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Blast and Fragment Injuries of the Musculoskeletal System

Investigation performed at the Department of Orthopaedic Surgery, United States Naval Hospital Okinawa, Japan, and the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Captain Dana C. Covey, Medical Corps, United States Navy Department of Orthopaedic Surgery, United States Naval Hospital Okinawa, PSC 482, Box 2563, FPO AP 96362-2563. E-mail address: coveydc{at}oki10.med.navy.mil Please address requests for reprints to D.C. Covey.

In support of the research or preparation of this manuscript, the author received grants or outside funding from the Chairman of the Joint Chiefs of Staff Award for Excellence in Military Medicine and from the Zachary and Elizabeth Fisher Foundation. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

The views expressed in this paper are those of the author and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States Government.

Abstract

Blast and fragment injuries of the musculoskeletal system are the most frequently encountered wounds in modern warfare.

Most injuries to the musculoskeletal system involve so-called secondary blast injuries in which casing fragments and other debris become flying projectiles.

Nonoperative treatment of selected wounds caused by small-fragment debris has been successful but remains controversial.

Successful surgical treatment depends on meticulous wound débridement, with excision of nonviable tissue and foreign material likely to cause infection; adequate drainage; and delayed closure.

Advanced internal fixation techniques used in modern trauma centers to treat predominantly blunt trauma may not be appropriate for care of orthopaedic war wounds in a field setting.

Injuries of the musculoskeletal system are the most common type of wounds seen in modern warfare, accounting for 60% to 70% of all wounds ^1-14 . In recent wars, most penetrating musculoskeletal injuries were not caused by bullets but by exploding ordnance such as bombs, artillery shells, mortar rounds, grenades, or land mines ^3,9,15-20 . In addition to their direct mutilating effects, the explosive force from these weapons drives casing fragments and other foreign material into both soft and osseous tissues, potentially causing secondary infection ^3,21,22 . Explosive devices have also been a preferred weapon of domestic and foreign terrorists, since they are relatively cheap to manufacture and can cause a large number of casualties. Although blast and fragment injuries have traditionally been the purview of military surgeons, these injuries are being seen more frequently among noncombatants during peacetime because of increasing worldwide terrorism ^23,24 . This has been starkly demonstrated by the tragic attacks on the Alfred P. Murrah Federal Building in Oklahoma City in 1995 ²⁵ , the United States embassies in Africa in 1998, and the World Trade Center and Pentagon in 2001. It is clear that at any time orthopaedic surgeons, military or civilian, may be called upon to treat patients with these injuries, often under difficult or austere conditions.

By the very nature of the subject, the literature on war wound surgery is retrospective, and clinical advances have evolved, to a considerable degree, from experiences in the past. However, from this body of literature, general principles of war wound surgery have emerged that form the foundation of the treatment of explosive injuries to the musculoskeletal system.

Pathophysiology

Blast Injury Classification
Blast injuries have been generally categorized as primary, secondary, tertiary, or miscellaneous ^26,27 . Primary blast injuries are caused by a sudden change in environmental pressure called the blast wave ²⁸ . The organs most commonly affected are the lungs, ears, bowel, central nervous system, and cardiovascular system. Severe primary blast injuries are rarely seen in survivors because anyone close enough to sustain such an injury is usually killed immediately by fragments ²⁹ . Secondary blast injuries occur from objects that have been energized by the explosion to become projectiles. Tertiary blast injuries result when a victim is thrown against the ground or an object or is injured by the collapse of a structure. Miscellaneous blast injuries include exposure to dust, thermal burns from an explosion, or burns from fires started by the blast. Any of these categories of blast injury may affect the musculoskeletal system.

Blast Physics
The high-speed chemical decomposition of an explosive into gas is termed detonation ²⁷ . When detonation occurs, the space formerly occupied by the explosive is filled with gas under high pressure and temperature. Explosives can generally be categorized as either high or ordinary ³⁰ . High explosives detonate rapidly, the chemical reaction being triggered by a mechanical shock wave that travels at high speed through the explosive ²⁷ . In addition, high explosives possess shattering power, termed brisance . Ordinary explosives, such as gunpowder, release their energy more slowly by deflagration, a process of rapid chemical burning.

