Emergency War Surgery (2004)

Extremity Fractures

Fig. 23-22. Addition of the cross bar and two bar-to-bar clamps.

Have your assistant apply longitudinal traction to reduce the frame,

and then tighten the frame in alignment.

Technique to span knee.

ο Indications are proximal tibia fractures, distal femur

fractures, or extensive knee injuries, or vascular repairs in

the popliteal fossa.

Fig. 23-23. Two-bar apparatus. As the majority of tibia fractures are

unstable, it creates a more stable construct by adding a second bar.

This requires the use of two of the kits but makes little difference when

you are using the tub container at the CSH or equivalent hospitals.

23.17

Emergency War Surgery

Check the distal vascular status of the limb prior to and

after the procedure. If there is a vascular injury, refer to

Chapter 27, Vascular Injuries.

An assistant will be required to help apply the frame.

General reduction maneuver should be longitudinal

traction with slight (10°-15°) flexion at the knee.

Pins are placed anterior medial on the proximal tibia and

antero-lateral on the distal femur. Pin placement should

be outside of the zone of injury, at least three fingerbreadths

from a fracture site, and outside of the knee joint. At the

distal femur, a longitudinal stab incision is made over the

antero-lateral aspect of the bone, so that the pin may be

inserted into the center of the bone at about a 45° angle

from the horizontal. Depending on the fracture config-

uration, it may also be placed directly anteriorly, though

it is generally better to avoid the quadriceps tendon.

Blunt dissection is used to create a corridor to the bone.

A single pin is inserted by hand through both cortices of

the bone fragment.

A multipin clamp is used as a guide for a second pin. The

second pin must be parallel to the first and also bicortical

— care should be taken to maintain pin alignment. The

proximal tibia should be palpated on the anterior medial

surface and the anterior and posterior border should be

identified. Midway anterior/posterior, a 1-cm longitudinal

stab incision should be made and a blunt soft tissue

dissection made to bone.

A multipin clamp should be used as a guide to insert a

second pin in the proximal tibia.

The two pin clusters (femur and tibia) should be connected

via two elbows, two bar-bar clamps, and a single bar. The

knee should be aligned.

A second bar should be added in the manner described

above.

Technique to span ankle.

ο An assistant will be required to help apply the frame and

reduce the ankle.

23.18

Extremity Fractures

General indications are for open distal tibia fractures and

open ankle wounds.

Pins should be inserted on the anterior medial surface of

the tibia and the medial aspect of the calcaneus.

Check the distal vascular status prior to and after the

procedure. Mark where the posterior tibial and dorsalis

pedis artery pulses can be felt.

Palpate the anterior medial border of the tibia. Make a 1-

cm longitudinal incision midway between the anterior and

posterior border of the tibia. Insert the most distal pin on

the tibia outside the zone of injury, at least three

fingerbreadths from the fracture site.

Using a multipin clamp as a guide, insert a second pin in

the tibia more proximal to the first. The pin must be parallel

and be aligned in the longitudinal axis to the first.

Palpate the medial border of the calcaneus. Make a

longitudinal incision over the calcaneus away from the

posterior neurovascular structures: dissect to the bone

with a clamp and insert the pin.

Using a multipin clamp as a guide, insert a second pin in

the calcaneus.

Connect the two clamps via two elbows, two bar-bar

clamps, and a single bar.

Skeletal traction.

ο Skeletal traction provides a quick means to immobilize a

large number of fracture cases with a minimum of technical

support.

ο Indications.

♦ Patients who are expected to have more than one

procedure in the same forward hospital prior to

evacuation.

♦ Large casualty load.

ο Technique.

♦ Large threaded Steinman pins are used to obtain skeletal

traction of a femur or tibia.

♦ Aseptic preparation of a pin site is necessary prior to

placement.

♦ Apply local anesthetic to pin site.

23.19

Emergency War Surgery

♦ Incise skin and dissect to bone bluntly.

♦ For femur fractures, incision is made 2 cm posterior and

lateral to the tibial tuberosity (directly under, as in Fig.

23-24). Place pin from lateral to medial through and

through the proximal tibia.

♦ Apply a Thomas splint with Pierson device, with weight

applied midthigh (10-20 lb), to the leg (10-20 lb), and

to the traction pin (20-40 lb) to obtain balanced skeletal

traction as shown in Fig. 23-25.

♦ For tibia fractures, incise medially 2 cm anterior and 2

cm cephalad from the tip of the heel. Place the pin from

medial to lateral through and through the calcaneus.

Place the leg on a Bohler-Braun frame and apply traction

to the calcaneal pin (10-20 lb).

♦ Wait at least ¹/2 hour after applying traction to obtain

radiographs.

Care in the evacuation

chain.

ο Patients do not

improve in the

evacuation system.

Fig. 23-24. Thomas splint with Fig. 23-25. Bohler-Braun frame with

Pierson device.

traction.

Consider patient safety during evacuation when planning

procedures.

ο Medications should be arranged prior to departure. Ensure

adequate pain control.

ο Skeletal traction should not be used for transportation.

23.20

Chapter 24

Open-Joint Injuries

Introduction

Open injuries to the joints are rarely immediately life

threatening. They are frequently quite dramatic in appearance

and draw the inexperienced caregiver’s attention away from

the truly life threatening, associated injuries. Neurovascular

structures are in close proximity to the major joints, and may

require vascular management and repair. Open joints have

long-term morbidity and some secondary mortality from

infection due to missed injury or inadequate treatment.

