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.

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Developing a Program for Advanced Physical Therapist Practice in Amputation Care.

INTRODUCTION: Over the past 20 years, military medicine made great strides in the medical management of traumatically injured patients. Significant advancements were made in the treatment and rehabilitation after limb loss. These advancements can be attributed to the large number of complex patients presenting to military treatment facilities and the demand for medical professionals to provide care to patients with complex injuries and multiple traumatic amputations. The concern now is to maintain the skills needed to be prepared for the next conflict. To meet this demand, the Extremity Trauma and Amputation Center of Excellence (EACE) initiated the documentation of knowledge, skills, and abilities (KSAs) to ensure that the skill sets needed to treat this unique population are not lost. The EACE developed KSAs to sustain advanced clinical practice for physical therapists, occupational therapists, and prosthetists and is in the process of developing KSAs for orthotists and physical medicine physicians. The learning objectives [terminal and enabling learning objectives (TLOs and ELOs)] derived from each set of KSAs will drive curricula development for enduring education, residencies, and fellowships. This article describes the KSAs and learning objectives for advanced physical therapist competencies in amputation care. METHODS: Clinical subject matter experts (SMEs) convened from the Department of Defense (DoD) Advanced Rehabilitation Centers (ARCs) to draft the initial KSAs. All experts had specific expertise in treating individuals with highly complex lower and upper limb amputation. In a quasi-Delphi methodology, the initial draft KSAs underwent five cycles of review and comment by an additional 15 DoD, Veterans Affairs, and civilian institution experts from clinical practice, education, and research. The consensus KSAs were then transcribed into learning objectives with collaboration between clinical subject matter experts and doctoral-level educators. RESULTS: The final program document has 21 instructional modules with 30 TLOs and 157 ELOs. CONCLUSION: The KSAs and the learning objectives describe the skills expected of an advanced practice physical therapist treating patients with traumatic limb loss. Weaknesses of this document include the focus on traumatic amputation and military specific needs. However, many of the central advanced practices are universal to all physical therapists working in amputation. Thus, this document should serve as a starting point and can evolve to include dysvascular, oncology, and other etiologies. To our knowledge, this is the first paper to describe the KSAs for the advanced practice physical therapist working with traumatic limb loss population. This work will form the framework for physical therapist advanced practice training programs.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Mangled extremity: limb salvage for reconstruction versus primary amputation.

PURPOSE OF REVIEW: While MESS has historically influenced limb salvage versus amputation decisions, its universal applicability remains uncertain. With trauma systems expanding and advancements in trauma care, the need for a nuanced understanding of limb salvage has become paramount. RECENT FINDINGS: Recent literature reflects a shift in the management of mangled extremities. Vascular surgery, plastic surgery, and technological advancements have garnered attention. The MESS's efficacy in predicting amputation postvascular reconstruction has been questioned. Machine learning techniques have emerged as a means to predict peritraumatic amputation, incorporating a broader set of variables. Additionally, advancements in socket design, such as automated adjustments and bone-anchored prosthetics, show promise in enhancing prosthetic care. Surgical strategies to mitigate neuropathic pain, including targeted muscle reinnervation (TMR), are evolving and may offer relief for amputees. Predicting the long-term course of osteomyelitis following limb salvage is challenging, but it significantly influences patient quality of life. SUMMARY: The review underscores the evolving landscape of limb salvage decision-making, emphasizing the need for personalized, patient-centered approaches. The Ganga Hospital Score (GHS) introduces a nuanced approach with a 'grey zone' for patients requiring individualized assessments. Future research may leverage artificial intelligence (AI) and predictive models to enhance decision support. Overall, the care of mangled extremities extends beyond a binary choice of limb salvage or amputation, necessitating a holistic understanding of patients' injury patterns, expectations, and abilities for optimal outcomes.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes.

BACKGROUND: Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility. METHODS: We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests. RESULTS: Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034). CONCLUSION: Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

Prehospital tourniquet placement in extremity trauma.

BACKGROUND: Extremity tourniquets (ET) use has increased in trauma systems to manage traumatic hemorrhage. This study aims to evaluate prehospital ET placement. METHODS: This is a retrospective review of a prospectively collected cohort of 211 adult patients who underwent prehospital ET placement over 3 ½ years. Data regarding ET placement was analyzed regarding ET applier, reported indications, extremity appearance at arrival and outcomes. RESULTS: A total of 211 patients had completed data sheets. Of these patients, 63.2% had no other intervention prior to ET placement. On arrival, nearly 1/3 of the patients had palpable pulses with ET in place and less than ½ had arterial bleeding upon ET release. DISCUSSION/CONCLUSIONS: This study shows that ET are frequently used as the initial intervention in the field. It is of paramount importance that we adapt our first responders training to teach wound assessment and appropriate steps in management of extremity hemorrhagic trauma.

