Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma.

BACKGROUND: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. METHODS: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. RESULTS: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. CONCLUSIONS: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

Bone transport combined with locking bridge plate fixation for the treatment of tibial segmental defects: a report of 2 cases.

Segmental tibial bone loss, specifically in the setting of high-energy trauma, presents a challenging problem to the treating orthopaedic surgeon. These injuries are often complicated by tissue loss, poor wound healing, and infection. Many techniques of reconstruction have been advocated from bone grafting to bone transport. Transport can accomplished using Ilizarov frames, monolateral external fixators, and intramedullary devices. Although transport over an intramedullary device offers the advantage of rigidity and controlled alignment, many authors consider prolonged external fixation and history of pin tract infection to be contraindications to this technique. To our knowledge, bone segment transport used in combination with locking plate fixation has not been described for the treatment of tibial bone defects. We describe two cases of bone transport using a combination of locked plate fixation and a monolateral external fixation frame for large tibial bone defects. This technique allows for easy correction of length and alignment, stable fixation, facilitates quicker, and easier frame removal and also allows for compression of transported segment at the time of docking.

Combat-related pelvis fractures in nonsurvivors.

BACKGROUND: The purpose of this study was to describe pelvic fractures and their associated injuries in service members who either died of wounds or were killed in action during Operation Iraqi Freedom and Operation Enduring Freedom and define any differences in associated injuries between penetrating versus blunt injury to the pelvis. METHODS: A review of all service members who sustained a pelvis fracture during Operation Iraqi Freedom and Operation Enduring Freedom in the year 2008 was performed. Data were recorded for analysis. RESULTS: One hundred four nonsurvivors were identified with pelvic fractures. Appropriate records, photos, and radiographs were available for 91, 70 were classified as "Not Survivable" (77%) and 21 "Potentially Survivable" (23%). Mechanisms of injury included 69 blast (76%), 14 gunshot wounds (15%), 4 motor vehicle accidents (4.5%), and 4 "other" (4.5%). Direct injury to the pelvis was penetrating in 60 (66%) and blunt in 31 (34%). Large pelvic vessel injury was observed more frequently in penetrating pelvic injuries (27%) than blunt injuries (3%). Hollow viscus abdominal injuries were more common in those with penetrating (57%) than blunt injuries (10%). There was an inverse relationship with intra-abdominal, solid organ injuries (blunt, 81%; penetrating, 55%). Head injuries were also more common in blunt pelvic injuries (blunt, 68%; penetrating, 45%), as were cardiopulmonary injuries (blunt, 84%, penetrating injuries, 57%). CONCLUSIONS: Large pelvic vessel and hollow viscus injuries occur more frequently in penetrating combat-related pelvic fractures, whereas intra-abdominal solid organ, head, and cardiopulmonary injuries are more common in blunt pelvic injuries.

Advances in the care of battlefield orthopaedic injuries.

Musculoskeletal wounds are the most common type of injury among survivors of combat trauma. The treatment of these wounds entails many challenges. Although methods of care are evolving, significant gaps remain as knowledge of civilian trauma is extrapolated to combat injuries. It is important to discuss issues related to the use of portable vacuum-assisted wound closure devices during transport, as well as the prevention of heterotopic ossification and the participation of civilian orthopaedic trauma experts in caring for injured service members through the Distinguished Visiting Scholar Program.

Orthopaedic war injuries: recent developments in treatment and research.

Musculoskeletal injury is the most common type of injury among survivors of combat trauma, and combat-related trauma is challenging for an orthopaedic surgeon to treat. Methods of treatment are evolving, but significant gaps remain as knowledge of civilian trauma is extrapolated to combat trauma.

Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report.

A case report of thermal necrosis of the tibia after reamed intramedullary nailing is presented. Given the consequences of this complication, the proper use of reaming technique and equipment is emphasized.

Orthopaedic war injuries: from combat casualty care to definitive treatment: a current review of clinical advances, basic science, and research opportunities.

Musculoskeletal war wounds often involve massive injury to bone and soft tissue that differ markedly in character and extent compared with most injuries seen in civilian practice. These complex injuries have challenged orthopaedic surgeons to the limits of their treatment abilities on the battlefield, during medical evacuation, and in subsequent definitive or reconstructive treatment. Newer methodologies are being used in the treatment of these wounds to prevent so-called second hit complications, decrease complications associated with prolonged medical evacuation, reduce the incidence of infection, and restore optimal function. Basic science advances hold the promise of providing foundations for future treatment options that may improve both bone and soft-tissue healing. Research on the treatment of these often devastating wounds also will have broad applicability to trauma resulting from acts of terrorism or from natural disasters.