All open-joint injuries must be explored and treated

within 6 hours to prevent infection and joint destruction.

With rare exceptions, closed-joint injuries should be treated

nonoperatively in the combat zone. Definitive intervention and

rehabilitation usually require months before complete recovery.

Thus, patients with closed injuries to major joints should be

evacuated from the theater for definitive surgical intervention

and rehabilitation.

The key to treating open-joint injures is recognition.

Once identified, goals are prevention of infection and

preservation/restoration of normal joint function.

Signs of possible open-joint injury are a wound associated

with the following:

ο Proximity to a joint.

ο Periarticular fracture.

ο Exposed joint.

ο Effusion.

24.1

Emergency War Surgery

ο Loss of joint motion.

ο Intra-articular air or foreign body on biplanar radiographs.

ο Abnormal joint aspiration demonstrating hemarthrosis.

ο Extravasation from joint on diagnostic injection.

Open-joint injuries always require surgery. Joint

aspiration/injection may be performed to confirm a

suspected open joint. If in doubt, treat as an open-joint

injury to prevent missed injury sequelae.

The technique for aspiration/injection involves:

ο Sterile prep.

ο 18-gauge needle, 30-cc syringe.

ο Enter suspected joint, avoiding neurovascular structures.

ο Attempt aspiration — if blood is aspirated a hemarthrosis

is present.

ο If no hemarthrosis, inject with normal saline (methylene

blue if available) until joint is fully distended — the joint

is damaged if extravasation is detected.

ο If there is no extravasation, open joint injury may still be

present.

Approaches for aspiration are shown for the shoulder, elbow

(Lateral), knee (Medial parapatellar), and ankle (Antero-

lateral) (Fig. 24-1a,b,c,d).

Treatment of All Open-Joint Injury

IV antibiotics should be started ASAP after wounding, and

continued postop for 48 hours.

Tourniquet control of operative bleeding is essential.

Standard arthrotomy incisions are utilized (Fig. 24-2a,b,c).

(Wound margins are incorporated if possible, provided they

do not compromise exposure or create non-viable flaps).

The extremity must be draped free to allow full range of

motion during surgery.

All intra-articular foreign material, loose cartilage (including

flaps), blood clots, and detached bony fragments without

major articular surface must be removed.

24.2

Open-Joint Injuries

Shoulder

Elbow

Ankle

Knee

Fig. 24-1a,b,c,d. Aspiration/injection approaches to the shoulder,

elbow, knee, and ankle.

All recesses must be explored and all damaged tissue must

be removed.

The joint must be thoroughly irrigated with normal saline

(pulse lavage and 6 to 9 L is recommended).

Internal fixation is contraindicated with the exception of

large articular fragments that may be stabilized with Kirscher

wire (K-wire) or Steinmann pins.

24.3

Emergency War Surgery

Ankle

Elbow

Knee

Fig. 24-2a,b,c. Surgical approaches to the ankle, elbow, and knee.

Close synovium if possible without tension and without

surgical tissue advancement. The remainder of the wound

should never be closed at the initial surgical exploration.

If synovial closure is not possible, the joint should be dressed

open with moist fine mesh gauze occlusive dressing.

The wound should be reexplored in 48-72 hours.

A bivalved cast or splints can be used to stabilize the joint.

24.4

Open-Joint Injuries

If there are delays in evacuation or inability to move the

patient, the following steps can be taken:

ο Delayed primary closure (DPC) can be undertaken in 4-7

days if there are no signs of infection.

ο If there is extensive soft-tissue loss, split-thickness skin

grafts may be applied to granulating synovium.

After DPC, gentle range-of-motion therapy is begun, based

on consideration of any associated fractures or neurovascular

injuries.

Any time joint infection is suspected, the joint should

be immediately explored/re-explored.

Signs of Joint Sepsis

Persistent swelling.

Marked pain.

Local warmth.

Fever.

Intense pain with restriction of the range of motion.

Special Considerations for Hip Wounds

Open injuries of the hip joint are problematic for several

reasons.

ο Difficulty in diagnosis.

ο Highly virulent organisms leading to mortality or long-

term morbidity.

Violations of the hollow viscus organs associated with

fractures that extend into the acetabulum or femoral neck

uniformly contaminate the joint.

ο Ruling out joint involvement is difficult in the field

environment due to poor radiographic support and

difficulty in reliable joint aspiration/injection. Therefore,

a high index of suspicion with a low threshold for joint

exploration is essential for preventing devastating

complications.

Presacral drainage is highly encouraged in rectal injury with

joint extension.

24.5

Emergency War Surgery

Hip Exploration Technique

Semilateral or lateral decubitus position, with the abdomen,

pelvis, and full lower extremity prepped and draped free.

A tibial traction pin to suspend the leg from the ceiling is

advantageous.

Anterior iliofemoral (Fig. 24-3a,b,c) approach gives the most

extensive exposure to the hip, acetabulum, and ilium. (If the

incision was extended superior and posterior, closure of the

Joint Capsule

Iliofemoral Tract

Rectus Femoris

Fig. 24-3a,b,c. Anterior iliofemoral approach to the hip.

24.6

Open-Joint Injuries

superior/posterior aspect of the incision only over the iliac

crest is necessary at the initial surgery to prevent muscle

retraction and subsequent inability to close the wound.)

