Skip to main content

Advertisement

SpringerLink
Log in

Challenges in definitive fracture management of blast injuries

  • Gunshot Wounds and Blast Injuries (D Stinner and MK Sethi, Section Editors)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

The United States military remains engaged in the longest armed conflict in this nation’s history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Belmont PJ et al. Combat wounds in Iraq and Afghanistan from 2005 to 2009. J Trauma Acute Care Surg. 2012;73(1):3–12.

    Article  PubMed  Google Scholar 

  2. Weil YA et al. Penetrating and orthopedic trauma from blast versus gunshots caused by terrorism: Israel’s National Experience. J Orthop Trauma. 2011;25(3):145–9.

    Article  PubMed  Google Scholar 

  3. Champion HR et al. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma. 2009;66(5):1468–77.

    Article  PubMed  Google Scholar 

  4. Simmons JW et al. Mechanism of injury affects acute coagulopathy of trauma in combat casualties. J Trauma. 2011;71(1):S74–7. This retrospective review of US military casualties demonstrated that despite similar ISS scores, patients injured by blast mechanism had a higher INR, more tachycardia, and a higher base deficit. This supports the concept that blast injury is a clinically distinct entity, and understanding the acute coagulopathy of trauma is key to maximizing survival and minimizing complications.

    Article  PubMed  Google Scholar 

  5. Doran CM et al. Feasibility of using rotational thromboelastometry to assess coagulation status of combat casualties in a deployed setting. J Trauma. 2010;69(1):S40–8.

    Article  PubMed  Google Scholar 

  6. Kutcher ME et al. Criteria for empiric treatment of hyperfibrinolysis after trauma. J Trauma Acute Care Surg. 2012;73(1):87–93. This useful article reviews the etiology of hyperfibrinolysis after trauma and provides empiric criteria for its diagnosis using readily available standard laboratory tests.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  7. Ramasamy A et al. The open blast pelvis: the significant burden of management. J Bone Joint Surg (Br). 2012;94-B(6):829–35.

    Article  Google Scholar 

  8. Jansen JO et al. Early management of proximal traumatic lower extremity amputation and pelvic injury caused by improvised explosive devices (IEDs). Injury. 2012;43(7):976–9. This review of complex blast injured patients provides a thorough, rational, stepwise approach to acute management. It stresses management of the systemic injury as well as the need for coordinated teamwork across surgical services.

    Article  CAS  PubMed  Google Scholar 

  9. Bowyer GW. Management of small fragment wounds: experience from the Afghan border. J Trauma Acute Care Surg. 1996;40(3S):S170–2.

    Article  CAS  Google Scholar 

  10. Bowyer GW et al. Small fragment wounds: biophysics and pathophysiology. J Trauma. 1996;40(3S):S159–64.

    Article  CAS  PubMed  Google Scholar 

  11. Yi C et al. Intraoperative fluoroscopic evaluation of screw placement during pelvic and acetabular surgery. J Orthop Trauma. 2014;28(1):48–56.

    Article  PubMed  Google Scholar 

  12. Lethaby A, et al. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database. 2013.

  13. Friedman J et al. Transarticular K-wire fixation of critical ankle injuries at risk: a neglected “damage control” strategy. Orthopedics. 2015;38(2):122–7.

    Article  PubMed  Google Scholar 

  14. Henry SL et al. The antibiotic bead pouch technique: the management of severe compound fractures. Clin Orthop Relat Res. 1993;295:54–62.

    PubMed  Google Scholar 

  15. Prasarn ML et al. Wound management of severe open fractures: antibiotic bead pouches and vacuum-assisted closure. Am J Orthop. 2009;38(11):559–63.

    PubMed  Google Scholar 

  16. Balsamo LH et al. Does antibiotic elution from PMMA beads deteriorate after 1-year storage? Clin Orthop Relat Res. 2007;462:195–9.

