Lerner / Soudry Armed Conflict Injuries to the Extremities

A Treatment Manual
1. Auflage 2011
ISBN: 978-3-642-16155-1
Verlag: Springer
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 413 Seiten

This book is designed to meet the continued need to re-learn the principles of treatment of complex war injuries to the extremities in order to minimize post-traumatic and post-treatment complications and optimize functional recovery. Most of the chapters are based on the unique experience gained in the treatment of military personnel who have suffered modern combat trauma and civilian victims of terror attacks at a single, large level 1 trauma center. The remaining chapters present the experience of leading international authorities in trauma and reconstructive surgery. A staged treatment protocol is presented, ranging from primary damage control through to definitive functional limb reconstruction. The organization of medical aid, anesthesiology, diagnostic imaging, infection prophylaxis, and management of complications are reviewed, and aspecial chapter is devoted to the challenging dilemma of limb salvage versus amputation in the treatment of limbs at risk.

Autoren/Hrsg.

Lerner, Alexander

Soudry, Michael

Inhaltsverzeichnis

1;Dedication;6
2;Foreword;8
3;Preface;10
4;Portraits of the Editors;12
5;Acknowledgments;14
6;Contents;16
7;1: Organization of Urgent Medical Aid, Including Mass Casualty and Triage;18
7.1;1.1 Introduction;18
7.2;1.2 Surge Capacity;18
7.3;1.3 Leadership;19
7.4;1.4 Hospital Incident Command System;21
7.5;1.5 Blood Product Management and Planning;22
7.6;1.6 Communication/Information Systems;22
7.7;1.7 Characterization of Injuries;23
7.8;1.8 Triage;24
7.8.1;1.8.1 Triage – A Brief History;24
7.8.2;1.8.2 Tactical Combat Casualty Care and PHTLS in the Military;25
7.8.3;1.8.3 U.S. Military Triage and Underlying Principles;26
7.8.4;1.8.4 Triage – Practical Application;27
7.8.5;1.8.5 The Evacuation Chain;29
7.8.6;1.8.6 Summary;32
7.8.7;1.8.7 Initial Assessment and Life Support;32
7.9;1.9 Conclusion;35
7.10;References;36
8;2: Wound Ballistics and Tissue Damage;38
8.1;2.1 Introduction;38
8.2;2.2 Bullet and Projectile Ballistics;38
8.2.1;2.2.1 Material Contamination;43
8.2.2;2.2.2 Lead Toxicity;43
8.3;2.3 Blast Mechanisms and Tissue Damage;43
8.3.1;2.3.1 Heterotopic Ossification;47
8.4;References;48
9;3: Damage Control Orthopaedics;51
9.1;3.1 The Origin of Damage Control in Trauma;51
9.2;3.2 Damage Control and Hemorrhage;51
9.3;3.3 Resuscitation;55
9.4;3.4 The Evolution of Damage Control Orthopedics;57
9.5;3.5 Trauma and the Inflammatory Cascade;58
9.6;3.6 Long Bone Fixation in Damage Control;59
9.7;3.7 Damage Control and Pelvic Ring Injuries;61
9.8;References;64
10;4: Crush Injury of the Limbs and Acute Mechanical Muscle-Crush Compartment Syndrome;66
10.1;4.1 Introduction;66
