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Objective: Despite advances in management, open fractures are at an elevated risk for deep fracture-related infection (FRI). Time to systemic antibiotic (ABX) administration and intraoperative topical administration of ABX powder have been used to decrease FRI risk. The purpose of this study was to determine whether topical application of antibiotic powder to type III open lower extremity fractures immediately on presentation to the emergency department (ED) reduces the rate of FRI., Design: Prospective cohort compared with retrospective historical control., Setting: Level I trauma center., Intervention: Application of 1 g of vancomycin and 1.2 g of tobramycin powder directly to open fracture wounds on presentation to the ED., Patient Selection Criteria: Patients with type III open lower extremity fractures treated from July 1, 2019, to September 17, 2022, who received topical ABX powder in the ED were compared with patients from a 4-year historical cohort from July 1, 2015, to June 30, 2019, who were treated without topical ABX powder., Outcome Measures and Comparisons: Development of a FRI within 6 months of follow-up. Patient demographics, injury characteristics, and postoperative data were analyzed as risk factors for FRI., Results: Sixty-six patients received topical ABX powder in the ED and were compared with 129 patients who were treated without topical ABX powder. The rate of FRI in the trial group was 6/66 (9.09%) versus 22/129 (17.05%) in the control cohort ( P = 0.133). Multivariate analysis demonstrated higher body mass index as a risk factor for development of FRI ( P = 0.036)., Conclusion: No statistically significant difference in rates of FRI in open lower extremity fractures treated with immediate topical ABX administration in the ED versus standard-of-care treatment without topical ABX was found. These findings may have been limited by insufficient power. Further large-scale study is warranted to determine the significance of topical antibiotic powder application in the ED., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To define the rate and primary drivers behind early and late amputation after flap-based limb salvage in the setting of combat extremity trauma., Design: Retrospective review., Setting: Level II trauma center., Patients: 307 (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003 and 2014., Intervention: We reviewed patient medical records, radiographs, and clinical photographs., Main Outcome Measurements: Early and late amputation rates, time to amputation, reason for amputation., Results: 307 patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion., Conclusions: This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered "successful" limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home., Methods: A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables., Results: The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32)., Conclusions: This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Objective: To compare the incidence of venous thromboembolism (VTE) among patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management., Design: Retrospective cohort., Setting: Tertiary care orthopaedic hospital., Patients: Six hundred ninety patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017., Intervention: Interfacility transfer for definitive management of pelvic or lower extremity fracture., Main Outcome Measurements: VTE incidence and time to surgery., Results: The interfacility transfer (TR) group comprised 126 patients, and the direct admission (DA) group comprised 564 patients. TR patients had a significantly higher incidence of VTE compared with the DA group: 9.5% versus 0.7%, respectively (P < 0.001). Time to surgery was also longer in the TR group compared with the DA group: 3.05 ± 3.00 days versus 2.16 ± 2.42 days, respectively (P = 0.005). Demographics for TR and DA did not significantly differ with regard to age, sex, length of stay, or American Society of Anesthesiologist score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found., Conclusions: Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at a significantly increased risk of the development of VTE., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: The purpose of this study is to report on a prospective series of patients in whom an algorithm was used to attempt to avoid releasing the posterior compartments in patients with lower leg compartment syndrome (CS) and the safety of such a practice., Design: Prospective cohort study., Setting: Level 1 trauma center., Patients: A consecutive series of 39 patients was managed by one surgeon for CS using the reported protocol., Intervention: Patients diagnosed with a CS of the leg were managed with a single operative protocol. After a standard anterior and lateral compartment release through a full-length lateral incision was performed, the superficial and deep posterior compartments were measured with the heel resting on a bolster. Using the preoperative diastolic blood pressure, a ΔP < 30 was considered to be a positive finding warranting a separate medial incision for release of the posterior compartments. If the ΔP was ≥30, the posterior compartments were not released., Main Outcome Measurements: Need for medial release or development of posterior CS or sequelae., Results: A consecutive series of 39 patients were managed by 1 surgeon for CS using the described protocol. Two patients with an isolated posterior CS were excluded. The other 37 had clinical symptoms or compartment pressures consistent with anterior compartment involvement. Of 37 patients, 21 had (57%) symptoms suggesting posterior compartment involvement. The preoperative pressure measurements averaged 41 mm Hg with an average ΔP of 38. After full-length release of the anterior and lateral compartments, only 3/37 (8%) required a posterior release for a ΔP of <30 mm Hg. The lowest ΔP in the posterior compartments of the remaining 34 patients averaged 59 (32-86). The compartment pressures in the superficial and deep posterior compartments decreased by 22 mm Hg and 24 mm Hg, respectively, after the anterolateral release. None of the patients who had only an anterolateral release developed sequelae of a missed posterior CS., Conclusions: The use of the reported algorithm is effective in avoiding posterior compartment release., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lower leg fasciotomy may be performed with a single lateral incision with or without fibulectomy, or by a double incision technique, with most surgeons preferring the later. The aim of this article is to describe a variation of an existing single-incision technique that will allow for the release of all four compartments with 1 incision. Our approach uses a paratibial route to release the deep posterior compartment (DPC) rather than a transfibular or parafibular route that has already been discussed in the literature. We approach the DPC from the anterior compartment, whereas the parafibular approach uses the posterior aspect of the fibula to reach the DPC. This affords a faster fasciotomy with a smaller flap, avoids potential damage to neurovascular bundle and among other advantages, makes its especially pragmatic for bedside fasciotomy, without the risk of injury to the peroneal nerves, which is common with dissection at the posterior aspect of the fibula.

