Traumatic Amputations

Abstract

With continued improvement in body armor and ballistic helmets as well as advances in modern combat casualty care, more and more combat casualties will survive following injury long enough to be resuscitated; therefore, the severity of extremity injuries among survivors of combat injuries will likely continue to increase. The primary mechanism for these injuries is blast and penetrating trauma, which is an unusual mechanism of injury in civilian medicine, even at Level I trauma centers. This must be understood in the context of overall patient management due to the systemic effects of blast and also in the management of the traumatic amputation when assessing the zone one injury in the injured extremities. Trauma surgery in a combat zone requires adaptation to a different injury paradigm.

Civilian Translation of Military Experience and Lessons Learned

• James C. Krieg 

While written for the military surgeon working in a forward position setting, this chapter on traumatic amputations provides many pearls of wisdom for civilian surgeons. The authors have done an excellent job of summarizing the current standard of care for lower limb-threatening injuries.

Context is important in guiding treatment of limb-threatening trauma . In a military setting, the vast majority of the patients will be young and physiologically fit. In that regard they are likely to be patients with the maximal ability to heal and recover from a physical perspective. In the present situation, they also have access to healthcare and follow-up treatment that is arguably among the best available to anyone in the world. In a civilian population, patients may be predominantly younger and male, but will obviously represent a more diverse group. This demographic includes a wider representation of age, medical comorbidities, social support, and access to care in the acute and recovery phases.

The authors point out the unique nature of polytrauma and survivorship in the military. Most of the injuries will be due to blast injury or high-energy penetrating trauma. Advances in body armor and vehicle reinforcement have improved protection from injury, but the overall picture of severe limb-threatening injury, often in the face of life-threatening blast injury, remains. In the civilian world, improved automobile safety and improved access to early trauma care as a result of trauma system organization have improved survivorship from polytrauma. One of the ironies of trauma care in both settings is that improved survivorship has increased the challenge of dealing with severe limb-threatening injuries.

Several aspects of trauma care have not translated readily from the military into the civilian population. One of those is the widespread use of tourniquets in early management of life-threatening hemorrhage from limb trauma. This may be due in part to the unique nature of blast injuries. Unlike blunt trauma or low-energy penetrating trauma, high-energy blast injuries are often not controllable by pressure alone. As a result, the use of tourniquets in the military has become popular and been proven to be quite effective. Whether due to the perceived risk of tourniquet use, an historical bias, or the availability of simpler means of hemorrhage control, such as pressure application, tourniquet use in civilian trauma is still relatively rare.

Despite the differences in limb trauma in the military and civilian settings , the common themes are much more significant, and lessons learned in one venue provide valuable lessons in the other. First and foremost, trauma care is a team effort, and care must be coordinated and cohesive. Like the tenents of ATLS, evaluation and treatment must be coordinated, simultaneous and continuous. The authors remind us that in the military care, it is often provided by multiple teams providing care in parallel. These principles are true across all spectrums of trauma care and remind care providers that life comes before limb, but often the care of severe limb trauma can be lifesaving.

Another principle that has been learned through the recent military experience in lower extremity amputation is that length should be preserved, even if it means managing a fracture above the level of amputation. This seems to run counter too much of the conventional wisdom in trauma care, and the lessons learned should be shared. Prosthetic design has changed much of the old thinking about hindfoot amputations in particular, with the use of the Intrepid Dynamic Exoskeletal Orthosis (IDEO ).

General principles hold true and are summarized quite well by Puttler, Parada, Horne, and Robins. These include early management of hemorrhage, systematic wound debridement, skeletal stabilization, and staged comprehensive reconstruction. Often this means a team approach. Technical pearls of amputation are also well summarized and apply to amputation done in any setting.

Despite the obvious differences in military and civilian care, the similarities and shared lessons are more significant. They provide all healthcare professionals with valuable lessons learned. Those lessons are well summarized here.