10.2;4.2 History of MMCI;66
10.3;4.3 Acute Mechanical Muscle-Crush Compartment Syndrome;66
10.3.1;4.3.1 Pathology and Pathophysiology;66
10.3.2;4.3.2 Diagnosis;67
10.3.3;4.3.3 Management;67
10.3.3.1;4.3.3.1 General;67
10.3.4;4.3.4 Local;67
10.3.4.1;4.3.4.1 Open High-Energy Injury Crush Wound and Open MMCI (OCW);67
10.3.4.2;4.3.4.2 Closed MMCI – Acute Mechanical Muscle-Crush Compartment Syndrome;68
10.4;References;69
11;5: Anesthesia and Intensive Care of the Patient with Severe Extremity Trauma;71
11.1;5.1 Preoperative Evaluation and Treatment;71
11.1.1;5.1.1 Evaluation of Underlying Medical Conditions;71
11.1.2;5.1.2 Determination of Surgery Urgency;72
11.1.3;5.1.3 Preoperative Fasting;72
11.1.4;5.1.4 Laboratory Testing;73
11.1.5;5.1.5 Imaging Studies;73
11.2;5.2 Anesthetic Techniques;74
11.2.1;5.2.1 General Anesthesia;74
11.2.1.1;5.2.1.1 Endotracheal Intubation;74
11.2.1.2;5.2.1.2 Rapid Sequence Induction;75
11.2.1.3;5.2.1.3 Cervical Spine Injury;75
11.2.1.4;5.2.1.4 Laryngeal Mask Airway;75
11.2.2;5.2.2 Sedation;75
11.2.3;5.2.3 Regional Anesthesia;76
11.2.3.1;5.2.3.1 Spinal Anesthesia;77
11.2.3.2;5.2.3.2 Epidural Anesthesia;77
11.2.3.3;5.2.3.3 Peripheral Nerve Blocks;77
11.2.3.3.1;Nerve Blocks for the Upper Extremity;77
11.2.3.3.2;Nerve Blocks for the Lower Extremity;78
11.3;5.3 Intraoperative Management;79
11.3.1;5.3.1 Monitoring;79
11.3.2;5.3.2 Body Temperature Regulation;79
11.3.2.1;5.3.2.1 Patient Warming Techniques;80
11.4;5.4 Hemodynamic Stabilization;80
11.4.1;5.4.1 Hypovolemic Shock;80
11.4.2;5.4.2 Cardiogenic Shock;80
11.4.3;5.4.3 Obstructive Shock;81
11.4.4;5.4.4 Distributive Shock;81
11.4.5;5.4.5 Fluid Resuscitation;81
11.4.5.1;5.4.5.1 Crystalloid Solutions;82
11.4.5.2;5.4.5.2 Colloid Solutions;82
11.4.6;5.4.6 Inotropes and Vasopressors;82
11.4.7;5.4.7 Hypocalcemia;83
11.4.8;5.4.8 Glycemic Control;83
11.4.9;5.4.9 Resuscitation Goals;83
11.5;5.5 Postoperative Analgesia;83
11.5.1;5.5.1 Regional Techniques;83
11.5.2;5.5.2 Systemic Analgesia;83
11.6;5.6 Intensive Care;84
11.6.1;5.6.1 General Considerations;84
11.6.1.1;5.6.1.1 Some Issues to Consider;84
11.6.2;5.6.2 Rhabdomyolysis;85
11.6.2.1;5.6.2.1 Signs and Symptoms;85
11.6.2.2;5.6.2.2 Laboratory and Diagnostic Tests;85
11.6.2.3;5.6.2.3 Monitoring;85
11.6.2.4;5.6.2.4 Management;86
11.6.2.5;5.6.2.5 Outcome;86
11.6.2.6;5.6.2.6 Prevention;86
11.6.3;5.6.3 Thrombo-Embolic Complications;86
11.6.3.1;5.6.3.1 Deep Vein Thrombosis (DVT);87
11.6.3.2;5.6.3.2 Clinical Significance and Complications;87
11.6.3.2.1;Local Complications (Limb Threatening);87
11.6.3.2.2;Systemic Complications (Life Threatening);87
11.6.3.3;5.6.3.3 Diagnosis;87
11.6.3.4;5.6.3.4 Management;87
11.6.3.4.1;Treatment Goals;87
11.6.3.4.2;Acute;88
11.6.3.4.2.1;Systemic Anticoagulation (Heparin or LMW Heparin);88
11.6.3.5;5.6.3.5 Thrombolysis;88
11.6.3.5.1;Chronic;88
