407A. Lerner and M. Soudry (eds.), Armed Conflict Injuries to the Extremities, DOI: 10.1007/978-3-642-16155-1, © Springer-Verlag Berlin Heidelberg 2011

AAbbreviated injury score (AIS), 84Above-knee amputation

level of, 345–346technique, 346, 349

Acinetobacter baumannii, 165Acinetobacter baumannii–calcoaceticus complex (ABC),

164–165Activated recombinant factor VIIa and antifibrinolytic

drugseligibility criteria, 89inhibitors, 90patient outcome, 89thrombin, 88trauma injury, 88–89uses, 89

Acute compartment syndrome, 220–224Acute renal failure (ARF), 71Acute respiratory distress syndrome, 39, 41Adult respiratory distress syndrome, 83Advanced trauma life support (ATLS), 8, 19AIS. See Abbreviated injury scoreAIIS. See Anterior inferior iliac spineAmputation

above-knee, 212blast wound, 338–339early complications

delayed hemorrhage, 349skin flap breakdown, 350surgical infection, 350

history ofether anesthesia, 336gunpowder, 335–336Morel’s tourniquet, 336mortality rates, 337Syme’s amputation, 336

indications forgeneral condition, 340local/extremity factors, 340surgeon and facility related, 340

injury severity scores, 195–196late complications

contractures, 351–352heterotopic ossification, 351neuroma, 351phantom limb pain, 351

stump instability, 351ulceration, 351

level of, 342vs. limb salvage, 319limb vascular injuries, 180, 181principles of

blast wound, 338–339care level, 337–338crush injury, 339–341lower limb injury, 337medical care, 338

rhabdomyolysis, 339surgical technique

above-knee (see Above-knee amputation)below knee amputation (see Below knee amputation)hemostasis, 342hip disarticulation, 349knee disarticulation, 345wound care, 342–343

Anesthesia and intensive care. See also Intensive caregeneral

cervical spine injury, 61endotracheal intubation, 60–61LMA and RSI, 61sedation, 61–62

general vs. regional, 60hemodynamic stabilization

cardiogenic shock, 66–67distributive shock, 67fluid resuscitation, 67–68glycemic control, 69hypocalcemia, 69hypovolemic shock, 66, 67inotropes and vasopressors, 68obstructive shock, 67resuscitation goal, 69shock etiology, 66

imaging study, 59–60intraoperative management

body temperature regulation, 65–66monitoring, 65

laboratory testing, 59medical condition evaluation, 57–58postoperative analgesia, 69–70preoperative fasting, 58–59regional

Index

408 Index

contraindications, 62epidural anesthesia, 63peripheral nerve block (see Nerve block)spinal anesthesia, 63

surgery urgency determination, 58treatment scheme, 57

Anterior inferior iliac spine (AIIS), 44Anterior superior iliac spine (ASIS), 44ARDS. See Acute respiratory distress syndrome;

Adult respiratory distress syndromeARF. See Acute renal failureArterial embolization, 106Arterio-venous fistula (AVF), 105, 106ATLS. See Advanced trauma life support

BBelow knee amputation

anesthesia, 343bone cut, 343fibular cut, 343–344guillotine amputation, 343level of, 344–345myodesis effect, 343postoperative management, 345skin flaps, 343, 344

Blast effectbehavior, 29, 30primary, 28radius difference, 28secondary, 28tertiary, 28wave characteristics, 27, 28

Blast mechanism. See also Blast effectantipersonnel mine, 29bomb fragments, 29explosive device, 27heterotopic ossification, 30–31musculoskeletal trauma, 26primary blast injury, 30secondary blast injury, 30

Blast wound amputation, 338–339Bone and joint pain

clinical presentation, 398–399diagnosis and classification, 397–398epidemiology, 398management of, 399musculoskeletal system, 397

