Combat extremity WoundsCombat extremity WoundsCombat Extremity WoundsCombat Extremity Wounds

. “

Improvements in body armor have reduced axial trauma, but the overall percentage of skeletal

trauma on the modern battlefield has increased. The severity of the wounds and the amount of

energy absorbed by the limbs with modern battlefield injuries cannot be overemphasized.”

Journal of Orthopedic Trauma

TLOTLOAction : The soldier will identify combat

extremity wounds and determine the correct interventions for these patients

Conditions: Classroom environment with PowerPoint presentation

Standard: Soldiers will complete a 10 question written exam in less than 5 mins

ELOsELOsELO #1: Factors effecting extremity wounds

ELO #2: Early management of extremity wounds

ElO #3: Interventions for extremity wounds

Safety RequirementsSafety Requirements

Be aware of your environment

Maintain professional behavior at all times

( No running with scissors)

Risk factorsRisk factors

LOW

Environmental considerationsEnvironmental considerations

Indoor Classroom

No opposing force

EvaluationEvaluation

The Solider will be evaluated using a 10 question exam. The solider will complete the exam in less than 5 minutes with a minimal score of 80%

Instructional lead inInstructional lead in

This block of instruction will take place in a classroom setting, using a PowerPoint presentation and reference materials.

In actual combat the solider would encounter enemy fire ,hostile terrain and host of environmental factors while weighed down weapons and equipment

TargetTarget

This presentation is designed forLine medics/ corpsman

W56, Nurses and physicians attached to

BAS, Forward surgical teams or Shock platoons.

SAFTYSAFTY

In the combat zone the provider will need to conscious of hostile fire, and environmental factors.

Scene safety and BSI should be observed at all times

ELO #1:ELO #1: Factors effecting Factors effecting extremity woundsextremity wounds

Action: Determine factors effecting extremity wounds.

Condition: same as TLO

Standards: Same as TLO

ELO#1ELO#1Factors affecting Extremity woundsFactors affecting Extremity wounds

ELO#1ELO#1Factors affecting Extremity Factors affecting Extremity

woundswoundsEnergy level (height of a fall / speed of car /

caliber of bullet) Degree of contamination (soil, broken glass,

shrapnel) Degree soft tissue injury (crushed / avulsed) Complexity of fracture pattern (number of bony

pieces) Vascular injury

High EnergyHigh Energy

High-energy sources produce wounds characterized by violent

tissue destruction. Violent tissue destruction and contamination

requires radical débridement

Compound FractureCompound Fracture

A compound fracture, also called a open fracture, is an injury that occurs when there is a break in the skin around a broken bone. Compound fractures are generally treated with surgery to clean the site of injury and stabilize the fracture

Fracture typesFracture types

Complexity of fracture patternComplexity of fracture pattern

Compound FractureCompound FractureCompound FractureCompound Fracture

Compound FracturesCompound Fractures

Traumatic AmputationsTraumatic Amputations

Though amputations are visually dramatic, attention must be focused on the frequently associated life-threatening injuries.

Most commonly due to explosive munitions, with penetration and blast effects or Parachute Injuries.

Compartment syndromeCompartment syndrome

Caused especially by crush injuries, electrical burns, circumferential scars, tight casts, hematoma in compartment, snake bites, and anything else that can increase pressure in a compartment.

Compartment SyndromeCompartment SyndromeSigns and symptomsSigns and symptoms

Severe, constant pain in affected limb, pain on muscle palpation, passive stretch, and active contraction, paresthesia loss of distal pulses are late signs and indicate poor outcome

Compartment syndromeCompartment syndrome

Check on learningCheck on learning High-energy sources produce wounds characterized by violent tissue

destruction

Though amputations are visually dramatic, attention must be focused on the frequently associated life-threatening injuries

Severe, constant pain in affected limb, pain on muscle palpation, passive stretch, and active contraction, paresthesia loss of distal pulses are late signs and indicate poor outcome

A compound fracture, also called a open fracture, is an injury that occurs when there is a break in the skin around a broken bone.

