Emergency War Surgery (2004)

Emergency War Surgery

The role of halo immobilization in the acute combat setting

is quite limited. In nonpenetrating trauma to the cervical

spine, immobilization with a cervical hard collar or sand bags

is preferable until arrival at a definitive treatment site.

Should traction be indicated for cervical spine injuries (eg,

facet joint dislocations or burst fractures with a tenuous

neurologic status), the Gardner-Wells tongs should be

applied and sufficient weight (generally 2-10 kg) placed

in line of the spine (Fig. 20-2, Table 20-2). It is paramount

to remember that injuries to occipitocervical articulation

should not be treated with traction-in effect, putting these

injuries in traction “pulls the head off”. If traction is

applied, radiographs must be obtained to be certain that

no undiagnosed ligamentous injury has been exacerbated

by the weight.

The role of collar immobilization in penetrating injuries

to the cervical spine is less well established. Soft-tissue care

is compromised by the collar’s position and, in general,

penetrating injuries coupled with osseous instability

should be managed in Gardner-Wells traction.

Fig. 20-2. Gardner-Wells tongs.

20.6

Wounds and Injuries of the Spinal Column and Cord

Table 20-2. Application of Gardner-Wells Tongs.

Step

Procedure

Comment

Inspect Insertion Site: Select a

Rule out depressed skull fracture

point just above apex of each ear.

in this area.

Shave and Prep Pin Insertion Site.

Inject Local Anesthetic: Inject 2-3

May omit if patient is unconscious.

cc of 1% Xylocaine or equivalent

agent 1 cm above each ear in line

with the external auditory meatus.

Advance Gardner-Wells Tong Pins:

A spring-loaded device in one of

Insert pins into skull by symmet-

the two pins will protrude when

rically tightening the knobs.

the pins are appropriately seated.

(A data plate on the tongs provides

additional information.)

Apply Skeletal Traction: Use a

Use 5 lb rule (ie, 5 lb of weight for

pulley fixed to the head of the

each level of injury). High cervical

litter or frame to direct horizontal

fractures usually require minimal

traction to the tongs.

traction to reduce. Monitor with

series radiographs. The tong-pin

site requires anterior or posterior

positioning to adjust for cervical

spine flexing or extension as

indicated.

Elevate Head of Litter: Use blocks

The knot in the cord should not be

in order to provide body-weight

permitted to drift up against the

counter traction.

pulley. Should this occur, traction

is no longer being applied.

Decrease Traction Weight: When

Unreducible or unstable fractures

radiographs confirm that

should be maintained in

reduction is adequate, decrease

moderate traction until surgical

traction to 5-15 lb.

intervention. If neurological

deterioration occurs, immediate

surgical intervention must be

considered.

Daily Pin Care.

Cleanse tracts with saline and apply

antibiotic ointment to the pin sites.

Maintain pin force (see Step 4)

by tightening as necessary to keep

spring-loaded device in the

protruded position.

20.7

Emergency War Surgery

Turn Patient Appropriately: Use When initially proned, obtain radio-

Stryker, Foster, or similar frame

graphs to ensure that the reduction

and turn patient every 4 h.

is maintained. If reduction is not

maintained when the patient is

proned, rotate the patient only

between the 30° right and left

quarter positions. The use of a

circle electric bed is contraindicated

with injuries of the spinal cord

or column.

If Satisfactory Alignment Cannot Consider myelogram, CT scan,

Be Obtained, Further Workup Is tomograms, and neurosurgical

Necessary.

/orthopedic consultations.

Thoracic and Lumbar Spine

Although the thoracic rib cage contributes considerable

rotatory stability, it does not protect completely against

injuries.

The vascular supply of the spinal cord is most vulnerable

between T-4 and T-6 where the canal is most narrow. Even

minor deformity may result in cord injury.

The most common place for compression injuries is at the

thoracolumbar junction between T-10 and L-2.

Most burst fractures result from an axial load, and occur at

the thoracolumbar junction. These fractures are associated

with compromise of the spinal canal and progressive angular

deformity. They are often associated with significant

neurologic injury.

Evaluation for surgical stabilization and spinal cord

decompression should be done with advanced imaging such

as CT and/or magnetic resonance imaging (MRI).

When complex wounds involving the head, thorax,

abdomen, or extremities coexist with vertebral column

injuries, lifesaving measures take precedence over the

definitive diagnosis and management of spinal column

and cord problems. During these interventions, further

injury to the unstable spine must be prevented by

appropriate protective measures.

20.8

Wounds and Injuries of the Spinal Column and Cord

Emergent Surgery

Emergent spine surgery for penetrating or closed injuries

of the spinal cord is indicated only in the presence of

neurological deterioration.

Penetrating Spine Injuries.

ο Injuries associated with a hollow-viscus should undergo

appropriate treatment of the viscus injury without

extensive debridement of the spinal injury, followed by

appropriate broad-spectrum antibiotics for 1-2 weeks.

Inadequate debridement and irrigation may lead to

meningitis.

ο Removal of a fragment from the spinal canal is indicated

for patients with neurologic deterioration.

ο In neurologically stable patients with fragments in the

cervical canal, delaying surgery for 7-10 days reduces

problems with dural leak and makes dural repair

considerably easier.

ο Casualties not requiring immediate surgery may be

observed with spine immobilization and treated with 3

days of IV antibiotics. Surgical stabilization can be

performed following evacuation.

Pharmacologic Treatment

Penetrating injuries of the spine should NOT receive

corticosteroid treatment.

Closed spinal cord injuries may be treated with an IV

corticosteroid if started within 8 hours of injury.

ο 30 mg/kg bolus of methylprednisolone initially.

ο 5.4 mg/kg/h of methylprednisolone for the next 24-48

hours.

♦ If therapy is started within 3 hours of injury, continue

treatment for 24 hours.

♦ If therapy is started within 3-8 hours after injury, then

treat for 48 hours.