Bone fixationanteroposterior X-rays, 221–223built-up fixators, 229civilian experience, 215–216decision-making process, 219diaphyseal fracturess

deep infection, 226femur fractures, 226, 227secondary intramedullary nailing, 225tibial shaft fracture, 226, 227upper extremity, 227

echelons, 217–218military experience

improvised explosive devices, 217military vs. civilian levels, 216

periarticular fracturesfixator management, 228goals for, 227multiple-staged protocols, 228ORIF, 228

pin tractcross-contamination, 224hydroxyapatite coating, 225secondary intramedullary nailing, 224

primary definitive internal fixation, 229skinny wire fixation, 229wounding mechanisms, combat environment

DBM and BMP–7, 219, 220I&D procedures, 219OIF/OEF, 218

Bone marrow injection, 371–372Bone morphogenetic protein–7 (BMP–7), 219, 220Broad-spectrum therapy, 167Bullet and projectile ballistics. See Wound ballistics

and tissue damage

CCardiac tamponade, 17–18Cardiogenic shock, 18Central venous pressure (CVP), 66Ciprofloxacin monotherapy, 169Coagulopathy

patient outcome, 83–84preemptive therapy, 84–85

Combat injury. See also Hemotransfusionantibiotics, 167–169arterial injury, 100–101blast injury

primary, 95–96quaternary, 96secondary, 96, 97tertiary, 96

bone and soft tissue injuryarticular depression, 99, 102avulsion fracture, 99, 102, 103compartment syndrome, 99, 100forearm, 98hematoma, 99, 100intra-articular shrapnel, 99, 101legs, 99ligament tear, 99, 103limb fractures and traumatic amputations,

99–100, 105lipohemarthrosis, 99, 105meniscal entrapment, 99, 104meniscal tear, 99, 104peroneal nerve, 99, 100sciatic nerve swelling, 99–100tendon damage, 99, 104thigh, 97, 100tibial plateau, 101wrist, 98

clinical sign, 106imaging modalities

conventional angiography, 107CTA (see CT angiography)Doppler sonography, 106

409Index

endovascular treatment, 112–113MRA, 107

multidrug-resistant organisms, 164–165nature of, 163–164open fractures

Gustilo-Anderson classification, 165–166osteomyelitis, 165

prevention of infectionclinical practice guidelines, 167, 168strength of recommendations, 166–167

vascular injuryarterial embolization, 106AVF, 105, 106hematoma, 101–103pseudoaneurysm, 103

wound microenvironment, 164Combat support hospital (CSH), 5Combination techniques

bone transport, 367–370consolidation phase, 382distraction phase, 382external fixator removal, 386femur, 385–386fixator-assisted acute femoral/tibial deformity, 367hardware removal and radical resection, 382IM nail insertion, 382, 385paprika sign, 382postoperative care, 386temporary external fixation, 382, 384tibia, 386, 387

Complex regional pain syndrome (CRPS)clinical presentation, 395–396diagnosis of, 396epidemiology of, 395management of, 396–397pathogenesis, 395

Conventional angiography (CA), 107Crush syndrome, 339, 341CSH. See Combat support hospitalCT angiography (CTA)

pitfallsaxial, 110, 112leg, 109, 110lower extremity, 109, 111peripheral, 109, 111

technique, 111–112vascular injury

conventional angiography, 108, 109leg, 109, 110lower extremity, 109, 111lower limb, 108multisystem-blast, 108, 109thigh, 109, 110

CVP. See Central venous pressure

DDamage control orthopaedics (DCO)

evolution, 39hemorrhage

colloids, 37exsanguination, 36tourniquets and hemostatic dressings, 36, 37

long bone fixationabdominal surgery procedure, 42ARDS, 39, 41borderline patient identification, 42clinical condition parameters, 42, 43intramedullary nailing, 41pulmonary complications, 40

origin, 35, 36pelvic ring injury

angiography, 45borderline polytrauma, 46–48external fixation, 44internal fixation, 43–44pin placement, 44, 45position marking, 44retroperitoneal packing, 45

provisional external fixation, 216, 217resuscitation

MODS, 38, 39monitoring study, 38recombinant factor VIIa, 38

trauma and the inflammatory cascade, 40Deep vein thrombosis (DVT), 73Demineralized bone matrix (DBM), 219, 220Direct nerve trauma

emergency procedurehigh-velocity isolated nerve injury, 191, 193low-velocity isolated nerve injury, 189–190medium-velocity isolated nerve injury,

191–192mechanism of

high-velocity injury, 185iatrogenic lesions, 185, 187low-velocity injury, 184–185medium-velocity injury, 185–187

Distal tibiofibular fracturesfibular stabilization

bilateral lower limb injuries, 247–248hinged fixation, 249–252limb salvage (see Limb salvage)malrotation, 272–275open reduction and external fixation,

244–246primary arthrodesis (see Primary arthrodesis)primary circular/hybrid fixation, 247, 249shortening and angulation, 269–272upper limb reconstruction, 252–254

Distraction osteogenesis techniques, 380, 381Doppler sonography, 106DVT. See Deep vein thrombosisDysfunctional pain, 403

EEnterobacteriaceae, 169Escherichia coli, 164Evacuation chain

levels of care, 14military priority categories, 14triage area, 15triage process, 12

Exchange nailing, 364–366, 368Extrafocal fixation technique, 134

410 Index

FFat embolism syndrome (FES)

biochemical and mechanical pathway, 77definition, 76incidence, 77laboratory and diagnostic test, 77management, 77patient outcome, 77–78prevention, 78signs and symptoms, 77

FFP. See Fresh frozen plasmaFibula transport, 380Flail chest, 17Flaps

anastomosis, 202free flaps, 202–203lower limb

ankle and foot, 207, 209, 211calf, 205, 207, 209, 210knee and thigh, 205, 209

pedicled flaps, 201–202perforator flaps, 203upper limb

arm, 203, 205, 206elbow, 203, 204fingers, 204, 205, 208forearm, 203–204hand, 204, 205, 207, 208shoulder, 203, 204

Fluid resuscitation, 67–68Foot surgery

battlefield stabilization and triageechelon II and III care, 296echelon IV hospital, 296foot compartment syndromes, 296–297K-wire, 297medical evacuation and treatment, 296open blast injury, 297, 298open talar neck and calcaneal fracture, 297

definitive care managementcombined injuries, 309forefoot reconstruction, 304, 306fracture and bone defect, 304hindfoot reconstruction, 307–309initial assessment and planning, 299–300midfoot reconstruction, 306–307operative strategy and limb salvage assessment,

300–301wound closure, 302–304wound management, 301–302

deformity and complicationchronic infection and treatment, 311–312compartment syndromes and blast trauma, 314, 315loss of tendon insertion, 312–313nerve deficit and neuropathic pain, 310–311posttraumatic arthritis and fusions, 312stiffness, 311treatment strategy, 309

epidemiology, 295interim wound management techniques, 298–299

Forefoot reconstruction, 304, 306

Fracture reposition and fixation. See Ilizarov frame assembly technique

Fresh frozen plasma (FFP), 81

GGlasgow Coma Scale (GCS), 16

HHalf-pins

external bone fixation, 138–142intraoperative shortening, 136, 137placement sites, 137tibial and femoral fracture fixation, 136–138

Hand injuryadvanced primary management

anesthesia, 281, 283primary wound excision (see Primary wound excision)systemic reassessment, 281–283

delayed primary and secondary surgical managementamputation, 292bone injury, 291nerve injuries, 291–292skin cover, 291tendon injury, 292wound closure, 289, 291

physical and occupational therapy, 292primary care, 280–281psychosocial implications of, 292–293tourniquet-related morbidity, 281

HBO. See Hyperbaric oxygenationHemorrhage, 18Hemostasis, 342Hemotransfusion

blood products available, 82–83coagulopathy, 83–84history, 81–82massive bleeding

Auckland general hospital, 86, 87Israel patient, 85labelled samples, 86Rambam health care campus, 86

MTP, 88preemptive therapy, 84–85rFVIIa and antifibrinolytic drugs, 88–90thromboelastography, 90–91

