Foot and Ankle Clinics Vol 15 No 1 2010

Traumatic Foot and Ankle Injuries Related to Recent International Conflicts
Edited by Eric M. Bluman and James R. Ficke
5.
War Wounds of the Foot and Ankle: Causes, Characteristics, and Initial Management Pages 1-21 Eric M. Bluman, James R. Ficke, Dana C. Covey
Graphical Abstract
Foot and ankle trauma sustained in the Global War on Terror have unique causes and characteristics. At least one-quarter of all battle injuries involve the lower extremity. These severe lower extremity wounds require specialized early treatment. Ballistic mechanisms cause almost all injuries, and as such, most combat foot and ankle wounds are open in nature. Wounds are characteristically caused by blast mechanisms, but high velocity gunshot injuries are also common. The severe and polytraumatic nature of injuries sustained frequently call for damage control orthopaedics to be utilized. Cautious early treatment of irregular and highly exudative ballistic wounds with subatmospheric wound dressings may ease their early management.
6.
Use of Tourniquets and Their Effects on Limb Function in the Modern Combat Environment Pages 23-40 John F. Kragh Jr.
Graphical Abstract
Tourniquets have been called powerful lifesaving devices by some authors, whereas others say they cause more harm than good. Given recent emergency tourniquet developments in scientific design of devices, widespread user training, modern doctrine based on evidence, and thorough fielding to users within an integrated trauma system with rapid evacuation, tourniquets have shown minor morbidity and major lifesaving results. Trauma systems with poorly designed devices, inadequate user training, no tourniquet doctrine, or slow casualty evacuation, however, have repeatedly shown severe morbidity and mortality. Tourniquets may save lives if the right device is used in the right way at the right time for the right patient.
7.
Compartment Syndrome and Lower-Limb Fasciotomies in the Combat Environment Pages 41-61 Kevin L. Kirk, Roman Hayda
Graphical Abstract
Prophylactic and therapeutic treatment of leg compartment syndrome with decompression by double-incision fasciotomy prevents progression of soft-tissue injury in high-energy trauma. This treatment is the standard of care in civilian trauma and combat settings. More controversial is the use of either single- or dual-incision fasciotomy of the foot for prophylactic treatment of foot compartment syndrome. Fasciotomy must be performed in the face of major trauma to the foot with severe swelling and unremitting pain. The role for prophylactic fasciotomy of the foot is unclear and should be considered on a case by case basis. The surgeon must maintain a high degree of vigilance for the development of compartment syndrome in the combat casualty.
8.
The Mangled Foot and Leg: Salvage Versus Amputation Pages 63-75 Scott B. Shawen, John J. Keeling, Joanna Branstetter, Kevin L. Kirk, James R. Ficke
Graphical Abstract
Determining whether to perform limb salvage or amputation in the traumatized lower extremity continues to be a difficult problem in the military and civilian sectors. Numerous predictive scores and models have failed to provide definitive criteria for prediction of limb-salvage success. Excellent support is available in the military health care system for soldiers electing to undergo either limb salvage or amputation. Recent experience with soldiers who sustained limb-threatening injuries has shown that delayed amputation after limb-salvage attempts is a viable option for soldiers wounded in combat.
9.
Issues in Revascularization of the Ischemic Foot and Ankle War Injury Pages 77-90 Ryan K. Lehmann, Reagan Quan, Niten Singh
Graphical Abstract
The battlefield has provided a multitude of advancements in the management of hemorrhage and vascular repair. Basic understanding of the anatomy and exposures of lower extremity injuries is essential to any surgeon caring for these patients. The techniques of repair and potential adjunctive measures (eg, shunts) available should always be considered when approaching a vascular injury. The most important concept from a vascular standpoint is the fact that a multidisciplinary approach to these complex patients is required with maximal tissue preservation when feasible and safe.
10.
Prevention and Treatment of Infected Foot and Ankle Wounds Sustained in the Combat Environment Pages 91-112 Brendan D. Masini, Clinton K. Murray, Joseph C. Wenke, Joseph R. Hsu
Graphical Abstract
Combat injuries to the foot and ankle are challenging to treat due to frequent high-energy mechanisms, environmental contamination, and soft tissue and bony damage. Prevention and treatment of infections in injuries to the foot and ankle are critical to achieving the goals of tissue healing and restoration of function. The guidelines for treatment of these foot and ankle injuries are similar to those in place for civilians; however, allowances must be made for the realities of combat including an often austere environment, the need for evacuation, and limitations on resources available for treatment.