Detonation releases a large amount of heat and gaseous products that are transmitted as the blast (shock) wave, a pressure pulse a few millimeters thick that travels at supersonic speed outward from the point of the explosion ( Fig. 1 . 1) ^27,31,32 . The leading edge of this wave, the blast front, causes an almost instantaneous rise in pressure to a peak overpressure that causes the blast wave to move faster than the speed of sound ³² . This front rapidly decreases in pressure as it travels away from the explosion, and the blast wave itself eventually becomes an acoustic wave ³² . The pressure then drops below ambient air pressure ³³ , and the resultant vacuum effect can suck debris into previously unaffected areas. The ensuing mass movement of air caused by the explosive products generates a blast wind, which travels more slowly than the blast wave but can propel objects and people considerable distances and may be as damaging as the original explosion ^28,31 .

View larger version (11K): [in this window] [in a new window]   Fig. 1: An idealized depiction of a blast wave after an explosion in air. The peak overpressure and the duration of the initial positive phase are functions of the size of the explosion and the distance from the detonation. (Adapted from: Bowen TE, Bellamy RF, editors. Emergency war surgery. Washington, DC: United States Department of Defense, United States Government Printing Office; 1988. p 75.)

Physical and Physiologic Responses to Blast
The sudden pressure change caused by the blast wave can damage living tissue by four putative mechanisms: spalling, implosion, acceleration-deceleration, and pressure differentials. Spalling occurs when particles from a more dense fluid are thrown into a less dense fluid at the interface of two different media ^27,30 . Implosion is the momentary contraction of gas pockets that occurs when the blast wave propagates through tissues. As the blast wave passes and the pressure falls, these gas pockets rapidly re-expand, causing injury from miniature internal explosions ^27,30 . With acceleration-deceleration injury, movement of organs is initiated by motion of the body wall in the direction of the blast wave. Adjacent structures with different physical properties may accelerate at different rates, shearing or disrupting tissues ^27,30 . When a blast wave impacts the body, internal injury due to pressure differentials between the outer surface of the body and the internal organs can also occur.

Cernak et al. studied the effects of blast overpressure in a random sample of sixty-five patients with acute injuries caused by explosive blasts ³⁴ . Compared with a control group of injured patients with similar wound severity scores, the blast-injury group showed significant elevations in the plasma arachidonic acid metabolites thromboxane A2, prostacyclin, and sulfidopeptide leukotrienes (p < 0.05). Their findings suggested that transmission of blast and stress wave energy through the body could cause extensive, measurable pathophysiologic alterations.

Mechanisms of Orthopaedic Injury
Musculoskeletal trauma resulting from an explosive detonation is manifested as a primary, secondary, tertiary, or miscellaneous blast injury, in isolation or in combination. Although relatively uncommon in survivors, the direct effects of changes in atmospheric pressure caused by the blast wave (primary blast injury) can fracture bones and are likely responsible for limb avulsions in victims exposed to stress waves of sufficiently high intensity ^23,35 . Mellor and Cooper showed that limb amputation has a grave prognosis, reporting that only nine of fifty-two servicemen who sustained traumatic amputations from explosions in Northern Ireland survived ²⁴ . Hull analyzed the nature of forty-one traumatic amputations in twenty-nine servicemen who had survived to reach medical care after sustaining blast injuries ³⁶ . He found that, in the lower limb, the prevalence of traumatic amputation was significantly higher (p < 0.001) at the level of the tibial tuberosity than at other sites. In the upper limb, there was a tendency for the traumatic amputation to occur through its distal portion, but this tendency was not significant. The pattern and mechanism of traumatic limb amputation by explosive blasts was studied by Hull and Cooper, who reviewed the cases of 100 consecutive individuals who had died in bomb blasts (thirty-four of whom had one or more major traumatic amputations), subsequently performed computer modeling with finite element analysis, and then carried out explosive trials using goat hindlimb bones ³⁷ . It was noteworthy that, of seventy-three upper and lower-limb amputations in their survey, only one occurred through a joint (the knee). They determined that major limb amputation by an explosive blast is a combination of blast-wave-induced fracture, due predominantly to coaxial forces, followed by limb avulsion through the fracture site by dynamic forces (the blast wind) acting on the whole limb.