11.6.3.6;5.6.3.6 Pulmonary Embolism (PE);88
11.6.3.7;5.6.3.7 Management;89
11.6.3.8;5.6.3.8 Outcome;89
11.6.3.9;5.6.3.9 Thrombo-Prophylaxis – DVT and PE Prevention;90
11.6.3.9.1;Primary Prevention;90
11.6.3.9.2;Secondary Prevention;90
11.6.3.9.3;Screening for DVT;90
11.6.4;5.6.4 Fat Embolism (FE) and Fat Embolism Syndrome (FES);90
11.6.4.1;5.6.4.1 Laboratory and Diagnostic Tests;91
11.6.4.2;5.6.4.2 Management;91
11.6.4.3;5.6.4.3 Outcome;91
11.6.4.4;5.6.4.4 Prevention;92
11.6.5;5.6.5 Critical Illness Polyneuropathy;92
11.6.5.1;5.6.5.1 Workup;92
11.6.5.2;5.6.5.2 Management;93
11.6.5.3;5.6.5.3 Prognosis;93
11.6.5.4;5.6.5.4 Prevention;93
11.7;References;93
12;6: Hemotransfusion in Combat Trauma;95
12.1;6.1 History of Blood Transfusion for Combat Injuries;95
12.2;6.2 Currently Available Blood Products;96
12.3;6.3 Role of Coagulopathy in the Outcome of Trauma Patients;97
12.4;6.4 Preemptive Therapy of Coagulopathy;98
12.5;6.5 Northern Israel’s Experience in Handling Massively Bleeding Trauma Patients;99
12.5.1;6.5.1 The Threshold of Blood Product Transfusion;99
12.6;6.6 Massive-Transfusion Protocols;102
12.7;6.7 Use of Activated Recombinant Factor VIIa (rFVIIa) and Antifibrinolytic Drugs;102
12.8;6.8 Thromboelastography;104
12.9;6.9 Conclusions;105
12.10;References;106
13;7: Diagnostic Imaging in Combat Trauma;108
13.1;7.1 Blast (Explosive) Injury;108
13.1.1;7.1.1 Primary Injuries;108
13.1.2;7.1.2 Secondary Injuries;109
13.1.3;7.1.3 Tertiary Injuries;109
13.1.4;7.1.4 Quaternary Injuries;109
13.2;7.2 Bone and Soft Tissue Injuries;110
13.2.1;7.2.1 Limb Fractures and Traumatic Amputation;112
13.3;7.3 Arterial Injury;113
13.4;7.4 Types of Vascular Injuries;114
13.4.1;7.4.1 Hematoma;114
13.4.2;7.4.2 Pseudoaneurysm;116
13.4.3;7.4.3 Arterio-Venous Fistula (AVF);118
13.4.4;7.4.4 Arterial Embolization;119
13.5;7.5 Clinical Signs of Arterial Injury;119
13.6;7.6 Imaging Modalities in Arterial Injury;119
13.6.1;7.6.1 Doppler Sonography;119
13.6.2;7.6.2 Magnetic Resonance Angiography (MRA);120
13.6.2.1;7.6.3 Conventional Angiography (CA);120
13.6.3;7.6.4 CT Angiography (CTA);120
13.6.3.1;7.6.4.1 CTA Signs of Vascular Injury in the Extremities;121
13.6.3.2;7.6.4.2 Pitfalls;121
13.6.3.3;7.6.4.3 CTA Technique;124
13.6.4;7.6.5 Endovascular Treatment;125
13.6.4.1;7.6.5.1 Percutaneous Transcatheter Embolization;125
13.6.4.2;7.6.5.2 Stent/Stent Graft;126
13.7;7.7 Conclusions;126
13.8;References;126
14;8: Tissue Debridement;128
14.1;8.1 Introduction;128
14.2;8.2 Tissue Damage Evaluation;128
14.3;8.3 Goals of Debridement;129
14.3.1;8.3.1 Timing of Debridement;129
14.4;8.4 Wound Irrigation;130
14.4.1;8.4.1 Local Antiseptics;130
14.4.2;8.4.2 Local Antibiotics;130
14.4.3;8.4.3 Surfactants;130
14.4.4;8.4.4 High-Pressure Pulsatile Lavage (HPPL);131
14.5;8.5 Debridement Technique;131
14.6;8.6 Fasciotomy;133
14.7;8.7 Repeated Debridement;137
