Damage control orthopaedics: an in-theater perspective.

Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.

Magnetic resonance imaging analysis of the subacromial space in the impingement sign positions.

External shoulder impingement is commonly diagnosed by passively moving the shoulder into various positions of elevation and internal rotation in order to perform impingement sign maneuvers. There is a lack of agreement among clinicians regarding the positions of the anatomic structures in the subacromial space when these maneuvers are performed. The purpose of this study was to use magnetic resonance imaging to identify and measure the changes in anatomic structures in the subacromial space as the arm was moved from complete rest to 160 degrees of forward flexion during the Neer and Hawkins impingement sign maneuvers. Ten subjects with normal shoulders (mean age, 32 years) were studied. The acromiohumeral interval was smallest with the arm at the side (mean, 6.4 mm) and progressively increased as the arm was elevated from 90 degrees to 160 degrees (mean, 7.7-14.2 mm). In no instance was the rotator cuff found to be in contact with the anterior acromion. The rotator cuff insertion appeared to be in closest proximity to the anteroinferior acromion, not at full elevation (Neer sign position), but at 90 degrees of flexion (Hawkins sign position). Our data suggest that a clinically positive Hawkins sign is consistent with external shoulder impingement. Clinical suspicion that mechanisms other than impingement may be involved, particularly if the Neer impingement sign is also positive, is nonetheless advised.