Experience in Managing War Trauma with a Damage Control Approach in the Hospital for Patients with Femur or Tibia Fractures
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Published:
Dec 20, 2023
Keywords:
Trauma, damage, control, fracture, tibia, femur
Main Article Content
Abstract
Introduction: The Central Military Hospital of Bogotá, Colombia has a specialized team for treating war trauma patients. They conduct an initial assessment of patients and promptly manage potentially fatal injuries using a damage control approach that aims to save the patient’s life, save the limb, and preserve its function.
Materials and Methods: An observational, descriptive, cross-sectional study was conducted on patients from the Colombian armed forces who, between 2012 and 2020, had femur or tibia fractures as a result of war trauma; these patients were treated using external fixation by the orthopedics and traumatology service of the Central Military Hospital in Bogotá, Colombia.
Objectives: To describe the complications associated with war trauma following a year of treatment for femur and/or tibia fractures under a damage control protocol at the Central Military Hospital, the nation’s reference facility for this kind of trauma.
Results: A retrospective review of war trauma patients between 2012 and 2020 with femoral or tibial fractures treated with DCO was performed. Fisher’s Exact tests were used for comparisons. Seventy-two soldiers were selected, 96% of fractures were open, 91% (66 cases) had some type of complication such as nerve injury, vascular injury, coverage defect, infection, and nonunion.
Conclusions: In our country, war trauma persists as one of the causes of polytrauma in young patients, which has significant clinical and financial implications. Bone injuries of severely affected extremities require staged management based on external fixation according to damage control principles.
Materials and Methods: An observational, descriptive, cross-sectional study was conducted on patients from the Colombian armed forces who, between 2012 and 2020, had femur or tibia fractures as a result of war trauma; these patients were treated using external fixation by the orthopedics and traumatology service of the Central Military Hospital in Bogotá, Colombia.
Objectives: To describe the complications associated with war trauma following a year of treatment for femur and/or tibia fractures under a damage control protocol at the Central Military Hospital, the nation’s reference facility for this kind of trauma.
Results: A retrospective review of war trauma patients between 2012 and 2020 with femoral or tibial fractures treated with DCO was performed. Fisher’s Exact tests were used for comparisons. Seventy-two soldiers were selected, 96% of fractures were open, 91% (66 cases) had some type of complication such as nerve injury, vascular injury, coverage defect, infection, and nonunion.
Conclusions: In our country, war trauma persists as one of the causes of polytrauma in young patients, which has significant clinical and financial implications. Bone injuries of severely affected extremities require staged management based on external fixation according to damage control principles.
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How to Cite
Calderón Uribe, O. H., Satizabal Azuero, C. A., León Balcero, F. A., & Arcos Lucero, D. S. (2023). Experience in Managing War Trauma with a Damage Control Approach in the Hospital for Patients with Femur or Tibia Fractures. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 88(6), 606-619. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1705
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Clinical Research
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References
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https://cifras.unidadvictimas.gov.co/Cifras/#!/hechos [Consulta: 19 de enero, 2021]
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6. Nikolić D, Jovanović Z, Popović Z, Vulović R, Mladenović M. Primary surgical treatment of war injuries of major joints of the limbs. Injury 1999;30(2):129-34. https://doi.org/10.1016/s0020-1383(98)00239-3
7. Koržinek K, Delimar D, Tripković B. External fixator for war purposes: the CMC fixator. Mil Med 1999;164(5):358-60. PMID: 10332177
8. Segrt B. Particularities of the therapeutic procedures and success in treatment of combat-related lower extremities injuries. Vojnosanit Pregl 2014;71(3):239-44. https://doi.org/10.2298/vsp1403239s
9. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64(2):295-9. https://doi.org/1097/TA.0b013e318163b875
10. Chandler H, MacLeod K, Penn-Barwell JG; Severe Lower Extremity Combat Trauma (SeLECT) Study Group. Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003-2014. Injury 2017;48(7):1439-43. https://doi.org/10.1016/j.injury.2017.05.022
11. Valencia C, Suárez J, Cogollos Á, Uribe R, Flores G. Heridos en combate, experiencia del Grupo de Trauma del Hospital Militar Central de Bogotá. Rev Colomb Cir 2015;30(1):18-23. Disponible en:
http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S2011-75822015000100003&lng=en
12. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58(4):453-8. PMID: 773941
13. Yim GH, Hardwicke JT. The evolution and interpretation of the Gustilo and Anderson classification. J Bone Joint Surg Am 2018;100(24):e152. https://doi.org/10.2106/JBJS.18.00342
14. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30(5):568-72; discussion 572-3.
