Ballistic Trauma: Lessons Learned from Iraq and Afghanistan

Abstract

Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.

Current Trends in the Management of Ballistic Fractures of the Hand and Wrist: Experiences of a High-Volume Level I Trauma Center

“…Techniques such as extracellular matrices, dermal templates, and fat transfer may have an increasing role in tissue recovery, whereas new bone graft techniques are promising developments in fracture treatment. 8,16 Specifically, research on primary bone grafting and techniques to improve patient follow-up should be explored.…”

Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study

“…As survival rates of burn, trauma and war casualty patients continue to improve through advances in medical care, the expanding complexity of their soft tissue and orthopaedic extremity injuries present ongoing challenges to both patients and reconstructive surgeons (Casey et al , ,b; Holcomb et al , ; Jeschke et al , ; Shin et al , ; Valerio et al , ). Extremity injuries due to war conflict and acts of terrorism, specifically those caused by improvised explosive devices (IEDs) and blast mechanisms, often result in heterogeneous massive soft tissue losses.…”

“…These soft tissue wounds are often complex in nature secondary to inherent foreign body contamination, infection‐related soft tissue necrosis, compartment syndrome, and vascular and microvascular compromise. Thus, serial debridement and multiple surgical procedures to control local wound environments are of critical importance prior to initiating definitive reconstruction measures (Casey et al , ; Shin et al , ; Valerio et al , ). Following surgical debridement, reconstruction of the soft tissue defects is necessary to cover exposed vital structures and/or restore the skin/soft tissue losses.…”

“…Several biological and synthetic adjuncts aiming to improve full‐thickness wound healing have been proposed. Bilayer dermal regenerate templates (DRTs) designed to provide immediate coverage of full‐thickness wounds are commonly used (Lohana et al , ; Shin et al , ; Weigert et al , ). DRT is comprised of a porous matrix of cross‐linked bovine tendon collagen and glycosaminoglycans, covered with a superficial semi‐permeable polysiloxane (silicone layer).…”

“…As keratinocytes and fibroblasts migrate into the matrix, the collagen is slowly absorbed and replaced with collagen produced by the patient's native cells that have populated the biological scaffold. Once native cells become integrated with the porous matrix, the silicone layer can be removed, and an autologous, thin, meshed split‐thickness skin graft (STSG) can be placed to restore epidermal coverage during a second stage procedure (Shin et al , ). While the DRT offers an immediate wound coverage and biological dermal substitute, the second stage relies on the availability of autologous skin for definitive coverage with a STSG.…”