Treatment of the mangled lower extremity after a terrorist blast injury

Pediatric peripheral vascular injuries and associated orthopedic considerations

Pediatric peripheral vascular trauma is a rare but highly morbid injury in children and is frequently associated with concomitant orthopedic injuries. These children require multidisciplinary care by pediatric, vascular, and orthopedic surgery. In this review, we describe elements of the complex care required for children with peripheral vascular trauma.

Where is the fracture? Penetrating injury with a foreign bone

Injuries in the explosion scenarios are usually hollow organ injuries including rapid gas expansion, thermal injuries, penetrating injuries due to secondary projectiles and secondary injuries like falls and burns. Our case is a penetrating injury that was considered open knee fracture (Gustilo Anderson Type 3A) and peroneal nerve palsy in the emergency service after bomb attack but later it was seen that the secondary projectile was a foreign bone and the patient's bone integrity was intact. Our aim is to show that specific human tissues must be considered as a factor in the secondary injuries.

Terror-Related Trauma

In our current era, terrorist attacks have become a part of our daily life experience almost worldwide. New terrorist groups are emerging and the number of terrorist attacks is constantly rising.

Blast Injuries

BACKGROUND

Blast injuries in the United States and worldwide are not uncommon. Partially due to the increasing frequency of both domestic and international terrorist bombing attacks, it is prudent for all emergency physicians to be knowledgeable about blasts and the spectrum of associated injuries.

OBJECTIVE

Our aim was to describe blast physiology, types of blast injuries associated with each body system, and manifestations and management of each injury.

DISCUSSION

Blast injuries are generally categorized as primary to quaternary injuries. Primary injuries result from the effect of transmitted blast waves on gas-containing structures, secondary injuries result from the impact of airborne debris, tertiary injury results from transposition of the entire body due to blast wind or structural collapse, and quaternary injuries include almost everything else. Different body systems are affected and managed differently. Despite previous dogma, multiple studies now show that tympanic membrane perforation is a poor predictor of other blast injury.

CONCLUSIONS

Blast events can produce a myriad of injuries affecting any and every body system. All emergency physicians should be familiar with the presentation and management of these injuries. This knowledge may also be incorporated into triage and discharge protocols guiding management of mass casualty events.

Wound management in disaster settings

BACKGROUND

Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management.

METHODS

We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy.

RESULTS

We included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons.

CONCLUSION

Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.

Blast injury: impact on brain and internal organs

Blast trauma can kill or injure by multiple different mechanisms, not all of which may be obvious on initial presentation. Patients injured by blast effects should be treated as having multisystem trauma and managed according to Advanced Trauma Life Support guidelines. For the most severely injured patients, damage control resuscitation should be practiced until definitive hemorrhage control has been achieved. Patients with blast injuries may present in mass-casualty episodes that can overwhelm local resources. This article reviews some specific injuries, as well as the importance of mild traumatic brain injury. The importance of rehabilitation is discussed.

Wound outcome in combat injuries is associated with a unique set of protein biomarkers

Background

The ability to forecast whether a wound will heal after closure without further debridement(s), would provide substantial benefits to patients with severe extremity trauma.

Methods

Wound effluent is a readily available material which can be collected without disturbing healthy tissue. For analysis of potential host response biomarkers, forty four serial combat wound effluent samples from 19 patients with either healing or failing traumatic- and other combat-related wounds were examined by 2-D DIGE. Spot map patterns were correlated to eventual wound outcome (healed or wound failure) and analyzed using DeCyder 7.0 and differential proteins identified via LC-MS/MS.

Results

This approach identified 52 protein spots that were differentially expressed and thus represent candidate biomarkers for this clinical application. Many of these proteins are intimately involved in inflammatory and immune responses. Furthermore, discriminate analysis further refined the 52 differential protein spots to a smaller subset of which successfully differentiate between wounds that will heal and those that will fail and require further surgical intervention with greater than 83% accuracy.

Conclusion

These results suggest candidates for a panel of protein biomarkers that may aid traumatic wound care prognosis and treatment. We recommend that this strategy be refined, and then externally validated, in future studies of traumatic wounds.

Blast injuries: from triage to critical care

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries.

Compartment Pressures, Limb Length Changes and The Ideal Spherical Shape: A Case Report and In Vitro Study

BACKGROUND

Changes in compartment pressures have been noted during traction, reduction, and intramedullary fixation of fractures. Changes in limb length and compartment volumes are suspected contributing factors. Pressure and volume changes are known to be related in animal models. If an acute increase in limb length can adversely affect compartment pressures, reversal or delay of such an increase in length may be of value in the treatment and prevention of compartment syndromes.

METHODS

A clinical example is presented in which a documented anterior compartment syndrome was successfully treated by deliberate loss of fracture reduction, without fasciotomy. Fracture reduction was later restored when swelling subsided. Anterior compartment pressures were recorded in response to limb length changes in osteotomized cadaver limbs stabilized with external fixation.

RESULTS

The pressure in the anterior compartment varies directly with acute changes in the length of the leg, in an experimental model. Mathematical analysis indicates that available volume within a compartment varies inversely with acute changes in its length.

CONCLUSIONS

Fracture reduction that restores the length of an acutely injured extremity may increase pressure in the compartments by decreasing available volume. Deliberate loss of reduction can decrease pressure in the compartments, offering a potential alternative to fasciotomy in the care of compartment syndrome in cautiously selected, monitored patients. Early stabilization without reduction, followed by delayed reduction, may be preferable during treatment of fractures prone to compartment syndrome. Decreased available compartment volume may contribute to compartment syndrome after distraction with intramedullary rods or skeletal traction.

TERRORISM AND BLAST EXPLOSIONS: LESSONS FOR THE AUSTRALIAN SURGICAL COMMUNITY

The prospect of a terrorist attack against Australian interests is currently being debated across our society. The explosive blast attack is most favoured by terrorists. Blast injuries create unique patterns of multisystem injury with contaminated wounds and extensive devitalized tissue. Australian civilian surgeons are increasingly likely to be involved in the management of these injuries, either in response to a terrorist incident in Australia or as part of delayed management of Australian nationals injured overseas. An appreciation of the unique complexities of blast injuries is equally important to both military and civilian surgeons. This paper covers the mechanisms and pathophysiology of blast injuries and discusses issues of surgical management as they would apply to an Australian civilian setting.

Foot and ankle reconstruction after blast injuries

Foot and ankle reconstruction following blast trauma is particularly challenging based on the devastating soft tissue injuries associated with open comminuted fractures. Considering the difficulties encountered in reconstruction, the functional limitations associated with many salvaged limbs, and the superior performance of contemporary prosthetics, many injured service members may benefit more from below knee amputation than from limb salvage. Limb salvage of blast-injured extremities is a multidisciplinary effort directed toward eradication of infection, treatment of soft tissue and bone defects, and management of late reconstructive procedures. External ring fixators have an important and expanding role in the treatment algorithm.