Damage control orthopaedics: an in-theater perspective.

Damage control orthopaedics is well described for civilian trauma. However, significant differences exist for combat-related extremity trauma. Military combat casualty care is defined by levels of care. Each level of care has a specific role in the care of the wounded patient. Because of lack of equipment, austere environments, and significant soft tissue wounds, most combat fractures are stabilized with external fixation even in a stable patient, unlike civilian trauma. External fixation allows for rapid stabilization of fractures and easy access to wounds and requires little shelf stock of implants. Unique situations exist in the care of the combat-injured casualty, which include working in an isolated facility, caring for enemy combatants, large soft tissue wounds, and the need to rapidly transport patients out of the theater of operations.

Effects of metal fragments on nerve healing in extremity injuries using a rat peroneal nerve model.

BACKGROUND: On the modern battlefield, the majority of injuries currently seen are to the extremities, often involving a large number of metallic fragments. Although they are typically left in place, the effects of these retained metal fragments on nerve healing have not been studied. STUDY DESIGN: In a rat model, the right peroneal nerve was surgically sectioned and reanastomosed (control group). In the study group, metal fragments from an artillery casing were placed around the reanastomosed peroneal nerve. Functional recovery in both groups was evaluated over a 4-week period by measuring maximum ankle dorsiflexion captured on video as the animals walked through a tunnel. Morphologic analyses included distal and proximal axon counts, measurement of nerve fiber and axon diameter ratios, and myelin thickness. RESULTS: A significant decrease (p < 0.05) in return toward baseline for the rats' ankle angle in the nerves exposed to metal fragments was noted at weeks 2 through 4. Distal axon counts were significantly less (p < 0.05) in the metal fragment group for weeks 1 through 4. Proximal axon counts were increased in both groups, with a greater (p < 0.05) increase in the metal fragment group. CONCLUSIONS: Functional recovery after rat peroneal nerve transection and repair is decreased when metal fragments are placed in and around the injury site. Select histologic indicators of nerve regeneration showed decreased healing when exposed to metal fragments. Further studies of functional recovery in patients sustaining penetrating injuries from bullets or explosive devices are indicated.