Secondary blast injuries caused by flying casing fragments or other debris are the blast injuries that most often involve the musculoskeletal system ³⁸ . Sufficiently large fragments can cause direct limb amputation ³⁷ . Although conventional military explosives may create multiple fragments with initial velocities of up to 1800 m/sec ³⁹ , Bowyer et al. ⁴⁰ indicated that most casualties who survived to reach surgical facilities had been struck by fragments with a velocity of <600 m/sec. The aerodynamic drag on these irregularly shaped projectiles also results in rapid deceleration outward from the point of detonation ^3,6,32 . Therefore, depending on the distance from the blast, fragments that strike the body can range from high to low velocity, absent the streamlining seen with bullets fired through a rifle barrel. In addition to their lack of streamlining, there are other ways in which low-velocity fragments from explosive munitions behave differently from low-velocity bullets. Upon striking tissue, even at a low velocity, these fragments may exhibit a tumbling or so-called shimmy effect that can increase the amount of tissue damage ^41,42 . Also, blast fragments often carry environmental debris into the wound, and they frequently cause more severe tissue injury than do low-velocity bullets ^3,39,43-45 . Furthermore, a large, slow projectile can crush a large amount of tissue, and missile fragmentation that may occur within the body can greatly increase temporary cavity effects ⁴⁶ . One or a combination of the above factors most likely account for the qualitative differences often seen between the tissue damage caused by explosive fragments and the damage caused by low-velocity gunshot wounds. In an animal study, Huang et al. showed that an extremity injury from a high-velocity fragment aggravates blast injury to the lung ⁴⁷ . With the increasing use of modern body armor that gives some protection to the thorax and abdomen from secondary blast injury, there has been a greater relative increase in fragment wounds to extremities ^6,48-50 .

The blast wind can accelerate bodies in its path and cause tertiary blast injuries of varying severity at a lesser distance from the point of detonation than that reached by secondary missiles ^28,32 . Often, victims tumble along the ground, sustaining multiple injuries, or are hurled through the air until they strike or are impaled on objects ³² . Fractures, crush injuries, amputations, and severe soft-tissue lacerations and contusions are all possible ³⁴ .

Miscellaneous orthopaedic blast injuries are much less common than secondary blast injuries and may include burns from the thermal effects of explosions or from secondary fires ³³ .

Diagnosis

History and Physical Examination
The first opportunity to evaluate the patient will probably occur in the field, and a systematic evaluation should be carried out according to the principles of Advanced Trauma Life Support for resuscitation and treatment of immediately life-threatening conditions ^51,52 . In the mass casualty scenario, patients must be triaged to allocate priority care to those with severe injuries who have a good potential for survival if they receive immediate medical intervention, and those with lesser injuries should receive delayed care ⁴⁸ . Patients with massive injuries who have a poor prognosis for survival will probably not receive the heroic medical care that might be afforded under other circumstances ⁴⁸ .

At the treatment facility, a primary survey is conducted to reassess the patient's status, and pertinent history is noted, including personal patient data, wounding mechanism (if known), time elapsed since the injury, any previous treatment received, and status of tetanus prophylaxis. Basic laboratory studies, including a complete blood-cell count, determination of serum electrolyte levels, and blood-typing and crossmatching are performed. As part of the secondary survey, an examination should be carried out with the patient undressed to determine the extent of injury from the blast or penetrating missiles. It is important, when conducting the physical examination, to be aware that (1) fragments do not always travel in straight lines, (2) small entry wounds can be associated with extensive internal injury, (3) entry wounds in the buttocks, thighs, or perineum can be associated with intra-abdominal injury, (4) a high degree of suspicion for compartment syndrome should be maintained, and (5) an entry wound in the groin or a hematoma elsewhere may mean a major vascular injury ⁵³ .

Penetrating joint injuries can be diagnosed clinically on the basis of the location of the wound, aspiration of intra-articular blood, or a positive reverse arthrocentesis test in which fluid injected into the affected joint exits through the wound.