A posterior or Kocher approach (Fig. 24-4a,b) allows for

posterior exposure and allows for posterior drainage. It may

be used in conjunction with the iliofemoral approach or in

select cases alone for debridement. In an echeloned care/

delayed evacuation scenario, dependent posterior drainage

may be more critical than currently practiced in the civilian

environment.

Gluteus Maximus

Piriformus

Sciatic Nerve

Sup & Inf

Obdurator Internus

Gemelius

Quadratus Femoris

Fig. 24-4a,b. Posterior approach to the hip.

24.7

Emergency War Surgery

Complete fractures of the femoral neck/head should be

resected due to nearly uniform complications of sepsis and

avascular necrosis.

Except as described above, the surgical incision is not closed.

Dressing of the wound is as previously described. The patient

may be placed in a spanning external fixator from the iliac

crest to the distal femur, or placed in a one and one-half hip

spica cast. (See Chapter 23, Extremity Fractures, for diagram.)

Special Considerations for the Shoulder

Often associated with life-threatening thoracic or vascular

injuries. See Chapter 27, Vascular Injuries, for approaches to

the axillary and subclavian arteries.

Technique for shoulder exploration:

Semilateral position will allow both anterior and posterior

approaches to the glenohumeral joint.

Anterior deltopectoral approach is recommended (Fig. 24-

5a,b,c,d). (Detachment of the short biceps, coracobrachialis,

and pectoralis minor off the coracoid may be needed for

adequate exposure.) The subscapularis is detached and the

joint capsule is trimmed of devitalized tissue. All attempts

are made to preserve the supraspinatus attachment.

Loose fragments or a completely devitalized humeral head

are resected to prevent infection. In an echeloned care/

delayed evacuation scenario, dependent posterior

shoulder drainage may be more critical than currently

practiced in the civilian environment.

At the time of the DPC, 4-7 days later, the infraspinatus

and teres minor are reattached if previously detached.

A Velpeau dressing is utilized for the wounds.

For transport, the shoulder can be wrapped in plaster,

suspending the cast from the opposite shoulder for

comfort. If this is not feasible, a sling and swath,

immobilizing the arm against the chest wall, may be used.

These patients will require litter transport.

24.8

Chapter 25

Amputations

Introduction

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

exsanguination.

Though amputations are visually dramatic, attention must

be focused on the frequently associated life-threatening

injuries.

Goals for initial care are to preserve life, prepare the

patient for evacuation, and leave the maximum number

of options for definitive treatment.

The following are indications for amputation.

ο Partial or complete traumatic amputation.

ο Irreparable vascular injury or failed vascular repair

with an ischemic limb.

ο Life-threatening sepsis due to severe local infection,

including clostridial myonecrosis.

ο Severe soft-tissue and bony injury to the extremity

precluding functional recovery.

The surgeon must balance the realistic likelihood of ultimate

reconstruction of a functional extremity against the risk of death

associated with attempts to preserve a limb. It is always desirable

to secure the opinion of a second surgeon before amputating.

The tactical situation may require amputation in cases where

the limb might otherwise have been preserved.

25.1

Emergency War Surgery

Battlefield amputations are unique.

ο Most commonly due to explosive munitions, with

penetration and blast effects (see Chapter 1, Weapons

Effects and Parachute Injuries).

ο Involve a large zone of injury with a high degree of

contamination, which may affect the level of amputation

and/or surgical intervention.

ο Require staged treatment with evacuation out of the

combat zone prior to definitive closure.

Amputations should be performed at the lowest viable

level of soft tissues, in contrast to traditional anatomic

amputation levels (eg, classic above knee (AK), below

knee (BK), and so forth), to preserve as much limb as

possible. A longer stump is desirable for final prosthetic

fitting.

The Open Length Preserving Amputation (formerly

Open Circular Amputation) procedure has two stages.

ο Initial. Complete the amputation at lowest possible

level of bone and prepare the patient for evacuation

to the next level of care.

ο Reconstructive. Involves final healing of the limb to

obtain the optimal prosthetic stump.

ο Final level of amputation and definitive treatment

of the residual limb should occur in the stable

environment of a CONUS hospital, not in the

combat zone hospital.

All viable skin and soft tissues distal to the indicated level

of bone amputation should be preserved for use in

subsequent closure of the amputation stump. These tissues

may be considered “Flaps of Opportunity” and can add

length to the stump. This is especially true for amputations

below the knee. Short tibial stumps can be saved with

posteriorly based flaps because the gastrocnemius and

soleus are frequently preserved following landmine injury.

25.2

Amputations

To save length, any shape or form of a viable muscle or

skin flap should be preserved. The lowest level may be an

oblique or irregular wound, creating an oblique or

irregular residual limb.

Technique of Amputation

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.

Excise nonviable tissue.

ο Necrotic skin and subcutaneous tissue or skin without

vascular support.

ο Muscle that is friable, shredded, grossly contaminated, or

noncontractile. (This muscle is usually at the level of the

retracted skin.)

ο Bone that is grossly contaminated or devoid of soft tissue

support. Bone is transected at a level at which it has the

potential for coverage. (This is usually at the level of the

retracted muscle.)

Identify and securely ligate major arteries and veins to

prevent hemorrhage in transport.

Identify nerves, apply gentle traction, and resect proximally

to allow for retraction under soft tissue. Ligate the major

nerves.

Preserved muscle flaps should not be sutured, but should be

held in their intended position by the dressing.

