JBJS Reviews Editor’s Choice–Open Fracture Care During War

Injuries to the musculoskeletal system are among the most common wounds of war. Compared with extremity injuries in the civilian population, injuries sustained in combat tend to be due to high-energy explosions and are associated with a greater degree of contamination and a longer timeline for recovery and healing. Importantly, the sequelae of musculoskeletal injuries sustained during combat tend to lead to more long-term disability than those affecting other organ systems.

In this month’s Editor’s Choice article, Rivera et al. review the current literature on combat injuries of the lower extremity and suggest that explosions are the most common mechanism of injury encountered by deployed service members. While exposure to an explosion does not necessarily result in a specific limb injury, the explosion mechanism does contribute to more severe injuries. Moreover, among service members who sustain open fractures of the tibia, foot, and ankle, infection is a common complication and is associated with more severe soft-tissue injury. As a result, surgeons who are deployed in combat settings are now performing more fasciotomies for limbs that are at risk. However, the outcomes and complication rates associated with these procedures are not well established, and the causes of late amputations are not always clear.

As part of a comprehensive review of this topic, Rivera et al. pose 3 important clinical questions that are ideal for translational research investigation. First, they ask, “What is the best way to manage and transport patients who have severe open fractures in order to minimize infection?” Indeed, while negative-pressure wound therapy (NPWT) appears to be a promising wound-care technique, additional study is needed in order to know how to best augment the standard of care for battlefield medicine. Second, “What is the best way to treat fasciotomy wounds and the late sequelae of the compartment syndrome?” In order to answer this question, a broader understanding of compartment syndrome detection and the indications for surgical treatment are needed. Finally, “What is the best way to select limbs for salvage and to optimize the reconstruction of injured tissues?” This question must explore not only the patient’s perspective but also the multitude of causes that lead to late amputation.

Thomas A. Einhorn, MD
Editor, JBJS Reviews