Objectives: An elevated maximal amplitude (mA) value with rapid thrombelastography on admission can identify general trauma patients with an increased risk of venous thromboembolic events (VTEs). We hypothesized that (1) the risk of VTE traditionally assigned to injury lies specifically in those who sustain major orthopaedic trauma and (2) an elevated admission mA value could be used to identify patients with major orthopaedic injuries at risk for VTE during initial hospital admission., Design: Retrospective., Setting: University level 1 trauma center., Patients/participants: Consecutive trauma patients admitted to an urban level 1 trauma center between September 2009 and February 2011 who met the criteria for level 1 trauma activation and who were between 18 and 85 years of age were included in our study group. Two groups were created, one whose extremity abbreviated injury severity score was 2 or greater (ORTHO) and the other whose extremity abbreviated injury severity score was <2 (non-ORTHO)., Main Outcome Measurements: Pulmonary emboli were confirmed by computed tomography angiography, and deep vein thromboses were confirmed by venous duplex. Univariate analyses were conducted and followed by purposeful regression analysis., Results: Of note, 1818 patients met the inclusion criteria (310 ORTHO and 1508 non-ORTHO). Despite more hypocoagulable r-TEG values on arrival (alpha angle 71 vs. 73 and mA 62 vs. 64, both P < 0.05), ORTHO patients had higher rates of VTE (6.5% vs. 2.7%, P < 0.001). Stepwise regression generated 4 values to predict development of VTE (age, male gender, white race, and ORTHO). After controlling for these variables, admission mA values ≥65 (odds ratio 3.66) and ≥72 (odds ratio 6.70) were independent predictors of VTEs during hospitalization., Conclusions: Admission rapid thrombelastography mA values can identify patients with major orthopaedic trauma injuries who present with an increased risk of in-hospital deep vein thromboses and pulmonary embolism with a 3.6-fold and 6.7-fold increased risk for mA values ≥65 and ≥72, respectively., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The triage of trauma patients is based on patient-given information. The aim of the study was the accuracy of pain intensity, subjective functional impairment, trauma history, and clinical examination in identifying patients with fractures., Methods: We prospectively asked 436 patients with an extremity trauma whether they believed they had a fracture. Pain intensity and subjective functional impairment were also assessed. The physicians were also asked, based on trauma history and clinical examination., Results: The sensitivity and specificity of patient opinion and of the functional questions for fracture detection were low. The combination of history and clinical examination delivered the best results. There was only a slight difference in pain intensity between patients with and those without fractures., Conclusion: Fracture diagnosis based only on patient opinion or subjective functional impairment can be misleading. Pain intensity needs further investigation for its role in fracture detection.

Objective: The aim of this study was to assess the femoral articular cartilage thickness of the intact knee in patients with traumatic lower extremity amputation compared with nonimpaired individuals., Design: A total of 30 male patients with traumatic lower extremity amputation (mean [SD] age, 31.2 [6.3] yrs) and a random sample of 53 age-matched and body mass index-matched male nonimpaired individuals (mean [SD] age, 29.8 [6.3] yrs) participated in the study. Exclusion criteria were age younger than 18 yrs, history of significant knee injury, previous knee surgery, or rheumatic disease. The femoral articular cartilage thickness was measured using ultrasound at the midpoints of the medial condyle, the intercondylar notch, and the lateral condyle. Ultrasonographic cartilage measurement was performed on the intact side of the patients with amputation and on both sides of the nonimpaired individuals., Results: The femoral articular cartilage thickness of the intact knees of the patients with amputation was significantly decreased at the lateral and medial condyles compared with the nonimpaired individuals (P < 0.05). There was no significant difference in the measurements at the intercondylar notch between the patients with amputation and the nonimpaired individuals (P > 0.05)., Conclusions: There was a premature cartilage loss in the intact limb knee of the patients with traumatic amputation. This result supports the view that patients with traumatic lower extremity amputation are at increased risk for developing knee osteoarthritis in the intact limb.

Background: Among patients with isolated below-knee fractures, previous studies have detected asymptomatic deep vein thrombosis in 10%-40% using contrast venography. However, the clinical relevance of these thrombi is unknown; there is considerable uncertainty about the risk: benefit of routine thromboprophylaxis and clinical practice guidelines differ in their recommendations., Methods: In this multicenter, double-blind trial, 265 patients with isolated lower leg fractures requiring surgery were randomized to subcutaneous dalteparin 5000 units or matching placebo once daily for 2 weeks with bilateral Doppler ultrasound (DUS) of the proximal leg veins on postoperative day 14±2 and 3-month follow-up. The primary effectiveness outcome was clinically important venous thromboembolism (CIVTE), defined as the composite of symptomatic venous thromboembolism within 3 months after surgery and asymptomatic proximal deep vein thrombosis on DUS. The primary safety outcome was major bleeding., Results: Two hundred fifty-eight patients (97%) were included in the primary outcome analysis for effectiveness (130: dalteparin; 128: placebo). Incidence of CIVTE in the dalteparin and placebo groups was 1.5% and 2.3%, respectively (absolute risk reduction, 0.8%; 95% confidence interval, -2.0 to 3.0). There were no fatal pulmonary emboli or major bleeding., Conclusions: The overall incidence of CIVTE after surgically repaired, isolated tibia, fibula, and ankle fractures was low (1.9%; 95% confidence interval, 0.7-4.7), with no observed differences between dalteparin and placebo either for CIVTE or safety. Recruitment was stopped at the first interim analysis. This study also demonstrates the substantial discrepancy in venous thromboembolism rates between trials that use venographic outcomes compared with more clinically relevant outcomes., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Rehabilitation therapy is an important aspect of recovery after volumetric muscle loss. However, the traditional rehabilitation approach involves a period of rest and passive loading followed by gradual active loading. Extracellular matrix is a naturally occurring material consisting of structural proteins that provide mechanical strength, structural support, and functional molecules with diverse bioactive properties. There is evidence to suggest that the addition of aggressive regenerative rehabilitation protocols immediately after surgical implantation of an extracellular matrix scaffold to an area of volumetric muscle loss has significant benefits for extracellular matrix remodeling. Rehabilitation exercises likely provide the needed mechanical signals to encourage cell migration and site-specific differentiation in the temporal framework required for constructive remodeling. Herein, the authors review the literature and present an example of an aggressive rehabilitation program implemented immediately after extracellular matrix transplantation into a severely injured quadriceps muscle.

