A new approach for reconstruction of the gunshot defect of the flexor surface of the ungual (distal) phalanx by the proper transverse branch of the digital artery: a case report of combat patient injured in the Russo-Ukrainian war.

BACKGROUND: Gunshot injury to the hand is severe trauma, requiring complicated reconstruction surgery for the damaged anatomic site to restore all the hand functions. The aim of this study was to show the example of the distal phalanx reconstruction by using a flap with distal transverse digital artery (DTDA) blood supply as well as to demonstrate the utility of the audio Doppler application at the reconstruction stage in the combat patient injured in the Russo-Ukrainian war. CASE PRESENTATION: In this report, we present a case of a 26-year-old service member of the Ukrainian Armed Forces delivered to the Military Medical Clinical Centre on the fourth day after the gunshot gutter shrapnel wound of the distal flexor of the 2nd digit with a gunshot fracture of the ungula (distal) and middle phalanges of the 2nd digit of the right hand along with a bone deficiency of the osseous structure of the distal and middle phalanges, volar soft tissues. The dorsal metacarpal artery (DMCA) flap is a universal variant among the tools of the reconstructive plastic surgeon engaged in reconstructing defects of the digital dorsum and flexors with a limited range of flaps. We consider this to be a key that conforms with the majority of the reconstructive principles, such as 'analog replacement', and which is simple, adequate, and easy for operating with a minimal sequela of the donor site. CONCLUSIONS: The distal transverse digital artery (DTDA) could be considered for hand reconstructive surgery for repairing defects of the flexor surface of the digit injury and hands after severe gunshot injury.

Telemedicine support aids lower limb reconstruction after combat injury in Ukraine.

Since the destructive and illegal full-scale invasion of Ukraine in February 2022, caring for the victims of war trauma has been an essential function of Ukrainian clinicians [ 1, 2]. The authors present a case where using novel dynamic digital thermography (DDT), combined with international telemedicine support, contributed to saving the lower limb of an injured Ukrainian soldier. A male soldier in his 30s presented with a 'through and through' fragmentation wound to the right thigh from an artillery shell exploding nearby. After initial haemorrhage control and resuscitation, the patient was transferred to a tertiary hospital. Using telemedicine support, reconstructive surgery was planned and performed successfully using a perforating flap technique. DDT was used pre-operatively to identify a perforating vessel and post-operatively to ensure perfusion of the flap. The patient made a good recovery and was discharged 14 d post-operatively.

PROSPECTS OF THE HIGH-SPEED MULTIMEDIA DATA TRANSMISSION TECHNOLOGIES USE IN THE STRUCTURE OF THE SYSTEM FOR PROVIDING AID TO INJURED PERSONS HAVING A GUNSHOT DEFECT OF SOFT TISSUES.

OBJECTIVE: The aim: To improve the results of providing medical care in the conditions of a full-scale war in Ukraine due to the use of medical technologies. PATIENTS AND METHODS: Materials and methods: From the first days, the Military Medical Clinical Center of the Southern Region provided medical assistance to the persons wounded as a result of the Russian Federation's armed aggression. The presented multidisciplinary observation includes data received from 24.02.22 to 26.05.22. During this term, the multidisciplinary team assisted by the Teladoc Health system (the connection between the Charite Clinic, Berlin, and the MMCC of the Southern Region, Ukraine) performed 39 reconstructive and remedial operations in the MMCC of the Southern Region (Department of Surgical Infection). RESULTS: Results: It has been found that the implementation of differentiated surgical tactics (developed in cooperation between Charite clinics, Berlin, and MMCC of the Southern Region, Ukraine, using the Teladoc health system) in wounded patients with gunshot defects of soft tissues at the III and IV levels of medical care improves functional results, increases indicators of satisfactory from 46.9 % to 53.7 %, reducing the relative number of unsatisfactory from 18.8 % to 11.6 %. CONCLUSION: Conclusions: The information exchange in the Teladoc Health system is performed in telephone mode through protected communication channels. It enabled real-time treatment strategy recommendations and improved functional outcomes, increasing the satisfactory rate from 46.9 % to 53.7 %, and reducing the relative unsatisfactory rate from 18.8 % to 11.6 %.

Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient.

The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.

Pulmonary artery embolism by a metal fragment after a booby trap explosion in a combat patient injured in the armed conflict in East Ukraine: a case report and review of the literature.

BACKGROUND: Pulmonary artery embolization due to projectile embolus is a rare complication in combat patients. Such embolization is rare for combat patients in the ongoing armed conflict, in East Ukraine since 2014. CASE PRESENTATION: We report a clinical case of a 34-year-old Caucasian combat patient who was injured after an explosion of a booby trap hand grenade. This soldier was diagnosed with severe abdominal and skeletal trauma: damage of the duodenum and transverse colon, internal bleeding due to inferior vena cava damage and fractures of both lower extremities. The patient was treated at a highly specialized surgical center within the "golden hour" time. Whole-body computed tomography scan was performed as a routine screening method for hemodynamically stable patients, at which we identified a projectile embolus due to the explosion of a booby trap hand grenade in the right midlobar pulmonary artery. Our patient had no clinical manifestation of pulmonary artery embolism. At follow-up, our patient was diagnosed with the following complications: multiple necrosis and perforations of the transverse colon leading to a fecal peritonitis; duodenum suture line leakage caused the formation of a duodenal fistula; postoperative wound infection. These complications required multiple secondary operations, and in accordance to the principles of damage-control tactics, the extraction of projectile-embolus was postponed. Open surgery retrieval of the metal fragment was successfully performed on the 80th day after injury. Our patient was discharged from the hospital on day 168th after injury. CONCLUSIONS: Literature analysis shows a significant difference of clinical management for patient with projectile embolism in hybrid war settings as compared to previously described cases of combat and civil gunshot injuries. Damage control tactics and the concept of the "golden hour" are highly effective for those injured in a hybrid war. A whole-body computed tomography scan is an effective screening method for asymptomatic patients with projectile-embolism of the great vessels. The investigation of a greater cohort of combat patients with severe injuries and projectile-embolism should be performed in order to develop a better guideline for these patients and to save more lives.

Hydrodynamic rupture of liver in combat patient: a case of successful application of "damage control" tactic in area of the hybrid war in East Ukraine.

BACKGROUND: The hybrid war of Russia against Ukraine has been started in certain districts of Donetsk and Luhansk oblasts within the Donbas area in 2014. CASE PRESENTATION: We report a clinical case of a combat patient who was injured after the multiple launcher rocket system "Grad" shelling, diagnosed with hydrodynamic liver rupture followed by medical management with application of damage control (DC) tactic in conditions of hybrid war. The patient underwent relaparatomy, liver resection, endoscopic papillosphincterotomy, endoscopic retrograde cholecystopancreatography, stenting of the common bile duct, and VAC-therapy. Applied treatment modalities were effective; the patient was discharged on the 49th day after injury. CONCLUSIONS: To our best knowledge, this is the first report describing a successful application of DC tactic in the hybrid war in East Ukraine. From this case, we suggest that application of DC tactic at all levels of combat medical care could save more lives.