K. Brown

Predicting the need for early amputation in ballistic mangled extremity injuries.

BACKGROUND Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate after high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The aim of this study was to assess the validity of the mangled extremity severity score (MESS), the only verified score, in a population of UK military patients with ballistic mangled extremity injuries. METHODS We identified from the prospectively kept Joint Theater Trauma Registry all patients who had sustained ballistic lower limb open fractures during the recent conflicts in Iraq and Afghanistan (May 2003-April 2008). Demographics were assessed using both the trauma audit and the hospital notes. Patients were retrospectively evaluated with the MESS system for lower extremity trauma. Those that required an amputation were compared with those that had successful limb salvage. RESULTS Seventy-seven military patients with 86 limbs who had ballistic mangled extremity injuries were identified, 22 of whom required amputation. The MESS did not help to decide whether or not an amputation was appropriate and in particular, the age was not relevant. A skeletal score of 4, while being associated with a higher amputation rate, was not predictive of its need. Most amputations were performed when an ischemic limb was present, and the general condition of the casualty precluded the lengthy reconstruction required for salvage. CONCLUSIONS The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have identified important factors in the management, in particular the need for early amputation, of the military mangled extremity.

Modern military surgery

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma. The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research. In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Complications of extremity vascular injuries in conflict

INTRODUCTION The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, secondary amputation, and graft thrombosis). AIM The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury. METHODS A prospectively maintained trauma registry was retrospectively reviewed for all UK military casualties with extremity injuries (Abbreviated Injury Score >1) December 8, 2003 to May 12, 2008. Demographics and the details of their vascular injuries, management, and outcome were documented using the trauma audit and medical notes. RESULTS Thirty-four patients (34%)--37 limbs (30%)--had sustained a total of 38 vascular injuries. Twenty-eight limbs (22.6%) had an associated fracture, 9 (7.3%) did not. Twenty-nine limbs (23.4%) required immediate revascularization to preserve their limb: 16 limbs (13%) underwent an initial Damage Control procedure, and 13 limbs (10.5%) underwent Definitive Surgery. Overall, there were 25 limbs (20.2%) with complications. Twenty-two were in the 28 limbs with open fractures, 3 were in the 9 limbs without a fracture (p < 0.05). There was no significant difference in the complication rate with respect to upper versus lower limb and damage control versus definitive surgery. CONCLUSION We have demonstrated that prognosis is worse after military vascular trauma if there is an associated fracture, probably due to higher energy transfer and greater tissue damage.

Outcome after vascular trauma in a deployed military trauma system

Military injuries to named blood vessels are complex limb‐ and life‐threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq.

Management of Vascular Trauma

Uncontrolled hemorrhage is the cause of up to 40% of deaths in civilian trauma and over half of combat deaths.1,2 Truncal hemorrhage has been identified as the leading cause of potentially survivable deaths in combat casualties, irrespective of injury severity.3 The combat environment provides a difficult working environment with possibilities for delayed patient transport, limitations on resources, and surgeons who lack vascular expertise. The significant advances made in vascular surgery over the course of the last century are closely related to the experience obtained during military conflict. Ligation - being the method of choice in both World Wars - resulted in an amputation rate of mangled extremities with vascular injuries of 50%.4 However, surgeons mobilized during the Korean War had the benefit of new understanding in surgical physiology and improved instrumentation that heralded restorative techniques, a reduction in the amputation rate to 13%, and the modern era of vascular surgery.5

Vascular trauma: survivability and surgical outcome in a deployed military trauma system

Objective: Military vascular injuries are complex limb and life-threatening wounds which pose significant difficulties in pre-hospital and surgical management. Our aim was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury amongst service personnel deployed on operations in Afghanistan and Iraq. Method: Analysis of the British Military Trauma Registry was combined with hospital record and post-mortem review of all cases of vascular trauma in deployed service personnel over a 5-year period ending in January 2008. Results: Of 1203 trauma patients, 121 sustained injuries to named vessels. Seventy-seven of 121 died prior to any opportunity for surgical intervention. All 19 patients who sustained an injury to a named vessel in the abdomen or thorax died; 18 did not survive to undergo surgery, one in extremis casualty underwent a thoracotomy and died. Six out of 15 patients with cervical vascular injuries survived to surgical intervention; two died following surgery. Of 87 patients with extremity vascular injuries, 37 survived to surgery with two postoperative deaths. Interventions on 38 limbs included 19 damage control (15 primary amputations, four vessel ligations) and 19 definitive limb revascularisation procedures (11 interposition vein grafts, eight direct repairs) of which four failed, necessitating three amputations. Conclusion: In operable patients with extremity injury, amputation or ligation is often required for damage control and preservation of life, but favourable limb salvage rates are achievable in casualties able to withstand revascularisation. Despite marked progress in contemporary battle-field trauma care, torso vascular injury is usually not amenable to surgical intervention.