Objective: Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients., Design: Retrospective review of a consecutive series of patients., Setting: Tertiary Military Medical Center., Patients/participants: Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009., Intervention: We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients., Main Outcome Measurements: The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status., Results: At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4)., Conclusions: In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

Objectives: Explosive traumatic injury to an extremity may lead to both local and distant organ injury. Regional traumatic tissue hypothermia has been reported to offer systemic protection; here we investigated the protective effects of regional limb hypothermia on local tissue trauma and the lungs. Furthermore, the optimal duration of regional traumatic limb hypothermic treatment was also evaluated., Design: Prospective, controlled, animal study., Setting: University research laboratory., Subjects: Adult male Sprague-Dawley rats., Interventions: Anesthetized rats were randomized to sham, blast limb trauma, sham and regional hypothermia for 30 minutes, and blast limb trauma and regional hypothermia for 30 minutes, 60 minutes, and 6 hours. Blast limb trauma was created using chartaceous electricity detonators., Measurements and Main Results: Distant lung and local tissue injury following blast limb trauma were attenuated by regional traumatic limb hypothermic treatment for 30 minutes, 60 minutes, and 6 hours reflected by reduced lung histopathological changes and water content. Regional traumatic limb hypothermic treatment for 60 minutes and 6 hours failed to further attenuate distant lung and local tissue injury compared with regional traumatic limb hypothermic treatment for 30 minutes. Inhibition of cystathionine gamma-lyase/hydrogen sulfide was reduced by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. A surrogate of neutrophil accumulation, myeloperoxidase activity, and release of tumor necrosis factor-α and interleukin-6 were also attenuated by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. Oxidative stress was alleviated by regional traumatic limb hypothermic treatment for 30 minutes evidenced by reduction of hydrogen peroxide and malondialdehyde and an increase of superoxide dismutase and glutathione in blast limb trauma rats., Conclusions: Our data indicate that regional traumatic limb hypothermic treatment for 30 minutes offers both local protection for traumatic tissue and systemic protection for the lungs, which is likely associated with restoration of the cystathionine gamma-lyase/hydrogen sulfide pathway and inhibition of the inflammatory response and oxidative stress.

We reviewed 13 patients without an underlying syndrome with traumatic hip dislocation between 3 and 10 years of age (mean 4.8 years) at the time of injury. The final reviews were between 1 and 11 years (mean 6 years). All children had posterior dislocation, except one, who had an anterior dislocation. Time taken from trauma to reduction was less than 6 h in three patients, 6 h to 1 day in two patients, 1 day to 3 weeks in seven patients, and 4 weeks in one. All of them underwent closed reduction, except two, who required open reduction through a posterior approach. All patients had excellent hip function and radiographic result on the basis of Garret classification, except for one with limping at 4 years after trauma. The patients treated with hip spica after reduction (10 patients) did not have recurrent dislocation whereas two out of three patients who were treated without postreduction hip spica developed recurrent dislocation. One out of 13 patients without an underlying syndrome and a 6-year-old patient with Down syndrome with neglected hip dislocation and radiological avascular necrosis at presentation recovered with congruent hip following a complete and maintained reduction. This case series suggested that closed reduction was possible for cases of neglected hip dislocation for up to 3 weeks. Open reduction through the posterior approach was safe in neglected irreducible posterior hip dislocation. Those hips that underwent complete reduction and were maintained reduced with hip spica had an excellent functional outcome even in the presence of avascular necrosis. This is a level IV study.

Background: Warfare-related extremity injury associated with pelvic and long-bone fractures, massive soft-tissue injuries, and high Injury Severity Scores predispose patients to venous thromboembolic events, including deep vein thrombosis and/or pulmonary embolism. The success of flap reconstruction in this setting has not been well described., Methods: A retrospective review of war-related extremity injuries requiring flap coverage from 2003 to 2012 was completed, and the incidence of venous thromboembolic events determined. Outcomes compared included flap and limb salvage success rates and complications, such as partial/total flap failure, hematomas, and failed limb salvage., Results: A total of 173 combat extremity injury flap procedures were performed during the period reviewed, with 50 of these flaps (28.9 percent of all cases) identified as having a venous thromboembolic event during the course of care. Preoperative or perioperative events affected 45 flap procedures (26 percent). In the 41 patients with a preoperative event diagnosis, 21 had deep vein thrombosis (51 percent), 17 had a pulmonary embolism (42 percent), and three had both (7 percent). The complication rate in these cases was 29 percent (most commonly flap or donor-site hematoma). While the total complication rate was similar between the event and nonevent groups (29 versus 20 percent; p = 0.141), the hematoma rate was significantly different (20 versus 5 percent; p = 0.009)., Conclusions: Venous thromboembolic events were detected in a high number of the authors' combat-injured patients requiring extremity flap coverage. Despite preoperative events and risks of therapeutic anticoagulation, flap transfers were performed with high success rates and comparable nonhemorrhage complication rates between flap cohorts., Clinical Question/level of Evidence: Therapeutic, III.

Objective: The goal of this investigation was to determine if obese patients with syndesmotic injuries have a higher incidence of early postoperative failure compared with nonobese patients., Design: Retrospective cohort study., Setting: Level 1 urban trauma center., Patients and Methods: Two hundred thirteen patients with operative syndesmotic injuries were divided into 2 cohorts: obese and nonobese. All syndesmotic injuries were confirmed by intraoperative stress testing, reduced, and stabilized with internal fixation., Intervention: Fixation of displaced syndesmosis injuries with solid 3.5- and 4.5-mm screws., Main Outcome Measures: The primary outcome was early failure of fixation, defined as revision surgery within 3 months for ankle mortise and/or syndesmosis displacement., Results: Two hundred thirteen patients were identified with operative syndesmosis injuries, of which 102 (48%) were obese and 111 (52%) were nonobese. Fifteen percent (n = 15) of patients in the obese cohort sustained a failure of fixation compared with 1.8% (n = 2) of patients in the nonobese cohort (P = 0.0005). Diabetes mellitus, smoking status, and the type of construct used (eg, screw caliber, number of screws, and number of cortices) were not predictive of loss of reduction. Adjusting for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients (odds ratio = 12.0, P = 0.02)., Conclusions: There is a strong association between obesity and loss of reduction after operative treatment of the syndesmosis. Further research is warranted to determine if a stronger mechanical construct or more conservative postoperative protocol can reduce the risk of loss of reduction in obese patients who sustain a syndesmotic injury.

