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Current Reviews in Musculoskeletal Medicine
Published in: Current Reviews in Musculoskeletal Medicine 3/2015

01-09-2015 | Gunshot Wounds and Blast Injuries (D Stinner and MK Sethi, Section Editors)

Soft tissue and wound management of blast injuries

Authors: Andrew J. Sheean, Scott M. Tintle, Peter C. Rhee

Published in: Current Reviews in Musculoskeletal Medicine | Issue 3/2015

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Abstract

The management of blast-related soft tissue wounds requires a comprehensive surgical approach that acknowledges extensive zones of injury and the likelihood of massive contamination. The experiences of military surgeons during the last decade of war have significantly enhanced current understandings of the optimal means of mitigating infectious complications, the timing of soft tissue coverage attempts, and the reconstructive options available for definitive wound management. Early administration of antibiotics in the setting of soft tissue wounds and associated open fractures is the single most important aspect of open fracture care. Both civilian and military reports have elucidated the incidence of invasive fungal infection in the setting of high-energy injuries with significant wound burdens, and novel treatment protocols have emerged. The type of reconstruction is predicated upon the zone of injury and location of the soft tissue defect. Multiple reports of military cohorts have suggested the equivalency of various techniques and types of soft tissue coverage. Longer-term follow-up will inform future perspectives on the durability of these surgical approaches.
Literature
1.
Emergency War Surgery, Fourth Revision. U.S. Department of Defense, U.S. Army, Office of the Surgeon General, 2014. Print.
2.
Centers for Disease Control. Explosions and blast injuries: a primer for clinicians. Centers for Disease Control; 2007, Atlanta, GA.
3.
Taxonomy of injuries from explosive devices. Medical Research for Prevention, Mitigation, and Treatment of Blast Injuries. Washington, DC: Department of Defense. Enclosure, 2, 9, July 5, 2006.
4.
Fleming M, Waterman S, Dunne J, D’Alleyrand JC, Andersen RC. Dismounted complex blast injuries: patterns of injuries and resource utilization associated with the multiple extremity amputee. J Surg Orthop Adv. 2012;212(1):32–7.
5.
Ritenour AE, Blackbourne LH, Kelly JF, McLaughlin DF, Pearse LA, Holcomb JB, et al. Incidence of primary blast injury in US military overseas contingency operations: a retrospective study. Ann Surg. 2010;251(6):1140–4.PubMedCrossRef
6.
Byrd HS, Cierny G, Tebbetts JB. The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg. 1981;68(1):73–82.PubMedCrossRef
7.
Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss: limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am. 1993;75(10):1431–41.PubMed
8.••
Sabino J, Polfer E, Tintle S, Jessie E, Fleming M, Martin B, Shashikant M, Valerio I. A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction. Plast Reconstr Surg, 2014. This series describes the outcomes of 359 flap reconstructions between 2003 and 2012. Of these procedures, 197 were muscle and 152 were fasciocutaneous flaps. There were no significant differences between the groups in terms of infection, osteomyelitis, or amputation. Moreover, the majority of reconstructions occurred within the subacute period underscoring the feasibility of a delayed approach to reconstructing blast-related soft tissue wounds.
9.••
Tintle SM, Gwinn DE, Andersen RC, Kumar AR. Soft tissue coverage of combat wounds. J Surg Orthop Adv Spring. 2010;19(1):29–34. This report provides a quality synopsis of results of 75 extremity reconstructions performed on combat-related injuries. Moreover, the authors present a succinct algorithm for the type of soft tissue coverage of upper and lower extremities based upon the zone of injuries.
10.
Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstruc Surg. 1987;80(1):1–14.CrossRef
11.••