14.8;8.8 Management of Retained Bullets, Shells, and Shrapnel in the Limbs;138
14.9;References;143
15;9: Primary External Fixation;146
15.1;9.1 Introduction;146
15.1.1;9.1.1 Important Advantages;147
15.1.2;9.1.2 Disadvantages;147
15.2;9.2 Unilateral External Fixation;147
15.2.1;9.2.1 Unilateral External Fixation Application Technique;148
15.2.2;9.2.2 Half-Pin Choice;149
15.2.3;9.2.3 Introduction of Half-Pins to the Bone;151
15.3;9.3 Specific Anatomical Locations;155
15.3.1;9.3.1 Femoral Bone Fractures;155
15.3.2;9.3.2 Tibial Bone Fractures;156
15.3.3;9.3.3 Humeral Bone Fractures;156
15.3.4;9.3.4 Forearm Bone Fractures;157
15.4;9.4 Small Bone External Fixation Frames;157
15.5;9.5 Multiplanar Configurations of Fixation Frames;158
15.6;9.6 Transarticular Bridging;158
15.7;9.7 Limb Suspension in the Early Post-traumatic Period;159
15.8;9.8 Hybrid Frames (Modular Combinations in Various Types External Fixation Devices) in Primary Fractures Stabilization Set;161
15.9;References;174
16;10: Prevention of Infection and Antibiotic Use in the Management of Armed Conflict Injuries to the Extremities;176
16.1;10.1 Background;176
16.2;10.2 The Nature of the Problem;176
16.3;10.3 The Wound Microenvironment;177
16.4;10.4 Epidemiology of Combat-Related Wound Infections Caused by Multidrug-Resistant Organisms;177
16.5;10.5 Combat-Related Extremity Injuries and Open Fractures;178
16.6;10.6 Prevention of Infections Associated with Combat-Related Extremity Injuries;179
16.7;10.7 The Use of Antibiotics in the Management of Combat-Related Extremity Injuries;180
16.8;References;183
17;11: Vascular Trauma to the Limbs;185
17.1;11.1 Incidence of Vascular Trauma in Armed Conflicts;185
17.2;11.2 Methods of Hemorrhage Control;186
17.3;11.3 Tourniquets;186
17.4;11.4 Evacuation Methods of Casualties with Vascular Injuries;186
17.5;11.5 Triage in Emergency Room;187
17.6;11.6 Vascular Injury Imaging;187
17.7;11.7 Priority in the Operating Room;188
17.8;11.8 Mechanisms of Vascular Injury;188
17.9;11.9 Methods of Vascular Repair;189
17.10;11.10 Endovascular Methods;190
17.11;11.11 Temporary Shunt;190
17.12;11.12 Compartment Syndrome and Fasciotomy;191
17.13;11.13 Arterial Versus Venous Injury;192
17.14;11.14 Amputation;192
17.15;References;193
18;12: Peripheral Nerve Injury;195
18.1;12.1 Introduction;195
18.2;12.2 Definitions;195
18.2.1;12.2.1 Low-Velocity Injury;195
18.2.2;12.2.2 Medium Velocity Injury (The Usual “Low Velocity” of Firearm Injury);195
18.2.3;12.2.3 High-velocity Injury;195
18.3;12.3 Nerve Injury Mechanism;195
18.3.1;12.3.1 Indirect Nerve Trauma;195
18.3.1.1;12.3.1.1 Nerve Trauma When a Blast Throws the Victim;195
18.3.1.2;12.3.1.2 Nerve Stretching Due to a Displaced Fracture;196
18.3.1.3;12.3.1.3 Shock Waves to the Adjacent Tissues Produced by a Penetrating Missile;196
18.3.1.4;12.3.1.4 Heat;196
18.3.2;12.3.2 Direct Nerve Trauma;196