Objectives: Previously, we reported on the use of emergency tourniquets to stop bleeding in war casualties, but virtually all the data were from adults. Because no pediatric-specific cohort of casualties receiving emergency tourniquets existed, we aimed to fill knowledge gaps on the care and outcomes of this group by surveying data from a trauma registry to refine device designs and clinical training., Methods: A retrospective review of data from a trauma registry yielded an observational cohort of 88 pediatric casualties at US military hospitals in theater on whom tourniquets were used from May 17, 2003, to December 25, 2009., Results: Of the 88 casualties in the study group, 72 were male and 16 were female patients. Ages averaged 11 years (median, 11 years; range, 4-17 years). There were 7 dead and 81 survivor outcomes for a trauma survival rate of 93%. Survivor and dead casualties were similar in all independent variables measured except hospital stay duration (median, 5 days and 1 day, respectively). Six casualties (7%) had neither extremity nor external injury in that they had no lesion indicating tourniquet use., Conclusions: The survival rate of the present study's casualties is similar to that of 3 recent large nonpediatric-specific studies. Although current emergency tourniquets were ostensibly designed for modern adult soldiers, tourniquet makers, perhaps unknowingly, produced tourniquets that fit children. The rate of unindicated tourniquets, 7%, implied that potential users need better diagnostic training., Levels of Evidence: Level 4; case series, therapeutic study.

Background: Complex wounds of the distal third of the leg are challenging to treat. Despite free tissue transfer, local pedicled flaps such as the distally pedicled sural artery flap remain a valuable option., Methods: The authors conducted a retrospective comparison of the classical harvesting technique of the sural artery flap with a simplified method without a skin island., Results: We report on 148 patients who were treated with 104 adipofascial flaps and 44 fasciocutaneus flaps from 1997 to 2010. The adipofascial group showed a shorter operative time and a better aesthetic outcome. Complications did not differ in this multimorbid patient group., Conclusions: With a simple modification, the distally based sural artery flap is easier and faster to perform. The study shows that the adipofascial flap is as safe as the classic version, with the advantage of an improved donor-site appearance. Therefore, the described technique is a valuable tool in cases where free tissue transfer is not suitable., Clinical Question/level of Evidence: Therapeutic, III.

Subcutaneous zygomycosis infection associated with a lower extremity open fracture is a potentially life- and limb-threatening condition. This rare and poorly characterized infection complicating war wounds is unique, complex, and poses a significant reconstructive challenge. The objective of this article is to report the reconstruction of a complex Gustilo IIIC warfare-related distal femur fracture with partial extensor mechanism loss complicated by a subcutaneous zygomycosis infection using a novel combination of local and systemic antifungals with negative pressure wound therapy. Negative pressure wound therapy with silver-impregnated sponges and antibiotic/antifungal beads was used to provide temporary wound coverage, improve revascularization, and deliver local antifungal therapy. The distal open femur fracture was fixed using a lateral approach and the medial distal thigh wound and extensor mechanism were reconstructed using an extended gastrocnemius flap with skin graft. The limb was successfully salvaged and the patient is now ambulatory.

Background: The objective of this retrospective study was to determine the incidence of pulmonary embolism (PE) in casualties of wartime extremity wounds and specifically in casualties with a trauma-associated amputation., Methods: Records of all combat-wounded evacuated and admitted between March 1, 2003, and December 31, 2007, were retrospectively reviewed. Continuous and categorical variables were studied with the Student's t test, Fisher's exact test or χ² test; multivariate analysis was performed using a stepwise regression logistic model., Results: A total of 1,213 records were reviewed; 263 casualties met the inclusion criteria. One hundred three (41.5%) had amputations and 145 (58.5%) had long-bone fractures not requiring amputation. The observed rate of PE in these 263 casualties was 5.7%. More casualties with amputations, 10 (3.7%), developed PE than those with long-bone fractures in the absence of amputation, 5 (1.9%) (p = 0.045). Casualties with bilateral lower extremity trauma-associated amputations had a significantly higher incidence of PE compared with those sustaining a single amputation (p = 0.023), and the presence of bilateral lower extremity amputations was an independent risk factor for development of a PE (p = 0.007, odds ratio 5.9) (univariate and multivariate analysis, respectively)., Conclusion: The cumulative incidence of PE was 5.7%. The incidence of PE is significantly higher with trauma-associated amputation than with extremity long-bone fracture without amputation. Bilateral amputations, multiple long-bone fractures, and pelvic fractures are independent risk factors for the development of PE. The use of aggressive prophylaxis, deep venous thrombosis screening with ultrasound, and use of prophylactic inferior vena cava filters should be considered in this patient population.

Background: Hemorrhage remains the main cause of preventable death on the modern battlefield. As Improvised Explosive Devices in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the windlass tourniquet to control distal hemorrhage after mid-thigh application. To evaluate the efficacy of the Combat Application Tourniquet (CAT) windlass tourniquet in comparison to the newer Emergency and Military Tourniquet (EMT) pneumatic tourniquet., Methods: Serving soldiers were recruited from a military orthopedic outpatient clinic. Participants' demographics, blood pressure, and body mass index were recorded. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid-thigh level, and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally, the EMT tourniquet was applied to the first leg and popliteal pulse change Doppler recorded again., Results: A total of 25 patients were recruited with 1 participant excluded. The self-applied CAT occluded popliteal flow in only four subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in two subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). This was a statistically significant difference at p < 0.001 for CAT versus EMT., Conclusion: This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid-thigh level. The EMT was successful in a significantly larger number of participants.