20.9

Emergency War Surgery

General Management Considerations

Neurogenic shock

Traumatically induced sympathectomy with spinal cord

injury.

Symptoms include bradycardia and hypotension.

Treatment:

ο Volume resuscitation to maintain systolic BP > 90 mm Hg.

ο May use phenylephrine (50-300 µg/min) or dopamine (2-

10 µg/kg/min) to maintain BP.

Gastrointestinal tract

Ileus is common and requires use of a nasogastric tube.

Stress ulcer prevention using medical prophylaxis.

Bowel training includes a schedule of suppositories and may

be initiated within one week of injury.

Deep vein thrombosis

Start mechanical prophylaxis immediately.

Initiate chemical prophylaxis after acute bleeding has stopped

(See Chapter 11, ICU Care).

Bladder Dysfunction

Failure to decompress the bladder may lead to autonomic

dysreflexia and a hypertensive crisis.

The bladder is emptied by intermittent or indwelling

catheterization.

Antibiotic prophylaxis for the urinary tract is not advised.

Decubitus ulcers

Skin breakdown begins within 30 minutes in the immobilized

hypotensive patient.

For prolonged transport, the casualty should be removed

from the hard spine board and placed on a litter.

Frequent turning and padding of prominences and diligence

on the part of caretakers are essential to protect the insensate

limbs.

All bony prominences are inspected daily.

Physical therapy is started early to maintain range of motion

in all joints to make seating and perineal care easier.

20.10

Chapter 21

Pelvic Injuries

Introduction

Injuries of the pelvis are an uncommon battlefield injury.

Blunt injuries may be associated with major hemorrhage and

early mortality.

Penetrating injuries to the skeletal pelvis are usually

associated with abdominopelvic organ injury.

Blunt Injuries

Patterns and mechanisms are the same as those seen in

civilian blunt trauma.

ο Lateral compression injuries are marked by internal

rotation or midline displacement of the hemipelvis.

ο Anterior posterior injuries demonstrate external rotation

of the hemipelvis.

ο Vertical shear injuries have cephalad displacement of the

hemipelvis.

Increasing degrees of displacement in any direction are

associated with greater risk of hemorrhage.

ο Anterior posterior injuries with complete disruption of all

sacroiliac ligaments represent an internal hemipelvectomy

and have the greatest potential for hemorrhage.

Early pelvic stabilization can control hemorrhage and

reduce mortality. This is particularly true in an austere

environment with limited blood replacement products and

other treatment resources.

Open injuries require early recognition and prompt treatment

to prevent high mortality due to early hemorrhage and late

sepsis.

21.1

Emergency War Surgery

Diagnosis.

ο Physical examination demonstrates instability of the pelvis

when manual pressure is applied to the iliac crests.

ο Leg length difference, scrotal or labial swelling/

ecchymosis, or abrasions over the pelvis raise suspicion

for pelvic ring injury.

ο Perineum, rectum, and vaginal vault must be evaluated

for lacerations to rule out an open injury.

ο Radiograph (AP pelvis, and when possible, inlet and outlet

views) confirm the diagnosis. Computed tomography (CT)

defines the location of injury more accurately.

ο Bladder and urethral injuries are suspected when blood is

present at the meatus or in the urine, or when a Foley

catheter cannot be passed. Retrograde urethrogram and

cystography confirm the diagnosis.

Treatment.

ο Hemorrhage control.

♦ Mechanical stabilization.

◊ Tying a sheet or placing a binder around the pelvis

at the level of the greater trochanters.

◊ Bean bags or sand bags.

◊ Lateral decubitus positioning with the affected side

dependent.

External fixator placement in the iliac crests allows for

the most direct control of the pelvis.

♦ Angiography is a useful adjunct, but is not usually

available in the deployed environment.

♦ As a last resort, retroperitoneal packing may be

attempted, but will expend tremendous resources and

is often unsuccessful.

ο Open blunt injuries require:

♦ Immediate hemorrhage control by packing.

♦ Aggressive and thorough debridement.

♦ Pelvic stabilization.

♦ Diverting colostomy in the presence of wounds at risk

for fecal soilage.

21.2

Pelvic Injuries

ο Definitive internal pelvic stabilization (plates, screws,

among others) is done outside of the combat zone.

Missile and fragmentation wounds can cause fracture of

the pelvis.

The pelvis usually remains stable.

The colon, small intestine, rectum, and the genitour-

inary tracts must all be assessed for associated injury.

Major hemorrhage can result from injury to the iliac

vessels.

Penetrating Injuries

Evaluation.

ο Diagnosis of associated injuries may require exploratory

laparotomy.

ο Fractures should be assessed with radiographs and CT

scans, when available, to rule out extension into the hip

and acetabulum.

Treatment.

ο Control hemorrhage.

ο Control hollow visceral injury.

ο Debride wounds and fractures.

For combined hollow-viscus and acetabulum /hip joint

injuries, the joint is contaminated and must be explored

and treated as described in Chapter 24, Open Joint

Injuries.

Technique of pelvic external fixator placement (Fig. 21-1).

ο Prep the iliac crests.

ο Place a 2-cm horizontal incision over the iliac crest, 2

fingerbreadths proximal or medial ventral to the anterior

superior iliac crest.

ο Bluntly dissect to the iliac crest.

ο To determine the angle of the pelvis, first slide a guide pin

between the muscle and the bone along the inner table of

the iliac wing, no deeper than 3-4 cm.

21.3

Emergency War Surgery

Fig. 21-1. Pelvic external fixator placement.

Failure to properly determine the angle of the iliac wing

leads to inadequate fixation and may cause significant

complications.

ο Locate the junction of the middle and medial thirds of the

thickness of the iliac crest with the tip of a 5-mm external

fixator pin.

ο Paralleling the guide pin, begin drilling the pin into the crest.

ο Drill between the inner and outer tables to a depth of about

4 cm, aiming generally towards the greater trochanter.

Only gentle pressure should be applied once the pin

threads have engaged, to allow for the pin to guide itself

between the tables.

