Volume 21-1, Spring 2012

The severe Dismounted Complex Blast Injury (DCBI) is characterized by high-energy injuries to the bilateral lower extremities (usually proximal transfemoral amputations) and/or upper extremity (usually involving the non-dominant side), in addition to open pelvic injuries, genitourinary, and abdominal trauma. Initial resuscitation and multidisciplinary surgical management appear to be the keys to survival. Definitive treatment follows general principals of open wound management and includes decontamination through aggressive and frequent debridement, hemorrhage control, viable tissue preservation, and appropriate timing of wound closure. These devastating injuries are associated with paradoxically favorable survival rates, but associated injuries and higher amputation levels lead to more difficult reconstructive challenges. Key words: DCBI, dismounted complex blast injury, damage control orthopaedics

The magnitude of recent combat blast injuries sustained by forces fighting in Afghanistan has escalated to new levels with more troops surviving higher-energy trauma. The most complex and challenging injury pattern is the emerging frequency of high-energy IED casualties presenting in extremis with traumatic bilateral lower extremity amputations with and without pelvic and perineal blast involvement. These patients require a coordinated effort of advanced trauma and surgical care from the point of injury through definitive management. Early survival is predicated upon a balance of life-saving damage control surgery and haemostatic resuscitation. Emergent operative intervention is critical with timely surgical hemostasis, adequate wound decontamination, revision amputations, and pelvic fracture stabilization. Efficient index surgical management is paramount to prevent further physiologic insult, and a team of orthopaedic and general surgeons operating concurrently may effectively achieve this. Despite the extent and complexity, these are survivable injuries but long-term followup is necessary. Key words: combat blast injury, complex dismounted IED injury, multiple limb amputations, open pelvic injury, damage control surgery

Given the current tempo of overseas contingency operations, military orthopaedic surgeons are increasingly performing their duties in an austere environment. At Level 1 trauma centers and combat support hospitals, resources tend to be more abundant than in less ‘‘metropolitan’’ locations. Combat casualty care has reinforced the idea of a multidisciplinary team approach to severely injured trauma patients. During mass casualty situations, as seen recently in Haiti and in the wake of Hurricane Katrina, all members of the trauma team may need to perform duties on the periphery of their comfort zone. Early involvement of orthopaedic surgeons in damage control surgery, as well as resuscitation, are critical to the survival of patients with high amputations, multiple amputations, open pelvic injuries, and mangled extremities common in high-energy penetrating and blast-induced trauma. This article introduces the concept of Damage Control Resuscitation to the orthopaedic surgeon, and also presents a treatment guideline for use as appropriate. Key words: damage control resuscitation, hypotensive resuscitation, combat casualty care, massive transfusion

Extremity injuries associated with natural disasters and combat are typically high-energy, often open injuries, and routinely represent only part of the scope of injury to a poly-traumatized patient. The early management of these injuries is normally performed in austere environments, and relies heavily on the principles of damage control orthopaedics, with external fixation of associated long bone and peri-articular fractures. While the general principles of ATLS, wound management, and external fixation do not differ from that performed in the setting of civilian trauma, there are special considerations and alterations in standard practice that become necessary when providing this care in an austere environment. The purpose of this article is to review the principles and techniques of damage control orthopaedics and external fixation in the management of extremity trauma in the setting of combat- and natural disaster-related injuries. Key words: war injuries, external fixation, damage control orthopaedics

The objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat between 2007 and 2010 was conducted. Data analyzed included age, injury mechanism, amputated limbs, number and type of associated injuries, blood products utilized, intensive care unit length of stay (ILOS), hospital length of stay (HLOS) and the Injury Severity Score (ISS). Patients were stratified based on the number of amputations. Sixty-three patients comprised the multiple extremity amputation (MEA) group. Ninety-eight percent sustained injuries from an improvised explosive device (IED) and 96% were dismounted. The ISS, number of surgical encounters, blood products utilized and ILOS were all clinically significantly different than controls. Care of multiple extremity amputees involves the utilization of significant resources. This knowledge may better help surgeons and administrators allocate assets at hospitals, both military and civilian, who care for this complex and challenging patient population. Key words: dismounted, blast, amputations, resources, injury severity score, ISS, multiple

Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. Second-look debridements and delayed wound closure are mandatory. A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries. Key words: hemipelvectomy, trauma, combat trauma, war wounds, amputation

Combat-related musculoskeletal injuries occur commonly during military conflicts, as in Iraq and Afghanistan, and are caused by high-energy blasts. Ligamentous knee injuries resulting from these blasts are often associated with lower extremity fractures or traumatic, transtibial amputations. Ligamentous knee injuries in amputees are often difficult to diagnose for a variety of reasons, including massive soft tissue trauma and delayed ambulation. While the algorithm for treatment is similar in non-combat, multi-ligamentous knee injuries, the timing of surgical intervention, graft choices, and methods of fixation are more limited. Additionally, the presence of traumatic brain injury and associated extremity trauma make rehabilitation of these injuries much more complicated. Despite these challenges, the recognition and treatment of ligamentous knee injuries in amputees is critical to returning these patients to an active lifestyle. Key words: ligamentous, knee, multi-ligamentous, high energy, lower extremity

Advances in combat casualty care have contributed to unprecedented survival rates of battlefield injuries, challenging the field of rehabilitation to help injured service members achieve maximal functional recovery and independence. Nowhere is this better illustrated than in the care of the multiple-limb amputee. Specialized medical, surgical, and rehabilitative interventions are needed to optimize the care of this unique patient population. This article describes lessons learned at Walter Reed National Military Medical Center Bethesda in providing advanced therapy and prosthetics for combat casualties, but provides guidelines for all providers involved in the care of individuals with amputation. Key words: rehabilitation, amputee, amputation, therapy, war injury

Much of the current prosthetic technology is based on developments that have taken place during or directly following times of war. These developments have evolved and improved over the years, and now there are many more available options to provide a comfortable, cosmetic, and highly functional prosthesis. Even so, problems with fit and function persist. Recent developments have addressed some of the limitations faced by some military amputees. On-board microprocessor-controlled joints are making prosthetic arms and legs more responsive to environmental barriers and easier to control by the user. Advances in surgical techniques will allow more intuitive control and secure attachment to the prosthesis. As surgical techniques progress and permeate into standard practice, more sophisticated powered prosthetic devices will become commonplace, helping to restore neuromuscular loss of function. Prognoses following amputation will certainly rise, factoring into the surgeon’s decision to attempt to save a limb versus perform an amputation. Key words: prosthesis, prostheses, prosthetic, amputation, rehabilitation