18.3.2.1;12.3.2.1 Low-Velocity Injury;196
18.3.2.2;12.3.2.2 Medium-Velocity Injury;197
18.3.2.3;12.3.2.3 High-Velocity Injury;197
18.3.2.4;12.3.2.4 Iatrogenic Injury;197
18.4;12.4 Treatment Guidelines;197
18.4.1;12.4.1 Emergency Procedure Scheduled for a Concomitant Lesion;197
18.4.1.1;12.4.1.1 Nerve Continuity;197
18.4.1.2;12.4.1.2 Nerve Disruption;197
18.4.2;12.4.2 No Other Lesion Requiring an Emergency Procedure;200
18.4.2.1;12.4.2.1 High Suspicion of Isolated Indirect Nerve Trauma;201
18.4.2.2;12.4.2.2 High Suspicion of Isolated Direct Nerve Trauma;201
18.4.2.2.1;Low-Velocity Injury;201
18.4.2.2.2;Medium-Velocity Injury;203
18.4.2.2.3;High-Velocity Injury;203
18.4.2.2.4;Other Indications;204
18.5;12.5 Discussion;204
18.6;References;205
19;13: Tissue Coverage After War Trauma;207
19.1;13.1 General Considerations;207
19.2;13.2 Physical Examination;208
19.3;13.3 Timing of Soft-Tissue Coverage;208
19.4;13.4 General Strategies of Treatment;209
19.5;13.5 Negative-Pressure Wound Therapy;211
19.6;13.6 Skin Grafts;212
19.7;13.7 Flaps;213
19.7.1;Free Flaps;214
19.7.2;Perforator Flaps;215
19.8;13.8 Specific Flaps According to Anatomical Area;215
19.9;13.9 Complications of Soft Tissue Coverage;219
19.10;References;224
20;14: Definitive Bone Fixation and Reconstruction: Conversion from Temporary External Fixation to Internal Fixation Methods;227
20.1;14.1 Introduction;227
20.1.1;14.1.1 The Problem;227
20.1.2;14.1.2 The Civilian Experience: Provisional External Fixation in the Staged Treatment of Musculoskeletal Injuries;227
20.1.3;14.1.3 The Military Experience;228
20.1.4;14.1.4 The Military Paradigm (Echelons of Treatment);229
20.1.5;14.1.5 Considerations;230
20.2;14.2 Wounding Mechanisms in the Combat Environment;230
20.3;14.3 Rationale and Timing of Conversion to Definitive Fixation;230
20.3.1;14.3.1 Synopsis;230
20.3.2;14.3.2 The Pin Tract;236
20.3.3;14.3.3 Staged Treatment of Diaphyseal Fracturess;237
20.3.4;14.3.4 Staged Treatment of Periarticular Fractures;239
20.3.4.1;14.3.4.1 Management of the Fixator at the Time of Reconstruction;240
20.3.5;14.3.5 Ring (“Skinny Wire”) and “Built-up” Fixators;241
20.3.6;14.3.6 Consideration for Primary Definitive Internal Fixation;241
20.4;14.4 Conclusions;241
20.5;References;242
21;15: Definitive Skeletal Reconstruction: Conversion to the Ilizarov Method;244
21.1;15.1 Introduction;244
21.2;15.2 Conversion from the Unilateral Tubular Fixator to Ilizarov Circular Frame;245
21.3;15.3 Preserving Bone Alignment During the Conversion Procedure;245
21.4;15.4 Ilizarov Frame Assembly Technique for Fracture Reposition and Fixation;248
21.4.1;15.4.1 General Principles;248
21.4.2;15.4.2 Specific Locations;251
21.4.2.1;15.4.2.1 Femur;251
21.4.2.2;15.4.2.2 Tibia;254
21.5;15.5 Fibular Stabilization in Distal Tibiofibular Fractures;255
21.5.1;15.5.1 Open Reduction and External Fixation;255