During combat operations, extremities continue to be the most common sites of injury with associated high rates of infectious complications. Overall, ∼ 15% of patients with extremity injuries develop osteomyelitis, and ∼ 17% of those infections relapse or recur. The bacteria infecting these wounds have included multidrug-resistant bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, extended-spectrum β-lactamase-producing Klebsiella species and Escherichia coli, and methicillin-resistant Staphylococcus aureus. The goals of extremity injury care are to prevent infection, promote fracture healing, and restore function. In this review, we use a systematic assessment of military and civilian extremity trauma data to provide evidence-based recommendations for the varying management strategies to care for combat-related extremity injuries to decrease infection rates. We emphasize postinjury antimicrobial therapy, debridement and irrigation, and surgical wound management including addressing ongoing areas of controversy and needed research. In addition, we address adjuvants that are increasingly being examined, including local antimicrobial therapy, flap closure, oxygen therapy, negative pressure wound therapy, and wound effluent characterization. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Background: Although most combat-related amputations occur early for unsalvageable injuries, >15% occur late after reconstructive attempts. Predicting which patients will abandon limb salvage in favor of definitive amputation has not been explored. The purpose of this study was to identify factors contributing to late amputation for type III open tibia fractures sustained in combat., Methods: Operative databases were reviewed to identify all combat-related type III open diaphyseal tibia fractures from March 2003 to September 2007. Patients were categorized based on their definitive treatment: group I, limb salvage; group II, early amputation (<12 weeks postinjury); group III, late amputation (≥ 12 weeks postinjury). Injury, treatment, and complication data were extracted from medical records and compared across groups., Results: We identified 213 consecutive fractures, including 166 (77.9%) treated definitively with limb salvage, 36 (16.9%) with early amputation, and 11 (5.2%) with late amputation. There was no difference in fracture severity among the three groups. Before amputation, group III was more likely to use autograft and bone morphogenic protein (27.3%), compared with group I (4.8%) and group II (0%), and was more likely to undergo rotational flap coverage (45.5%), compared with group II (0%). Group III patients had the highest average number of revision surgeries and rate of deep soft tissue infection and were more likely to have osteomyelitis (54.5%) before amputation compared with group I (13.9%) and group II (16.7%)., Conclusion: Patients definitively managed with late amputation were more likely to have soft tissue injury requiring flap coverage and have their limb salvage course complicated by infection.

Background: Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects., Methods: The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1)., Results: Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent., Conclusions: Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Background: Multidetector computed tomographic angiography (MDCTA) is increasingly being used for the assessment of extremity vascular injury. However, to date, there are only retrospective series and a single small prospective study evaluating its efficacy. Therefore, the objective of this study was to prospectively evaluate the ability of MDCTA to detect arterial injury in the injured upper and lower extremities., Methods: After institutional review board approval, all trauma patients aged 16 years or older admitted to a Level I trauma center who sustained extremity trauma and underwent initial evaluation with a 64-channel MDCTA from March 2009 to June 2010 were prospectively enrolled. The sensitivity and specificity of MDCTA were tested against an aggregate gold standard of operative intervention, conventional angiography, and clinical follow-up., Results: During the 20-month study period, 635 patients with extremity trauma underwent a structured clinical examination. Hard signs of vascular injury was observed in 5.5% of patients with a 97.1% incidence of clinically significant injury requiring operative intervention. Eighty-three percent of patients had no signs of vascular injury with no missed injuries detected during follow-up. Eighty-nine MDCTAs were performed in the remaining 73 patients (11.5%) with soft signs. The mechanism of injury was penetrating in 69.9% (42 gunshot wound, 5 stab wound, and 4 shotgun). There were 24 positive studies, 23 of which were confirmed at operation (5 brachial artery injuries, 2 radial, 1 ulnar, 1 external iliac, 2 common femoral, 5 proximal superficial femoral, 2 distal superficial femoral, 4 popliteal, and 1 posterior tibial artery injury). A left posterior tibial artery occlusion was managed nonoperatively. There were 58 negative studies with clinical follow-up available in 100%, for a mean of 10.6 days ± 11.7 days (median, 6 days; range, 1-41 days). MDCTA was nondiagnostic in seven patients (9.6%), five secondary to artifact from retained missile fragments (3 shotgun and 2 gunshot wound), and two secondary to technical errors in reformatting. In the absence of artifact, MDCTA achieved 100% sensitivity and 100% specificity in detecting all clinically significant arterial injuries., Conclusions: Physical examination is critical in the decision-making process for the injured extremity and can accurately reduce unnecessary imaging. If imaging is required, MDCTA is a sensitive and a specific noninvasive modality for arterial evaluation and may replace conventional angiography as the diagnostic modality of choice for the evaluation of the acutely injured extremity.

Objective: This study was to evaluate the current pattern and risk factors of Marjolin's ulcer in the authors' setting., Settings and Participants: Twenty-one patients with histological diagnosis of skin malignancy at the University of Calabar Teaching Hospital, Calabar, Nigeria., Methods: Presented are patients with histologic diagnosis of Marjolin's seen in the University of Calabar Teaching Hospital, Calabar, Nigeria from January 2007 through December 2007., Results: Five patients (3 men and 2 women) with Marjolin's ulcer whose ages ranged from 32 to 70 years (mean 46.6 years) accounted for 45.5% of squamous cell carcinoma. All the patients suffered traumatic injuries (4 lower limb injuries from road traffic accidents and 1 puncture wound of the upper limb) and the latency was 21.4 years., Conclusions: Chronic trauma-induced limb ulceration is the leading risk factor for Marjolin's ulcer. Health education, early detection, and proper management of chronic wounds would improve outcome.

