Soft-Tissue Reconstructive Considerations in the Damage Control Environment

  • Graham LawtonEmail author


Trauma is a leading cause of mortality and morbidity accounting for 11% of the global burden of disease [1]. Worldwide 16,000 people succumb to injuries everyday [2] with a similar number of fatalities every year in England and Wales as described by the Office for National Statistics, London, in 2011. For every trauma death, there are two survivors with serious and debilitating injuries. In 2004, approximately 30 million Americans were treated for a nonfatal injury in emergency medicine departments, of these, 2 million required in-patient care [3]. In the landmark 1985 publication Injury in America, one in every eight hospital beds was occupied by an injured patient.


Damage control Damage control reconstructive surgery Debridement Degloving Limb decompression Topical negative pressure Fasciotomy 


  1. 1.
    Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380(9859):2197–223.CrossRefPubMedCentralGoogle Scholar
  2. 2.
    Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000;90(4):523–6.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Thacker SB, Stroup DF, Carande-Kulis V, Marks JS, Roy K, Gerberding JL. Measuring the public's health. Public Health Rep. 2006;121(1):14–22.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev. 2006;12(4):212–8.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L, Flint L. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60(2):371–8. discussion 378CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Minei JP, Fabian TC, Guffey DM, Newgard CD, Bulger EM, Brasel KJ, et al. Increased trauma center volume is associated with improved survival after severe injury: results of a resuscitation outcomes consortium study. Ann Surg. 2014;260(3):456–64. discussion 464-5CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Duchesne JC, Kimonis K, Marr AB, Rennie KV, Wahl G, Wells JE, et al. Damage control resuscitation in combination with damage control laparotomy: a survival advantage. J Trauma. 2010;69(1):46–52.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Wood FM. Quality assurance in burn patient care: the James Laing memorial essay, 1994. Burns. 1995;21(8):563–8.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Maitland L, Lawton G, Baden J, Cubison T, Rickard R, Kay A, Hettiaratchy S. The role of military plastic surgeons in the management of modern combat trauma: an analysis of 645 cases. Plast Reconstr Surg. 2016;137(4):717e–24e.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Klem C, Sniezek JC, Moore B, Davis MR, Coppit G, Schmalbach C. Microvascular reconstructive surgery in operations Iraqi and enduring freedom: the US military experience performing free flaps in a combat zone. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):S228–32.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Coupland RM. Technical aspects of war wound excision. Br J Surg. 1989;76(7):663–7.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Coupland RM. The role of reconstructive surgery in the management of war wounds. Ann R Coll Surg Engl. 1991;73(1):21–5.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Jackson DS. Sepsis in soft tissue limbs wounds in soldiers injured during the falklands campaign 1982. J R Army Med Corps. 1984;130(2):97–9.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Stephens CT, Gumbert S, Holcomb JB. Trauma-associated bleeding: management of massive transfusion. Curr Opin Anaesthesiol. 2016;29(2):250–5.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Clasper J, Lower Limb Trauma Working Group. Amputations of the lower limb: a multidisciplinary consensus. J R Army Med Corps. 2007;153(3):172–4.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38(8):879–89.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94(12):1057–64.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Srour M, Inaba K, Okoye O, Chan C, Skiada D, Schnüriger B, et al. Prospective evaluation of treatment of open fractures: effect of time to irrigation and debridement. JAMA Surg. 2015;150(4):332–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006;88(3):351–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clin Orthop Relat Res. 2005;439:27–31.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am. 2009;91(1):92–8.CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Evriviades D, Jeffery S, Cubison T, Lawton G, Gill M, Mortiboy D. Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the royal centre for defence medicine. Philos Trans R Soc Lond B Biol Sci. 2011;366(1562):219–30.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Jacobson C, Osmon DR, Hanssen A, Trousdale RT, Pagnano MW, Pyrek J, et al. Prevention of wound contamination using duraprep solution plus ioban 2 drapes. Clin Orthop Relat Res. 2005;439:32–7.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Yang CC, Chang DS, Webb LX. Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg. J Surg Orthop Adv. 2006;15(1):19–23.