21.5.2;15.5.2 Bilateral Lower Limb Injuries;258
21.5.3;15.5.3 Primary Circular/Hybrid Fixation Frame Assembly;258
21.5.4;15.5.4 Hinged Fixation of Extensive Periarticular Injuries;260
21.5.5;15.5.5 Peculiarity of Upper Limb Reconstruction: Methods of Isolated Hybrid External Fixation of the Humerus, Ulna, and Radi;263
21.5.6;15.5.6 Primary Arthrodesis for Joint Destruction;265
21.5.7;15.5.7 Limb Salvage in Severe Bone and Soft Tissue Loss;267
21.5.7.1;15.5.7.1 Bone Reconstruction by Callotasis (Bone Induction at the Site of Injury);267
21.5.7.2;15.5.7.2 Bone Reconstruction Using the Bifocal Technique;270
21.5.8;15.5.8 Acute Temporary Malalignment in Limb Salvage;274
21.5.8.1;15.5.8.1 Acute Limb Shortening;274
21.5.9;15.5.9 Acute Shortening and Angulation;280
21.5.10;15.5.10 Acute Shortening, Angulation, and Malrotation;283
21.6;15.6 Summary;286
21.7;15.7 Conclusion;287
21.8;References;287
22;16: War Injuries of the Hand;289
22.1;16.1 Introduction;289
22.2;16.2 Primary Care of the Wounded Hand;290
22.3;16.3 Tourniquet-Related Morbidity;291
22.4;16.4 Advanced Primary Management;291
22.4.1;16.4.1 Reassessment: General and Local;291
22.4.2;16.4.2 Anesthesia;291
22.4.3;16.4.3 Primary Wound Excision;293
22.4.3.1;16.4.3.1 Skin;293
22.4.3.2;16.4.3.2 Subcutaneous Tissues and Muscles;293
22.4.3.3;16.4.3.3 Vascular Structures;293
22.4.3.4;16.4.3.4 Nerves;295
22.4.3.5;16.4.3.5 Bone;295
22.4.3.6;16.4.3.6 Amputation;298
22.5;16.5 Delayed Primary and Secondary Surgical Management;299
22.5.1;16.5.1 Wound Closure: General Principles;299
22.5.2;16.5.2 Principles of Skin Cover;301
22.5.3;16.5.3 Management of Bone Injury;301
22.5.4;16.5.4 Management of Nerve Injuries;301
22.5.5;16.5.5 Management of Tendon Injury;302
22.5.6;16.5.6 Amputation;302
22.6;16.6 Physiotherapy, Occupational Therapy, and Early Motion;302
22.7;16.7 The Hidden Injury: Psychosocial Implications of Hand Injuries;302
22.8;References;303
23;17: Foot Surgery in War Trauma;304
23.1;17.1 Epidemiology, Battlefield Stabilization, and Triage;304
23.1.1;17.1.1 Epidemiology;304
23.1.2;17.1.2 Battlefield Stabilization and Triage;305
23.1.3;17.1.3 Interim Wound Management Techniques;307
23.2;17.2 Definitive Care Management;308
23.2.1;17.2.1 Initial Assessment and Planning;308
23.2.2;17.2.2 Initial Operative Strategy and Limb Salvage Assessment;309
23.2.3;17.2.3 Follow-on Wound Management;310
23.2.4;17.2.4 Wound Closure;311
23.2.5;17.2.5 Fracture and Bone Defect Management;313
23.2.6;17.2.6 Forefoot Reconstruction;313
23.2.7;17.2.7 Midfoot Reconstruction;315
23.2.8;17.2.8 Hindfoot Reconstruction;316
23.2.9;17.2.9 Combined Injuries;318
23.3;17.3 Deformity and Complication Correction Following Limb Salvage;318
23.3.1;17.3.1 Treatment Strategy;318
23.3.2;17.3.2 Nerve Deficit and Neuropathic Pain;319
23.3.3;17.3.3 Stiffness After Foot and Ankle Blast Trauma;320
