Abstract
Purpose: The purpose of this study is to evaluate the results of the treatment by severe blast injuries to limbs.
Materials and methods: Twenty-seven patients after blast injuries were treated. There were 13 patients with tibial fractures, 7 fractures of the femur, 4 – fractures of the humerus and 3 with fractures of the forearm bones. According to Gustilo all fractures were open grade 3B and 3C. According to MESS a median value was 4,7 points (range 3 – 7). Six had on admission vascular injuries, and 12 had peripheral nerve injuries. There was other major organ trauma in 55,5% of patients.
On admission, the fractured bones are realigned and stabilized with an AO tubular external fixation frame followed by immediate thorough soft tissue debridement, vascular reconstruction. In patients with peri-articular fractures temporary trans-articular bridging was needed.
After 5 to 7 days or when wound condition permits, delayed primary sutures, the application of skin grafts or free tissue flaps are performed. At this stage, the tubular fixator is exchanged for a circular frame that allows stability, sufficient for full weight bearing by minimal invasive fixation and meticulous attention to freeing the previously bridged joints. Hybrid frames allows combination of advantages of each type of external fixators. Closed reduction of fractures was performed in most patients by ligamentotaxis and use thin wires with olives. Fixation in elastic frame combined with cyclic loading provide favorable biomechanical environment for fracture healing.
In patients with high-energy “floating elbow” injuries the hybrid circular devices of the humerus and forearm were connected by hinges to allow immediate elbow joint movements. The separate fixation of the forearm bones was performed to allow early pronation/supination motions.
Results: In all patients the external fixation was the definitive treatment. Fracture union was achieved at median time of 240 days (range 90 – 546). Throughout the period of fracture healing the patients were fully ambulatory, living at home. In three patients with bilateral highly complex blast injuries of lower extremities, where one limb had to be amputated, the Ilizarov device for severely injured contralateral limb provided the conditions necessary for early prosthetic fitting. There was one non-union and one patient developed chronic osteomyelitis treated by serial debridement and sequestrectomies.
Conclusions: Based on this experience, we suggest that the stabilization in ring frame with radical debridement and early tissue transfer provides fracture healing and good functional results in extensive compound blast injuries of the extremities even in limbs categorized as high risk.
The abstracts were prepared by Ms Orah Naor. Correspondence should be addressed to Israel Orthopaedic Association at PO Box 7845, Haifa 31074, Israel.
