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External fixation a good option for military surgeons in combat zones
Treatment for military injuries needs to be quick and must render the patient stable enough to transport.
Soldiers and local nationals often suffer extremity injuries in combat zones, but the United States military has up until recently barely made use of external fixators for these injuries. New experiences in Baghdad with Operation Iraqi Freedom have shown that external fixation works well for many types of injuries suffered in combat zones where other treatment options are often scarce.
“With U.S. conflicts we’ve been in, [there are] not a lot of reports as far as external fixation. In Panama, there were about eight fixators there; from Desert Storm we found a report … of 23, and from Operation Enduring Freedom nine cases have been reported,” said Maj. Reagan Parr, MD. He spoke at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting in Washington.
Parr said that the large number of extremity injuries in combat zones, especially Iraq, make external fixation a valuable treatment option. He treated patients at the 31st Cache South in the center of the Green Zone in Baghdad. “[We worked] at one of Saddam’s old hospitals with real ORs and real wards, like what you might have seen 30 or 40 years ago in the United States,” he said.
He performed a retrospective review of all patients treated with external fixators during an eight-month period in 2004, all from the same hospital. The hospital treated 2300 cases in all services in that time period, with 209 external fixation cases. Parr noted that some patients required more than one external fixator, and he found no relationship between category of patient and where the fixator was applied.
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Challenges
“The patient categories were a little bit challenging, especially with the local national population, because their status frequently changed during the hospitalization. They would show up a good guy and turn out to be a bad guy and vice versa, so … I couldn’t divide those up,” Parr said.
Examining time of procedures also proved to be difficult, as many patients required treatment from more than one service, including general surgeons or ophthalmologists. Radiographs were limited as well, often with only one view available.
Surgeons used the same external fixation device for several parts of the body, including tibia, femur, shoulder and humerus injuries. There was a C-arm in the OR. The surgeons made incisions for pin placement without concern for scarring.
“Afterwards, all [patients] received antibiotics, and U.S. personnel were evacuated out of our facility usually in under 24 hours, but never in more than 48 hours unless they had concomitant injuries that kept them there,” Parr said. Many of the local nationals stayed longer, and often had secondary procedures including secondary nailings, ORIF and soft tissue procedures. “They would then either be transferred to a detention facility or discharged.”
Of the total external fixation cases, surgeons placed 32.5% of them on the upper extremities. Some patients received fixation around the shoulder as well. Approximately two-thirds of the fixators were applied to the lower extremities, and “as you might expect, most of them were centered around the knee with spanning external fixators for the joints,” Parr said.
Fragment injuries
Most cases were caused by fragment injuries, and Parr found a significant difference between the mechanism of injury for U.S. personnel and local nationals. U.S. personnel injuries were fragment-related 72% of the time, while local nationals more often suffered gunshot wounds.
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Surgeons spent slightly longer on tibia and humerus fixation operations than on femur operations, and Parr said he was unsure why this was the case.
Transportation of patients becomes an important issue in combat zones, as often the conditions do not live up to the U.S. high standards of care. “[External fixation] was a good way to stabilize and then comfortably transport them all the way back to the United States. Many facilities, including us, were limited in alternatives. We did not use internal fixation for U.S. personnel in the theater because of the risk of infection, and we knew we could get a higher standard of care elsewhere,” Parr said.
He noted that while surgeons did use external fixation on many injuries, “we didn’t just go crazy with [it]. We did use splints and the like for some.” Other options, such as traction, were not available for use. Furthermore, the bone often did not represent the most important aspect of the injury; often, the soft tissue damage was more important.
“We learned that external fixators work very well, and they are safe,” Parr said. “In the future, [surgeons should] expect a lot of fragment injuries and large soft tissue wounds. Be prepared to put external fixators on for multiple locations all over the body.”
For more information:
- Hofer S. Combat orthopaedics: ongoing care in the global war on terror: external fixation for fractures in the combat zone: combat support hospital experience during Operation Iraqi Freedom. Presented at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting. Feb. 23-27, 2005. Washington.