Subcutaneous versus intravenous tramadol for extremity injury with moderate pain in the emergency department: a randomised controlled noninferiority trial.

BACKGROUND AND IMPORTANCE: Musculoskeletal trauma is a common presentation in the emergency department (ED). Tramadol as an analgesic has been recommended by pain management guidelines for musculoskeletal pain. Parenteral tramadol in the ED is commonly administered intravenously. Subcutaneously administered tramadol may have other advantages such as easier and faster preparation, avoids the need for intravenous (i.v.) access, and reduces the incidence of respiratory and gastrointestinal effects. However, studies comparing subcutaneous (s.c.) and i.v. tramadol for the management of acute moderate pain in patients with extremity injury are lacking. OBJECTIVE: The objective of this study was to compare the clinical efficacy of s.c. tramadol vs. i.v. tramadol in patients with moderate pain due to extremity injury in the ED. DESIGN, SETTINGS, AND PARTICIPANTS: This non-inferiority randomized controlled trial included adult patients presented to an academic, tertiary hospital ED with moderate pain (pain score of 4-6 on the visual analog scale) due to extremity injury. Intervention patients stratified to pain score were randomized to receive 50 mg of i.v. or s.c. tramadol. OUTCOMES MEASURE AND ANALYSIS: Primary outcome measure was the difference in the pain score reduction at 30 min after tramadol administration between the two groups. The noninferiority null hypothesis was that the therapeutic difference in terms of pain score reduction of more than 0.8 exists between the two treatment groups at the endpoint. MAIN RESULTS: In total 232 patients were randomized to i.v. ( n = 115) or s.c. ( n = 117). Although 225 were analyzed in the per-protocol population (i.v. = 113; s.c. = 112). The baseline median pain score was 6 (IQR, 5-6). Median pain score reduction at 30 min after administration was 2 (IQR, 1-3) in the IV group vs. 2 (IQR, 1-2) in the s.c. group with a median difference of 0 (IQR, 0-0), which was below the prespecified noninferiority margin of 0.8. Adverse events in the i.v. group were higher compared to the s.c. group (33.6% vs. 8.9%, P ≤ 0.001). CONCLUSIONS: The s.c. tramadol is noninferior to i.v. tramadol in the treatment of moderate pain from extremity injuries.

Tourniquets, types and techniques in emergency prehospital care: A narrative review.

Massive uncontrolled hemorrhage is an important cause of preventable death in trauma. Therefore, applying an arterial tourniquet (TQ) is recommended as a pre-hospital measure to control bleeding after severe traumatic bleeding. Limb TQ applies circumferential compression proximally to the injury site to compress the arteries, resulting in blood flow and consequently hemorrhage interruption. The use of commercial tourniquets (C-TQ), which are designed, tested, and registered to control hemorrhages in pre-hospital care, is a consensus. However, they are still uncommon in many prehospital emergency services and the overall level of evidence in most studies is low. This narrative review aimed to characterize the importance of tourniquets use in prehospital emergency care and its application techniques. Furthermore, it proposes to stimulate the development of new devices, more accessible and easier to use, to suggest new directions of studies and medical education demands, with manikin and simulation development.

[Interdisciplinary extremity board in the treatment of complex injuries]. / Interdisziplinäres Extremitäten-Board in der Behandlung von Komplexverletzungen.

BACKGROUND: Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines. METHODS: After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6 months were subsequently descriptively analyzed. RESULTS: The agreed primary aim of an extremity board is the timely and transparent preparation of a high-quality holistic reconstruction plan for optimized treatment of a challenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40 years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2 patients were approved in an interdisciplinary team per session. CONCLUSION: The extremity board serves as a platform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables a high degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.

Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture.

BACKGROUND: Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS: In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS: A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS: In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).

Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness.

INTRODUCTION: As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. MATERIALS AND METHODS: We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. RESULTS: Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. CONCLUSION: Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

[Acute compartment syndrome of the extremities]. / Akutes Kompartmentsyndrom der Extremitäten.

Acute compartment syndrome of the extremities is a surgical emergency and a rapid diagnosis and immediate surgical treatment are essential for the outcome. The cause is an increase in the tissue pressure inside a muscle compartment enclosed by fasciae and the resulting disruption of microperfusion. This can have potentially disastrous consequences, such as loss of the extremity due to extensive tissue necrosis or a threat to life due to infectious complications. Although mostly triggered by trauma, a multitude of other causes can lead to the formation of a compartment syndrome, so that a basic knowledge of this condition is of great importance not only for trauma surgeons. This is particularly true because a timely treatment necessitates rapid diagnosis and evaluation of the indications. This article provides an overview of the underlying pathophysiology, the causes, the symptoms and the treatment of acute compartment syndrome.

Concussion is not associated with elevated rates of lower-extremity musculoskeletal injuries in National Football League Players.