Heparin induced thrombocytopenia (HIT), 74Heterotopic ossification, 30–31, 351High-pressure pulsatile lavage (HPPL), 118High-velocity nerve injury

definitions, 183direct nerve trauma, 185isolated direct nerve trauma, 191, 193

Hindfoot reconstruction, 307–309Hip disarticulation, 349Hybrid external fixation

clinical appearance, 148, 157construction elements, 161proximal tibial and pylon fractures, 150, 158–160transitional blocks, 149unmarried ring, 160

Hyperbaric oxygenation (HBO), 54

411Index

IIatrogenic injury, 185, 187IEDs. See Improvised explosive devicesIlizarov method

bone alignment preservation, 234, 236–237fibular stabilization (see Distal tibiofibular fractures)frame assembly technique (see Fracture reposition and

fixation)unilateral tubular fixator, 234–236

Ilizarov frame assembly techniqueassembled rings diameter, 238circular fixation frame, 240degree of mechanical system stability, 238–239femur, 240–243high-energy injury, 238, 239preliminary assembly, 237–238Shanz screws, 238tibia, 243–245wire insertion technique, 240

Improvised explosive devices (IEDs), 217IMN. See Intramedullary nailingIndirect nerve trauma

emergency procedure, 189fracture displacement, 184heat, 184shock waves, 184tertiary blast, 183–184

Inferior vena cava (IVC), 76Injury severity score (ISS), 84Inotropes and vasopressors, 68Intensive care. See also Anesthesia and intensive care

Bowell management system, 70–71critical illness polyneuropathy

(see Polyneuropathy)FE and FES (see Fat embolism syndrome)rhabdomyolysis (see Rhabdomyolysis)stress ulcer prophylaxis, 70systemic complications, 70thrombo-embolic complications

clinical significance, 73diagnosis, 73DVT, 73management, 73–75patient outcome, 75–76pulmonary embolism, 74–75thrombolysis, 74thrombo-prophylaxis, 76

Interim wound management techniques, 298–299

Intramedullary nailing (IMN), 41, 224, 226

JJavid shunt, 179

KKilled in action (KIA), 9Kinetic energy

amount, 22equation, 21

Klebsiella pneumoniae, 164Knee disarticulation, 345

LLaryngeal mask airway (LMA), 61Lax nonunions, 357, 358Less invasive stabilization system (LISS), 221Limb salvage

acute temporary malalignment, 263–269amputation, 321antitank rocket blast injury, 326–328bone reconstruction

bifocal technique, 259, 262–263callotasis, 256, 259

classification, 322–323decision-making, 323injury severity scores, 322–323lower limb, 322mine blast injury, 323–325, 330–332patient compliance, 320preoperative counseling, 320–321primary internal fixation and wounds closure, 322, 325road traffic injury, 328–329

Limb salvage index (LSI), 195Limb vascular trauma

amputation, 180, 181arterial vs. venous injury, 180, 181compartment syndrome and fasciotomy, 179–181endovascular methods, 178, 179evacuation methods, 174hemorrhage control methods, 174imaging, 175–176incidence of, 173mechanisms of, 176–177operating room, priority in, 176repairing methods, 177–178severe vasospasm, 175temporary shunts, 178, 179tourniquets, 174

LISS. See Less invasive stabilization systemLMA. See Laryngeal mask airwayLocal and systemic antibiotherapy, 379Loss of consciousness (LOC), 16Low-velocity nerve injury

definitions, 183direct nerve trauma, 184–185isolated direct nerve trauma, 191, 193

LSI. See Limb salvage index

MMagnetic resonance angiography (MRA), 107Mangled extremity eeverity score (MESS), 195Mass casualty and triage. See Medical aid organizationMassive hemothorax, 17Massive transfusion protocol (MTP), 88Mechanical muscle crush injury (MMCI)

closed, 53–54death causes, 51diagnosis, 52history, 51management, 52, 53open, 52–53pathology, 51–52pathophysiology, 51–52

412 Index

Medical aid organization. See also Triagearmed conflicts, 1ATLS, 8, 19blood product management and planning, 5communication, 5–6, 18hospital incident command system, 4–5information system, 5–6injuries characterization, 6–7leadership

paramount factor, 2standard trauma team, 3surveys and treatment, 3, 4

surge capacity, 1–2trauma, 18triage (see Triage)