23.3.4;17.3.4 Chronic Infection and Treatment;320
23.3.5;17.3.5 Posttraumatic Arthritis and Fusions;321
23.3.6;17.3.6 Deformity Correction Following Loss of Tendon Insertion;321
23.3.7;17.3.7 Residual Deformities After Compartment Syndromes and Blast Trauma;322
23.4;References;324
24;18: Limb Salvage Versus Amputation: The Dilemma;327
24.1;18.1 Introduction;327
24.2;18.2 Limb Salvage;328
24.3;18.3 Amputation;329
24.4;18.4 Classifications, Scoring, and Decision-Making;329
24.5;18.5 Clinical Examples of Lower and Upper Limb Salvage Reconstruction Using the Staged Protocol;330
24.5.1;18.5.1 Lower Limb Salvage;330
24.5.2;18.5.2 Upper Limb Salvage;330
24.6;18.6 Conclusion;333
24.7;References;341
25;19: Amputation in Combat Trauma;342
25.1;19.1 Introduction;342
25.2;19.2 History;342
25.3;19.3 General Principles;344
25.3.1;19.3.1 Introduction;344
25.3.2;19.3.2 Level of Care;344
25.3.3;19.3.3 Medical Care;345
25.3.4;19.3.4 Blast Wound Amputation;345
25.3.5;19.3.5 Amputation in Crush Injury;346
25.3.6;19.3.6 Indications for Amputation;347
25.3.6.1;19.3.6.1 Patient Related;347
25.3.6.1.1;General Condition;347
25.3.6.1.2;Local/Extremity Factors;347
25.3.6.2;19.3.6.2 Surgeon and Facility Related;347
25.3.7;19.3.7 Determination of the Level of Amputation;349
25.4;19.4 Surgical Technique;349
25.4.1;19.4.1 General;349
25.4.1.1;19.4.1.1 Hemostasis;349
25.4.1.2;19.4.1.2 Secondary Examination;349
25.4.2;19.4.2 Wound Care;349
25.4.3;19.4.3 Below-Knee Amputation;350
25.4.3.1;19.4.3.1 Postoperative Management;352
25.4.4;19.4.4 Knee Disarticulation;352
25.4.5;19.4.5 Above-Knee (Transfemoral) Amputation;352
25.4.5.1;19.4.5.1 Level of Amputation;353
25.4.5.2;19.4.5.2 Amputation Technique;356
25.4.6;19.4.6 Hip Disarticulation;356
25.5;19.5 Complications;356
25.5.1;19.5.1 Early Complications;356
25.5.1.1;19.5.1.1 Delayed Hemorrhage;356
25.5.1.2;19.5.1.2 Skin Flap Breakdown;357
25.5.1.3;19.5.1.3 Infection;357
25.5.2;19.5.2 Late Complications;358
25.5.2.1;19.5.2.1 Stump Instability;358
25.5.2.2;19.5.2.2 Ulceration;358
25.5.2.3;19.5.2.3 Neuroma;358
25.5.2.4;19.5.2.4 Heterotopic Ossification;358
25.5.2.5;19.5.2.5 Phantom Limb Pain;358
25.5.2.6;19.5.2.6 Contractures;358
25.6;19.6 Conclusion;359
25.7;References;359
26;20: Delayed Union and Nonunions;362
26.1;20.1 Introduction;362
26.2;20.2 Classification;362
26.3;20.3 Evaluation;364
26.3.1;20.3.1 Clinical Evaluation;364
26.3.2;20.3.2 Radiologic Evaluation;366
26.3.3;20.3.3 Laboratory Studies;366
26.4;20.4 Treatment;366
26.4.1;20.4.1 External Fixation Modalities;367
26.4.1.1;20.4.1.1 Monofocal Distraction;367
26.4.1.2;20.4.1.2 Consecutive Monofocal Compression Distraction;368
26.4.1.3;20.4.1.3 Bifocal Strategy: Acute Shortening and Gradual Lengthening;368
26.4.1.4;20.4.1.4 Computer-Assisted External Fixation (Hexapod Systems);368
26.4.2;20.4.2 Internal Fixation;369
