In reality there is no way to separate today’s surgery and our practice from the experiences of all the surgeons who have preceded us.Ira M. Rutkow

Advanced trauma life support principles guide all facets of care, including traumatic amputations and mangled extremity injuries. It is easy for the medical team to be distracted by major extremity war injuries, but principles of controlling hemorrhage, securing airway and breathing, and ATLS secondary surveys remain the cornerstone of initial treatment. It is important for orthopaedic and limb surgeons to support and direct the priorities of initial trauma care.

To this end, early application of tourniquets for hemorrhage control is a mainstay of wartime trauma care. Limb-threatening injuries due to blast effects can lead to massive hemorrhage and quickly become life-threatening injuries. This can occur through characteristic pulsatile bleeding from an arterial injury or sustained low pressure bleeding from venous sources, injured muscle, and fractures. While civilian trauma care approaches tourniquet use as a treatment of last resort, in the combat setting, tourniquets are applied early and often. Orthopaedic and trauma surgeons can encourage and support the use of tourniquet application by first responders/field medics to help preserve both life and limb.

Initial trauma care for patients with mangled extremities and amputations is to stop the bleeding. A well-applied tourniquet can control hemorrhage immediately. Additionally, the application of topical hemostatic dressings and compression dressings can aid in controlling less profound sources of blood loss. If initial surveys determine hemorrhage cannot be controlled once a tourniquet is released, then surgical control is the only option. Initial resuscitation should include judicial use of blood product replacement. Most patients with traumatic amputation or mangled limbs present with significant loss of blood volume. The typical combat casualty is young and healthy and will have significant reserve but will crash physiologically once they lose a critical amount of blood. Replacement with intravenous fluids most often is inadequate, therefore many times patients require the use of multiple units of packed red blood cells, plasma, platelets (often recommended as a “pack” of 4 units pRBCs, 4 units FFP, and 1 “6 pack” of platelets per mangled/amputated limb), and occasionally whole blood.

For mangled extremities and traumatic amputations , administer tetanus toxoid and a first-generation cephalosporin early in the the patient’s resuscitation. Studies from civilian trauma centers support the most important factor in preventing infections in open fractures is time from injury to administration of antibiotics [5]. Surveillance data from the Joint Theater Trauma Registry has demonstrated that administration of additional antibiotics to include aminoglycosides and/or penicillin actually leads to increased infection rates over the ensuing days and weeks of treatment [6]. If the patient is stable for transport, go to the OR. However, trauma bay debridement focused on removing gross contamination, copious amounts of irrigation with sterile saline, and application of a sterile dressing should be accomplished. The use of supplements such as antibiotics and soaps in irrigation solutions has demonstrated increased wound complications and infection rates, so sterile saline is the best solution of choice for irrigation [7]. Do not forget splints if time/situation permits. This can decrease pain and blood loss.

In combat trauma, teams often must operate on multiple sites at the same time. Prep the entire body, including all involved extremities, so that all teams may operate simultaneously. This will save significant time and resources and get the patient to the ICU/recovery in rapid fashion. Before removing field tourniquets, apply a pneumatic tourniquet above the site of injury. If needed, prep the field tourniquet into the sterile field prior to removal to minimize blood loss between the time of tourniquet removal and surgical control. The first operation is damage control: control hemorrhage and debride the wound. A therapeutic amputation may need to be considered at this time for both hemorrhage control and to stabilize the patient in extremis. If required, proceed rapidly and without delay. Use a tourniquet, remove the limb, identify vascular structures, and suture ligate with stout “stick ties.” 0 silk works well. For large vessels, consider double ligature. Tag large nerves for later revision if identified.

The keys to successful management of open fractures are early antibiotics, temporary stabilization, and irrigation and debridement (I&D) of wounds that is repeated until a clean wound bed is established, followed by eventual definitive stabilization and closure. Early fracture stabilization has multiple benefits in physiologically stabilizing the distressed trauma patient. It will significantly decrease fracture-related pain and can often stop bony and soft tissue blood loss. It will decrease the systemic inflammatory response and may provide protection against fat embolization. In addition, the surrounding neurovascular structures will be protected from further injury due to mechanical instability. Appropriate stabilization is absolutely required before mobilization or transportation to another facility.

