J Am Acad Orthop Sur
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Blast injury to the extremities is the most common form of injury in recent military campaigns and in civilian terror attacks. Most orthopaedic trauma is caused by the secondary effect of blast--penetrating fragment injury. Timely wound débridement and excision of contaminated or avascular tissue, along with prevention of sepsis, are crucial to managing extremity injury. Late reconstruction and functional results are very challenging for the surgical team to achieve.
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Blast trauma is a complex event. Pathophysiologically, blast injuries are identified as primary (caused solely by the direct effect of blast overpressure on the tissue), secondary (caused by flying objects or fragments), tertiary (caused by bodily displacement), or quaternary (indirectly caused by the explosion). The range of primary blast injuries includes fractures, amputations, crush injury, burns, cuts, lacerations, acute occlusion of an artery, air embolism-induced injury, compartment syndrome, and others. ⋯ Débridement and wound excision are started as early as possible, with repeat débridement performed as necessary; fasciotomies also are performed to prevent compartment syndrome. Well-vascularized muscular free flaps provide soft-tissue coverage for blast-injured extremities. The closed-open technique of flap closure allows reexamination of the wound, further irrigation, débridement, and later bone and soft-tissue reconstruction.
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Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. ⋯ Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.
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J Am Acad Orthop Sur · Jan 2006
ReviewFactors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP).
The Lower Extremity Assessment Project (LEAP) is a multicenter study of severe lower extremity trauma in the US civilian population. At 2- and 7-year follow-ups, the LEAP study found no difference in functional outcome between patients who underwent either limb salvage surgery or amputation. However, outcomes on average were poor for both groups. ⋯ In addition, outcomes often are more affected by the patient's economic, social, and personal resources than by the initial treatment of the injury--specifically, amputation or reconstruction and level of amputation. A conceptual framework for examining outcomes after injury may be used to identify opportunities for interventions that would improve outcomes. Because of essential differences between the civilian and military populations, the findings of the LEAP study may correlate only roughly with combat casualty outcomes.
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J Am Acad Orthop Sur · Jan 2006
ReviewFrom the battlefields to the states: the road to recovery. The role of Landstuhl Regional Medical Center in US military casualty care.
The transformation of the modern battlefield with respect to weaponry, modes of transportation, enemy capabilities and location, as well as technological advances, has greatly altered the tactical approach to the mission. Combat casualty care must continually evolve in response to the differences in types of injury, the number and triage of casualties, timing of treatment, and location of care. ⋯ Even in the new environment of armed conflict and with the advent of new technologies, the principles of managing orthopaedic combat casualties remain clear: preservation of life and limb, skeletal stabilization, and aggressive wound débridement. For United States service members wounded in the current conflicts, Landstuhl Regional Medical Center is a crucial stop along the road to recovery.