Background: During the wars in Iraq and Afghanistan, extremity injuries have predominated; however, no systematic review of field and stabilization care with subsequent infectious complications exists. This study evaluates the infectious complications and possible risk factors of British military casualties with mangled extremities, highlighting initial care and infections., Methods: This is a retrospective cohort study of British military casualties in Iraq and Afghanistan between August 2003 and May 2008. Casualties with mangled extremities undergoing limb salvage were evaluated for management strategies at the time of injury through evacuation back to the United Kingdom and subsequent infections., Results: There were 84 casualties with 85 extremities (20 infected and 65 uninfected). Infected extremities had more Gustilo Classification IIIb. There were no differences by Injury Severity Score, age, durations from injury to evacuation, or surgery, or arrival in England, use of clotting materials, or method of extremity stabilization between infected and uninfected extremity injuries. Tourniquet use in the field and fasciotomy were associated with infections. Antimicrobial coverage was associated with infections. Staphylococcus aureus were recovered later in casualties' clinical course in contrast to early recovery of Acinetobacter. On multivariate analysis, tourniquet in the field, antibiotics during evacuation and in the operating room, and fasciotomy were associated with infection as were certain bacteria, notably, Pseudomonas aeruginosa., Conclusion: Infections occurred in 24% of those with mangled extremities including 6% with osteomyelitis. Certain procedures, likely reflective of injury severity, were associated with infections along with certain bacteria, P. aeruginosa and possibly S. aureus. Continued clarification is required for antimicrobial coverage (penicillin-based regimens vs. additional anaerobic coverage) and certain surgical procedures to improve casualty care.

Background: The management strategies for reconstruction of soft-tissue defects of the lower leg and the foot remain disputed. To date, no comprehensive studies have been reported on the saphenous perforator flaps in reconstructive surgery in patients with posttraumatic osteomyelitis., Material: Fifty patients with lower leg postinjury chronic osteomyelitis were included in a retrospective, noncontrolled clinical study conducted from 1995 to 2006. All study patients were managed by distally based saphenous neurofasciocutaneous perforator flaps, the feeding perforators originating from the tibial artery. An endpoint survey was conducted after flap surgery, mean follow-up period 4 years, response rate 60%., Results: Six patients had short-term flap failure (12%, 95% confidence interval: 5-24). An additional six patients had flap necrosis of <(1/4) that healed without surgical revision. Based on the endpoint data, the long-term success rate was 70% (95% confidence interval: 51-85). Three variables had impact on flap failure rates: the number of previous reconstructive operations, the identity of the performing surgeon, and the area of the primary defect. Other assumed risk factors had no statistically significant impact on short- or long-term results. The anatomic localization of the perforating arteries is described., Conclusion: The saphenous perforator flap is a sturdy flap with low short-term failure rates, also in high-risk patients. The success rate compares well with results of free flap transfers in the management of posttraumatic osteomyelitis. The saphenous flap is a feasible option for posttraumatic reconstructions of osteomyelitis, especially in low-resource settings.

The case reported here describes early posttraumatic rotationplasty after severe degloving of the entire soft tissue sleeve from the left hemipelvis to the knee in an 80-year-old man who was knocked off his bicycle by a truck. During his treatment and rehabilitation, we observed severe complications (cerebrovascular accident, pneumonia, and spondylodiscitis). At the 2-year follow up, bony union of the rotationplasty osteotomy site was seen. The Enneking score was 10 points. The patient stated satisfaction with the outcome. At the last follow up, he was able to move around the house using his prosthesis and a walker and reported that he had been getting better at independent walking in the last 60 months, but for longer distances, he was still using a wheelchair.

Objective: The purpose of this study was to determine the incidence of deep venous thrombosis (DVT) in a prospective protocol of early spanning external fixation with the concurrent use of low-molecular weight heparin (LMWH) in patients with high-energy lower extremity trauma., Setting: Three level I trauma centers., Design: Prospective observational study., Patients: One hundred thirty-six consecutive patients with 151 complex lower extremity injuries were treated with a protocol of immediate joint spanning external fixation application and LMWH administration within 24 hours of admission. A total of 143 external fixators were applied. Early patient mobilization was encouraged and possible due to the skeletal stability provided by the external fixator. There were 87 men and 49 women with a mean age of 43 years. There were 62 proximal tibia fractures (Orthopaedic Trauma Association [OTA] Fracture Classification 41), 4 tibial shaft fractures (OTA 42), 49 distal tibia-fibula fractures (OTA 43, 44), 14 femur fractures (OTA 32, 33), 8 calcaneus fractures (OTA 73), 10 knee dislocations, and 4 talus fracture dislocations. Forty-eight injuries (32%) were open., Intervention: Temporary joint spanning external fixator placement, LMWH administration, and early mobilization within 24 hours of admission. Duplex ultrasonography of the bilateral lower extremities within 1 day to 3 days before fixator removal and definitive fixation procedure., Main Outcome Measurements: Presence of DVT on duplex ultrasound examination., Results: Duplex ultrasonography was negative for DVT in all but three patients for an incidence of 2.1% (3 of 143 fixators). There were no bleeding complications secondary to the use of LMWH while the temporary external fixator was in place., Conclusion: The incidence of DVT in patients treated with a protocol of early joint spanning external fixation and LMWH administration does not exceed historical controls. The early restoration of limb length, alignment, and stability allows early mobilization, which may contribute to the prevention of DVT.