There is no consensus on timing for open fracture irrigation and debridement, timing on fixation, amount of irrigation to use, or how long to prescribe antibiotics. Common practice that is supported in the literature, based on Joint Theater Trauma System data, is urgent administration of antibiotics (upon arrival in the trauma bay/prior to surgical intervention) and debridement and irrigation of open wounds as soon as possible. Low-pressure, high-flow irrigation with normal saline is the best choice for irrigation.

It is important to take open fractures or potentially open fractures to the OR for debridement and provisional stabilization. There is no practical role for culturing acute fracture wounds. Repeat irrigation and debridement of open fractures every 24–48 h or arranging for that to be done through the evacuation chain is the standard of care. Consider performing an irrigation and debridement on the day of transfer to a higher level of care to accommodate potential delays during transport. Clearly mark the dressing with the date of the last operative debridement so that colleagues who receive the patient will be aware of the last intervention.

Occasionally, it can be difficult to determine whether a fracture is truly open or is closed with a local abrasion. There is a fair amount of disagreement regarding how to treat these. In the combat environment , treat them as open fractures until proven otherwise.

It is common to encounter injured nerves and tendons during exploration and debridement of extremity wounds. It may be difficult to distinguish tendon from nerve; inspecting the cut end (after debriding devitalized segments) will help with identification: nerves will be yellow-white and contain multiple round fibers, while tendons will be blue-white and have cross-hatching (like wood). Blast injuries in war trauma typically result in massive wounds with significant contamination and nonviable tissue, so there is little role for immediate primary repair. Tendon repairs can wait until the wound is cleaner, and most combat nerve injuries will be repaired in a delayed fashion. In general, leave hand tendon repairs for someone with specialized training. Tag the ends of the nerve for easy identification later.

Occasionally, one will encounter a very clean and sharp major nerve transection suitable for immediate primary repair with no orthopaedic surgeon or neurosurgeon immediately available. Common examples are median or ulnar nerve transections (often associated with brachial artery injuries). In these cases, align the ends of the nerve properly, sharply debride the ends to a clean edge, and reapproximate the epineurium only using fine Prolene (6–0) or nylon sutures (Fig. 20.1). Ensure adequate tissue coverage of the repair. Splint or stabilize the extremity in some degree of flexion to prevent tension and motion at the repair site. It will take months to determine the success of repair and ultimate degree of return of function.

Much attention is given to compartment syndrome and fasciotomies when discussing combat trauma , with emphasis focused on never missing a potential or existing compartment syndrome. Some have advocated using a very lowh threshold to perfom fasciotomies, particularly on patients with extremity injury who are being placed into the evacuation chain.

Management of compartment syndrome, even in war trauma , needs to be indicated. Fear of missing a compartment syndrome should not drive a surgeon to perform fasciotomies “just to be safe.” Indications for compartment fasciotomies are certainly indicated in patients with tense compartments that are easily noted with palpation and described as noncompressible or “woody hard.” Other indications are in alert patients with pain out of proportion and pain with passive stretch, as well as patients with reperfusion of a previously dysvascular limb when intensive care observation is not available. Some discussion has focused on performing prophylactic fasciotomies on patients prior to transfer to higher echelons of care. It should be remembered that lower limb fasciotomies will be associated with a 25% complication rate in regard to sensory function, wound complications, and infection, as well as cause potential need for skin graft, and can complicate definitive fixation options. When hard signs and symptoms are present, there should be no hesitation on the surgeon’s part to perform emergent fasciotomies. If transfer time between levels of care is greater than 4 h and patients are at reasonable risk of developing a compartment syndrome in transit, then fasciotomies may be indicated in this situation. However, when short transfer times are available or the capacity to hold a patient for 24 h of observation exists, then close observation and clear communication with the receiving surgeon are likely to be of greater benefit to the patient. See Chap. 19 for detailed review of extremity fasciotomy techniques.

As a final word regarding compartment syndrome, strongly resist the urge to release a missed compartment syndrome. If receiving a patient and time of injury or time of onset of compartment syndrome is unknown, or if it is uncertain that onset occurred less than 8–12 h ago, it is best to not perform fasciotomies. Experience in the Global War on Terror has demonstrated a threefold increase in mortality and twofold increase in amputation rate when fasciotomies are performed on delayed or missed compartment syndromes [8]. Please recognize the chance to intervene to save function has passed, and opening a necrotic compartment will likely harm the patient. In these cases, splint the affected extremity, treat pain, monitor renal function, and ensure appropriate hydration occurs to prevent renal damage from the onset of myoglobinuria.

The decision to amputate can be agonizing. There are generally two absolute indications for amputations in wartime surgery: