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