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Stannard JP, Volgas DA, Stewart R, McGwin G, Alonso JE. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma. 2009;23(8):552–7.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Arnez ZM, Khan U, Tyler MP. Classification of soft-tissue degloving in limb trauma. J Plast Reconstr Aesthet Surg. 2010;63(11):1865–9.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Glass GE, Nanchahal J. Why haematomas cause flap failure: an evidence-based paradigm. J Plast Reconstr Aesthet Surg. 2012;65(7):903–10.CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    McGrouther DA, Sully L. Degloving injuries of the limbs: long-term review and management based on whole-body fluorescence. Br J Plast Surg. 1980;33(1):9–24.CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Owens BD, Kragh JF, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in operation iraqi freedom and operation enduring freedom. J Trauma. 2008;64(2):295–9.CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Banerjee M, Bouillon B, Shafizadeh S, Paffrath T, Lefering R, Wafaisade A, German Trauma Registry Group. Epidemiology of extremity injuries in multiple trauma patients. Injury. 2013;44(8):1015–21.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Balogh ZJ, Reumann MK, Gruen RL, Mayer-Kuckuk P, Schuetz MA, Harris IA, et al. Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 2012;380(9847):1109–19.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005;36(6):691–709.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Gabbe BJ, Simpson PM, Sutherland AM, Wolfe R, Lyons RA, Cameron PA. Evaluating time points for measuring recovery after major trauma in adults. Ann Surg. 2013;257(1):166–72.CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Wordsworth M, Lawton G, Nathwani D, Pearse M, Naique S, Dodds A, et al. Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of major trauma networks and national guidelines. Bone Joint J. 2016;98-B(3):420–4.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Labbe R, Lindsay T, Walker PM. The extent and distribution of skeletal muscle necrosis after graded periods of complete ischemia. J Vasc Surg. 1987;6(2):152–7.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Glass GE, Staruch RM, Simmons J, Lawton G, Nanchahal J, Jain A, Hettiaratchy SP. Managing missed lower extremity compartment syndrome in the physiologically stable patient: a systematic review and lessons from a level I trauma center. J Trauma Acute Care Surg. 2016;81(2):380–7.CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Taylor CJ, Hettiaratchy S, Jeffery SL, Evriviades D, Kay AR. Contemporary approaches to definitive extremity reconstruction of military wounds. J R Army Med Corps. 2009;155(4):302–7.CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285–92.CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Hildebrand F, Giannoudis P, Kretteck C, Pape HC. Damage control: extremities. Injury. 2004;35(7):678–89.CrossRefPubMedCentralPubMedGoogle Scholar
  40. 40.
    Pape H, Stalp M, Weinberg A, Dahlweit M, Tscherne H. Optimal timing for secondary surgery in polytrauma patients: an evaluation of 4,314 serious-injury cases. Der Chirurg; Zeitschrift Fur Alle Gebiete Der Operativen Medizen. 1999;70(11):1287–93.CrossRefPubMedCentralPubMedGoogle Scholar
  41. 41.
    Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy: worse or worth? J Plast Reconstr Aesthet Surg. 2009;62(5):675–83.CrossRefPubMedCentralPubMedGoogle Scholar
  42. 42.
    Pidcoke HF, Aden JK, Mora AG, Borgman MA, Spinella PC, Dubick MA, et al. Ten-year analysis of transfusion in operation Iraqi freedom and operation enduring freedom: increased plasma and platelet use correlates with improved survival. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S445–52.CrossRefPubMedCentralPubMedGoogle Scholar
  43. 43.
    Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1–79.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Valerio IL, Campbell P, Sabino J, Lucas DJ, Jessie E, Rodriguez C, Fleming M. TXA in combat casualty care: does it adversely affect extremity reconstruction and flap thrombosis rates? Mil Med. 2015;180(3 Suppl):24–8.CrossRefPubMedCentralPubMedGoogle Scholar
  45. 45.
    Lewis CJ, Li P, Stewart L, Weintrob AC, Carson ML, Murray CK, et al. Tranexamic acid in life-threatening military injury and the associated risk of infective complications. Br J Surg. 2016;103(4):366–73.CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Fox CJ, Mehta SG, Cox ED, Kragh JF, Salinas J, Holcomb JB. Effect of recombinant factor viia as an adjunctive therapy in damage control for wartime vascular injuries: a case control study. J Trauma. 2009;66(4 Suppl):S112–9.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Academic Department Military Surgery and Trauma, Honorary Clinical Senior Lecturer Imperial CollegeImperial College Healthcare NHS Trust, St Mary’s HospitalLondonUK

Personalised recommendations