Flaps should not be constructed at the initial surgery, to

facilitate later closure.

In blast injuries, particularly landmine injuries, the blast forces

drive debris proximally along fascial planes. It may be necessary

to extend incisions proximally parallel to the axis of the extremity

to ensure adequate surgical decontamination of the wound.

The stump is never closed primarily.

25.3

Emergency War Surgery

Special considerations.

Primary Symes (ankle disarticulation) has a high failure

rate due to heel pad necrosis during transport. The wound

should simply be debrided, retaining the clean hindfoot

(talus and calcaneus).

Primary knee disarticulation is problematic due to skin

and tendon retraction necessitating reamputation at a

higher less functional level. It is preferable to leave even a

very short (1-2 cm) clean transtibial stump, even though

nonfunctional, to prevent retraction.

Fractures, when present proximal to the mangled segment,

should not determine amputation level, but must be

treated appropriately (cast, external fixator) to preserve

maximal length.

Plan the initial amputation solely on the qualities of the

wound and surrounding tissues, never on the hope of

achieving a particular level or flap pattern as a final result.

The combat surgeon’s goal is a thorough and complete

debridement. Trying to preserve marginal tissue in the

hope that a better stump can be constructed may lead to

subsequent infection and a higher amputation level.

Dressings and Prevention of Skin Retraction

Since amputations must be left open, skin retraction is likely,

causing the loss of usable limb length by making definitive

closure difficult. This is particularly true of a patient who is the

evacuation chain. Because of this, patients who will be evacuated

should be placed in skin traction in order to leave the wound

open and prevent skin retraction. Surgeons working for the

International Committee of the Red Cross (ICRC) in a stable

environment have successfully treated refugees by delayed

primary closure. However, ICRC surgeons work in a relatively

stable environment where evacuation is not a consideration for

the refugee population. This situation does not apply to those

in the air evacuation system.

Skin Traction

Ideally, skin traction should be maintained throughout the

course of treatment. If evacuation times are reliably very short

25.4

Amputations

(1-3 days), skin traction may be omitted. If there is the possibility

of any delay, use skin traction to preserve limb length. When

tactical conditions or resources are not available for application

of casts, skin traction may be applied through weights off the

end of the bed before and after transport.

Dry fine mesh gauze is loosely placed over the open

wound. Preserved flaps are not suspended freely, but are

held in their intended position by the dressing (Fig. 25-1).

Absorbent dressing is

placed over the stump.

Tincture of benzoin is

applied proximally on

the skin up to 2 cm from

the wound edge, but not

including the preserved

flap.

A stockinette for skin

traction is applied.

Wrap stockinette with a

figure-of-8 elastic wrap.

Two to six pounds of trac-

tion is applied through

the stockinette/wrap.

This may simply involve

a weight attached via

parachute cord to the

stockinette. However,

Fig. 25-1. Skin Tractions

during transport, hanging

weights are problematic

and may be substituted with a light elastic such as surgical

tubing or elastic exercise tubing applied through a

transportation cast described below.

A transportation cast should be applied to prevent

contracture and allow for continuous traction (Fig. 25-2).

Postoperative Management

Prevention of contracture.

ο BK amputations are at risk for knee flexion contractures.

These contractures are preventable by using a long leg cast.

25.5

Emergency War Surgery

Cast

Pad

Spreader

Pad

Fig. 25-2. Transportation cast allows for continuous traction.

Splinting in extension requires closer monitoring. Pillows

should never support the knee, because of the increased

risk of flexion contractures.

ο AK amputations are at risk for hip-flexion contractures.

Prone positioning and active hip extension exercises will

avoid this complication. When the casualty is supine,

sandbags may be applied to the anterior distal thigh as

well.

Prevention of hemorrhage: A tourniquet should be readily

available at the bedside or during transport for the first week

following injury.

Pain control: Patient comfort is paramount following

amputation, particularly if dressing changes are required.

Adequate analgesia should be available and the patient

should be counseled regarding phantom limb pain.

Transportation Casts

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.

Cast Application Techniques

Low Hip Spica cast

Indications: Transfemoral amputation.

Technique.

ο Adequate anesthesia is administered and the patient is

placed on the fracture table.

25.6

Amputations

Nonviable tissue is excised, as indicated above.

Stockinette or Webril is applied over lower abdomen and

thigh on side of amputation. Stockinette should already

be applied for skin traction.

Felt padding is placed over sacrum and anterior superior

iliac spine (ASIS).

Towel is placed over abdomen to allow breathing space.

Six-inch Webril or similar cotton batting is wrapped in 1-2

layers (Fig. 25-3).

Six-inch plaster is then rolled over the

Webril from the ASIS to the end of the

residual limb on the affected side. Splints

are applied over the posterior, lateral,

and groin areas. Use a finishing roll after

turning down the edges of the stock-

inette to give it a neat appearance.

Prior to the last roll, a Cramer wire splint

should be attached over the distal end

of the cast to provide skin traction via

the stockinette.

An adequate perineal space must be left

for hygiene.

The towel should be removed, the cast

bivalved, and a circular area over the

abdomen should be cut out.

Use an indelible marker to label the cast

Fig. 25-3. Low

with the date of injury and surgery(ies).

hip spica cast.

Indications: Transtibial amputations.

Technique.

ο Adequate anesthesia is provided. The wound is evaluated,

nonviable tissue is excised, and the wound is irrigated.