Medium-velocity nerve injurydefinitions, 183direct nerve trauma, 185–187isolated direct nerve trauma, 191–192

MESS. See Mangled extremity severity scoreMidfoot reconstruction, 306–307Mine blast injury

bone healing, 324bone regeneration, 324emergency care, 323extensive soft-tissue and bone necrosis,

331follow up, radiological pictures, 332Ilizarov external fixation, 332Ilizarov fixation, 323–324radiological appearance, 323roentgenogram, 330skin grafting, 331, 332temporary right knee bridging, 323transankle hybrid external fixation frame,

330–331transarticular half-pins fixation, 330unilateral tubular external fixation, 323

Monofocal distraction, 360MRA. See Magnetic resonance angiographyMultidrug-resistant organisms, 164–165Multiorgan dysfunction syndrome (MODS),

38, 39Musculoskeletal trauma, 26Myodesis effect, 343Myofascial pain syndrome

clinical presentation, 400–401definition of, 399–400epidemiology, 400management of

exercise and physical activity, 403medications, 402needling and infiltrations, 402–403noninvasive therapy, 402

pathophysiology, 401–402Myoglobinuria, 339

NNegative pressure wound therapy (NPWT)

complications, 200lower extremity wound, 299VAC system, 199–200

Nerve blocklower extremity, 64–65upper extremity, 63–64

Neurogenic shock, 18Neuroma, 351Neuropathic pain

clinical presentation, 392definition of, 391diagnosis of, 392epidemiology, 391–392management of

nerve blocks, 394pharmacotherapy, 392–394prevention of, 394–395surgical procedures, 394

Non-hemorrhagic shock, 18NPWT. See Negative pressure wound therapy

OOpen blast injury, 297, 298Open crush wound (OCW). See Mechanical muscle crush

injuryOpen fractures

antibiotic therapy, 167, 169classification, 115, 116compartment syndrome, 120débridement, 116–117Gustilo-Anderson classification, 165–166osteomyelitis, 165wound irrigation, 118

Open pneumothorax. See Sucking chest woundOpen reduction and external fixation

debridement, 245pylon fracture, 245superficial pin-tract infection, 245, 246

Open reduction and internal fixation (ORIF), 221, 228Operation Iraqi Freedom/Operation Enduring Freedom

(OIF/OEF), 218, 229MDR gram-negative bacteria, 164, 165osteomyelitis, 165tourniquets, 174

Osteomyelitisclinical evaluation

bone healing capacity, 375–376gadolinium-enhanced MRI, 376medical history, 375scarring of, 376–377University of Texas Medical Branch Staging

System, 376vascularity, 376

complications of, 386open fractures, 165principles of therapy

bone and soft tissue stabilization, 379–380Cierny-Mader staging system, 377combined technique (see Combined technique)debridement, 378–379distraction osteogenesis techniques, 380, 381fibula transport, 380final bone reconstruction, 380local and systemic, 377local and systemic antibiotherapy, 379

413Index

management plan, 377–378titanium cage, 382, 384vascularized bone grafts, 382, 383

PPacked red blood cell (PRBC), 5, 38, 82Pain

bone and jointclinical presentation, 398–399diagnosis and classification, 397–398epidemiology, 398management of, 399musculoskeletal system, 397

CRPSclinical presentation, 395–396diagnosis of, 396epidemiology of, 395management of, 396–397pathogenesis, 395

dysfunctional, 403myofascial pain syndrome

clinical presentation, 400–401epidemiology, 400management of, 402–403pathophysiology, 401–402

neuropathic (see Neuropathic pain)Paprika sign, 382Partial fibulectomy, 371Partial thromboplastin time (PTT), 86Patient-controlled analgesia (PCA), 70Patient warming technique, 66PE. See Pulmonary embolismPelvic ring injury, 18Peripheral nerve injury

definitions, 183emergency procedure

isolated direct nerve trauma, 189–193isolated indirect nerve trauma, 189nerve continuity, 185nerve disruption, 185, 187–188treatment algorithm, 188, 189

mechanism ofdirect nerve trauma, 184–187indirect nerve trauma, 183–184

median and ulnar nerves, 192, 193negative influence, 193radial nerve repairs, 193