ELO #2ELO #2 Early Management of Extremity Early Management of Extremity

woundswounds

Action: Determine the management techniques for extremity wounds

Conditions: Same as TLO

Standards: Same as TLO

"There is no good reason why wounded soldiers are continuing to

die on the battlefield from extremity bleeding.“

Capt. Michael J. Tarpey, Battalion

surgeon ,3rd Infantry Division's 1-15 Infantry

Early Management of Early Management of Extremity woundsExtremity wounds

Control of hemorrhage

Temporary splinting

IV antibiotics

Tetanus prophylaxis

The TourniquetThe Tourniquet

Designed for one-handed application, the tourniquet allows a soldier to apply the tourniquet to himself if needed and replaces the Army's field-expedient method, where a soldier would use a bandage and a stick to stop blood flow from a wound

“There is no pre-hospital device deployed in this war that has saved more lives than tourniquets.” Col. Holcom , 10th CSH

The Special Operations Forces Tactical Tourniquet

IMMBOLISATIONIMMBOLISATION

It is essential for the provider to immobilize any

fractures prior to CASVAC

Failure to immobilize all fractured extremities could

lead to vascular injuries or compartment syndrome

Transportation castTransportation cast

ElO #3:ElO #3: Interventions for extremity woundsInterventions for extremity wounds

Action: Determine interventions for extremity wounds

Conditions: Same

Standards: Same

Treatment of fracturesTreatment of fractures

Débridement

Reduction

Fixation

Evacuation

Wound ManagementWound Management

Compound FracturesCompound FracturesWound Management

Treat by irrigation and Debridement as soon as feasible to prevent infection.

Neurovascular status of the extremity

should be documented and checked repeatedly.

Biplanar radiographs should be

obtained.

PULSE LAVAGEPULSE LAVAGEPULSE LAVAGEPULSE LAVAGE

PULSE LAVAGEPULSE LAVAGE

High Pressure Irrigation

Irrigation can remove enough wound

bacteria to render the wound non-contaminated but only if the irrigant is delivered with sufficiently high pressure ( <7 PSI) to mechanically remove bacteria from the wound surface

Antibiotic beads and spacersAntibiotic beads and spacers

Antibiotic beads and spacersAntibiotic beads and spacers

After fracture stabilization has been completed, bone defects may be filled with antibiotic-impregnated methacrylate beads. these beads provide local depot administration of antibiotic and maintain space for subsequent bone graft

Internal fixationInternal fixation

Internal fixation is the definitive treatment for compound fracture.

This procedure is not performed in theater

INTERNAL FIXATION (ORIF)INTERNAL FIXATION (ORIF)

EXTERNAL FIXATIONEXTERNAL FIXATION

Advantages of external Advantages of external fixationfixation

Technically easy to perform   

No soft tissue stripping;   

Ease of removing hardware

    Disadvantages of external Disadvantages of external fixationfixation

Pin tract infections,

Delayed union

Non union , and Mal-union

Technique of Amputation

Tourniquet control is mandatory.

Surgical preparation of the entire limb, because planes of injury may be much higher than initially evident.

If a tourniquet was placed in the prehospital setting for hemorrhage control, it is prepped entirely within the surgical field.

FasciotomyFasciotomy

Indications for performing a Indications for performing a fasciotomyfasciotomy

Treatment is by fasciotomy and requires immediate surgical consultation

FasciotomyFasciotomy

Technique of Amputation

Indications for performing a Indications for performing a fasciotomyfasciotomy

Greater than a 6-hour delay between injury and treatment.

Prolonged hypotension and shock.

Massive swelling, either preoperatively, postoperatively, or during evacuation.

Massive associated soft tissue injury

Postoperative Management

Prevention of hemorrhage Pain control Prevention of contracture

EXAMEXAM1

• Neurovascular status of the extremity should be documented and checked repeatedly. True or false

• 2 Name one Advantages of external fixation • • 3 Irrigation can remove enough wound bacteria to render the wound non-

contaminated. True or False

• 4 If a tourniquet was placed in the prehospital setting for hemorrhage control, it is prepped entirely within the surgical field. True or false

• 4 Fasciotomy is the definitive treatment for what extremity injuries.Fasciotomy is the definitive treatment for what extremity injuries.

• 5 This injuries is 5 This injuries is Most commonly due to explosive munitions, with penetration and blast effects or Parachute Injuries.

ExamExam

6 It is essential for the provider to immobilize any fractures prior to CASVAC. True or false

7 These provide local depot administration of antibiotic and maintain space for subsequent bone graft

8 Name the best option for controlling hemorrhage in extremity injuries

9 Name a disadvantage of external fixation

10 A fracture that breaks the skin causing a open wound