ο Stockinette is applied to the distal end of the residual limb

with tincture of Benzoin to maintain skin traction.

ο Two to three layers of Webril are applied from the

amputation to the proximal thigh.

ο A six-inch plaster is then rolled over the thigh and leg.

ο Prior to application of the last layer, a Cramer wire splint

should be incorporated over the distal end of the residual

limb. Apply skin traction when the cast is dry.

25.7

Emergency War Surgery

ο Bivalve the cast.

ο Label the cast with dates of injury and surgery(ies).

Shoulder Spica Cast

Indications: Transhumeral amputation.

Technique.

ο Administer adequate anesthesia.

ο Irrigate wound and excise nonviable tissue.

ο Apply stockinette to axilla for skin traction applied with

tincture of Benzoin.

ο Wrap Webril over chest wall and around to edge of residual

limb.

ο Apply 4-6 in. plaster over the Webril.

ο A Cramer wire splint outrigger should be applied with

the last roll to allow for connection of the stockinette and

application of skin traction.

ο Label the cast with dates of injury and surgery(ies).

Long Arm Cast

Indications: Transradial amputation.

Technique.

ο Administer adequate anesthesia.

ο After treatment of open wounds and application of a

dressing, apply a stockinette over the distal edge of the

residual limb.

ο Apply 4-inch Webril from the residual limb to the axilla.

ο Apply 4-inch plaster from the residual limb to the axilla.

ο Use plaster to incorporate a Cramer wire splint over the

distal edge of the residual limb in order to apply skin

traction.

ο Bivalve the cast.

ο Label the cast with dates of injury and surgery(ies).

25.8

Chapter 26

Injuries to the Hands and Feet

Introduction

Combat injuries to the hands and feet differ from those of the

arms and legs in terms of mortality and morbidity. Death is rare,

but a minor wound, causing no lasting impairment if inflicted,

for example, on the thigh, can result in life-long disability when

it occurs in a hand or foot. The hands and feet have an important

commonality: an intricate combination of many small structures

that must function smoothly together.

Types of Injury

Nonbattle injuries resulting in laceration of the hands and

crush injuries involving either the hands or feet are common.

Such crush injuries may result in compartment syndrome.

Missile and blast injuries involving the hands and feet are

common in combat and may result in mutilating injuries with

a permanent loss of function.

The Hand

Even apparently minor wounds distal to the wrist crease

may violate tendon sheaths and joints, resulting in a

serious deep space infection. Such wounds require a high

index of suspicion for injury and a low threshold for

operative exploration.

Evaluation and Initial Management

The casualty’s upper extremities should be exposed.

Rings, watches, and other constrictive material must be

removed immediately.

26.1

Emergency War Surgery

A preliminary neurologic exam should be performed and

documented.

Vascular status of the hand should include an assessment of

radial and ulnar arteries (Allen test, Doppler, among others).

Treatment of Hand Compartment Syndrome

The hand has 10 separate fascial compartments (4 dorsal

interossei, 3 volar interossei, the thenar muscles, the

hypothenar muscles, and the adductor pollicis [Fig. 26-1]).

4 Dorsal

+ 3 Volar Interosseous Compartments

Adductor

Pollicis

Hypothenar

Thenar

Compartment

Ulna Nerve

Fig. 26-1. Compartments of the hand.

A complete hand fascio-

tomy consists of four

incisions (shown in Fig.

26-2).

One incision on the radial

side of the thumb meta-

carpal releases the thenar

compartment.

A dorsal incision over

the index finger meta-

carpal is used to release

the 1st and 2nd dorsal

interossei, and to reach

ulnar-to-index finger

metacarpal and to release

Fig. 26-2. Hand fasciotomy incisions.

the volar interossei and

adductor pollicis.

26.2

Injuries to the Hands and Feet

A dorsal incision over the ring finger metacarpal is used to

release the 3rd and 4th dorsal interossei, and to reach down

along the radial aspect of the ring finger and small finger

metatarsal to release the volar interossei.

An incision is placed at the ulnar aspect of the small finger to

release the hypothenar muscles.

Although compartments

are not well defined in the

fingers, grossly edematous

fingers may require release

of dermal and fascial

constriction; care should

be taken to place the skin

incision away from the

neurovascular bundles

(Fig. 26-3).

Fig. 26-3. Incisions for finger

fasciotomy.

Surgical Technique

Do not blindly clamp bleeding tissues because nearby

nerves may be injured. If unable to control the bleeding

with pressure, isolate the vessel under tourniquet control

and tie off or clamp under direct vision.

General or regional (block) anesthetic is required; local

infiltration of anesthetic is inadequate. Epinephrine is never

injected into the hands or fingers.

Although either the radial or ulnar artery may be ligated,

both should not be.

Thorough exploration under tourniquet down to normal

tissue is mandatory to define the extent of the injury.

Debridement removes buried foreign matter and deep

devitalized tissue.

ο Dead tissue is removed.

ο Tissue, including skin, with marginal or questionable

viability is left for subsequent evaluation to improve

chances for optimal outcome.

The fingers are not amputated unless irretrievably mangled.

26.3

Emergency War Surgery

Viable tissue, even though nonfunctional, is retained and

stabilized for later reconstruction.

Provisional stabilization of fractures with Kirscher wires (K-

wires) may enhance patient comfort and later management.

Specific Tissue Management

Bone: Unless extruding from the body or severely contam-

inated, fragments should be left in place. At forward hospitals,

only small K-wires should be used for internal fixation.