ο A second pin is inserted 1-2 cm more posteriorly on the crest.

ο Check the stability of each pin. If unsatisfactory, attempt

reinsertion by aiming between the tables.

ο Place pins in the contralateral iliac crest in the same

manner.

ο Reduce the pelvis by applying pressure on the pelvis (not

the pins!) and connect the external fixator pins with bar(s)

across the abdomen and pelvis to maintain reduction.

21.4

Chapter 22

Soft-Tissue Injuries

All war wounds are contaminated and should not be

closed primarily.

The goal in treatment of soft-tissue wounds is to save lives,

preserve function, minimize morbidity and prevent infections

through early and aggressive surgical wound care far forward

on the battlefield.

Presurgical Care

Prevent infection.

ο Antibiotics:

♦ Antibiotics are not a replacement for surgical

treatment.

♦ Antibiotics are therapeutic, not prophylactic, in war

wounds.

♦ Give antibiotics for all penetrating wounds as soon as

possible.

ο Sterile dressing.

♦ Place a sterile field dressing as soon as possible.

♦ Leave dressing undisturbed until surgery. A one-look

soft-tissue examination may be performed on initial

presentation. Infection rate increases with multiple

examinations prior to surgery. Initial wound cultures

unnecessary.

Surgical Wound Management Priorities

Life-saving procedures before limb and soft-tissue wound care.

Save limbs.

ο Vascular repair.

ο Compartment release.

22.1

Emergency War Surgery

Prevent infection.

ο Wound surgery within 6 hours of wounding.

ο Antibiotics.

ο Sterile dressing.

ο Fracture immobilization.

Superficial penetrating fragment (single or multiple)

injuries usually do not require surgical exploration. Simply

cleanse the wounds with antiseptic and scrub brush.

Nonetheless, depending on location and clinical presentation,

maintain high suspicion for vascular injury or intraabdominal

penetration.

ο Avoid “Swiss cheese” surgery (in an attempt to excise all

wounds and retrieve fragments).

Wound Care

Primary Surgical Wound Care

Limited longitudinal incisions.

Excision of foreign material and devitalized tissue.

Irrigation.

LEAVE WOUND OPEN—NO PRIMARY CLOSURE.

Antibiotics and tetanus prophylaxis.

Splint for transport (improves pain control).

Longitudinal incisions.

ο Wounds are extended with incisions parallel to the long

axis of the extremity, to expose the entire deep zone of

injury. At the flexion side of joints, the incisions are made

obliquely to the long axis to prevent the development of

flexion contractures.

ο The use of longitudinal incisions, rather than transverse

ones, allows for proximal and distal extension, as needed,

for more thorough visualization and debridement.

Wound excision (current use of the term debridement).

ο Skin.

♦ Conservative excision of 1-2 mm of damaged skin edges

(Fig. 22-1a).

♦ Excessive skin excision is avoided; questionable areas

can be assessed at the next debridement.

22.2

Soft-Tissue Injuries

Fig. 22-1. (a) Skin excision, (b) removal of fascia, (c) removal of avascular

tissue, (d) irrigation.

ο Fat.

♦ Damaged, contaminated fat should be generously

excised.

ο Fascia.

♦ Damage to the fascia is often minimal relative to the

magnitude of destruction beneath it (Fig 22-1b).

♦ Shredded, torn portions of fascia are excised, and the

fascia is widely opened through longitudinal incision

to expose the entire zone of injury beneath.

♦ Complete fasciotomy is often required as discussed

below.

ο Muscle.

22.3

Emergency War Surgery

Removal of dead muscle is important to prevent

infection. ACCURATE INITIAL ASSESSMENT OF MUSCLE VIABILITY

IS DIFFICULT. Tissue sparing debridement is acceptable if

follow-on wound surgery will occur within 24 hours.

More aggressive debridement is required if subsequent

surgery will be delayed for more than 24 hours.

♦ Sharply excise all nonviable, severely damaged,

avascular muscle (Fig. 22-1c).

♦ The “4 Cs” may be unreliable for initial assessment of

muscle viability (color, contraction, consistency,

circulation).

◊ Color is the least reliable sign of muscle injury.

Surface muscle may be discolored due to blood under

the myomesium, contusion, or local vasoconstriction.

◊ Contraction is assessed by observing the retraction

of the muscle with the gentle pinch of a forceps.

◊ Consistency of the muscle may be the best predictor

of viability. In general, viable muscle will rebound to

its original shape when grasped by a forceps, while

muscle that retains the mark has questionable viability.

◊ Circulation is assessed via bleeding tissue from a

fresh wound. Transient vasospasm, common with

war wounds, may not allow for otherwise healthy

tissue to bleed.

Bone.

♦ Fragments of bone with soft-tissue attachments and

large free articular fragments are preserved.

♦ Remove all devitalized, avascular pieces of bone smaller

than thumbnail size that have no soft-tissue attachment.

♦ Deliver each of the bone ends of any fracture indepen-

dently, clean the surface and clean out the ends of the

medullary canal.

Nerves and tendons.

♦ Do not require debridement, except for trimming frayed

edges and grossly destroyed portions.

♦ Primary repair is not performed. To prevent desiccation,

use soft-tissue or moist dressings for coverage.

22.4

Soft-Tissue Injuries

Vessels.

♦ Only minimal debridement of vessel is required for a

successful repair.

Irrigation.

♦ Following surgical removal of debris and nonviable

tissue, irrigation is performed until clean (Fig. 22-1d).

♦ While sterile physiologic fluid is preferred, do not

deplete resuscitation fluid resources. May use potable

water as an alternative. The last liter of irrigant should

be a sterile solution with antibiotics.

Local soft-tissue coverage.

♦ The development and rotation of flaps for this purpose

should not be done during primary surgical wound care.

♦ Local soft-tissue coverage through the gentle mobilization

of adjacent healthy tissue to prevent drying, necrosis,

and infection is recommended. Saline-soaked gauze is

an alternative.