Radiographic Evaluation
Radiographs are invaluable in the assessment of musculoskeletal blast injuries. The presence and severity of osseous injury will have a major bearing on the overall treatment plan, and the radiographic findings may be the factor deciding whether the injured limb can be salvaged ( Fig. 2 ) ^21,48-54 . Metallic foreign material indicates the type of weapon and the depth of penetration, while the absence of metallic fragments usually indicates a through-and-through wound and the need to search for an inconspicuous entry point ⁴³ . Alternatively, foreign material such as shoe leather, dirt, and plastic casing fragments may not be radiopaque but still may be associated with severe injury ²¹ . Intra-articular air or foreign bodies seen radiographically indicate joint penetration ⁵⁴ . High-velocity missiles may be associated with palpable and radiographically visible intrafascial gas in healthy tissue some distance from the wound, so this finding does not necessarily indicate clostridial infection ⁴³ .

View larger version (130K): [in this window] [in a new window]   Fig. 2: Radiograph of both lower extremities of a twenty-two-year-old soldier injured in an antitank-mine explosion. Treatment consisted of bilateral below-the-knee amputation.

Fig. 3-A: Figs. 3-A, 3-B, and 3-C A twenty-five-year-old-soldier sustained a blast injury to the foot that did not require amputation. Fig. 3-A The injury was caused by a "fishbox" plastic antipersonnel blast mine containing 200 g of explosive. (Reprinted, with permission, from: Covey DC, Peterson DA. Treatment of musculoskeletal blast wounds at a Navy field hospital during the Balkans War. Tech Orthop. 1995;10:196.)

View larger version (79K): [in this window] [in a new window]   Fig. 3-B: Severe soft-tissue injury of the hindfoot region.

View larger version (39K): [in this window] [in a new window]   Fig. 3-C: Lateral radiograph showing extensive comminution of the calcaneus.

Nonoperative Treatment

Initial Care
In the field, after the primary survey and initial resuscitation, open wounds should be covered with sterile dressings and any fractures should be gently aligned and splinted before transport. In my experience, bleeding from blast and fragment injuries can usually be controlled by direct compression, even in cases of traumatic amputation. If a tourniquet is required, the time that it was applied should be clearly noted and communicated to all personnel immediately involved in the care of the patient. In the casualty receiving area of a field hospital or in the emergency room, the patient's vital signs should be reassessed; large-bore venous access should be established if it has not been established already, and indicated resuscitation should be carried out. A secondary survey is performed to include a thorough examination of the musculoskeletal system. Dressings and splints are removed as necessary to check the status of soft tissues, fractures, and neurovascular functions. Although fractures or dislocations may have been treated with splints in the field, they should be reevaluated to ensure that there is no skin or neurovascular compromise and then resplinted as indicated.

Antimicrobial Prophylaxis
Musculoskeletal wounds caused by explosive munitions are contaminated with bacteria and associated with a very high risk of infection; thus, tetanus prophylaxis and antibiotics are important adjuncts to the surgical treatment of these injuries ⁶⁵ . This treatment should begin in the casualty receiving area. To provide protection against Clostridium tetani , the cause of tetanus, all patients should receive tetanus toxoid, and those who have not been immunized should receive anti-tetanus immunoglobulin as well ^2,22,66-70 . Another major infectious threat from blast and fragment wounds is gas gangrene, which is caused by anaerobic Clostridium species, particularly Clostridium perfringens ⁷¹ . For additional protection, injured patients should receive high doses of intravenous penicillin ^{2,22,66,71-73} or, alternatively, erythromycin, chloramphenicol, or a cephalosporin ⁵³ . When a blast injury includes severe contamination and high-grade open fractures, Pseudomonas aeruginosa may be a problem ^21,70,71,73 , and an aminoglycoside antibiotic should be added ^67,7I,72,74 . Additionally, open fractures necessitate coverage for gram-positive organisms with a cephalosporin or penicillinase-resistant penicillin ^74-76 . Although it has not been specifically studied for the treatment of war wounds, a polymethylmethacrylate antibiotic bead pouch ⁷⁷ may be an efficacious means of dealing with high-grade open fractures caused by explosive devices. In wounds involving severe osseous and soft-tissue injury, this technique can deliver high local concentrations of antibiotics, decrease wound dead space, and reduce bone desiccation until coverage is achieved ⁷⁷ .