Murray CK, Obremskey WT, Hsu JR, Andersen RC, Calhoun JH, Clasper JC, Whitman TJ, Curry TK, Fleming ME, Wenke JC, Ficke JR; Prevention of Combat-Related Infections Guidelines Panel. Prevention of infections associated with combat-related extremity injuries. J Trauma. Aug. 7 (2 Suppl): S235-57. This report provides an exhaustive, evidence-based review of civilian and military data to offer recommendations for management strategies to mitigate infection in the setting of combat-related extremity injuries. The authors describe the incidence of novel pathogen colonization and provide guidance for antibiosis, the role of negative pressure dressing therapy, oxygen supplementation, and wound effluent characterization.
12.
Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East practice management guidelines work group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(30):751–4.PubMedCrossRef
13.••
Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, et al. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29(1):1–6. This report emphasizes the importance of expeditious antibiotic dosing in the setting of type III open tibia fracture. The authors provide convincing data on 137 patients with type III open tibia fractures that greater than 5 days to wound coverage and greater than 66 min to antibiotic administration were univariate predictors of infection, with the primary outcome measure being deep infection within 90 days. Age, smoking, diabetes mellitus, injury severity score, and type IIIA versus IIIB/C were not associated with increased rates of deep infection within 90 days of injury. PubMedCrossRef
14.
Melvin S, Dombroski D, Torbert J, Kovach SJ, Esterhai JL, Mehta S. Open tibia shaft fractures I: evaluation and initial wound management. J Am Acad Orthop Surg. 2010;18(1):10–9.PubMed
15.
Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, REssler R, et al. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529–33.PubMedCrossRef
16.
Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;246:36–40.
17.•
Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, et al. Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011. N Engl J Med. 2012;367(23):2214–25. This case series reports on civilian casualties of a natural disaster with invasive fungal infection. Thirteen patients, all of which were injured in the most severe zones of damage secondary to a tornado, developed invasive fungal infections. These authors report a 38 % mortality rate among this cohort. PubMedCrossRef
18.
Paolino KM, Henry JA, Hospenthal DR, Wortmann GW, Hartzell JD. Invasive fungal infections following combat-related injury. Mil Med. 2012;177(6):681–5.PubMedCrossRef
19.
Tribble DR, Rodriguez CJ. Combat-related invasive fungal wound infections. Curr Fungal Infect Rep. 2014;8(4):277–86.PubMedCrossRef
20.••
Warkentien T, Rodriguez C, Lloyd B, Wells J, Weintrob A, Dunne JR, et al. Infectious disease clinical research program trauma infectious disease outcomes study group. invasive mold infections following combat-related injuries. Clin Infect Dis. 2012;55(11):1441–9. This is a case series is a report on 37 culture-proven, invasive fungal infections among combat-wounded personnel over an 18-month period. The authors outline common factors amongst those subjects with IFI—blast injury mechanism (100 %), injury occurring while subject on foot patrol (92 %), association with traumatic amputation (80 %), and large volume blood product transfusion (97.2)—and describe an 8.1 % mortality rate.PubMedCentralPubMedCrossRef
21.••
Treatment of suspected invasive fungal infection in war wounds. Joint Theater Trauma System Clinical Practice Guideline. 2012 Nov. This resource provides a concise description of injury characteristics commonly associated with IFI and clinical practice guidelines for the initial management of these injuries.
22.
Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta J. Vacuum-assisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg. 2006;117(Suppl):121S.PubMedCrossRef
23.
Streubel PN, Stinner DJ, Obremskey WT. Use of negative-pressure wound therapy in orthopaedic trauma. J Am Acad Orthop Surg. 2012;20(9):564–74.PubMedCrossRef
24.
Stannard JP, Volgas DA, Stewart R, McGwin Jr G, Alonso JE. Negative pressure wound therapy after severe open fractures: a prospective randomized study. J Orthop Trauma. 2009;23(8):552–7.PubMedCrossRef
25.
Rispoli DM, Horne BR, Kryzak TJ, Richardson MW. Description of a technique for vacuum-assisted deep drains in the management of cavitary defects and deep infections in devastating military and civilian trauma. J Trauma. 2010;68(5):1247–52.PubMedCrossRef
26.