No Primary Closure of War Wounds.

Dressing.

♦ Do not plug the wound with packing as this prevents

wound drainage. Leaving the wound open allows the

egress of fluids, avoids ischemia, allows for unrestricted

edema, and avoids the creation of an anaerobic

environment.

♦ Place a nonconstricting, nonocclusive dry dressing over

the wound.

Wound Management After Initial Surgery

The wound undergoes a planned second debridement and

irrigation in 24-72 hours, and subsequent procedures until a

clean wound is achieved.

Between procedures there may be better demarcation of

nonviable tissue or the development of local infection.

Early soft-tissue coverage is desirable within 3-5 days, when

the wound is clean, to prevent secondary infection.

22.5

Emergency War Surgery

Delayed primary closure (3-5 days) requires a clean wound

that can be closed without undue tension. This state may be

difficult to achieve in war wounds.

Soft-tissue war wounds heal well without significant loss of

function through secondary intention. This is especially true

of simple soft-tissue wounds.

Definitive closure with skin grafts and muscle flaps should

not be done in theater when evacuation is possible. These

techniques may be required, however, for injured civilians

or prisoners of war.

Crush Syndrome

When a victim is crushed or trapped with compression on

the extremities for a prolonged time, there is the possibility

for the crush syndrome (CS), characterized by ischemia and

muscle damage or death (rhabdomyolysis).

ο With rhabdomyolysis there is an efflux of potassium,

nephrotoxic metabolites, myoglobin, purines, and

phosphorous into the circulation, resulting in cardiac and

renal dysfunction.

ο Reperfusion injury can cause up to 10 L of third-space fluid

loss per limb that can precipitate hypovolemic shock.

ο Acute renal failure (ARF) can result from the combination

of nephrotoxic substances from muscle death (myoglobin,

uric acid) and hypovolemia resulting in renal low-flow state.

Recognition.

ο History.

♦ Suspect in patients in whom there is a history of being

trapped (eg, urban operations, mountain operations,

earthquakes, or bombings) for a prolonged period (from

hours to days).

♦ Clear history is not always available in combat, and the

syndrome may appear insidiously in patients who

initially appear well.

ο Physical findings.

A thorough examination must be done with attention to

extremities, trunk, and buttocks. The physical findings

depend on the duration of entrapment, treatment

rendered, and time since the victim’s release.

22.6

Soft-Tissue Injuries

♦ Extremities.

◊ May initially appear normal just after extrication.

◊ Edema develops and the extremity becomes swollen,

cool, and tense.

◊ May have severe pain out of proportion to examination.

◊ Anesthesia and paralysis of the extremities, which

can mimic a spinal cord injury with flaccid paralysis,

but there will be normal bowel and bladder function.

♦ Trunk/buttocks: may have severe pain out of proportion

to examination in tense compartments.

Laboratory findings.

♦ Creatinine phosphokinase (CK) is elevated with values

usually > 100,000 IU/mL.

♦ The urine may initially appear concentrated and later

change color to a typical reddish-brown color, so called

“port wine” or “iced tea” urine. The urine output

decreases in volume over time.

♦ Due to myoglobin, urine dipstick is positive for blood,

but microscopy will not demonstrate red blood cells

(RBCs). The urine may be sent to check for myoglobin,

but results take days and should not delay therapy.

♦ Hematocrit/hemoglobin (H/H) can vary depending on

blood loss, but in isolated crush syndrome H/H is

elevated due to hemoconcentration from third spacing

fluid losses.

♦ With progression, serum potassium and CK increase

further with a worsening metabolic acidosis. Creatinine

and BUN will rise as renal failure ensues. Hyperkalemia

is typically the ultimate cause of death from cardiac

arrhythmia.

Therapy.

ο On scene while still trapped.

♦ The primary goal of therapy is to prevent acute renal

failure in crush syndrome. Suspect, recognize, and treat

rhabdomyolysis early in victims of entrapment.

♦ Therapy should be initiated as soon as possible,

preferably in the field, while the casualty is still trapped.

Ideally it is recommended to establish IV access in a

free arm or leg vein.

22.7

Emergency War Surgery

◊ Avoid potassium and lactate containing IV solutions.

◊ At least 1 L should be given prior to extrication and

up to 1 L/h (for short extrication times) to a

maximum of 6-10 L/d in prolonged entrapments.

♦ As a last resort, amputation may be necessary for rescue

of entrapped casualties (ketamine 2 mg/kg IV for

anesthesia and use of proximal tourniquet).

Hospital care.

♦ Other injuries and electrolyte anomalies must be treated

while continuing fluid resuscitation, as given above, to

protect renal function.

♦ Foley catheter for urine output monitoring.

♦ Establish and maintain urine output > 100 cc/h until

pigments have cleared from the urine. If necessary, also

◊ Add sodium bicarbonate to the IV fluid (1 amp/L

D5W) to alkalinize the urine above a pH of 6.5.

If unable to monitor urine pH, put 1 amp in every

other IV liter.

◊ Administer mannitol, 20% solution 1-2 g/kg over 4

hours (up to 200 g/d), in addition to the IV fluids.

♦ Central venous monitoring may be needed with the

larger volumes (may exceed 12 L/d to achieve necessary

urine output) of fluid given.

♦ Electrolyte abnormalities.

◊ Hyperkalemia, hyperphosphatemia, hypocalcemia,

hyperuricemia must be addressed.

♦ Dialysis.

◊ ARF requiring dialysis occurs in 50%-100% of those

with severe rhabdomyolysis.

♦ Surgical management centers on diagnosis and

treatment of compartment syndrome—remember to

check torso and buttocks as well.

◊ Amputation: consider in casualties with irreversible

muscle necrosis/necrotic extremity.

♦ Hyperbaric oxygen therapy: may be useful after surgical

therapy to improve limb survival.

22.8

Soft-Tissue Injuries

Compartment Syndrome (see Chapter 27, Vascular Injuries)

Compartment syndrome may occur with an injury to any

fascial compartment. The fascial defect caused by the injury

may not be adequate to fully decompress the compartment,

and compartment syndrome may still occur.