Nonoperative treatment of selected small-fragment wounds can be successful ^19,78 , but not all surgeons pursue this approach because these injuries usually occur under battlefield conditions, where there is often heavy contamination and delays in medical evacuation ^{2,3,22,23,43,48,79,80} . Using an experimental model of small-fragment wounds in pigs, Bowyer et al. demonstrated that a conservative approach to these injuries could be successful if early bacterial colonization is prevented by the timely use of antibiotics ⁴⁰ . However, their experiment did not simulate the characteristics of fragments resulting from detonation of a land mine. Coupland reported a case series of sixty-eight survivors who had sustained a total of eighty-nine wounds from hand grenades ⁸¹ . Twenty-four of these wounds were treated with dressings and intravenous antibiotics without primary surgery, and the only complication was a wound hematoma that required evacuation. It was recommended that soft-tissue fragment wounds of <1 cm in size without evidence of hematoma or injury to a vital structure be initially managed conservatively. Bowyer reported on the treatment of 1222 small-fragment wounds sustained by eighty-three patients during the 1979 to 1989 Soviet-Afghan War ¹⁵ . Of these wounds, 866 met the following prerequisites for nonoperative treatment: (1) involvement of soft tissue only with no breach of pleura or peritoneum and no major vascular involvement, (2) an entry or exit wound of <2 cm in maximum dimension, (3) not frankly infected, and (4) not caused by a mine blast (these wounds tend to have extensive contamination). Nonoperative management consisted of cleaning and dressing the wound, tetanus prophylaxis, and parenteral administration of benzylpenicillin for one day followed by oral administration of penicillin V for the next four days. The only complications were superficial abscesses involving two wounds (0.23% infection rate). Operating only to remove small metal fragments in soft tissue is usually unnecessary ^51,81,82 .

Operative Treatment

General Principles
Although the war surgery literature stresses the need for complete wound débridement, it is an incorrect assumption that this is an easy surgical exercise, for it is frequently performed inadequately ⁴³ . The key to success is meticulous wound débridement with excision of nonviable tissue and foreign material likely to cause infection. However, even some terms associated with surgical treatment of war wounds have led to confusion about what exactly is meant. Authors in North America and Sweden use the term débridement to describe the entire surgical procedure in war wound treatment, but in the United Kingdom and France the term refers only to the first stage of the operation, in which the wound is unbridled (laid open) in preparation for formal wound excision ³ .

There are a number of important technical points to consider during the actual wound surgery. Many parallel techniques are used in the treatment of high-grade open fractures in civilian practice. A tourniquet may be applied (if available), depending on the site of injury and only if there is uncontrollable bleeding. Before the surgery is begun, the wound is cleaned of gross contamination, with a brush if needed. Appropriate extending incisions should be used to enable exposure of the missile track, nonviable tissue, and foreign material. The wound should be copiously irrigated with an isotonic solution to help to remove bacteria and foreign material. Fasciotomy may be required for compartment syndrome. Débridement of skin should be conservative because of skin's inherent resiliency and to facilitate delayed wound closure ^43,83 . The cornerstone of war wound surgery is removal of all nonmetallic foreign material and excision of nonviable fat, muscle, and fascia back to healthy tissue. Viable tissue can be differentiated from nonviable tissue on the basis of its color, consistency, contractility, and ability to bleed ⁸³ , although these are only guidelines at best ³ . When there is osseous involvement, as much bone as possible is saved to provide stability, but small fragments detached from their vascular supply are removed. Contaminated bone ends should undergo curettage to remove foreign material. Wounds should be dressed open, with enough bulky gauze to absorb the wound drainage.

Primary closure of blast wounds greatly increases the likelihood of infection; thus, the wounds should be left open until they are clean and granulation tissue has appeared. Unless infection supervenes or additional débridement is needed, the wound should be ready for delayed primary closure, skin-grafting, or other coverage four to six days after the primary surgery ^3,14,43 . If repair of damaged tendons and nerves is deemed possible, they may be tagged with suture ^2,54 ; alternatively, they can be left untagged in situ ⁸² for secondary surgery.