Objectives: To review the efficacy of the current diagnostic methods of acute compartment syndrome (ACS) after leg fractures., Data Sources: A Medline (PubMed) search of the English literature extending from 1950 to May 2007 was performed using "compartment syndromes" as the main key word. Also a manual search of orthopaedic texts was performed., Study Selection and Extraction: The results were limited to articles involving human subjects. Of 2605 primary titles, 489 abstracts limited to compartment syndromes in the leg and 577 articles related to the diagnosis of compartment syndromes were identified and their abstracts reviewed. Further articles were identified by reviewing the references. Sixty-six articles were found to be relevant to diagnostic techniques for compartment syndrome in the leg and formed the basis of this review., Conclusions: Early diagnosis of an ACS is important. Despite its drawbacks, clinical assessment is still the diagnostic cornerstone of ACS. Intracompartmental pressure measurement can confirm the diagnosis in suspected patients and may have a role in the diagnosis of this condition in unconscious patients or those unable to cooperate. Whitesides suggests that the perfusion of the compartment depends on the difference between the diastolic blood pressure and the intracompartmental pressure. They recommend fasciotomy when this pressure difference, known as the Delta p, is less than 30 mm Hg. Access to a precise, reliable, and noninvasive method for early diagnosis of ACS would be a landmark achievement in orthopaedic and emergency medicine.

Background: Hemorrhage from extremity wounds is a leading cause of potentially preventable death during modern combat operations. Optimal management involves rapid hemostasis and reversal of metabolic derangements utilizing damage control principles. The traditional practice of damage control surgery favors a life over limb approach and discourages elaborate, prolonged vascular reconstructions. We hypothesized that limb preservation could be successful when the damage control approach combines advanced resuscitative strategies and modern vascular techniques., Methods: Trauma Registry records at a Combat Support Hospital from April to June 2006 were retrospectively reviewed. Patients with life-threatening hemorrhage (defined as >4 units of packed red blood cells) who underwent simultaneous revascularization for a pulseless extremity were included. Data collection included the initial physiologic parameters in the emergency department (ED), total and 24-hour blood product requirements, and admission physiology and laboratory values in the intensive care unit (ICU). Outcome measures were survival, graft patency, and amputation rate at 7 days., Results: Sixteen patients underwent 20 vascular reconstructions for upper (3) or lower extremity (17) wounds. Patients were hypotensive (blood pressure 105/60 +/- 29/18), acidotic (pH 7.27 +/- 0.1; BD -7.50 +/- 5.5), and coagulopathic (international normalized ratio 1.3 +/- 0.4) on arrival to the ED and essentially normal upon admission to the ICU, 4 hours later. Vein grafts (19/20, 95%) were used preferentially. Prosthetic grafts (1), shunting and delayed repair (4) or amputation (1) were infrequent. Heparin was not used or limited to a half dose (5/20, 25%). Tourniquets (12/16, 75%) and fasciotomies (13/16, 81%) were routine. Most (75%) received recombinant factor VIIa in the ED and in the operating room. All survived with normalized physiology on arrival in the ICU. Twenty-four-hour crystalloid use averaged 7.1 +/- 3.2 L, whereas packed red blood cells averaged 23 +/- 18 units, and 88% were massively transfused. Median operative time was 4.5 hours (range, 1.7-8.4 hours)., Conclusions: Aggressive damage control resuscitation maneuvers in critically injured casualties successfully permitted prolonged, complex extremity revascularization with excellent early limb salvage and graft patency. Recombinant VIIa and liberal resuscitation with fresh whole blood, plasma, platelets and cryoprecipitate, while minimizing crystalloid, allowed limb salvage and did not result in early graft failures.

Objective: To examine the incidence of peripheral nerve injury within 90 days of a limb trauma diagnosis in patients who have presented to the hospital or outpatient clinic., Design: This study is a retrospective, descriptive study that uses the 1998 MarketScan Commercial Claims and Encounters Database (The MEDSTAT Group) to track peripheral nerve injuries in extremity trauma. We selected our sample by using ICD9 codes for limb trauma during the first 9 mos of 1998. Nerve injuries within 90 days after limb trauma were the main outcome measure. Finally, we report how the rates of trauma and accompanying nerve injuries were contrasted by gender and age group, using univariate and bivariate statistics. All data analyses were conducted using Stata 9.0 statistical software., Results: Out of 16 million insureds in the database, 220,593 (1.4%) were diagnosed with limb trauma. Eighty-three percent of the patients were less than 55 yrs old, and 50% were male. The total incidence of nerve injuries within 90 days of upper- or lower-limb trauma was 1.64%. The type of extremity trauma with the highest incidence of nerve injury within 90 days of the diagnosis was a crush injury at 1.9%. Approximately 50% of our sample was selected because of a dislocation, which had an associated nerve injury prevalence of 1.46%., Conclusions: When looking at the population sampled, rates for peripheral nerve injury in people incurring limb trauma are low. Crush injuries seem to have the highest rate of associated nerve injury. Further studies are needed to observe outcomes for people with nerve damage after trauma.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the evaluation of a patient with a lower extremity wound. 2. Determine when an attempt at wound salvage is likely to be successful. 3. Select an appropriate technique for wound management. 4. Anticipate and identify wound complications., Summary: Successful management of a patient's wound at or distal to the knee includes accurate site assessment, meticulous debridement, planning, and execution of a reasonable operative procedure. Outlining a reconstructive plan requires consideration of alternatives from basic to most complex, then selection of the simplest technique likely to achieve wound closure with minimal donor-site morbidity. Healing by secondary intention, with or without vacuum-assisted closure, demands few surgical resources. A skin graft may close a well-vascularized wound. A local skin, fasciocutaneus, or muscle flap can provide vascularized tissue to an otherwise ischemic area. A plastic surgeon may use free tissue transfer in the more difficult anatomic regions, particularly for defects of the distal one-third of the lower leg. Other issues demand consideration when treating a patient with a lower extremity wound. Anesthetic options range from none in the case of secondary intention healing, through prolonged general anesthesia in the circumstance of free tissue transfer. Early recognition of a complication makes successful treatment of that problem more rapid and more likely to be successful. Accurate CPT coding ensures appropriate reimbursement for the reconstructive surgeon and fairness to the payer. Finally, some wounds are so extensive and patients so ill from related or unrelated pathologic processes that attempts at reconstruction are ill advised. These patients are better served by early amputation and prompt rehabilitation.