Mechanisms of injuries associated with compartment

syndrome.

ο Open fractures.

ο Closed fractures.

ο Penetrating wounds.

ο Crush injuries.

ο Vascular injuries.

ο Reperfusion following vascular repairs.

Early clinical diagnosis of compartment syndrome.

ο Pain out of proportion.

ο Pain with passive stretch.

ο Tense, swollen compartment.

Late clinical diagnosis.

ο Paresthesia.

ο Pulselessness and pallor.

ο Paralysis.

Measurement of compartment pressures: Not recommended,

just do the fasciotomy.

ο The diagnosis of a compartment syndrome is made on

clinical grounds.

ο Measurement of compartment pressures is not recommended

in the combat zone.

Consider prophylactic fasciotomy.

ο High-energy wounds.

ο Intubated, comatose, sedated.

ο Closed-head injuries.

ο Circumferential dressings or casts.

ο Vascular repair.

ο Prolonged transport.

ο High index of suspicion.

22.9

Emergency War Surgery

Fasciotomy Technique

Upper extremity.

Arm: The arm has two compartments:

The anterior flexors (biceps, brachialis) and the posterior

extensors (triceps).

♦ Lateral skin incision from the deltoid insertion to the

lateral epicondyle.

♦ Spare the larger cutaneous nerves.

♦ At the fascial level the intermuscular septum between

the anterior and posterior compartment is identified,

and the fascia overlying each compartment is released

with longitudinal incisions.

♦ Protect the radial nerve as it passes through the

intermuscular septum from the posterior compartment

to the anterior compartment just below the fascia.

♦ Compartment syndrome in the hand is discussed in

Chapter 26, Injuries to the Hands and Feet.

Forearm: The forearm has three compartments:

The mobile wad proximally, the volar compartment, and

the dorsal compartment (Fig 22-2).

♦ A palmar incision is made between the thenar and

hypothenar musculature in the palm, releasing the

carpal tunnel as needed.

♦ This incision is extended transversely across the wrist

flexion crease to the ulnar side of the wrist, and then arched

across the volar forearm back to the ulnar side at the elbow.

♦ At the elbow, just radial to the medial epicondyle, the

incision is curved across the elbow flexion crease. The

deep fascia is then released.

♦ At the antecubital fossa, the fibrous band of the lacertus

fibrosus overlying the brachial artery and median nerve

is carefully released.

♦ This incision allows for soft-tissue coverage of the

neurovascular structures at the wrist and elbows, and

prevents soft-tissue contractures from developing at the

flexion creases.

♦ A second straight dorsal incision can be made to release

the dorsal compartment, reaching proximally to release

the mobile wad if necessary.

22.10

Soft-Tissue Injuries

Volar Compartment

Mobile Wad

Medial

Lateral

Dorsal Compartment

Fig. 22-2. Forearm compartments.

Lower extremity.

ο Thigh: The thigh has three compartments:

The anterior (quadriceps), the medial compartment

(adductors), and the posterior compartment (hamstrings).

♦ A lateral incision is made from greater trochanter to

lateral condyle of the femur.

♦ Then iliotibial band is incised, and the vastus lateralis

is reflected off the intermuscular septum bluntly,

releasing the anterior compartment.

♦ The intermuscular septum is then incised the length of

the incision, releasing the posterior compartment.

♦ This release of the intermuscular septum should not be

made close to the femur, because there are a series of

perforating arteries passing through the septum from

posterior to anterior near the bone.

♦ The medial adductor compartment is released through

22.11

Emergency War Surgery

a separate anteromedial incision.

ο Calf: The calf has four compartments:

The lateral compartment, containing peroneal brevis and

longus; the anterior compartment, containing extensor

hallucis longus, extensor digitorum communis, tibialis

anterior, and peroneus tertius; the superficial posterior

compartment, containing gastrocnemius and soleus; and

the deep posterior compartment, containing the flexor

hallucis longus, flexor digitorum longus, and the tibialis

posterior (Fig. 22-3).

♦ Two-incision technique.

EDL EHL

Tibialis Anterior

Cmpt.

Anterior Tibial

Artery, Vein,

Anterolateral

Peroneal Nerve

Incision

Tibia

G. Saphenous V.

Peroneus Brevis

and Longus in

Posterior Medial

Lateral Cmpt.

Incision

Tibialis Posterior

Gastrocnemius M.

FHL in the

Deep Posterior

Cmpt.

Superficial

Posterior Cmpt.

Fig. 22-3. Calf compartments.

◊ Incisions must extend the entire length of the calf to

release all of the compressing fascia and skin (Fig. 22-4).

◊ A lateral incision is made centered between the fibula

and anterior tibial crest.

◊ The lateral intermuscular septum and superficial

peroneal nerve are identified, and the anterior

compartment is released in line with tibialis anterior

22.12

Soft-Tissue Injuries

turn

Fig. 22-4. Anteromedial incision of the calf.

muscle, proximally toward the tibial tubercle, and

distally toward anterior ankle.

◊ The lateral compartment is then released through this

incision in line with the fibular shaft, proximally

toward the fibular head, distally toward the lateral

malleolus.

◊ A second incision is made medially at least 2 cm medial

to the medial-posterior palpable edge of the tibia.

◊ A medial incision over or near the subcutaneous

surface of the tibia is avoided, preventing exposure

of the tibia when the tissues retract.

◊ The saphenous vein and nerve are retracted anteriorly.

◊ The superficial compartment is released through its

length, and then the deep posterior compartment

over the FDL is released. Then identify the tibialis

posterior and release its fascia.

22.13

Emergency War Surgery

ο Foot: See Chapter 26, Injuries to Hands and Feet.

Fasciotomy wound management.

ο Following the fasciotomy, the fasciotomy wound undergoes

primary surgical wound management, removing all

devitalized tissue.

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

covered with sterile dressings.