PHTLS. See Prehospital trauma life supportPlate osteosynthesis, 361–362, 367Polymorphonuclear leukocytes (PMNLs), 41Polyneuropathy

clinical significance, 78complications, 78definition, 78differential diagnosis, 78management, 79pathophysiology, 78prevention, 79prognosis, 79signs and symptoms, 78workup, 78

Predictive salvage index (PSI), 195

Prehospital trauma life support (PHTLS), 8Primary arthrodesis

joint destructionelbow, 256Ilizarov external fixation frame, 255joint resection, 255–256limb-length restoration, 256micromovements, axial plane, 256

Primary external fixationadvantages, 134contamination, 133disadvantages, 134femoral bone fractures

external tubular fixation, 142–143unilateral Orthofix frame, 143, 144

forearm bone fractures, 144, 148, 149humeral bone fractures, 143, 146, 147hybrid frames

clinical appearance, 148, 157construction elements, 161proximal tibial and pylon fractures, 150, 158–160transitional blocks, 149unmarried ring, 160

limb suspension, 146, 148, 156–157methods, 133–134modern equipment, 134multiplanar configurations, 145, 151small external fixators

additional percutaneous thin wire, 144, 145, 150foot fractures, 144, 150rules and principles, 144

temporary external fixation, 134, 148tibial bone fractures

tubular Delta frame, 143, 145unilateral AO external tubular frame, 143, 144

transarticular bridgingbone fragment displacement, 146fracture reduction procedure, 146lower limb injury, 145, 153–154peri- and intraarticular fractures, 145, 152shoulder joint, 146, 155upper limb injury, 145, 153

unilateral tubular external fixationapplication technique, 135, 136fracture stabilization, 134half-pins, 136–142polytraumatized patients, 134–135proximal femoral and humeral fractures,

134, 135types, 135

Primary wound excisionamputation, 288–289bone, 285–288debridement, 283, 284nerves, 285skin, 283–285subcutaneous tissues and muscles, 283vascular structures, 283, 285

Pseudoaneurysm, 103Pseudomonas aeruginosa, 164–165, 169PTT. See Partial thromboplastin timePulmonary embolism (PE), 74–75

414 Index

RRapid sequence induction (RSI), 61Red Cross EXCVFM wound classification, 21, 115Rhabdomyolysis

amputation, 339laboratory and diagnostic tests, 71management, 72monitoring, 71patient outcome, 72prevention, 72signs and symptoms, 71

SSeptic shock, 18Shimmy effect, 30SIRS. See Systemic inflammatory response syndromeSkeletal reconstruction. See Ilizarov methodSkin traction, 343Soft-tissue injury

causes, 195complications

functional impairment, 212partial flap necrosis, 209, 210scars, 212wound dehiscence and infections, 209, 210

flapsanastomosis, 202ankle and foot, 207, 209, 211arm, 203, 205, 206calf, 205, 207, 209, 210elbow, 203, 204fingers, 204, 205, 208forearm, 203–204free flaps, 202–203hand, 204, 205, 207, 208knee and thigh, 205, 209pedicled flaps, 201–202perforator flaps, 203shoulder, 203, 204

imaging methods, 196injury severity scores, 195–196location, 195negative-pressure wound therapy

complications, 200VAC system, 199–200

physical examination, 196skin grafts, 200–201timing, 196, 197treatment strategies, 197–199

Spanning external fixation, 133Split thickness skin grafts (STSG), 200–201Stab injury, 183, 190Staphylococcus aureus, 164, 169, 224Stiff nonunions, 357Streptococcus pyogenes, 164Sucking chest wound, 17Systemic inflammatory response syndrome (SIRS), 67Systemic vascular resistance (SVR), 66