    Article  PubMed  Google Scholar 

  17. Fleischmann et al. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg. 1993;96(9):489–92.

    Google Scholar 

  18. Pollak AN et al. Use of negative pressure wound therapy with reticulated open cell foam for lower extremity trauma. J Orthop Trauma. 2008;22:S142–5.

    Article  PubMed  Google Scholar 

  19. Hinck D et al. Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries-literature review. Mil Med. 2010;175(3):173–81.

    Article  PubMed  Google Scholar 

  20. Stannard JP et al. Incisional negative pressure wound therapy after high risk lower extremity fractures. J Orthop Trauma. 2012;26(1):37–42.

    Article  PubMed  Google Scholar 

  21. Doucet JJ et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma Acute Care Surg. 2011;70(5):1241–7.

    Article  Google Scholar 

  22. Turchin DC et al. Do foot injuries significantly affect the functional outcome in multiply injured patients? J Orthop Trauma. 1999;13(1):1–4.

    Article  CAS  PubMed  Google Scholar 

  23. Ferreira RC et al. Long-term results of salvage surgery for severely injured feet. Foot Ankle Int. 2010;31(2):113–23.

    Article  PubMed  Google Scholar 

  24. Ramasamy A et al. The modern “deck slap” injury—calcaneal blast fractures from vehicle explosions. J Trauma Acute Care Surg. 2011;71(6):1694–8.

    Article  Google Scholar 

  25. Ellington JK et al. The mangled foot and ankle: results from a 2-year prospective study. J Orthop Trauma. 2013;27(1):43–8. In this prospective longitudinal study involving eight Level-1 trauma centers, the authors compared multiple outcome variables between patients who received limb salvage vs early amputation. At two year followup, the patients who required free flap coverage or acute fusion procedures had poorer outcomes than those who did not require flap coverage or those with early BKA. This article provides clear outcome data to inform the amputation vs salvage decision.

    Article  PubMed  Google Scholar 

  26. Hegelson MD et al. Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 2007;21(6):394–9.

    Article  Google Scholar 

  27. Fleming ME et al. Application of the orthoplastic reconstruction ladder to preserve lower extremity amputation length. Ann Plast Surg. 2014;73(2):183–9.

    Article  CAS  PubMed  Google Scholar 

  28. Kumar AR et al. Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg. 2009;123(1):218–29.

    Article  CAS  PubMed  Google Scholar 

  29. Burns TC et al. Does the zone of injury in combat-related type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma. 2010;24(11):697–703.

    Article  PubMed  Google Scholar 

  30. Tintle SM et al. Soft tissue coverage of combat wounds. J Surg Orthop Adv. 2010;19(1):29–34.

    PubMed  Google Scholar 

  31. Tintle SM et al. Traumatic and trauma-related amputations part I: lower extremity and general principles. J Bone Joint Surg Am. 2010;92(17):2852–68.

    Article  PubMed  Google Scholar 

  32. Owens BD et al. Combat wounds in operation Iraqi freedom and operation enduring freedom. J Trauma Acute Care Surg. 2008;64(2):295–9.

    Article  Google Scholar 

  33. Laurence VG et al. External tissue expanders as adjunct therapy in closing difficult wounds. J Plast Reconstr Aesthet Surg. 2012;65(10):e297–9.

    Article  PubMed  Google Scholar 

  34. Formby P et al. Use of a continuous external tissue expander in the conversion of a type IIIB fracture to a type IIIA fracture. Orthopedics. 2013;36(2):e249–51.

    Article  PubMed  Google Scholar 

  35. Lerner AL et al. Acute shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities. J Trauma Acute Care Surg. 2004;57(3):603–8.

    Article  Google Scholar 

  36. Beltran MJ et al. Composite bone and soft tissue loss treated with distraction histiogenesis. J Surg Orthop Adv. 2010;19(1):23–8.

    PubMed  Google Scholar 

  37. Keeling JJ et al. Short term outcomes of severe open wartime tibial fractures treated with ring external fixation. J Bone Joint Surg Am. 2008;90(12):2643–51.