https://doi.org/10.1097/00005373-199005000-00007
15. Durrant CA, Mackey SP. Orthoplastic classification systems: the good, the bad, and the ungainly. Ann Plast Surg 2011;66(1):9-12. https://doi.org/10.1097/SAP.0b013e3181f88ecf
16. Doucet JJ, Galarneau MR, Potenza BM, Bansal V, Lee JG, Schwartz AK, et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011;70(5):1241-7.
https://doi.org/10.1097/TA.0b013e3182095b52
17. Suárez F, Satizábal C, Calderón O, Ramírez V, García A, Náquira L. Flora bacteriana en heridas de guerra. Experiencia de dos años en el Hospital Militar Central de Bogotá. Revista Med 2008;16(1):127-33. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0121 52562008000100017
18. Méndez M, Ramírez A, Jiménez S, Vargas A, Gómez A, Bandera J, et al. Flora bacteriana en fracturas abiertas de grado III ocasionadas por traumatismo de guerra. Rev Colomb Ortop Traumatol 2018;32(1):38-42. https://doi.org/10.1016/j.rccot.2017.07.006
19. Mathieu L, Bertani A, Gaillard C, Chaudier P, Ollat D, Bauer B, et al. Surgical management of combat-related upper extremity injuries. Chir Main 2014;33(3):174-82. https://doi.org/10.1016/j.main.2014.02.003
20. Kalinterakis G, Koutras A, Syllaios A, Michalakeas N, Lytras D, Tsilikis I. The evolution and impact of the “damage control orthopedics” paradigm in combat surgery: a review. Eur J Orthop Surg Traumatol 2019;29(3):501-8. https://doi.org/10.1007/s00590-018-2320-x
21. Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg Br 2003;85(4):478-83. https://doi.org/10.1302/0301-620x.85b4.14217
22. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. En: Tornetta P III (ed). Instructional Course Lecture Trauma. Illinois: American Academy of Orthopaedic Surgeons; 2006, p. 319-34.
23. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53(3):452-61; discussion 461-2. https://doi.org/10.1097/00005373-200209000-00010
24. Covey DC. Combat orthopaedics: a view from the trenches J Am Acad Orthop Surg 2006;14(1):10-7.
https://doi.org/10.5435/00124635-200600001-00004
25. Rigal S, Tripon P, Rochat G. Le fixateur en chirurgie de guerre. En: Cahiers d’enseignement de la SOFCOT N° 58. Fixation externe du squelette. Paris: Expansion Scientifique Francaise; 1996, p. 277-9.