Vacuum Wound Closure Systems.

Vacuum assisted wound closure is an important adjunct

to modern combat wound care.

Only one device is currently approved for this application:

the Wound Vacuum Assisted Closing (VAC) Therapy

System.

Field expedient vacuum assisted wound closure is an

alternative. Field expedient vacuum dressings are easily

created with standard issue items, including the following:

♦ Laparotomy sponges.

♦ Jackson-Pratt (JP) drains.

♦ Ioban.

♦ Benzoin.

♦ Adaptec (nonadherent gauze, for skin grafts).

♦ Sterile perforated IV bags.

◊ For wounds of the soft tissue and extremities, layer

laparotomy sponges with JP drains sandwiched

between the sponges and covered with Ioban. Apply

benzoin to the skin edges to prevent leaks.

◊ Attach the JP drains to the standard vacuum pump,

adjusted to 125 mm Hg suction. This dressing

eliminates the need for skin traction in amputations.

◊ For skin grafts, staple the graft to the edges of the

wound. Apply nonadhering gauze, and apply to

field-expedient vacuum dressing. Do not remove for

3 days. Grafts can be dressed with Silvadene when

the field-expedient vacuum dressing is removed.

◊ For open abdominal wounds, place sterile

perforated IV bags on the bowel, and sew the IV bag

to the fascia, or underlay the fascia with the IV bag.

Place laparotomy sponges on the IV bags and layer

22.14

Soft-Tissue Injuries

with JP drains. Apply benzoin to the skin edge and

cover with Ioban. Attach the drains to suction. This

dressing prevents leaking of abdominal fluids during

transport.

Many surgeons consider this an important part of wound

management because the use of vacuum systems may improve

and accelerate wound healing in a variety of conditions to

include: pressure ulcers, partial thickness burns, orthopaedic

wounds with large soft tissue defects, open abdominal wounds,

and assistance with skin graft viability.

The treatment of soft tissue injury is the most common

denominator in the management of war wounds. This chapter

summarizes some principles of this mangement.

22.15

Chapter 23

Extremity Fractures

Introduction

This chapter discusses two techniques for safe transportation

of a wounded soldier with a long bone fracture: transportation

casts and temporary external fixation. Both of these methods

are acceptable for initial treatment of a patient who will be

evacuated out of theater. Precise indications for external fixator

use versus casting have not been established.

In general, good indications for external fixator use include

when the soft tissues need to be evaluated while en route, such

as with a vascular injury; when other injuries make use of casting

impractical, such as with a femur fracture and abdominal injury;

or when the patients have extensive burns. Advantages of

external fixation are that it allows for soft tissue access, can be

used for polytrauma patients, and has a minimal physiologic

impact on the patient. Disadvantages are the potential for pin

site sepsis or colonization and less soft tissue support than casts.

Advantages of transportation casts are that they preserve the

maximum number of options for the receiving surgeon; the soft

tissues are well supported, and the casts are relatively low tech.

Disadvantages are that casts cover soft tissues, may not be

suitable for polytrauma patients, and are more labor-intensive

than external fixators.

Both transportation casts and external fixators are equally

acceptable methods for the initial management of long bone

fractures. In the end, the choice of initial fracture stabilization

must be made on a case-by-case basis by the treating surgeon.

That decision should be based on the surgeon’s experience, his

assessment of the evacuation process, the materials available,

23.1

Emergency War Surgery

the nature of the patient’s wounds and the patient’s overall

condition.

Though standard in civilian trauma centers, intramedullary

nailing of major long bone fractures is contraindicated in

combat zone hospitals because of a variety of logistical

and physiologic constraints. This method may be used

once a patient reaches an echelon above corps (EAC) or

other site where more definitive care can be provided.

In this chapter, the term casting material is used in place of

describing either plaster or fiberglass for constructing casts. Both

are acceptable materials for application of transportation casts.

General Considerations of Wound Management

Initial management.

ο Treat by irrigation and debridement as soon as feasible to

prevent infection.

ο Femur fractures are at high risk for infection (about 40%,

historically).

ο Biplanar radiographs should be obtained.

ο Neurovascular status of the extremity should be documented

and checked repeatedly.

ο Internal fixation is contraindicated.

ο Begin IV antibiotics as soon as possible and maintain

throughout the evacuation chain. Use a broad spectrum

cephalosporin (cefazolin 1 g q 8 h). An aminoglycoside

may be harmful for someone in shock or dehydrated. The

two most harmful bacteria—clostridia and streptococci—

are covered by a 1st generation cephalosporin.

Wound incision/excision.

ο Guidelines as per soft tissue injury section.

ο Longitudinal incisions to obtain exposure.

ο Fascia incised longitudinally to expose underlying

structures and compartment release.

ο All foreign material in the operative field must be removed

(Fig. 23-1a, b, c).

23.2

Emergency War Surgery

ο Detached bone fragments smaller than a thumbnail are

discarded.

ο Larger fragments that contribute to the structural integrity

of the long bone should be retained.

ο Irrigation is essential (Fig. 23-1d).

Closure of wounds.

ο Primary closure is never indicated. Loose approximation

of tissues with one or two retention sutures is appropriate

to cover nerves, vessels, and tendons, but there must be a

provision for substantial free drainage.

ο Skin grafts, local flaps, and relaxing incisions are

contraindicated in the initial management.

ο Delayed primary closure may be attempted as described

in the section on soft tissue wounds. This should be

accomplished in a stable environment.

Transportation Casts

Introduction.

A transportation cast is a well-padded cast that is unique

to the treatment of combat casualties. It is used to transport

patients between hospitals and not intended as a means

of definitive care.

Definitive reduction is not required with the initial surgical

procedure.

The goal of transportation casts is to immobilize a fracture

along the evacuation chain. The cast must meet the

dimensions of the standard NATO litter (FM 8-10-6).

Transportation casts are applied prior to evacuation.

All casts must be bivalved prior to evacuation. (Hip spica

— univalved.)