Stinner DJ, Waterman SM, Masini BD, Wenke JC. Silver dressings augment the ability of negative pressure wound therapy to reduce bacterial in a contaminated open fracture model. J Trauma. 2011;71(1 Suppl):S147–50.PubMedCrossRef
27.
Eckman Jr JB, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988;237:213–5.PubMed
28.
Wahlig H, Dingeldein E, Bergmann R, Reuss K. The release of gentamicin from polymethylmethacrylate beads. An experimental and pharmokinetic study. J Bone Joint Surg Br. 1978; 60-B(2): 270–5.
29.•
Stinner DJ, Hsu JR, Wenke JC. Negative pressure wound therapy reduces the effectiveness of traditional antibiotic depot in a large complex musculoskeletal wound animal model. J Orthop Trauma. 2012;26(9):512–8. This study provides convincing evidence that the concomitant use of antibiotic bead pouch with negative pressure wound therapy is less effective than antibiotic bead pouch alone at reducing the number of bacteria in an animal model. Based upon their results, these authors state that negative pressure wound therapy reduces the effectiveness of the local antibiotic depot provided by antibiotic bead pouches. PubMedCrossRef
30.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285–96.PubMedCrossRef
31.•
Gopal S, Majumder S, Batchelor AGB, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg (Br). 2000;82(7):959–66. This report describes a consecutive series of 84 patients with type IIIB or IIIC open tibia fractures that underwent early soft tissue coverage with a muscle flap and skeletal stabilization. Advocating the “fix and flap” approach, these authors described excellent results with an overall rate of successful limb salvage to be 95 %. Of note, the authors also report that soft tissue reconstructions occurring beyond 72 h from the initial injury were associated with significantly higher rates of complications. CrossRef
32.
Foong DP, Evriviades D, Jeffery SL. Integra permits early durable coverage of improvised amputation device (IED) amputation stumps. J Plast Reconstr Aesthet Surg. 2013;66(12):1717–24.PubMedCrossRef
33.•
Iorio ML, Shuck J, Attinger CE. Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices. Plast Reconstr Surg. 2012;130(5 Suppl 2):232–41S. This is a systematic review of the availability and application of several different acellular dermal matrices currently being implemented in the reconstruction of soft tissue defects.CrossRef
34.
Rizzo M. The use of Integra in hand and upper extremity surgery. J Hand Surg. 2012;37(3):583–6.CrossRef
35.
Friedrich JB, Katolik LI, Hanel DP. Reconstruction of soft-tissue injury associated with lower extremity fracture. J Am Acad Orthop Surg. 2011;19(2):81–90.PubMed
36.
Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial dermal substitute: a preliminary report on its use for the management of complex combat-related soft tissue wounds. J Orthop Trauma. 2007;21(6):349–9.
37.
Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period. J Trauma. 2009;67(4):752–7.PubMedCrossRef
38.
Pollack AN, McCarthy ML, Burgesss AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am. 2000;82-A(12):1681–91.
39.••
Burns TC, Stinner DJ, Possley DR, Mack AW, Eckel TT, Potter BK, et al. Skeletal Trauma Research Consortium (STReC). Does the zone of injury in combat-related type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma. 2010;24(11):697–703. These authors present retrospective data on 67 type IIIB open tibia fractures that underwent either rotational or free flap coverage. Contrary to prior reports, the rotational coverage group demonstrated significantly lower rates of reoperation and amputation (30 versus 9 %) compared to the free flap group (64 versus 36 %). Additionally, the rate of flap failure was lower in the rotational coverage group (7 versus 27 %) than in the free coverage group. From these data, the authors conclude that the zone of injury does not preclude the use of rotational flap coverage for type III open tibia fractures. PubMedCrossRef
Metadata
Title
Soft tissue and wound management of blast injuries
Authors
Andrew J. Sheean
Scott M. Tintle
Peter C. Rhee
Publication date
01-09-2015
Publisher
Springer US
Published in
Current Reviews in Musculoskeletal Medicine / Issue 3/2015
Electronic ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-015-9275-x

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