2. Registro Único de Víctimas. Fecha de corte 31/12/2020. Disponible en:
https://cifras.unidadvictimas.gov.co/Cifras/#!/hechos [Consulta: 19 de enero, 2021]
3. Centro Nacional de Memoria Histórica (2016), Tomas y ataques guerrilleros (1965- 2013) CNMH-IEPRI, Bogotá. Disponible en: https://centrodememoriahistorica.gov.co/tomas-y-ataques-guerrilleros-1965-2013/ [Consulta: 19 de enero, 2021]
4. La guerra escondida: Minas antipersona y remanentes explosivos. Centro Nacional de Memoria Histórica 2020. Disponible en: https://centrodememoriahistorica.gov.co/la-guerra-escondida-minas-antipersonal-y-remanentesexplosivos-en- / [Consulta: 19 de enero, 2021]
5. Camargo J, Pérez LE, Franco C, Rodríguez E, Sánchez W. “Plan pantera”, trauma militar. Rev Colomb Cir 2011;29(4):293-304. Disponible en: http://www.scielo.org.co/scielo.phpscript=sci_arttext&pid=S2011-75822014000400005
6. Nikolić D, Jovanović Z, Popović Z, Vulović R, Mladenović M. Primary surgical treatment of war injuries of major joints of the limbs. Injury 1999;30(2):129-34. https://doi.org/10.1016/s0020-1383(98)00239-3
7. Koržinek K, Delimar D, Tripković B. External fixator for war purposes: the CMC fixator. Mil Med 1999;164(5):358-60. PMID: 10332177
8. Segrt B. Particularities of the therapeutic procedures and success in treatment of combat-related lower extremities injuries. Vojnosanit Pregl 2014;71(3):239-44. https://doi.org/10.2298/vsp1403239s
9. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64(2):295-9. https://doi.org/1097/TA.0b013e318163b875
10. Chandler H, MacLeod K, Penn-Barwell JG; Severe Lower Extremity Combat Trauma (SeLECT) Study Group. Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003-2014. Injury 2017;48(7):1439-43. https://doi.org/10.1016/j.injury.2017.05.022
11. Valencia C, Suárez J, Cogollos Á, Uribe R, Flores G. Heridos en combate, experiencia del Grupo de Trauma del Hospital Militar Central de Bogotá. Rev Colomb Cir 2015;30(1):18-23. Disponible en:
http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S2011-75822015000100003&lng=en
12. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58(4):453-8. PMID: 773941
13. Yim GH, Hardwicke JT. The evolution and interpretation of the Gustilo and Anderson classification. J Bone Joint Surg Am 2018;100(24):e152. https://doi.org/10.2106/JBJS.18.00342
14. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30(5):568-72; discussion 572-3.
https://doi.org/10.1097/00005373-199005000-00007
15. Durrant CA, Mackey SP. Orthoplastic classification systems: the good, the bad, and the ungainly. Ann Plast Surg 2011;66(1):9-12. https://doi.org/10.1097/SAP.0b013e3181f88ecf
16. Doucet JJ, Galarneau MR, Potenza BM, Bansal V, Lee JG, Schwartz AK, et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011;70(5):1241-7.
https://doi.org/10.1097/TA.0b013e3182095b52
17. Suárez F, Satizábal C, Calderón O, Ramírez V, García A, Náquira L. Flora bacteriana en heridas de guerra. Experiencia de dos años en el Hospital Militar Central de Bogotá. Revista Med 2008;16(1):127-33. Disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0121 52562008000100017
18. Méndez M, Ramírez A, Jiménez S, Vargas A, Gómez A, Bandera J, et al. Flora bacteriana en fracturas abiertas de grado III ocasionadas por traumatismo de guerra. Rev Colomb Ortop Traumatol 2018;32(1):38-42. https://doi.org/10.1016/j.rccot.2017.07.006
19. Mathieu L, Bertani A, Gaillard C, Chaudier P, Ollat D, Bauer B, et al. Surgical management of combat-related upper extremity injuries. Chir Main 2014;33(3):174-82. https://doi.org/10.1016/j.main.2014.02.003
20. Kalinterakis G, Koutras A, Syllaios A, Michalakeas N, Lytras D, Tsilikis I. The evolution and impact of the “damage control orthopedics” paradigm in combat surgery: a review. Eur J Orthop Surg Traumatol 2019;29(3):501-8. https://doi.org/10.1007/s00590-018-2320-x
21. Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg Br 2003;85(4):478-83. https://doi.org/10.1302/0301-620x.85b4.14217
22. Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. En: Tornetta P III (ed). Instructional Course Lecture Trauma. Illinois: American Academy of Orthopaedic Surgeons; 2006, p. 319-34.
23. Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53(3):452-61; discussion 461-2. https://doi.org/10.1097/00005373-200209000-00010
24. Covey DC. Combat orthopaedics: a view from the trenches J Am Acad Orthop Surg 2006;14(1):10-7.
https://doi.org/10.5435/00124635-200600001-00004
25. Rigal S, Tripon P, Rochat G. Le fixateur en chirurgie de guerre. En: Cahiers d’enseignement de la SOFCOT N° 58. Fixation externe du squelette. Paris: Expansion Scientifique Francaise; 1996, p. 277-9.