If a patient is expected to have multiple procedures at the

same hospital, balanced skeletal traction should be utilized

until the last procedure prior to transportation. The traction

pin may be incorporated into the transportation cast.

Slab splinting may not be adequate for transportation,

particularly for severely unstable fractures. Splinting is

appropriate for stable fractures, particularly in the hand,

wrist, forearm, foot, ankle and lower leg.

23.4

Extremity Fractures

Fig. 23-2. Portable fracture table.

ο Portable skeletal traction should not be used for transpor-

tation of a patient.

ο Tobruk splint (a Thomas splint with circular plaster)

should not be used.

Hip, femur, and knee, and some proximal tibia fractures.

ο Low hip spica transportation cast.

ο Disadvantages: Limited soft tissue access. Not suitable in

polytrauma.

ο Technique.

♦ Adequate anesthesia is given, and patient is placed on

fracture table (Fig. 23-2).

♦ Irrigation and debridement as indicated above.

♦ Precise reduction not necessary, but usually requires two

assistants.

♦ Stockinette over abdomen, distal thigh of uninvolved

side, and foot of the involved side (Fig. 23-3).

Fig. 23-3. Patient position on fracture table.

23.5

Emergency War Surgery

Fig. 23-4. Hip spica transportation cast.

♦ Felt padding is placed over sacrum and anterior

superior iliac spine (ASIS) and other bony prominences.

♦ Towel is placed over abdomen to allow breathing space.

♦ Six-inch Webril or similar cotton batting is wrapped, 2-

4 layers.

♦ Six-inch casting material is then rolled over the Webril

from ASIS to the foot on the affected side to the distal

thigh on the unaffected side (Fig. 23-4). Splints are

applied over the posterior, lateral, or groin areas to

reinforce the groin (Fig. 23-5). Use a finishing roll after

turning down the edges of the stockinette to give a neat

appearance.

♦ An adequate perineal

space must be left for

hygiene.

♦ Use a ¹/2" dowel or

similar material to

make anterior/post-

erior crossbars.

♦ Affected knee bent

about 20°.

♦ Space between feet

must not exceed stan-

dard litter, although

this makes perineal

access difficult.

♦ Towel is removed,

cast is bivalved, and

a circular area over

Fig. 23-5. Reinforce cast at hip with

the abdomen is cut

splints.

out.

23.6

Extremity Fractures

♦ Use an indelible marker to draw the fracture configuration,

and note the dates of surgery and wounding on the cast.

♦ Support the cast with towels, blankets, or pillows to

relieve pressure on the cast, especially the back edge.

Proximal/mid/distal tibia and ankle fractures.

ο Long Leg Cast (Fig. 23-6).

Fig 23-6. Long leg cast.

ο Technique.

♦ The foot, leg, and thigh are placed in a stockinette at

the conclusion of the operation for the open wounds.

♦ Two people are needed to maintain the reduction and

apply the cast. Hold the knee flexed about 20°.

♦ Webril applied from the toes to the groin.

♦ Six-inch wide casting material is then rolled over this

region, with a turn down of the stockinette prior to the

final layer, to make a neat edge.

♦ Reinforce the knee to strengthen the cast.

♦ Make a supracondylar mold to provide support (Fig. 23-7).

Fig. 23-7. Supracondylar mold of long leg cast.

23.7

Emergency War Surgery

♦ Bivalve the cast.

♦ Label the cast with the dates of injury and surgery, and

draw the fracture on outside of the cast.

♦ Elevate the leg so the tibia is parallel to the litter or bed.

Shoulder and humeral shaft fractures.

Velpeau technique. (External fixator is an acceptable

alternative, however without direct visualization there is

a high risk of iatrogenic injury to the radial nerve and

vascular structures. Review anatomy carefully.)

♦ At the conclusion of open wound treatment, the

extremity is manipulated on the fracture table to obtain

the best alignment.

♦ Large cotton pads are placed under the axilla and arm

(Fig. 23-8a).

♦ The Webril is wrapped around the torso and affected

extremity to the wrist (Fig. 23-8b).

♦ Six-inch wide casting material is then wrapped over the

extremity and the torso. The first wrap should start

around the trunk, go over the shoulder posteriorly,

down the arm anteriorly, around the elbow, and then

up the posterior aspect of the arm (Fig. 23-8c).

♦ The trunk and the extremity should be wrapped in

plaster to stabilize the cast.

♦ Four layers should be sufficient (Fig. 23-8d).

♦ Bivalve this cast, and wrap with elastic bandages. There

are no cast saws available on the aircraft. If a patient in

a Velpeau cast develops any respiratory problems,

emergency measures cannot be taken if the cast cannot

be removed.

Elbow/forearm.

ο Long arm cast.

ο Technique.

♦ After treatment of open wounds, the extremity is

wrapped in stockinette from the fingers to the axilla.

♦ Gross alignment of fractures is the goal. Precise

reduction is not necessary.

♦ Four-inch wide Webril is wrapped from metacarpal

heads to axilla.

23.8

Extremity Fractures

♦ Four-inch wide casting material is applied from

metacarpal heads to axilla.

♦ Fold the stockinette before finishing layer for a neat edge.

♦ Bivalve cast after drying.

♦ Reassess neurovascular status.

Bivalving Casts

When a cast is bivalved, it is completely split longitudinally

along opposing sides of the cast. Splitting the cast into anterior

and posterior halves is preferred. The purpose of bivalving is

to allow room for soft tissue swelling, thus lessening the chance

Fig. 23-8a. Padding Velpeau.

Fig. 23-8b-c. Webril application for Velpeau cast.

Fig. 23-8d. Completed Velpeau cast.

23.9

Emergency War Surgery

of postcasting compartment syndrome. It is important that the

underlying cast padding also be completely split underneath

the cast cuts; otherwise, the cast padding can restrict swelling

and a compartment syndrome could still develop.

