Combat extremity Wounds

Journal of Orthopedic Trauma 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.” “ . Orthopedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts.. The spectrum of injuries include open fractures, amputations, neurovascular, and soft-tissue injuries. 85% will receive treatment beyond local wound care prior to arrival at a military medical center. 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

This presentation is designed for 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 Though amputations are visually dramatic, attention must be focused on the frequently associated life-threatening injuries. Most commonly due to explosive munitions, with penetration and blast effects or Parachute Injuries. Involve a large zone of injury with a high degree of contamination, which may affect the level of amputation and/or surgical intervention. Battle casualties who sustain amputations have the most severe extremity injuries. Historically, one in three patients with a major amputation (proximal to the wrist or ankle) will die, usually of hemorrhage .

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 These high-energy sources produce wounds characterized by violent tissue destruction. Violent tissue destruction and contamination requires radical débridement. This combination of high-energy injury, massive evolving tissue destruction, and widespread contamination and increased zone of injury. This evolving zone of injury respects no tissue planes, anatomic boundaries, or normal physiologic rules. .The result of such trauma is open, complex wounds with severe bone fragmentation.

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 The Casualty exposed to blast and high velocity weapons will often present with multiple fracture types.

Complexity of fracture pattern

Compound Fracture Compound Fracture Debridement and irrigation is the most commonly performed procedure due to the contaminated nature of these combat injuries .According to the trauma registry There were no infections among evacuated patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days. .

Compound Fractures Longitudinal incisions to obtain exposure. Fascia incised longitudinally to expose underlying structures and compartment release. All foreign material in the operative field must be removed

Traumatic Amputations Though amputations are visually dramatic, attention must be focused on the frequently associated life-threatening 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 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 At risk for ischemic necrosis above 30 mm

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 Combat life savers. 98w, self aid .aid buddy aid Tourniquets, direct pressure

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 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... Once the tourniquet has been applied, a pulse needs to be checked on either the hand or foot where the injury is. "No pulse means the tourniquet is working,"

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 Prior to evacuation, transportation casts should be applied to maintain traction of the residual limb and support the soft tissues. The transportation cast is a well-padded cast that has integral skin traction maintained by use of an outrigger.

ElO #3: Interventions for extremity wounds Action: Determine interventions for extremity wounds Conditions: Same Standards: Same

Treatment of fractures Débridement Reduction Fixation Evacuation The goals of the FST are to Control Hemorrhage and contamination, stabilize any fractures and evacuate to higher echelon for definitive care.

Wound Management High velocity GSW need to be treated like open fractures. generally requires formal operative débridement and fixation. Begin IV antibiotics as soon as possible and maintain throughout the evacuation chain. Use a broad spectrum cephalosporin (cefazolin 1 g q 8 h) . The two most harmful bacteria—clostridia and streptococci—are covered by a 1st generation cephalosporin.

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 High Pressure Irrigation Irrigation can remove enough wound bacteria to render the wound non-contaminated but only if the irrigant is delivered with sufficiently high pressure ( <7 PSI)to mechanically remove bacteria from the wound surface.

High Pressure Irrigation PULSE LAVAGE High Pressure Irrigation Irrigation can remove enough wound bacteria to render the wound non-contaminated 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

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) ORIF NOT PERFORMED AT THE FST

EXTERNAL FIXATION

Missile and fragmentation wounds can cause fracture of the pelvis. The pelvis usually remains stable. The colon, small intestine, rectum, and the genitourinary tracts must all be assessed for associated injury. Major hemorrhage can result from injury to the iliac vessels.

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. Surgical preparation of the entire limb, because planes of injury may be much higher than initially evident Tourniquet control is mandatory. 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 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. 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 Prevention of hemorrhage: A tourniquet should be readily available at the bedside or during transport for the first week following injury. Pain control Adequate analgesia should be available and the patient during dressing changes Prevention of contracture : BK amputations are at risk for knee flexion contractures. These contractures are preventable by using a long leg cast. AK amputations are at risk for hip-flexion contractures. Prone positioning and active hip extension exercises will avoid this complication.

EXAM Neurovascular status of the extremity should be documented and checked repeatedly. True or false 2 Name one Advantages of external fixation 3 Irrigation can remove enough wound bacteria to render the wound non-contaminated. True or False 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. 1

Exam It is essential for the provider to immobilize any fractures prior to CASVAC. True or false These provide local depot administration of antibiotic and maintain space for subsequent bone graft Name the best option for controlling hemorrhage in extremity injuries Name a disadvantage of external fixation A fracture that breaks the skin causing a open wound