Periarticular blast wounds without fracture a prospective case series.

BACKGROUND: During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture. METHODS: The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement. RESULTS: Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01). CONCLUSION: Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Field tourniquets in an austere military environment: A prospective case series.

OBJECTIVE: Field tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications. METHODS: Twenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use. RESULTS: Tourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application. CONCLUSION: Field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.

Management of the rigid arthritic flatfoot in the adults: alternatives to triple arthrodesis.

Every alternative to triple arthrodesis in the rigid acquired flatfoot deformity is predicated on limiting the patient exposure to the complication associated with triple arthrodesis. When possible, avoiding arthrodesis of either the talonavicular and calcaneocuboid joints, with their higher nonunion rates, seems a cogent option. Successful treatment is dependent on thoughtful patient evaluation and examination, meticulous joint preparation, careful positioning with rigid fixation, and judicious use of adjunctive procedures to achieve the goal of a plantigrade foot that functions well and is minimally painful.