DAMAGE CONTROL ORTHOPEDICS FOR TREATMENT OF SEVERE COMBAT INJURIES TO THE LIMBS
Ziv Medical Center, Safed, Israel
The modern high energy combat injury causes deep and wide injuries to tissues which significantly limit possibilities of restorative treatment and range of medical interventions. The main factors for selecting an optimal method for open fractures of the extremities are patient’s general state, state of soft tissues, degree, deepness and wideness of soft tissue injury; all of them determine tactics and process of curative process, as well as treatment outcome and long term results [1-6].
Unlike open fractures with relatively insignificant injury to soft tissues (types 1 or 2 according to the classification by Gustilo-Andersen) usually treated with internal fixation techniques, which are used for closed fractures with similar characteristics (different types of intramedullary and external fixation), open fractures of type 3 require an approach with principles of maximal sparing attitude toward tissues, and, if possible, atraumatic techniques of bone fixation.
Single-step surgical reduction of such fractures and a surgical approach for internal fixation result in additional tissue injury (second hit) associating with possible difficult wound healing and higher possibility of purulent septic complications. An immersible surgical implant (an internal fixator) can be a foreign body promoting the inflammatory process, especially during treatment of significant soft tissue injuries or defects and insufficient covering the bone fragments and fracture site.
As result, for patients with significant injuries to soft tissues it is more preferable to use low traumatic methods for external fixation of fractures which allow relatively fast stabilization for an injured extremity segment and cause only minimal injury, as well as prevent application of foreign bodies for an injured region and do not cause additional blood loss.
Bone fragment fixation with use of unilateral rod device for external fixation is the technique for rapid and effective fracture stabilization providing sufficient surgical approach for realization of required vascular and plastic surgical interventions, early mobilization, transportation and easy postsurgical management after multiple injuries.
The important advantages are simplicity of the technique and relatively short time interval for fracture stabilization (20-30 minutes for fixation of an injured segment) [5, 7, 8] that are actual for patients suffering from consequences of multiple injuries and in cases of mass admissions (terrorist attack, natural and industrial disasters).
Unilateral configuration of a fixator and introduction of rods into the bone from single side of an extremity reduce risk of iatrogenic vascular and nerve injuries, decrease degree of muscle sewing, especially in fracture stabilization in proximal departments of the extremities, leave space for topical treatment of wounds and sufficient approach for necessary vascular and plastic surgical interventions.
The above-mentioned principles are especially important for treatment of consequences of modern combat injury.
MATERIALS AND METHODS
During the last year and six months on the basis of our regional medical center we have been realizing medical assistance (simultaneously with treatment for the local population) for the citizens of Syria suffered from the domestic warfare.
Hospital treatment was realized only for the patients in state of middle-critical severity. 409 patients (adults and children) received treatment. Orthopedic treatment was required in more than 80 % of the cases. Such characteristics with dominating extremity injuries are common for modern combat injuries because the head and the body of combatants are covered with safety helmets and body armour. Absence of protection measures in civilian population results in high prehospital mortality after head and body injuries. As result, injuries to extremities prevail in such individuals.
Most individuals requesting medical assistance suffered from consequences of explosive and fragment wounds. Bullet wounds were noted in relatively small group of the victims which are customary from modern combat injury. Isolated injuries were noted in 41 % of the victims, wounds in two or more regions – in 59 %.
Hospital triage, primary diagnostics and total stabilization were realized with the generally accepted principles of Advance Trauma Life Support (ATLS) under control of the general surgeon. The patients with multiple injuries who required total body CT also received CT for injured extremities with addition of contrast media (CT-Angio). In some cases it resulted in timely identification of vascular injuries to extremities (including asymptomic cases).
After realization of the measures for stabilizing the general state of the patients we carried out surgical fixation for fractures in combination with radical primary surgical preparation with proper irrigation using saline and appropriate extensive dissection of all devitalized tissues and removal of free bone fragments [8, 10]. The state of soft tissues, incidence and deepness of their injuries and defects determine the choice of treatment technique after severe high energy injuries. Quality and thoroughness of primary surgical preparation are critical for course and predicted outcomes of disease. The unique capabilities of the method by G.A. Ilizarov relating to subsequent replacement of posttraumatic and postsurgical tissue defects allow primary surgical preparation with full volume and maximal radicality providing non-complicated wound healing.