    Article  PubMed  Google Scholar 

  38. Gordon WT et al. Outcomes associated with the internal fixation of long-bone fractures proximal to traumatic amputations. J Bone Joint Surg Am. 2010;92(13):2312–8.

    Article  PubMed  Google Scholar 

  39. Wagner SC, et al. Retrograde intramedullary fixation of long bone fractures through ipsilateral traumatic amputation sites. J Orthop Trauma. 2014.

  40. Tintle SM et al. Reoperation after combat-related major lower extremity amputations. J Orthop Trauma. 2014;28(4):232–7.

    Article  PubMed  Google Scholar 

  41. Yun HC et al. Osteomyelitis in military personnel wounded in Iraq and Afghanistan. J Trauma Acute Care Surg. 2008;64(2):S163–8.

    Article  Google Scholar 

  42. Rodriguez CJ et al. Infectious disease clinical research program trauma infectious disease outcomes study group. Surg Infect. 2014;15(5):521–6. doi:10.1089/sur.2013.123.

    Article  Google Scholar 

  43. Lewandowski L et al. Early complications and outcomes in combat injury related invasive fungal wound infections. Mil Med. 2013;178(4):e503–7.

    Article  PubMed  Google Scholar 

  44. Barsoumian A et al. In vitro toxicity and activity of Dakin’s solution, mafenide acetate, and amphotericin B on filamentous fungi and human cells. J Orthop Trauma. 2013;27(8):428–36. doi:10.1097/BOT.0b013e3182830bf9.

    Article  PubMed  Google Scholar 

  45. Kluk MW et al. Fibroregulation of mesenchymal progenitor cells by BMP-4 after traumatic muscle injury. J Orthop Trauma. 2012;26(12):693–8.

    Article  PubMed  Google Scholar 

  46. Forsberg JA et al. Heterotopic ossification in high-energy wartime extremity injuries: prevalence and risk factors. J Bone Joint Surg Am. 2009;91(5):1084–91.

    Article  PubMed  Google Scholar 

  47. Potter BK et al. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am. 2007;89(3):476–86.

    Article  PubMed  Google Scholar 

  48. Potter BK et al. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am. 2010;92 Suppl 2:74–89.

    Article  PubMed  Google Scholar 

  49. Evans KN et al. Outcomes of manipulation under anesthesia versus surgical management of combat-related arthrofibrosis of the knee. J Surg Orthop Adv. 2013;22(1):36–41.

    Article  PubMed  Google Scholar 

  50. Stinner DJ et al. Prevalence of late amputations during the current conflicts in Afghanistan and Iraq. Mil Med. 2010;175(12):1027.

    Article  PubMed  Google Scholar 

  51. Helgeson MD, Potter BK, Burns TC, Hayda RA, Gajewski DA. Risk factors for and results of late or delayed amputation following combat-related extremity injuries. Orthopedics. 2010;33(9):669.

    PubMed  Google Scholar 

  52. Huh J et al. Infectious complications and soft tissue injury contribute to late amputations. J Trauma Acute Care Surg. 2011;71(1):S47–51.

    Article  Google Scholar 

  53. Bedigrew KM et al. Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma? Clin Orthop Relat Res. 2014;472(10):3017–25.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Kevin Kuhn, Greg Staeheli, and David Dromsky declare that they have no conflict of interest. Wade Gordon reports personal fees from Orthofix, Ltd.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Walter Reed National Military Medical Center, Bethesda, MD, USA

    Wade Gordon

  2. Naval Medical Center San Diego, San Diego, CA, USA

    Kevin Kuhn, Greg Staeheli & David Dromsky

Authors
  1. Wade Gordon
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kevin Kuhn
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Greg Staeheli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Dromsky
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Dromsky.

Additional information

This article is part of the Topical Collection on Gunshot Wounds and Blast Injuries

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gordon, W., Kuhn, K., Staeheli, G. et al. Challenges in definitive fracture management of blast injuries. Curr Rev Musculoskelet Med 8, 290–297 (2015). https://doi.org/10.1007/s12178-015-9286-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-015-9286-7

Keywords

Search

Navigation