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This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. Eleven patients with a mean age of 27.4 years (range 21–35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180–360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand–forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm–hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility. Level of evidence: IV

IntroductionThe objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.MethodsA retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.ResultsFifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.ConclusionThe severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Objective We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. Methods We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. Results A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. Conclusions The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.

Treatment of war wounds is based on a sequential surgical strategy, which frequently faces therapeutic failures, which then burden the final functional result. The aim of this study was to identify risk factors of failure of the different treatments to prevent the therapeutic failure. A monocentric case–control study was done on French war-wounded soldiers treated for an open fracture caused by an invasive war weapon. The primary end point was the treatment failure three months after the injury. The risk factors of failure studied were the traumatic mechanism, the general and local lesional assessment, and the surgery performed. Between January 1, 2004 and December 31, 2016, 57 soldiers were included, with an average follow-up of 3.42 years. On 81 limb segments studied, the most injured segment was the leg (37.0%). A vital or urgent surgery requirement (OR = 1.56; p = 0.02) and bone loss substance (OR = 5.45; CI95% = 1.54–20.09) were risk factors of failure for limb salvage treatment. Improvised explosive device traumatic mechanism (OR = 1.56; p = 0.02) and the persistence of surgical site contamination after two debridement procedures (OR = 1.20; p = 0.04) were risk factors of failure for amputation procedures. Two main risk factors of treatment failure are highlighted: those in relation to traumatic mechanisms and general lesional assessment and those in relation to surgical site conditions. There is no over risk of failure in relation to surgical procedure and treatment.

Hand ballistics traumas often produce complex limb injuries and large segmental bone defects. The induced membrane (IM) technique is a simple and effective procedure for reconstruction of segmental bone defects. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four metacarpal bone reconstructions with the IM technique but without PMMA cement after ballistic trauma in a low-resources setting. Two patients were treated in a forward surgical unit for gunshot wounds of the hand. A 33 years old man presented a 4th and 5th metarcarpal bone fracture with critical bone defect and a 25 years old man presented a 2nd and 3rd metacarpal bone and soft tissue defect. In addition to the surgical initial management, we performed the IM technique with a syringe's body in polypropylene (PP) instead of PMMA cement that was not available in this situation. A thick membrane was observable six weeks after the spacer implantation. We performed the bone graft in one case with an iliac crest and in the other with a tibial cortical and cancelous graft. Bone union was achieved in the two cases for the four metacarpal bones. We report cases treated in an austere environment where PMMA cement was not available. This PP induced membrane technique as first been described in a public communication at the SICOT congress by Mozumder et al. It involved critical bone defects from the lower limb. The IM technique has proven its efficiency in hand and wrist bone defect reconstruction but its success is based on strict compliance with technical execution. Our plastic spacers met the requirements of surgical technique. After six weeks, an IM membrane macroscopically similar to cement's IM was found in all cases. The PP spacer shows interesting characteristics: it does not contain antibiotics, it does not heat the surrounding tissues and it is not expensive and easily available. The use of a PP spacer allowed us to achieve bone union in four critical metacarpal bone defects related to ballistic trauma. This procedure respects the technical execution of the IM technique. It is achievable in very low-resources settings. Further biomolecular studies are necessary to assess the PP IM biological properties.