TTactical combat casualty care (TCCC), 8Temporary external fixation, 134, 148

Tension pneumothoraxinjury, 17shock, 18

Thromboelastographyabnormalities, 90patterns, 91

Thrombo-embolic complications. See Intensive careThrombolysis, 74Thrombo-prophylaxis, 76Tibial bone fractures

tubular Delta frame, 143, 145unilateral AO external tubular frame, 143, 144

Tissue debridementfasciotomy and compartment syndrome

blast injury, 120, 124Gustilo-Andersen IIIC fractures, 120–123high-energy lower-limb injury, 120–121open postdebridement wound, 124ulnar bone fracture, 124

goals, 116–117osteomyelitis, 378–379principles and practice of surgery, 115removal of foreign bodies, 125, 127–130serial repeated procedures, 124–127shrapnel wound management, 125, 128techniques, 118–120tissue damage evaluation, 115, 116wound irrigation

high-pressure pulsatile lavage, 118local antiseptics and antibiotics, 117low-pressure irrigation methods, 118sterile saline, 117surfactants, 117–118

Titanium cage, 382, 384Tourniquets, 174Traumatic brain injury (TBI), 16Triage

evacuation chain (see Evacuation chain)goal, 15history, 7–8initial assessment and life support

airway maintenance, 15–16breathing and ventilation, 16circulation with hemorrhage, 16disability with neurologic injury, 16exposure/environmental control, 16GCS, 16hemorrhage shock, 18life-threatening abdominal injury, 18life-threatening thoracic injury, 17–18non-hemorrhagic shock, 18pelvic ring injury, 18primary survey, 15reevaluation, 17secondary survey, 17

operations enduring and Iraqi freedom, 7practical application

affecting factors, 12, 13categorization process, 10officer and registration team, 10, 11red cross triage category, 11, 12special triage category, 10, 12

415Index

standard military triage category, 10, 11process, 15TCCC and PHTLS, 8–9US military triage and principles, 9–10

UUlceration, 351Umbrella effect, 338Unilateral tubular external fixation

application technique, 135, 136fracture stabilization, 134half-pins, 136–142mine blast injury, 323polytraumatized patients, 134–135proximal femoral and humeral fractures, 134, 135types, 135

Union and nonunionsanabolic and catabolic responses, 359–360biologic stimulation

bone marrow injection, 371–372central bone grafting, 370electrical stimulation, 370–371partial fibulectomy, 371

bone tissue engineering, 372classification

atrophic, 356, 357avascular, 355, 356hypertrophic, 356lax, 357, 358stiff, 357type A and B bone defect, 357vascular, 355, 356

clinical evaluation, 357, 358combination techniques

bone transport, 367–370fixator-assisted acute femoral/tibial deformity, 367

external fixation modalitiesbifocal strategy, 361, 363–365compression distraction, 360–363computer-assisted external fixation, 361, 366monofocal distraction, 360

internal fixationcage and grafting for, 366exchange nailing, 364–366, 368plate osteosynthesis, 361–362, 367

laboratory study, 359morbidity and duration, 360radiologic evaluation, 359

United States Army Institute of Surgical Research (USAISR), 225

VVacuum assisted closure (VAC), 199–800Vascularized bone grafts (VBGs), 382, 383

WWire insertion technique, 240Wound ballistics and tissue damage

blast effectbehavior, 29, 30primary, 28radius difference, 28secondary, 28wave characteristics, 27, 28

blast mechanism (see also Blast effect)antipersonnel mine, 29bomb fragments, 29explosive device, 27musculoskeletal trauma, 26primary blast injury, 30secondary blast injury, 30

bullet and projectile ballisticscherry-hue appearance, 24, 25classification, 21energy transfer, 22exit wound, 25–26femoral fracture, 23, 24lead toxicity, 26material contamination, 26patella fracture, 25rosette pattern, 22, 23shotgun injury, 23

energy transmission, 21Wound irrigation

high-pressure pulsatile lavage, 118local antiseptics and antibiotics, 117low-pressure irrigation methods, 118sterile saline, 117

surfactants, 117–118