OBJECTIVE: Emerging evidence has identified an ~2x elevated risk of musculoskeletal (MSK) injury in the year following a concussion. Most of these studies have examined a single college/university athletic department and may lack generalizability to professional sports. Therefore, the purpose of this study was to assess the odds of post-concussion MSK injury utilizing publicly available National Football League (NFL) injury reports. METHODS: Concussions were identified through a review of published NFL injury reports during the 2015, 2016, and 2017 regular seasons. Concussed players were matched by team and position, and injuries were tracked for both groups for the remainder of the season. A chi-square analysis compared the frequency of MSK injury in both groups and a Cox Proportional Hazard model calculated the risk of sustaining a subsequent MSK injury. RESULTS: There were 322 concussed NFL players who met inclusion criteria and were successfully matched. From the time of concussion through the remainder of the season, 21.4% of the concussed players were injured and 26.4% of control participants were injured. There was no difference in MSK injury rates (p = 0.166), and the relative risk ratio was 0.90 for subsequent injury in the concussion group. There was no difference in the time to event for subsequent MSK between the two groups (p = 0.123). CONCLUSION: The primary finding of this study was no elevated risk of post-concussion MSK in NFL football players.

A multicomponent neuromuscular warm-up program reduces lower-extremity injuries in trained basketball players: a cluster randomized controlled trial.

OBJECTIVE: To assess the effects of a novel multicomponent neuromuscular warm-up program on lower-extremity injury incidence in basketball players competing at the regional level. METHODS: A cluster randomized controlled experimental design was adopted to compare injury incidence between players exposed to the injury prevention warm-up program and those exposed to a typical warm-up program across an entire basketball season. Four teams consisting of 57 players (male: n = 42; female: n = 15) were allocated to the intervention group (age: 21.6 ± 2.5 years; height: 186.2 ± 8.8 cm; body mass: 80.0 ± 10.4 kg) and four teams consisting of 55 players (male: n = 43; female: n = 12) were allocated to the control group (age: 21.6 ± 2.6 years; height: 186.9 ± 9.1 cm; body mass: 81.5 ± 10.9 kg). The novel warm-up combined running exercises with active stretching, plyometrics, balance, strength, and agility drills. Coaching and medical staff provided details on injury incidence each week. Data analyses included the use of poisson regression analyses and the incidence rate ratio (IRR) with 95% confidence intervals (CI). RESULTS: The intervention group experienced a significantly lower ankle sprain incidence rate (IRR = 0.26, 95% CI = 0.05, 0.98, p = 0.02) and a tendency toward a lower knee injury incidence rate (IRR = 0.32, 95% CI = 0.03, 1.78, p = 0.07) compared to the control group. Considering only non-contact lower-extremity injuries of any type, the intervention group experienced a significantly lower incidence rate compared to the control group (IRR = 0.26, 95% CI = 0.05, 0.98, p < 0.001). CONCLUSION: This multi-team study demonstrated a novel multicomponent warm-up program resulted in less lower-extremity injuries, particularly ankle sprains and knee injuries, compared to a typical warm-up program in regional-level male and female basketball players.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction.

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Isolated limb fractures - the underestimated injury in the Israeli Defence Forces (IDF).

INTRODUCTION: Musculoskeletal injuries dominate warfare-related trauma and differ from civilian settings in higher hospitalization costs, morbidity, and mortality. Partly due to introduction of personal protective equipment in the Israel Defence Force (IDF) to minimize head and torso injuries while the extremities remained unprotected. This study describes military extremity injury patterns, prehospital treatment and injury sequela regarding return-to-duty and disability compensation. METHODS: This retrospective study examined cases of battle and non-battle trauma casualties treated by the IDF Medical Corps from 2013 to 2020. Data from the IDF Trauma Registry (IDF-TR) was merged with The Israeli National Trauma Registry (INTR). Cases with high morbidity discharged from military service were compared with lower morbidity patients who returned to active duty service. RESULTS: Out of 1360 injured soldiers, 280 (20.6%) were found to have isolated limb fractures (ILFs). High morbidity casualties had more open fractures (63% vs. 42%) and higher involvement of lower extremities (79% vs. 58%) (p < 0.001), higher rates of tourniquets use (28% compared to 9%, p < 0.001), external fixation (34% vs. 19%, p < 0.001) and amputations (9% vs. 1%, p = 0.003), required more rehabilitation (34% vs. 7%, p < 0.001), and had 46% medical disabilities compared to 24% with low morbidity (p < 0.001). CONCLUSIONS: ILFs are associated with significant morbidity and disability. High morbidity is associated with high energy, scar-producing, lower-extremity open fractured limbs treated by tourniquets. Future studies should evaluate whether junctional or extremity protective gear is combat feasible and whether introducing Clinical Practice Guidelines to manage suspected limb fractures can decrease morbidity rates and improve return to duty.