Tendon: Minimal excision of tendons should occur. No

attempt at repair should be made in the field.

Nerve: Do not excise nerve tissue. No attempt at repair should

be made in the field.

The ends of lacerated nerves and tendons may be tagged with

4-0 suture so that they may be more easily identified later

during definitive reconstruction and repair.

Closure of wounds is delayed; however, exposed tendon,

bone, and joint should be covered with viable skin, if

possible, to prevent desiccation.

Dressing and Splinting

Splint the hand in the safe position (Fig. 26-4). The wrist

is extended 20°, the metacarpalphangeal joints are flexed

70°-90° and the fingers (proximal and distal interphan-

geal joints) are in full extension.

Fine mesh gauze is first laid on

the wounds and covered with a

generous layer of fluffed gauze.

The entire wound should be

covered but the fingertips left

exposed, if possible, to eval-

uate perfusion.

Fig. 26-4. Hand splint position.

26.4

Injuries to the Hands and Feet

A splint is applied, immobilizing all injured parts and

extending one bone or joint beyond. A palmar plaster slab is

routine, but a dorsal one may be added for additional stability.

The Foot

Penetrating injuries of the foot frequently result in prolonged

morbidity and disability. Crush injuries and injuries from blast

are more likely to result in an unsatisfactory result than are

wounds made by low-velocity bullets or isolated fragments. This

is especially true when there is loss of the heel-pad, significant

neurovascular injury or when the deep plantar space has been

contaminated. The ultimate goal of treatment of these injuries

is a relatively pain free, plantigrade foot with intact plantar

sensation.

Evaluation and Initial Management

The zone of injury with both open and closed injuries of the

foot is often more extensive than is apparent with the initial

inspection.

The vascular status of the foot should be assessed by

palpation of the dorsalis pedis and posterior tibial pulses.

An assessment of capillary refill in the toes should also be

made as a compartment syndrome of the foot can coexist with

intact pulses.

Anesthesia of the plantar aspect of the foot indicates an injury

to the posterior tibial nerve or one of its major branches and

portends a poor prognosis for a satisfactory outcome.

Compartment syndrome of the foot can occur even in the

presence of an open foot injury, and when identified, requires

emergency treatment.

At the time of debridement, small, contaminated bone

fragments without soft tissue attachment should be removed.

High-volume irrigation for all open wounds is mandatory.

All wounds should be left open.

26.5

Emergency War Surgery

Injuries to the Hindfoot

Severely comminuted, open fractures of the talus may require

talectomy, but this decision should be left to higher levels of

care.

The talus is best debrided through an anterolateral approach

to the ankle extended to the base of the 4th metatarsal.

Penetrating wounds into the plantar aspect of the heel pad

can be approached through a heel-splitting incision to avoid

excessive undermining of this specialized skin.

Transverse gunshot wounds of the hindfoot are best managed

by medial and lateral incisions with the majority of surgery

performed laterally to avoid medial neurovascular structure.

Injuries to the Midfoot

Tarsal and metatarsals are best approached through dorsal

longitudinal incisions. In addition, compartment release can

be adequately performed through longitudinal incisions

medial to the 2nd metatarsal and lateral to the 4th metatarsal

in order to leave a wide skin bridge.

Contamination of the deep plantar compartments of the foot

is best managed through a plantar medial incision that begins

1 inch proximal and 1 inch posterior to the medial malleolus

and extends across the medial arch ending on the plantar

surface between the 2nd and 3rd metatarsal heads. The medial

neurovascular structures must be identified during this

approach. A full compartment release can also be performed

through this incision.

Injuries to the Toes

Every effort should be made to preserve the great toe.

Amputation of the lateral toes is generally well-tolerated.

Foot Compartment Syndrome

There are 5 compartments in the foot.

ο The interosseous compartment is bounded by the lateral

1st metatarsal medially, metatarsals and dorsal interossous

fascia dorsally, and the plantar interosseous fascia

plantarly.

26.6

Injuries to the Hands and Feet

ο The lateral compartment is bounded by the 5th metatarsal

shaft dorsally, the plantar aponeurosis laterally, and the

intermuscular septum medially.

ο The central compartment is bounded by the intramuscular

septum laterally and medially, the interosseous fascia

dorsally, and the plantar aponeurosis plantarly.

ο The medial compartment is bounded by the inferior sur-

face of the 1st metatarsal dorsally, the plantar aponeurosis

extension medially, and the intramuscular septum laterally.

ο The calcaneal compartment contains the quadratus plantae

muscle.

The foot may be released through a double dorsal incision.

One incision placed slightly medial to the 2nd metatarsal,

reaching between the 1st and 2nd metatarsals into the medial

compartment, and between the 2nd and 3rd metatarsals, into

the central compartment (Fig. 26-5).

A second dorsal incision is made just lateral to 4th metatarsal,

reaching between 4th and 5th metatarsals into the lateral

compartment.

To spare the dorsal soft tissue, a single incision medial

fasciotomy may be used.

Dorsal Interosseous Compartments

Lateral

Compartments

Central

Medial

Compartments

Fig. 26-5. Interosseous compartment releases through two dorsal

incisions.

26.7

Emergency War Surgery

A medial approach to the foot is made through the medial

compartment, reaching across the central compartment into

the interosseous compartment dorsally and lateral compart-

ment releasing all the away across the foot (see description

in this chapter’s Injuries to the Midfoot and Fig. 26-6).