The injured part can be immobilized with a bulky dressing, plaster of paris, traction, or external fixation ^43,83 . Has et al. employed external fixation to treat 215 (16.3%) of 1320 open upper and lower-limb fractures, mostly from exploding devices, and reported that twenty fractures (9.3%) were complicated by osteomyelitis and another twenty-one (9.8%) had nonunion requiring secondary surgery ⁸⁴ . Although they did not grade the fractures or indicate the criteria for use of external fixation, they concluded that proper wound treatment combined with external fixation was the treatment of choice for open fractures caused by exploding ordnance. Drawing on the experience of the International Committee of the Red Cross in treating over 45,000 war-wounded patients during a twelve-year period, Coupland weighed the advantages and disadvantages of external fixation in the context of a thoroughly debrided wound and advised caution regarding the universal use of this approach for war wounds ⁸⁵ . Noting marked differences between open fractures seen in civilian practice and those sustained in war, he recommended that external fixation not be placed during the initial wound surgery because of an increased risk of pin-track infection. However, he did not present specific data to support this recommendation. Other authors who have used external fixation for open fractures associated with blast and fragment wounds have not delayed its placement ^21,22,66,86 .

Although in theory it should be possible to perform an adequate initial débridement to preclude the need to return the patient to the operating room, it can be difficult to initially appreciate the entire zone of some large blast injuries ^43,51,66,87 . It has been my experience and that of others that repeat débridement may be necessary for large or very contaminated blast injuries and should be carried out every twenty-four to forty-eight hours as indicated ( Figs. 4-A , 4-B , and 4-C ) ^{21,51,66,87-91} . On the basis of the extensive experience of the International Committee of the Red Cross, Coupland recommended that wounds be thoroughly and extensively debrided primarily and then reexamined after five days unless there are earlier symptoms or signs of wound infection ⁴³ . Although inadequate wound débridement or excision is the most common technical error, some authors have also pointed out the pitfalls of excessive excision of war wounds ^88,92 .

View larger version (102K): [in this window] [in a new window]   Fig. 4-A: Figs. 4-A, 4-B, and 4-C: A twenty-three-year-old soldier sustained severe soft-tissue and osseous injuries from an exploding mine. Fig. 4-A Severe soft-tissue wounds with necrotic muscle encompassing the sacral and gluteal regions seen at the time of the second débridement. (The patient is prone with his head toward the top of the figure.)

View larger version (112K): [in this window] [in a new window]   Fig. 4-B: Radiograph demonstrating loss of the sacrum caudad to the third sacral level.

View larger version (106K): [in this window] [in a new window]   Fig. 4-C: Débridement to healthy muscle. (The patient's head is toward the top of the figure.)

Fig. 5: Diagram of an explosive injury causing traumatic below-the-knee amputation. The blast causes proximal compartment injury and propels dirt and other debris upward along tissue planes of the leg so that the extent of contamination is often more proximal than is initially appreciated. (Reprinted, with permission, from: Coupland RM. Amputation for war wounds. Geneva: International Committee of the Red Cross; 1992. p 6.)

Blast and fragment injuries of the hand present unique challenges. The basic principles of war wound care presented above are germane to hand wounds, but with some modification. On the basis of a series of 147 patients with war wounds of the hand and forearm, which were caused by blasts and fragments in 108 (73%), Jabaley and Peterson advocated a two-stage method of wound management ⁹⁸ . At the initial operation, they performed a relatively conservative débridement that included minimum skin excision, fasciotomies if indicated, removal of devascularized bone, minimal débridement of divided nerves, trimming of frayed tendons, hematoma evacuation, and any needed arterial repair. At a second operation three to five days later, any additional required débridement was carried out, fractures were stabilized with Kirschner wires, and, if appropriate, wound coverage was obtained. An infection developed in only one patient (infection rate, 0.68%). Rautio and Paavolainen ⁶⁶ and Bajec et al. ⁸² also used Kirschner wires to stabilize hand fractures resulting from explosive injuries.

Although the fundamentals of war wound surgery apply to foot injuries, overzealous débridement and wound excision of all damaged soft and osseous tissue could cause irreversible loss of function; thus, moderation has been recommended ⁴³ . When tendons are torn or damaged, the excision must reach healthy tendon, which can be tagged for later repair or reconstruction ⁷³ . Although small bone fragments devoid of their blood supply should be removed, excision of bone should be sparing to preserve the architecture of the foot ⁹⁹ . Splinting or external fixation is used as appropriate, with the goal being delayed closure by suture, skin grafts, or flaps ^21,99,100 . Minimal osteosynthesis with use of Kirschner wires has been successful in approximating the osseous anatomy of the foot after land mine injury ( Figs. 6-A , 6-B , 6-C and 6-D ) ^21,81,99 . Kirschner wires can also be used as temporary spacers in cases involving bone loss ( Figs. 7-A , 7-B , 7-C , and 7-D ).