From Iraq back to Iraq: modern combat orthopaedic care.

War wounds are often large and complex, with high degrees of contamination and tissue loss differing significantly from typical civilian injuries. Infection has been a common complication driving the tenets of care, even in the antibiotic age. Fractures were historically treated with casting or traction because of the risk of infection with internal fixation. However, current civilian fracture care has evolved significantly with extensive use of internal and external fixation with early mobilization and other adjuncts to restore function earlier and more completely. Whether the application of modern techniques and implants can better restore function in patients with these severe injuries is currently being evaluated.

Displaced apophyseal olecranon fracture in a healthy child.

Olecranon apophyseal fractures in children are uncommon. The bulk of these injuries are nondisplaced and therefore can be treated nonoperatively. Few published reports of children with displaced fractures of the olecranon apophysis exist, and the large majority of reports describe children with osteogenesis imperfecta. We report our experience with the case of an 11-year-old, healthy, male patient without osteogenesis imperfecta who sustained a displaced olecranon apophyseal fracture during a fall.

The scope of wounds encountered in casualties from the global war on terrorism: from the battlefield to the tertiary treatment facility.

Injuries seen in Operation Iraqi Freedom range from those that can be managed with nonsurgical wound care only to those requiring amputation or multiple bony and soft-tissue procedures for limb salvage. The contamination and soft-tissue injury caused by exploding ordnance requires an aggressive treatment approach. Severe wounds treated near the battlefield (ie, level II) require meticulous surgical débridement, early fracture stabilization, broad-spectrum antibiotics, and rapid evacuation. Treatment at a level III combat support hospital involves a greater volume of patients and a longer stay because of the presence of Iraqi national patients. In the authors' experience, most US patients requiring surgical treatment were evacuated to a level IV facility (ie, Landstuhl Regional Medical Center) after one or two surgeries. The basic war surgery principles of aggressive resuscitation, early and thorough débridement, short-duration damage-control surgical procedures, and rapid evacuation were critical in our reduction of wound infection rates to below 7% for all admissions.

Extension block pinning for large mallet fractures.

PURPOSE: The purpose of this report is to review the results of displaced mallet fractures treated with an extension block pin and transarticular fixation of the distal interphalangeal joint. METHODS: We retrospectively reviewed 23 patients with 24 fractures to determine the results of treatment, time to union, range of motion, and associated complications. RESULTS: The average patient age was 24 years and the average fracture size was 40% of the joint surface. Ten patients were treated acutely (less than 10 days), 10 subacutely (10-30 days), and 3 chronically (greater than 30 days). Average time to fracture union was 35 days. At 1-year or greater follow-up evaluation the average extension loss was 4 degrees and the average flexion was 77 degrees. There were no major complications and there were 5 minor complications. Using the established outcome criteria for mallet injuries, 92% had excellent or good results. CONCLUSIONS: The results of this study showed that this surgical technique resulted in rapid fracture union with only minor complications and has excellent functional outcome based on established criteria.

Successful reimplantation of a large segment of femoral shaft in a type IIIA open femur fracture: a case report.

Segmental bone loss associated with high-energy open fractures is a difficult problem. The more perplexing and controversial problem is that faced when the extruded segment of bone is retrieved from the field and available for potential reimplantation. Here we present successful reimplantation of a 13-cm segment of meta-diaphyseal femur in a 15-year-old boy. Successful reimplantation of the fragment was attributed to the anatomic location of the injury, meticulous wound care, multiple debridements, sterilization of the extruded fragment in chlorhexidine, and the patient's age.

Extension-block pinning for treatment of displaced mallet fractures.

Mallet injuries are common in active individuals, particularly those who participate in sports such as basketball and football. Although a majority of patients with displaced mallet fractures are treated conservatively with extension splinting, their treatment is often complicated by residual loss of extension and fracture displacement secondary to unfavorable fracture biomechanics and poor patient compliance. An attractive alternative to nonoperative treatment is the minimally invasive technique of extension-block percutaneous pinning. Extension-block percutaneous pinning allows anatomic restoration of the articular surfaces and avoids the complications associated with closed treatment. The technique is easy to perform and is an effective, safe alternative to the conservative treatment of displaced mallet fractures, particularly those associated with joint subluxation.