11.
Soft Tissue Management of War Wounds to the Foot and Ankle Pages 113-138 Martin F. Baechler, Adam T. Groth, Leon J. Nesti, Barry D. Martin
Graphical Abstract
This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.
12.
Strategies for Managing Massive Defects of the Foot in High-Energy Combat Injuries of the Lower Extremity Pages 139-149 John J. Keeling, Joseph R. Hsu, Scott B. Shawen, Romney C. Andersen
Graphical Abstract
Blast-related lower extremity trauma presents many challenges in its management that are not frequently experienced in high-energy civilian trauma. Because many of the blasts experienced in the current conflicts are ground based, the foot and ankle have sustained considerable severity and extent of injury because of the proximity of the blast. The high functional demands required of active service members create several reconstructive challenges. The authors' experience in the current conflicts has shown a similar trend, with the magnitude of soft tissue injury usually dictating whether or not salvage may be possible. Several reconstructive options for bone defect management are outlined and discussed.
13.
Recent Advances in Lower Extremity Amputations and Prosthetics for the Combat Injured Patient Pages 151-174 John Fergason, John J. Keeling, Eric M. Bluman
Graphical Abstract
Blast-related extremity trauma represents a serious challenge because of the extent of bone and soft tissue damage. Fragmentation and blast injuries account for 56% of all injuries produced within the Iraqi and Afghan theaters where, as of July 2009, 723 combatants have sustained lower extremity limb loss. If limb salvage is not practical, or fails, then amputation should be considered. Amputation can be a reliable means toward pain relief and improvement of function. Optimizing functional outcome is paramount when deciding on definitive amputation level. Preservation of joint function improves limb biomechanics in many cases. Increased limb length also allows for the benefits associated with articular and distal limb proprioception. Amputees with improved lower extremity function also usually exhibit less energy consumption. Function and length are generally directly correlated, whereas energy consumption and length are inversely related. This article discusses the surgical principles of lower extremity amputation and postoperative management of amputees, and the various prosthetic options available.
14.
Physical Therapy of the Patient with Foot and Ankle Injuries Sustained in Combat Pages 175-186 Johnny G. Owens
Graphical Abstract
The rehabilitation of soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom after combat-related trauma poses significant challenges. Polytrauma from high-energy blasts are common and frequently associated with mangled extremities, axial fractures, and traumatic brain injuries. Current evidence in the physical therapy literature is scant for this population and an empiric approach is often used. This article highlights the challenges encountered and techniques used in the rehabilitation of soldiers with foot and ankle injuries sustained in recent combat operations.
15.
Rehabilitation of the Lower-Extremity War-Injured at the Center for the Intrepid Pages 187-199 Robert Granville, Jennifer Menetrez
Graphical Abstract
The Center for the Intrepid (CFI) is a unique facility among the three amputee care centers that comprise the Armed Forces Amputee Care Program. The mission of the CFI is threefold: (1) to provide the best possible patient care to the severely war-wounded, (2) to educate providers in the most advanced methods of rehabilitation for the severely wounded, and (3) to perform research to improve the care of these war-wounded patients. The center's program is based on three critical factors: (1) concentration of similarly injured patients as a cohort, (2) a multidisciplinary approach to patient care, and (3) the concentration of subspecialty skills that ensures the best possible care at an institutional level. The center's active training program benefits professional and ancillary personnel from military community hospitals that may subsequently treat the center's patients as they transition back to duty or retirement. The center's research may ultimately be generalized to amputees of various ages and etiologies, with the goal of returning these patients to productive, fulfilling lives.
16.
Unique Complications of Foot and Ankle Injuries Secondary to Warfare Pages 201-208 Richard L. Ursone
Graphical Abstract
This article discusses the common complications associated with lower extremity trauma and amputations secondary to combat injuries. The complications include retained fragments, soft tissue adhesions, poor wound healing, painful bursae, neuroma formation, heterotopic ossification, and depleted uranium. Although there is some literature on these topics, most is based on noncombat injuries, indicating a need for further research into the management of these devastating injuries.