War Wounds of the Foot and Ankle: Causes, Characteristics, and Initial Management

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Cause

Although the signature weapon used by insurgents in the current conflicts has been the explosion (in its many forms), most battle casualties have been caused by small arms fire when both coalition and insurgent casualties are taken together. This combination of wounding methods has led to unique challenges. Much “wisdom” in the treatment of wounds caused by high-velocity small arms fire is flawed. Compounding this was a lack of experience before the current wars among United States military

Tissue Effects

Different tissues have different susceptibility to projectile damage. This has been well characterized with well-controlled empiric studies.

Bone

Bone is unable to deform and return to its initial state after interaction with projectiles. Because there is a high percentage of energy transfer from the projectile to the bone, fractures commonly result, even from relatively low-energy injuries. The speed at which a projectile must travel to penetrate skin is 163 ft/s and to break bone is 200 ft/s, both

The Combat Casualty in Global War on Terror

The care and transport of patients presently used by US Department of Defense Forces in the global war on terror has grown out of a medical modernization plan put together by the Office of the Army Surgeon General following Operations Desert Shield and Desert Storm.13 This modernization was termed “Medical Force 2000.” It is a hierarchical system of patient care and transport organized into five echelons or levels (Fig. 9). In-theater musculoskeletal care is centered around the principles of

Summary

There are many challenges inherent in caring for battlefield injuries to the foot and ankle. Optimal treatment for these injuries continues to change over time. Newer techniques in the management of massive soft tissue and bony wounds will help to restore the best possible function. These include early damage control surgery, modern limb salvage techniques, and SAWD. The current wars in Iraq and Afghanistan will continue to provide a stimulus for advances in the treatment of high-energy,

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      If the provider felt the condition could be treated in less than 14 days and a service member could return to his or her unit than the member remained at Landstuhl. If the injury could not be treated and healed within that 14-day window, then the patient was evacuated to the Level V facilities at Walter Reed Army Medical Center (East Coast), Brooke Army Medical Center (Central U.S.) or Naval Medical Center San Diego (West Coast) (2). During World War II, at the hospitals in the Mediterranean Theater of Operations, compound fractures of the bones of the foot made up from 18% to 20% of all compound fractures managed in general hospitals.

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      A crude calculation using both studies would show that looking only at the foot injuries (excluding toe fractures) about 1% of all foot injuries is an open fracture, making it a rare injury. In war time, up to 12% to 22% of injuries are foot related.3,4 A complex trauma to the foot is associated with polytrauma or multiple injury in 22% to 50% of cases, making the management of these injuries an even greater challenge.5–8

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      The relationship has also been recognized in the combat injured; in 2011, Ramasamy et al. [8] reported a 30% incidence of spine fractures in UK soldiers sustaining calcaneal fractures from improvised explosive devices (IEDs) in combat operations in Iraq and Afghanistan. This blast pattern of injury is not unique to OIF/OEF and has been acknowledged in conflicts dating back through World War II [8,11]. In the current OIF/OEF conflicts, the typical blast injury results from an explosion originating beneath a target that transmits energy through the lower extremities and into the axial skeleton [8,12].

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      Experience during recent international conflicts has led armed forces around the world to adapt a policy of so-called damage-control orthopaedics, a surgical treatment protocol that includes immediate stabilization, usually in forward field hospitals, of complex open musculoskeletal limb and pelvic injuries with external fixation (combined with aggressive wound debridement and open treatment of soft-tissue wounds), followed by prompt evacuation to larger facilities for definitive management31,32. In some cases, a temporary external fixator spans the area of injury, especially when internal fixation is contemplated as part of the final reconstruction of the injured bones33. In other cases, however, external fixation may remain in place, or may be modified secondarily, when such treatment is appropriate, particularly when a large segmental bone defect exists, either in isolation or in combination with concomitant soft-tissue loss.

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