Reconstruction of injured vessels was performed if it was appropriate. Temporary vascular shunting was used for quick restoration of distal perfusion in cases of late admission. Only after this procedure the stabilization was performed for fractures with external devices providing subsequent final vascular reconstruction in conditions of stable surgical field. During primary surgical preparation the fasciotomy was performed in presence of signs of compartment syndrome and during treatment of fractures complicated with vascular injuries.
In case of severe general state of the patients the fixation with restoration of the clinical axis of an extremity was realized without intention towards anatomic reduction of bone fragments, with prevention of additional injury to an extremity suffered from primary trauma. Minimal traumatic fast general stabilization for severe patients with non-stable hemodynamics (Damage control) and stabilization of critically injured extremities (Local damage control) allowed stabilizing general and local state with provision of subsequent reconstructive treatment in appropriate conditions. Primary fixation was carried out after corrected rough displacement of bone fragments and absence of pressure to the skin and surrounding vascular nervous structures.
Temporary blocking of hip, knee, ankle, ulnar and radiocarpal joints was made for the patients with intraarticular and periarticular fractures, and also for significant injuries to the joint capsule and ligamentous apparatus (Fig. 1, 4). In some cases simultaneous transfixation for two adjacent joints was made (hip – knee, knee – ankle, ulnar – radiocarpal). Only external fixation techniques were used, because we think that it is absolutely unacceptable to use internal fixation of fractures during primary treatment of modern high energy trauma.
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Figure 1 External fixation of the right lower extremity using temporary locking the hip joint with rod device for external fixation. Damage control during treatment of open subtrochanteric fracture of the right femur with soft tissue defect and closed chest injury |
Figure 2 Vacuum treatment for the wounds in the patient with open mine-explosion fractures of the lower extremities
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Primary wound suture is unacceptable for combat gun shot or mine-explosive high energy injuries and injuries after compression of tissues (Fig. 2). Upon completing the surgical preparation all wounds remained as open, and were usually covered with wet drapes. Recurrent surgical preparation of wounds (second look) was made after 48-72 hours under anesthesia in the operating room. For most patients further treatment of extensive wounds was realized by means of constant vacuum pumping, which relatively quickly stimulates development of granulation tissues in the deep departments of the wound with relative decrease in its size and constant evacuation of wound discharge. Further plastics with split flap was the last stage for covering the wounds.
Use of flaps from adjacent skin or soft tissues is potentially dangerous in treatment of consequences of modern combat high energy trauma (possible necrosis of transferred tissue flap) due to extensive disorders in microcirculation in the region of an injured segment. Non-free plastics with skin fascial flaps from the anterior abdominal wall was required only for two patients who needed for covering the extensive defects in the hand and the ulnar joint.
For 12 patients with extensive bone and soft tissue defects in the extremities the covering of fracture site was realized with temporary acute shortening of an injured segment with the following restoration of its length according to G.A. Ilizarov. Among them, for 3 patients with unilateral extensive soft tissue defects the shortening was combined with temporary angulation (Fig. 3).
Figure 3
Covering the open fracture region by means of temporary annulation in the child, age of 10, with extensive soft tissue defect along the anterointernal surface of the right leg
Further choice of the method for final reconstruction and fixation of fractures mainly depended on state of soft tissues. Open fracture as result of modern combat injury corresponds to, at first instance, an extensive and deep soft tissue injury combining with disordered bone integrity, but not contrarily.
In some patients with relatively good state of bone fragments as result of primary surgical preparation and stabilization it was possible to continue treatment of fractures with unilateral rod devices for external fixation. It allowed reducing admission time, with prevention of additional surgical interventions and enhancement of return to home for outpatients. Introduction of 3 threaded rods to each of main bone fragments (proximal and distal) provided stability of construction and fixation, and allowed early functional controlled activity in relative mobility of the patient.
Such technique can be successfully used in mass disasters with high volume of admitted victims and limited abilities of hospital treatment including cases with medical assistance in mobile field hospitals, which are organized for limited time interval.
Transition to internal fixation of fractures with use of locking intramedullary rods or plates is realized only in satisfactory state of soft tissues over bone fragments and fracture region (Fig. 4).
