Recent advanceCombat-related upper extremity injuries: Surgical management specificities on the theatres of operationsTraumatismes de guerre du membre supérieur : spécificités du traitement chirurgical sur les théâtres d’opérations
Introduction
Guidelines for management of gunshot wounds and blast injuries of the hand and upper extremity have been widely described [1], [2], [3], [4], [5], [6], [7]. Although war-type wounds can be encountered in civilian practice, surgeons in combat situation have to treat highly contaminated wounds with specific constraints due to associated injuries, delayed management and limited resources [3], [6]. In current asymmetric conflicts, the use of Improvised Explosive Devices (IEDs) often causes devastating blast injuries that combine multiple high-energy fractures, traumatic amputations and extensive soft-tissue defects. A sequential management approach based on damage control surgery principles is always required. Life and limb-salvage procedures are provided in battlefield Medical Treatment Facilities (MTFs) prior to intercontinental medical evacuation to military trauma centres where definitive treatment is provided [8], [9].
Despite numerous publications about modern war Damage Control Orthopaedics (DCO), details of the primary care for hand and upper extremity injuries are rarely described in published studies [9]. Conversely, principles for secondary reconstruction have been recently defined – they are nearly the same as those used in civilian practice [4], [10], [11], [12]. However, definitive treatment is also performed within the combat zone for local resident patients [13]. Due to the lack of hand and plastic surgeons in local hospitals or forward MTFs, reconstructive procedures are mostly performed by orthopaedic surgeons with limited microsurgery training.
The main purpose of this article is to describe how DCO procedures apply to managing hand and upper extremity injuries on the battlefield. Possibilities for reconstruction procedures on local residents without performing complex microvascular surgery are also detailed.
Section snippets
Levels of medical care on the battlefield
Various levels of medical care with sequential management have been developed to ensure that injured military personnel receive the best possible medical care [2].
Level 1 care is performed by the wounded soldier's immediate combat colleagues, then by paramedics or an emergency medical team. The first objective is to stop the bleeding by applying pressure dressings, tactical tourniquets or local haemostatic agents into the wound. When junctional bleeding in the axillary area cannot be controlled
Haemorrhage control
The first priority is to stop the bleeding by identifying and controlling any injured blood vessel. This can easily be performed using a pneumatic tourniquet above the elbow, but proximal brachial artery injuries require control by clamp at the axillary level through a deltopectoral or transpectoral approach (Fig. 3). In this case the field tourniquet is included in the sterile draping and removed once vascular control has been achieved [16]. Otherwise, salvage amputation should be considered
Soft-tissue coverage
Repeated marginal debridement is required every 48–72 hours until the wound becomes clean enough to be closed safely. Delayed primary closure should ideally be performed within 5 to 7 days [10]. However, this task is difficult or impossible to achieve in heavily contaminated wounds and/or in polytrauma patients [10], [13]. Soft-tissue reconstruction is often delayed until the subacute phase once the wound is macroscopically clean and the patient stabilized. This delay does not seem to negatively
Conclusion
Initial management of upper extremity combat-related injuries is based on bleeding control, wound decontamination and temporary bone stabilization according to war DCO principles. Definitive management is performed after evacuation out of the combat zone, except for local residents for whom the reconstruction has to be carried out in battlefield MTFs. Expertise in nerve microsurgery and pedicled flaps is useful for every orthopaedic surgeon deployed in these structures.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
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