Fasciotomy wound management.

ο Following the fasciotomy, the fasciotomy wound undergoes

primary surgical wound management; all devitalized

tissue is removed.

ο As with all battle wounds, the fasciotomy is left open and

is covered with a sterile dressing.

Interosseous

Central

Lateral

Medial

Fig. 26-6. Central compartment releases through medial approach.

Stabilization

K-wires can be utilized for temporary stabilization.

A bivalved cast or splint is adequate for transport to a site of

more definitive care.

26.8

Chapter 27

Vascular Injuries

Introduction

History.

ο World War II: Popliteal artery injuries were routinely

ligated with a 73% amputation rate.

ο Korean War: Formal repair of peripheral arterial injuries

instituted.

ο Vietnam War: Further refinements in arterial repair; ampu-

tation rate for popliteal artery injuries is reduced to 32%.

There are various types of wounds seen in combat.

ο Low-velocity missile damages a blood vessel lying directly

in its path.

ο High-velocity missile blast effect causes fragmentation of

the missile or bone and widespread destruction, including

vascular injury at a distance.

ο Blunt trauma, often resulting from sudden deceleration in

motor vehicle accidents, falls, rail and air disasters.

ο Popliteal artery injury associated with posterior knee

dislocations.

Evaluation and Diagnosis

Physical examination — detailed examination is paramount.

ο Hard signs of arterial injury (pulsatile external bleeding,

enlarging hematoma, absent distal pulses, a thrill/bruit,

or ischemic limb) should lead to immediate surgical

exploration, without further preoperative studies.

♦ The 6 Ps of acute ischemia are: pain, pallor, pulse-

lessness, poikilothermia, paresthesia, and paralysis.

♦ Degree of injury and adequacy of collateral flow will

determine the severity of distal ischemia. Remember:

Warm ischemia of striated muscle for > 4-6 hours will

likely lead to myonecrosis and major amputation.

27.1

Emergency War Surgery

♦ Falsely attributing loss of pulse, diminished pulse, or

asymmetry of pulses to arterial spasm may cause delay

in detection/repair of limb-threatening arterial injury.

♦ Distal pulses may be intact in up to 20% of patients with

arterial injuries.

ο Soft signs of arterial injury that require additional

diagnostic evaluation include proximity of wound to major

vessels, history of hemorrhage/shock, nonexpanding

hematoma, diminished pulse, and anatomically related

nerve injury.

Doppler examination.

ο A patient with penetrating or blunt trauma who has a

normal distal pulse exam and ankle-brachial index (ABI)

> 1.0 does not require arteriography.

ο In the patient without a palpable pulse distal to the injury,

perform a Doppler examination and an ABI. ABI < 0.9 or a

difference in ABI between extremities of > 0.1 indicate an

arterial injury until proven otherwise. Because of extensive

collateral flow, injuries to the deep femoral or deep brachial

artery are not ruled out by this technique.

Duplex ultrasound (US).

ο Color flow duplex ultrasonography has demonstrated high

sensitivity and specificity for detecting arterial injuries. It

is noninvasive, portable, and painless, and repeated exams

are easily performed.

ο Duplex is highly operator-dependent and may fail to detect

all arterial injuries (eg, deep femoral or tibial injuries).

Contrast angiography.

ο Precise localization of vascular injury is useful in patients

with multiple pellet wounds (eg, shotgun blast), fractures,

and penetrating injuries to the neck and thoracic outlet.

ο Consider with high-velocity wounds, where arterial injury

may occur outside the path of the missile, or in the presence

of soft signs of arterial injury.

ο Consider as routine for knee dislocations where occult

arterial injuries may occur, and undetected delayed

popliteal artery thrombosis may lead to major amputation.

27.2

Vascular Injuries

Management Aspects

Initial management.

ο Control external bleeding immediately! Blind or

imprecise placement of vascular clamps in a bloody field

is discouraged. Direct pressure to the bleeding wound is

preferable; temporary tourniquet (BP cuff) placed

proximal to the injury site and inflated above systolic blood

pressure may be useful.

ο Administer IV antibiotics, tetanus toxoid, and analgesia.

ο In most long-bone fractures, resuscitation and fracture

alignment will restore distal flow.

ο Indications for operation for a suspected vascular injury:

♦ Hard signs as discussed above.

♦ Soft signs confirmed by duplex US and/or angiography.

Operative management.

ο Preparation and draping of injured extremity as well as

contralateral uninjured lower or upper extremity in case

repair requires autogenous vein graft.

ο Surgical approaches to the femoral popliteal, and brachial

arteries are shown in Figures 27-1-Figure 27-5.

Inguinal Ligament

External Iliac Artery

Femoral Nerve

Rectus

Femoris

Saphenous Vein

Sartorius

Fig. 27-1. Inguinal anatomy.

27.3

Emergency War Surgery

ο Longitudinal incisions usually directly over injured vessel

followed by proximal and distal control. A tourniquet (eg,

blood pressure cuff) may occasionally be useful to obtain

proximal control or to improve intraoperative visualization.

ο Once control is obtained, perform the following steps:

♦ Debride injured vessels to macroscopically normal wall.

♦ Pass balloon catheters proximal and distal to remove

any residual thrombus.

♦ Flush both directions with heparinized saline.

ο Consider temporary intraluminal shunting.

