Tibia and Below-the-Knee Injuries and Fractures

The highest percentage of injuries sustained by the soldiers in Afghanistan has been to the extremities. These injuries will be nothing like you have seen in civilian trauma, even if you worked in a level I trauma center (Fig. 6.1). The injuries are rarely isolated, so that you are managing a soft tissue and fracture of the tibia that is attached to a soldier with multiple other injuries. Whether you are in a role 2 or 3 medical treatment facility, this is damage control orthopaedics. Lessons learned over the past 12 years of this conflict are that these injuries are more extensive than initial impression with a greater risk for compartment syndrome, wound infection, and osteomyelitis than is seen in the civilian world. There is no place for definitive stabilization of these high-energy injuries at the time of initial treatment and debridement. Most, if not all, surgeons who routinely manage these injuries throughout the echelons of care have regularly experienced frustrations due to the prolonged period of wound evolution and the expanded zone of injury that is caused by high-energy blast trauma. Not infrequently have experienced surgeons agonizingly watched the soft tissue envelope die over well-placed internal fixation, even after the wound appeared to have stabilized and the soft tissue envelope begun to recover. Caution is critical to avoiding further salvage procedures, bailout strategies, and worse yet amputation or amputation to a higher level. Local national patients treated in a military level II or III facility likewise benefit from judicious management of their injuries. Sterility, surgical instruments, imaging, and technically qualified assistance are not often found at near the same level as we routinely expect in our regular practices. This limits what we can and should try to do in managing the injuries in this subset of our patients. A well-placed external fixator can be easily removed by local physicians, or auto mechanics, long after we have departed the area, whereas an intramedullary nail, plate, or especially a locking plate cannot be so easily removed. Cases have been reported of the need for amputation in order to remove an infected locking plate. Keep this in mind when considering primary management strategies and secondary implications for these patients. Further, external fixation imparts minimal further damage to the soft tissue envelope; allows for continued, staged wound management; and provides the least risk of catastrophic osteomyelitis.