26.4.2.1;20.4.2.1 Plate Osteosynthesis;369
26.4.2.2;20.4.2.2 Exchange Nailing;371
26.4.2.3;20.4.2.3 Cage and Grafting for Defect Nonunions;373
26.4.3;20.4.3 Combination Techniques;373
26.4.3.1;20.4.3.1 Bone Transport;374
26.4.4;20.4.4 Biologic Stimulation;377
26.4.4.1;20.4.4.1 Central Bone Grafting for Tibial Nonunions;377
26.4.4.2;20.4.4.2 Electrical Stimulation;377
26.4.4.3;20.4.4.3 Partial Fibulectomy;378
26.4.4.4;20.4.4.4 Bone Marrow Injection;378
26.5;20.5 Future;379
26.6;References;379
27;21: Osteomyelitis;381
27.1;21.1 Introduction;381
27.2;21.2 Clinical Evaluation;381
27.3;21.3 Principles of Therapy;383
27.3.1;21.3.1 Debridement;384
27.3.2;21.3.2 Local and Systemic Antibiotherapy;385
27.3.3;21.3.3 Bone and Soft Tissue (Temporary) Stabilization;385
27.3.4;21.3.4 Final Bone (Defect) Reconstruction;386
27.3.5;21.3.5 Distraction Osteogenesis Techniques;386
27.3.6;21.3.6 Fibula Transport;386
27.3.7;21.3.7 Vascularized Bone Grafts (VBGs);388
27.3.8;21.3.8 Titanium Cage;388
27.3.9;21.3.9 The Combined Technique;388
27.3.9.1;21.3.9.1 Step I;388
27.3.9.2;21.3.9.2 Step II (IM Nail Insertion/Application of External Fixator and Osteotomy);388
27.3.9.3;21.3.9.3 Femur;391
27.3.9.4;21.3.9.4 Tibia;392
27.3.9.5;21.3.9.5 Postoperative Care;392
27.3.9.6;21.3.9.6 Step III (Removal of External Fixator and Static Locking of the Nail);392
27.4;21.4 Complications;392
27.5;21.5 Conclusion;392
27.6;References;394
28;22: Chronic Pain Subsequent to Armed Conflict Injuries to the Extremities;396
28.1;22.1 Introduction;396
28.2;22.2 Neuropathic Pain;396
28.2.1;22.2.1 Definitions;396
28.2.2;22.2.2 Epidemiology;396
28.2.3;22.2.3 Clinical Presentation;397
28.2.4;22.2.4 Diagnosis;397
28.2.5;22.2.5 Management of Post-traumatic Neuropathic Pain;397
28.2.5.1;22.2.5.1 Pharmacotherapy;397
28.2.5.2;22.2.5.2 Nerve Blocks;399
28.2.5.3;22.2.5.3 Peripheral and Spinal Cord Stimulation;399
28.2.5.4;22.2.5.4 Surgery;399
28.2.5.5;22.2.5.5 Prevention;399
28.3;22.3 Complex Regional Pain Syndrome (CRPS);400
28.3.1;22.3.1 Epidemiology;400
28.3.2;22.3.2 Pathogenesis;400
28.3.3;22.3.3 Clinical Presentation;400
28.3.4;22.3.4 Diagnosis;401
28.3.5;22.3.5 Management of CRPS;401
28.4;22.4 Bone and Joint Pain;402
28.4.1;22.4.1 Overview;402
28.4.2;22.4.2 Diagnosis and Classification;402
28.4.3;22.4.3 Epidemiology;403
28.4.4;22.4.4 Clinical Presentation;403
28.4.5;22.4.5 Management of Bone and Joint Pain;404
28.5;22.5 Myofascial Pain Syndrome;404
28.5.1;22.5.1 Overview;404
28.5.2;22.5.2 Epidemiology;405
28.5.3;22.5.3 Clinical Presentation;405
28.5.4;22.5.4 Pathophysiology;406
28.5.5;22.5.5 Management of MPS;407
28.5.5.1;22.5.5.1 Noninvasive Therapy;407
28.5.5.2;22.5.5.2 Medications;407
28.5.5.3;22.5.5.3 Needling and Infiltrations;407
28.5.5.4;22.5.5.4 Exercise and Physical Activity;408
28.6;22.6 Dysfunctional Pain;408
28.7;References;408
29;Index;412