External Fixation

General technique: The surgeon should be familiar with four

types of standard constructs of external fixation for use in

the initial care of battle casualties: femur, tibia, knee, and

ankle. External fixation can also be applied for humerus and

ulna fractures as needed.

A thorough understanding of the anatomy of the lower

extremity is essential for application of the pins in a safe

corridor.

The external fixator for military purposes should be modular

and allow for building up or down as healing progresses.

Application of the external fixator may be done without

the use of plain films or fluoroscopy.

Pins can be inserted by hand using a brace without power

instruments.

Enough pins should be used to adequately stabilize the

fracture for transport. This is usually two per clamp, but

three may occasionally be required.

The present external fixation system (Hoffmann II) allows

for the use of either single pin clamps or multipin clamps.

Both clamps are acceptable to use in standard constructs.

Multipin clamps provide geater stability and are the

current fixators fielded. Dual pin placement (with multipin

clamps) is described here. The technique for single pin

placement is similar.

Femur diaphyseal fracture technique.

ο The entire limb is prepared for surgery, from the ASIS to the toes.

ο A standard OR table or portable fracture table may be used.

ο An assistant should apply counter pressure while pins are

inserted.

ο Precise reduction is not necessary. A padded “bump”

under the thigh will help reduce the fracture (Fig. 23-9).

23.10

Extremity Fractures

ο The position of the proximal femur should be identified

by palpation. A 1-cm longitudinal stab incision is made

over the midaxis, or midlateral axis, of the femur (Fig. 23-

10). The pin closest to the fracture should be outside of the

fracture hematoma, and at least three fingerbreadths from

the fracture (Fig. 23-11).

ο Bluntly spread with a clamp down to bone. Put the pin

down on the bone, and determine the midportion of the

bone by moving the pin back and forth across the width

of the femur. You do not want to plunge to one or the other

side. Your assistant should provide stability and counter

Fig. 23-9. Placing a towel underneath the thigh helps to reproduce

the bow of the femur.

Fig. 23-10. A 1-cm or so incision Fig. 23-11. Femur pin placement.

directly over the middle of the bone,

cut in a longitudinal direction.

23.11

Emergency War Surgery

pressure. Two taps on the end of the bit brace should

provide an indent in the bone and allow you to start

insertion. Apex pins are placed by hand. There is no

predrill nor power insertion. 5-mm half-pins should be

used. Insert the pin in the midportion of the bone through

both the near and far cortex of the

bone (Fig. 23-12). The pin will

move easier as it enters the inter-

medullary canal, and then get

more difficult to drive as it enters

the far cortex.

Place a multipin clamp over the

inserted pin (Fig. 23-13). Ideally,

the pin should occupy one of the

end positions (eg, position 1, Fig.

23-14).

Fig 23-12. Bicortical

Using the clamp as a guide, insert

placement of 5-mm

a second pin through the clamp.

half-pin.

An assistant should hold the

clamp. Ensure that the clamp is aligned to the bone and

that bicortical purchase is obtained with the second pin.

The second pin must be parallel to the first (Fig. 23-15).

Use the pin sites that are the farthest apart on the clamp as

possible for biomechanical stability (clamp positions 1 and

Fig. 23-13.

23.12

Extremity Fractures

5 are best, see Fig. 23-14). A third pin

may be inserted if needed for

additional clamp stability.

ο Apply a second multipin clamp and

pins in the same manner to the distal

femoral fracture fragment.

ο Connect the two clamps with elbows,

Fig. 23-14.

bar-to-bar clamps, and two

Multipin clamp

longitudinal bars placed parallel to

showing pin

each other (Fig. 23-16).

positions 1-5.

Fig. 23-15.

ο Reduce the fracture with longitudinal traction. Manipulating

the fracture fragments using the clamps may be helpful.

Once adequate reduction is achieved, tighten all the

connections. Precise reduction is not necessary.

Tibia shaft fracture technique.

ο Palpate the anterior-medial border of the tibia. Place a 1-

cm longitudinal incision over the midportion of the surface

(Fig. 23-17). The pin closest to the fracture site should be

outside the hematoma and at least three fingerbreadths

away from the fracture site (Fig. 23-18).

23.13

Emergency War Surgery

Fig 23-16.

ο Insert one pin into either the proximal or distal fragment,

engaging both cortices. This pin should be placed

perpendicular to the subcutaneous border of the tibia, and

centered across the width of the tibia (Fig. 23-19).

Fig. 23-17. Palpation of the anterior and posterior margins of the

medial face of the tibia where a 1 cm incision has been made

midway between these two points.

23.14

Extremity Fractures

Fig. 23-18. The anteriomedial surface is the safest way to introduce pins

to the tibia. The pin should be a minimum of two or three fingerbreadths

from the fracture site.

o Using the clamp as a guide, insert a second pin through

the clamp. An assistant should hold the clamp. Ensure that

the clamp is aligned to the bone and that bicortical

purchase is obtained with the second pin. The second pin

Fig. 23-19. This is the ideal bicortical placement for a pin in the tibia.

must be parallel to the first. Use the pin sites as far apart

on the clamp as possible for biomechanical stability (Figure

23-20 and positions 1 and 5 in Fig. 23-14). The second pin

should be through the clamp farthest away from the

fracture site (Fig. 23-20).

23.15

Emergency War Surgery

Fig. 23-20. Application of tibia external fixation with multipin clamps.

ο Apply a second multipin clamp and two pins in the same

manner to the other main fracture fragment (Fig. 23-21).

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

and a single bar (Fig. 23-22).

ο Most battle caused fractures are comminuted; therefore, a

second bar should be added to the construct (Fig. 23-23).

Use a single bar for stable fractures only.

ο Check the reduction.

Fig. 23-21. Application of the second multipin clamp and two pins.

Repeat those steps with the other major fracture fragment so that

you have two sets of multipin clamps as shown here. You will then

add the 30 degree elbows as shown here, pointing them in a

direction that allows for the best access. At this point you should

have gross alignment of the fracture.

23.16

Emergency War Surgery (2004) - page 8