Combat-related upper extremity injuries: Surgical management specificities on the theatres of operations

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Wartime upper-extremity injuries in the Sahelian strip: Experience from a French Forward Surgical Team deployed in Mali

This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

Military Orthopedic Surgeons Are Not Just Traumatologists

INTRODUCTION

Each French military orthopedic surgeon is both an orthopedic surgeon and a trauma surgeon. Their mission is to support the armed forces in France and on deployment. The aim of this study was to describe the type of orthopedic surgery performed for the armed forces in France. Our hypothesis was that scheduled surgery was more common than trauma surgery.

METHODS

We conducted a retrospective descriptive analysis of the surgical activity for military patients in the orthopedic surgery departments of the four French military platform hospitals. All surgical procedures performed during 2020 were collected. We divided the procedures into the following categories: heavy and light trauma, posttraumatic reconstruction surgery, sports surgery, degenerative surgery, and specialized surgery. Our primary endpoint was the number of procedures performed per category.

RESULTS

A total of 827 individuals underwent surgery, 91 of whom (11%) were medical returnees from deployment. The surgeries performed for the remaining 736 soldiers present in metropolitan France (89%) consisted of 181 (24.6%) trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) scheduled surgery procedures (of which 60.8% were sports surgery). Among the medical returnees, there were 71 traumatology procedures (78%, of which 87.3% were light traumatology) and 20 procedures corresponding to surgery usually carried out on a scheduled basis (22%, of which 95% were sports surgery).

CONCLUSION

Military orthopedic surgeons are not just traumatologists; their activity for the armed forces is varied and mainly consists of so-called programmed interventions.

Management of upper extremity war injuries in the subacute period: A review of 62 cases

OBJECTIVE

In this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use.

METHODS

Patients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed.

RESULTS

Sixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001).

CONCLUSION

Upper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.

Blast injury of the hand related to warfare explosive devices: experience from the French Military Health Service

INTRODUCTION

The objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.

METHODS

A retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.

RESULTS

Fifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.

CONCLUSION

The severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Diffusion Tensor Tractrography Visualizes Partial Nerve Laceration Severity as Early as 1 Week After Surgical Repair in a Rat Model Ex Vivo

BACKGROUND

Previous studies in our laboratory have demonstrated that a magnetic resonance imaging method called diffusion tensor imaging (DTI) can differentiate between crush and complete transection peripheral nerve injuries in a rat model ex vivo. DTI measures the directionally dependent effect of tissue barriers on the random diffusion of water molecules. In ordered tissues such as nerves, this information can be used to reconstruct the primary direction of diffusion along fiber tracts, which may provide information on fiber tract continuity after nerve injury and surgical repair.

METHODS

Sprague-Dawley rats were treated with different degrees of partial transection of the sciatic nerve followed by immediate repair and euthanized after 1 week of recovery. Nerves were then harvested, fixed, and scanned with a 7 Tesla magnetic resonance imaging to obtain DTIand fiber tractography in each sample. Additional behavioral (sciatic function index, foot fault asymmetry) and histological (Toluidine blue staining) assessments were performed for validation.

RESULTS

Tractography yielded a visual representation of the degree of injury that correlated with behavioral and histological evaluations.

CONCLUSIONS

DTI tractography is a noninvasive tool that can yield a visual representation of a partial nerve transection as early as 1 week after surgical repair.

Ballistic Axillary Vein Transection: A Case Report

Patient: Male, 25-year-old

Final Diagnosis: Axillary vein transection

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: Ligation of the axillary vein

Specialty: Surgery

Osteomyelitis Risk Factors Related to Combat Trauma Open Upper Extremity Fractures: A Case-Control Analysis

OBJECTIVE

To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures.

DESIGN

Retrospective observational case-control study.

SETTING

US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009).

PATIENTS/PARTICIPANTS

Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASUREMENTS

Multivariable odds ratios (ORs; 95% confidence interval [CI]).

RESULTS

Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis.

CONCLUSIONS

Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Missile Injury of the Sciatic Nerve: Observational Study Supporting Early Exploration and Direct Suture With Flexed Knee

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.

[Role of the nurse in the case of complex hand wounds]

The initial assessment and care determine the quality of the secondary surgical treatment of complex hand wounds. The caregiver providing this initial care plays a critical role. The analysis of the management of these traumas in exceptional situations enables the key stages of the initial treatment to be identified: bleeding control, infection prevention and an accurate assessment of the injury. These measures thereby help to optimise the patient's transfer towards a specialised unit.

Temporary fixation of limbs and pelvis

"Urgent, complete, definitive" treatment still today seems to be an appropriate attitude in many trauma cases. There are, however, several situations in which emergency definitive fixation is not the optimal strategy for all cases of fracture. Temporary fixation has a role to play in the orthopedic "trauma damage control" design comprising successive steps, as applied in multiple trauma, multiple fracture, severe multi-tissue limb lesions and soft-tissue lesions of unpredictable progression. The aim of this study is to define the strategies, indications, principles and limitations of temporary fixation in limb and pelvis fracture.

Defining the Indications of Pedicled Groin and Abdominal Flaps in Hand Reconstruction in the Current Microsurgery Era

Three decades ago, pedicled flaps from the groin and abdomen were the workhorses in hand and forearm reconstruction. These pedicled flaps have several disadvantages including patient discomfort, stiffness, the need for flap division, and the inability to elevate the hand after acute trauma. Hence it is not surprising that free flap reconstruction has become the method of choice in coverage of complex hand and forearm defects. Despite this, pedicled flaps may still be indicated in the current era of microsurgery. Based on a review of the literature and the author's experience, the current review defines these indications as follows: complex defects in children aged less than 2 years; coverage of digital stump defects in preparation for toe-to-hand transfer; high-voltage electric burns with the hand surviving on collateral blood supply; salvage of the thumb ray in high-voltage electric burns with concurrent thrombosis of the radial artery; mutilating hand injuries; length preservation of multiple digital amputations in manual workers; and multiple defects within the digits, hand, or forearm. These indications are discussed along with clinical examples.

Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience

PURPOSE

Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery.

METHODS

This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities.

RESULTS

To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments.

CONCLUSION

Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.