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Figure 4 Damage control principles for treating the fracture of the femoral bone in the patient with multiple injury: a) the clinical presentation of the right lower extremity fixed with a tubular device for external fixation; b) the X-ray view of the temporary transfixation of the knee joint; c) radiologic view of the femoral bone after transition from temporary external fixation to the final internal fixation with an extramedullary locking plate
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 a
 b  c
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In cases of extensive injuries and defects in soft tissues the treatment was continued only with minimal invasive techniques of external extrafocal fixation with transition from the unilateral rod device to the ring device by G.A. Ilizarov, which provided closed reduction of bone fragments in most patients and following stable fixation of fractures. For decreasing injury possibility and duration of the operation the threaded rods of the primary rod device for external fixation were usually introduced into the final construction of Ilizarov device.
In patients with floating joints the devices on the hip and the leg and, correspondingly, on the shoulder and the forearm, were connected in the axis of joint with use of hinged joints constructed from the standard details of Ilizarov kit. It allowed initiating motions at early stages of treatment. It is important to correctly estimate the axis of joint. Incorrect choice is associated with possible injury to articular surface, limited motion and secondary displacement of bone fragments. Three-dimensional stability of fixation in Ilizarov device is sufficient not only for early mobilization of injured extremities in all patients, but also it allowed providing early full axial load during standing and walking even in patients with fractures in both lower extremities (Fig. 5) including patients after amputation of the leg or the hip.
Figure 5
Full early functional load to the left lower extremity fixed with Ilizarov device in the patient, age of 15, with traumatic rupture of the right lower extremity after mine-explosion injury
The hospital social worker was a natural participant of treatment process for all Syrian patients. Clowns worked for psychological support for children.
RESULTS
Lethal outcomes were stated in 7 patients (1.7 %) among 409 persons who were admitted for hospital treatment. All other patients returned home after completing their treatment. The middle duration of hospital treatment was 12.5 days. The patients who completed their treatment and got home did not demonstrate active purulent processes in wound region or cases of posttraumatic or postsurgical osteomyelitis. The superficial rod infection in some patients with external fixation devices was successfully treated with local antiseptics and oral administration of antibiotics. Early motions in the joints of the injured extremities in the patients with articular instability were initiated in maximally possible early terms with use of joint devices for external fixation. The circular Ilizarov device provided sufficient stabilization for bone fragments and saved a possibility of single-step or gradual correction of deformation and replacement of bone defects by means of distraction compression osteosynthesis [6, 13, 14].
Stable fixation of fractures allowed realization of early mobilization with full axial load. Early controlled motions and functional load stimulate not only bone fusion, but also recovery of injured tendons, ligamentous apparatus and skeletal muscles [11, 13].
Considering the difficult humanitarian position and impossibility of primary prosthetics in their country, most patients with amputated extremities received early prosthetics at the expenses of the private persons or the public facilities. Use of Ilizarov device for 5 patients with severe injuries to one lower extremity and another amputated limb allowed realization of early prosthetics, initiation of early functional load and return home when patients were able to move and maintain independent lifestyle.
Contact with most patients was lost after their discharge. Only some patients realized their recurrent admission for hospital treatment with planned reconstructive operations and replacement of extensive bone defects. There were no cases of chronic wound infection. Peripherical neurologic deficit in some patients admitted for hospital treatment gradually regressed during hospital period. The results are consistent with the data from by G.E. Omer who reported about 70 % of recovery rate after peripheral nerve injuries after gun shots [12].
CONCLUSION
1. Use of the technique for staged treatment of consequences of modern combat injury with damage control principles allow preventing severe systemic and local complications, saving severely injured extremities with severe cases of limbs at risk.
2. Unilateral rod devices for external fixation allow appropriate bone fixation with time that is important during the primary medical measures for stabilizing state in wounded persons with multiple and concomitant injuries (damage control orthopedics). Besides, they almost do not limit surgical access to the injured extremity.
3. The publication from the leading centers note high rate of deep chronic purulence and posttraumatic osteomyelitis after modern combat injuries [15]. Our experience shows efficiency of maximal radical primary surgical preparation with proper wound bathing, early antibiotic therapy and open management of postsurgical wounds by means of active vacuum pumping.
4. Temporary acute shortening, combining with angulation of an injured segment of the extremity, allows covering the fracture site and the ends of bone fragments in patients with extensive bone and soft tissue defects.
5. Transition to the methods for final internal fixation should be realized only in presence of satisfactory state of soft tissues over bone fragments and fracture site that allows reducing risk of purulent septic complications during treatment of open combat injury to the extremities.