty.pdf. Accessed August 20, 2007.
- Owens BD, Kragh JF, Macaitis J, Svoboda SJ, Wenke JC: Characterization of extremity wounds in operation Iraqi freedom and operation enduring freedom. J Orthop Trauma 2007; 21: 254-257. [Web of Science][Medline]
- Pollak A, Calhoun J: Extremity war injuries: State of the art and future directions. J Am Acad Orthop Surg 2006; 4: viii-ix.
- Walters TJ, Kauvar DS, Baer DG, Holcomb JB: Battlefield tourniquets: Modern combat lifesavers. U.S. Army Medical Department Journal, April-June 2005. Available at: http://findarticles.com/p/articles/mi_m0VVY/is_2005_April-June/ai_n17213744. Accessed August 20, 2007.
- Alam HB, Burris D, DaCorta JA, Rhee P: Hemorrhage control in the battlefield: Role of new hemostatic agents. Mil Med 2005; 170: 63-69. [Web of Science][Medline]
- Beekley AC, Starnes BW, Sebesta JA: Lessons learned from modern military surgery. Surg Clin N Am 2007; 87: 157-184. [Web of Science][Medline]
- Walters TJ, Mabry RL: Issues related to the use of tourniquets on the battlefield. Mil Med 2005; 170: 770-775. Available at http://findarticles.com/p/articles/mi_qa3912/is_200509/ai_n15615221. Accessed August 20, 2007. [Web of Science][Medline]
- Mabry RL: Tourniquet use on the battlefield. Mil Med 2006;171:352-356. Available at: http://findarticles.com/p/articles/mi_qa3912/is_200605/ai_n16452285. Accessed August 20, 2007.
- Lakstein D, Blumenfeld A, Sokolov T, , et al: Tourniquets for hemorrhage control on the battlefield: A 4-year accumulated experience. J Trauma 2003; 54: S221-S225. [Web of Science][Medline]
- Welling DR, Burris DG, Hutton JE, Minken SL, Rich NM: A balanced approach to tourniquet use: Lessons learned and relearned. J Am Coll Surg 2006; 203: 106-115. [Web of Science][Medline]
- Walters TJ, Wenke JC, Kauvar DS, , et al: Laboratory evaluation of battlefield tourniquets in human volunteers. U.S. Army Medical Department Journal. April-June 2005. Available at: http://findarticles.com/p/articles/mi_m0VVY/is_2005_April-June/ai_n17213746. Accessed August 20, 2007.
- Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000; 48: 613-621. [Web of Science][Medline]
- Bhandari M, Zlowodzki M, Tornetta P, Schmidt A, Templeman DC: Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma 2005; 19: 140-144. [Web of Science][Medline]
- Cochrane Handbook for Systematic Reviews of Interventions (formerly the Reviewers’ Handbook). Available at: http://www.cochrane.dk/cochrane/handbook/hbook.htm. Accessed August 20, 2007.
- Burris DG, FitzHarris JB, Holcomb JB, , et al (eds): Emergency War Surgery, ed 3. Washington, DC: United States Department of Defense, 2004, pp 6.3-6.4.
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