Fig. 6-A: Figs. 6-A through 6-D A nineteen-year-old soldier sustained severe trauma to the foot from an antipersonnel mine. Fig. 6-A Lateral photograph showing extensive soft-tissue injury with marked contamination. (Reprinted, with permission, from: Covey DC, Peterson DA. Treatment of musculoskeletal blast wounds at a Navy field hospital during the Balkans War. Tech Orthop. 1995;10:203.)

View larger version (101K): [in this window] [in a new window]   Fig. 6-B: Lateral radiograph showing extensive comminution and bone loss involving the calcaneus.

View larger version (87K): [in this window] [in a new window]   Fig. 6-C: Kirschner wires were used to reapproximate the subtalar architecture.

View larger version (111K): [in this window] [in a new window]   Fig. 6-C: Appearance after delayed closure and placement of a split-thickness skin graft.

View larger version (123K): [in this window] [in a new window]   Fig. 7-A: Figs. 7-A through 7-D A forty-six-year-old United Nations soldier sustained secondary blast injuries from an antipersonnel mine that included open fractures of the second and third metatarsals with segmental bone loss. Fig. 7-A A relatively innocuous-appearing entry wound.

View larger version (79K): [in this window] [in a new window]   Fig. 7-B: Anteroposterior radiograph showing the extent of the osseous injury.

View larger version (133K): [in this window] [in a new window]   Fig. 7-C: Metal fragments, shoe leather, and an unattached bone fragment removed at the primary surgery.

View larger version (83K): [in this window] [in a new window]   Fig. 7-D: Kirschner wire spacers placed during secondary surgery maintained metatarsal length until a subsequent bone-graft procedure was performed.

Penetrating fragments can cause spinal cord or cauda equina injury, and, if there is concomitant bowel injury, the risk of infection is high ¹⁰¹ . The injuries should be treated surgically with concomitant use of antibiotics. Rautio and Paavolainen observed that spinal cord injury can occur even if fragments do not enter the spinal canal or cause apparent vertebral damage ⁶⁶ .

Rehabilitation
The importance of timely rehabilitation following severe blast and fragment injuries cannot be overemphasized. In a series of forty-one patients treated for blast injuries in a field hospital during the 1991 to 1995 Balkans War, my colleagues and I found that physiotherapist-supervised early mobilization, gait training, range of motion, and strengthening exercises were important to enable patients to return to functional activities ⁵¹ . Physical therapy and special orthotics have been successful in facilitating walking by patients treated with foot salvage following a land mine injury ¹⁰² .

Overview

Fragments from the detonation of explosive ordnance are the most prevalent wounding agents causing military casualties during combat. These injuries are also being seen with increasing frequency in the civilian setting as a result of an upsurge in terrorist bombings. In warfare, the limbs are the anatomical regions most commonly injured by explosive munitions, and, as a result of the increasing use of modern body armor, this preponderance of extremity injuries had increased relative to the incidence of thoracoabdominal wounds.

Orthopaedic surgery for blast and fragment injuries is often performed under conditions that differ radically from those of normal civilian practice. It is often necessary to treat these injuries under field or other austere conditions, in circumstances far removed from that of modern trauma centers ¹⁰³ . Severe contamination and delayed medical evacuation are often the norm. The quality of care provided for patients with blast and fragment injuries depends on following the basic tenets of war wound surgery, which include meticulous wound débridement, adequate drainage, immobilization, delayed wound coverage or closure, and appropriate antibiotics. Early internal fixation techniques used in trauma centers to treat predominantly blunt trauma may have limited applicability in the care of war wounds in the field setting, where supply, equipment, and personnel resources are constrained. External fixation, Kirschner wires, plaster of paris, and traction are often the mainstays for providing skeletal stability and facilitating soft-tissue healing.

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