Background: Orthopedic injuries occurring in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) are complicated by infections with multidrug resistant bacteria. We describe demographics and microbiology of OIF/OEF casualties with primary and recurrent osteomyelitis., Methods: A retrospective cohort study was performed of OIF/OEF casualties admitted to our facility from February 1, 2003 to August 31, 2006. Electronic records were queried for demographic information, bacteria recovered, antibiotic therapies and duration, site of osteomyelitis, orthopedic devices, and outcomes., Results: There were 110 patients with 139 hospitalizations for osteomyelitis; 94 involved lower extremities, 43 involved upper extremities, and 2 involved the axial skeleton. One hundred three admissions were initial episodes whereas 36 admissions were recurrences. The median age was 27 years; 95% were men. Duration of follow-up ranged from 2 weeks to 36 months. Those patients with orthopedic devices had recurrent infections more frequently (26 vs. 5%, p < 0.01). Bacteria, antibiotics, or infection site were not predictive of recurrence. Acinetobacter spp. (70 vs. 5%, p < 0.01), Klebsiella pneumoniae (18 vs. 5%, p = 0.04), and Pseudomonas aeruginosa (24 vs. 5%, p < 0.01) were more likely to be recovered during original episodes than during recurrences. Gram-positive organisms were more likely during recurrences; Staphylococcus aureus (13 vs. 53%, p < 0.01); methicillin susceptible S. aureus (5 vs. 22%, p < 0.01), methicillin resistant S. aureus (8 vs. 31%, p < 0.01)., Conclusions: The microbiology of osteomyelitis in veterans of OIF/OEF differs substantially depending upon whether the infection is new or recurrent. Gram-negative pathogens predominate early, being replaced with staphylococci after treatment, despite nearly universal use of gram- positive therapy.

Introduction: Secondary abdominal compartment syndrome (ACS) is the development of ACS in the absence of abdominal injury. The development of secondary ACS has been viewed by some authors as an unavoidable sequela of the aggressive crystalloid resuscitation often employed in the treatment of severe shock. We hypothesized that poor resuscitation techniques, including early and excessive crystalloid administration, places patients with extremity injuries at risk for developing secondary ACS., Methods: The Trauma Registry of the American College of Surgeons database was queried for all patients with an extremity Abbreviated Injury Scale (AIS) score of 3 or greater and abdominal AIS score of 0 treated at our institution between January 1, 2001 and December 31, 2005. The study group included those patients who developed secondary ACS, whereas the comparison cohort included those who did not develop secondary ACS., Results: Forty-eight patients developed secondary ACS and were compared with 48 randomly selected patients who had an extremity AIS score of 3 or greater and an abdomen AIS score of 0. There were no differences between the groups with respect to age, sex, race, or individual AIS scores. However, the secondary ACS group had a slightly higher Injury Severity Score (25.6 vs. 21.4, p = 0.02), significantly higher operating room crystalloid administration (9.9 L vs. 2.7 L, p < 0.001), and more frequent use of a rapid infuser (12.5% vs. 0.0%, p = 0.01). Multiple logistic regression identified prehospital and emergency department crystalloid as predictors of secondary ACS., Conclusions: Aggressive resuscitation techniques, often begun in the prehospital setting, appear to increase the likelihood of patients with severe extremity injuries developing secondary ACS. Early, large volume crystalloid administration was the greatest predictor of secondary ACS.

Background: Up to 9% of casualties killed in action during the Vietnam War died from exsanguination from extremity injuries. Retrospective reviews of prehospital tourniquet use in World War II and by the Israeli Defense Forces revealed improvements in extremity hemorrhage control and very few adverse limb outcomes when tourniquet times are less than 6 hours., Hypothesis: We hypothesized that prehospital tourniquet use decreased hemorrhage from extremity injuries and saved lives, and was not associated with a substantial increase in adverse limb outcomes., Methods: This was an institutional review board-approved, retrospective review of the 31st combat support hospital for 1 year during Operation Iraqi Freedom. Inclusion criteria were any patient with a traumatic amputation, major extremity vascular injury, or documented prehospital tourniquet., Results: Among 3,444 total admissions, 165 patients met inclusion criteria. Sixty-seven patients had prehospital tourniquets (TK); 98 patients had severe extremity injuries but no prehospital tourniquet (No TK). Extremity Acute Injury Scores were the same (3.5 TK vs. 3.4 No TK) in both groups. Differences (p < 0.05) were noted in the numbers of patients with arm injuries (16.2% TK vs. 30.6% No TK), injuries requiring vascular reconstruction (29.9% TK vs. 52.5% No TK), traumatic amputations (41.8% TK vs. 26.3% No TK), and in those patients with adequate bleeding control on arrival (83% TK vs. 60% No TK). Secondary amputation rates (4 (6.0%) TK vs. 9 (9.1%) No TK); and mortality (3 (4.4%) TK vs. 4 (4.1%) No TK) did not differ. Tourniquet use was not deemed responsible for subsequent amputation in severely mangled extremities. Analysis revealed that four of seven deaths were potentially preventable with functional prehospital tourniquet placement., Conclusions: Prehospital tourniquet use was associated with improved hemorrhage control, particularly in the worse injured (Injury Severity Score >15) subset of patients. Fifty-seven percent of the deaths might have been prevented by earlier tourniquet use. There were no early adverse outcomes related to tourniquet use.

Inferior vena cava filter migration is an uncommon event. Temporary inferior vena cava filters offer protection against pulmonary embolism in the trauma patient in whom anticoagulation is contraindicated. We present the case of a 53-year-old man who suffered a lower extremity injury, which left him unable to walk for an extended period of time. The patient developed a deep venous thrombosis in the early postoperative course and decision was made to place a retrievable inferior vena cava (IVC) filter. One week later the IVC filter had migrated to the right ventricle and destroyed the tricuspid valve. Although there are a limited number of cases describing the migration of IVC filters to the heart, there have been no cases in the literature, to our knowledge, where an IVC filter has destroyed the tricuspid valve and required valve replacement.