♦ Successful shunt placement allows ample time for wound

debridement and copious irrigation, identification of

nerve injuries, and careful consideration of reconstruction

vs primary amputation.

Shunt placement technique.

ο Proximal and distal vessel control with Silastic vessel loops

or Rumel tourniquet.

ο Release proximal control to flush clot and place Argyle shunt.

ο Distal thrombectomy (Fogarty catheter) until no clot is returned.

ο Instill heparinized saline (20 U/mL) into distal vessel.

ο Place shunt into distal end and secure.

ο Check for distal pulse/perfusion.

In injuries to both artery and vein in which no shunt is used,

repair artery first to minimize ischemic time, followed by

venous repair.

Suture: 5-0 or 6-0 Prolene; 7-0 Prolene for small arteries. All

completed repairs must be tension free.

Upon completion, forward and back bleed repaired segment

until clear of air and debris prior to final closure.

Type of repair will depend on the extent of injury.

ο Lateral suture repair: Required for minimal injuries that,

when repaired, will not compromise the lumen > 25%,

result in a thrill, nor decrease pulse or Doppler signal.

ο Patch angioplasty: Needed for larger, tangential wounds;

to prevent stenosis.

ο End-to-end anastomosis: Excise extensively damaged

segments and perform anastomosis if able to mobilize ends

(generally, < 2 cm gap) without tension. An oblique

anastomosis is less likely to stenose.

27.6

Vascular Injuries

Interposition graft: Required if the vessel cannot be

primarily repaired without undue tension.

♦ Autogenous vein grafts preferred, usually the contra-

lateral greater saphenous vein (GSV).

◊ Harvest vein from the contralateral limb, if possible.

The reason for this is in the injured limb, superficial

veins may be an important source of venous outflow

if deep veins are injured.

◊ Order of preference vein harvest for arterial conduit

is contralateral GSV, ipsilateral GSV (if no concom-

itant deep venous injury), contralateral lesser

saphenous vein (LSV), ipsilateral LSV (if no deep

venous injury), cephalic vein, and basilic vein.

♦ Prosthetic grafts may be required when autogenous

vein is inadequate or unavailable, expeditious repair is

indicated, or for large vessels (aortoiliac system) for

which there is a large size discrepancy.

◊ Polytetrafluoroethylene (PTFE) grafts are more resist-

ant to infection than Dacron and have acceptable

patency rates when used in the above-knee position.

◊ The use of prosthetic grafts can hasten the comple-

tion of a procedure in patients whose physiology

requires expeditious surgery.

◊ Prosthetics can also be used in areas of extensive

soft-tissue debridement as a “prolonged shunt”

where planned revision days to weeks later, out of

theatre, will be expected.

Graft coverage: Exposed vein grafts will desiccate, leading

to graft blow-out and potential exsanguination. They must

be covered by soft tissue or muscle; superficial muscles such

as sartorius or gracilis in the thigh may be mobilized to cover

a graft. If coverage is not possible, an alternate subcutaneous

or subfascial route through uncontaminated viable tissue

must be chosen.

Prolonged shunting: If the above techniques are unsuccessful

or precluded by patient physiology or the tactical environ-

ment, shunting (as outlined above) with the following

modifications can be used for up to 72 hours.

ο Replace silastic loops with suture, and secure firmly.

27.7

Emergency War Surgery

ο Systemic heparinization is not required.

ο Monitor distal perfusion hourly.

ο Re-evaluate/evacuate early for definitive repair.

Ligation of artery: If the above options for repair are

unsuccessful or unavailable, vessels can be ligated in light of

known rates of morbidity. Emphasis is Save Life Over Limb.

Intraoperative completion angiogram or duplex US (if

available) should be done to evaluate the technical adequacy

of the repair, visualize the runoff, and detect any missed distal

clot.

ο Full strength contrast 30-60 cc.

ο 20 gauge Angiocath.

ο Inflow occlusion.

Venous repair: Options are similar to arterial repairs outlined

above.

ο Ligation of major veins is acceptable in life-threatening

situations, although in a stable patient and time permitting,

venous repair should be performed and may enhance

arterial repair patency.

Compartment syndrome: Muscle compartments of the

forearm and palm in the upper extremity and anterior

compartments of the lower leg are particularly susceptible.

ο Indications for fasciotomy:

♦ 4-6 hour delay after vessel injury.

♦ Combined vein and artery injury.

♦ Arterial ligation.

♦ Concomitant fracture/crush, severe soft-tissue injury,

muscle edema or patchy necrosis.

♦ Tense compartment/compartment pressures exceeding

40 mm Hg.

♦ Prophylactic for patients with prolonged transport times

or long periods without observation (no surgical care

available enroute).

ο A standard two-incision, four-compartment approach for the

calf is simple and effective (see Chapter 22, Soft-Tissue Injury).

ο Arm fasciotomy will consist of a longitudinal centrally

placed incision over the extensor compartment and a

curvilinear incision on the flexor aspect beginning at the

antecubital fossa.

27.8

Vascular Injuries

Post-op care.

ο Palpable pulses obtained in the operating room (OR)

should remain palpable post-op.

♦ Pulse changes, even if Doppler signals remain, may

indicate graft thrombosis and should be investigated.

ο Consider low-dose heparin as deep vein thrombosis (DVT)

prophylaxis.

♦ Use with caution in multiply injured and head-injured

patients.

ο Slight elevation of injured extremity improves post-op

edema.

27.9

Emergency War Surgery (2004) - page 9