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Extremity War Injuries: Challenges in Definitive Reconstruction

Dr. Pollak is Chief, Orthopaedic Trauma, RAC Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD. Dr. Ficke is Orthopaedic Consultant to the US Army Surgeon General and Chief, Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX.

Dr. Pollak or a member of his immediate family has received research or institutional support from Synthes, Stryker, Smith & Nephew, Zimmer, and Wyeth and is an employee or consultant of KCI. Dr. Hayda or a member of his immediate family has received research or institutional support from Howmedica, Synthes, and Smith & Nephew and has received miscellaneous nonincome support from Synthes. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Ficke, Dr. Andersen, Dr. Keeling, Dr. Keeney, Dr. Levin, Dr. Mazurek, Dr. Miclau, Dr. Nork, Dr. Bagg, Dr. Swiontkowski, and Dr. Watson.

*COL Mark R. Bagg, MD (Ret); CPT L. Scott Levin, MD, FACS; CDR Michael T. Mazurek, MD; J. Tracy Watson, MD; LTC Romney C. Andersen, MD; Sean E. Nork, MD; COL Roman A. Hayda, MD; Theodore Miclau, MD; LCDR John Keeling, MD; Marc Swiontkowski, MD; and LTC James Keeney, MD (Ret).

The opinions or assertions expressed herein are those of the authors and do not reflect those of the Army, Navy, Air Force, or the Department of Defense.

Reprint requests: Dr. Pollak, University of Maryland School of Medicine, Room T3R54, 22 South Greene Street, Baltimore, MD 21201-1544.

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.