Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVI: Wounds and Injuries of the Soft Tissues

Introduction

United States Department of Defense

To maximize the preservation of life and minimize the attendant morbidity of battle wounds, the surgeon attempts to localize or isolate the deleterious effects of injury and to optimize healing. This objective is best accomplished by removal of all foreign material and detached or severely disrupted muscle from the wound, by the establishment of open drainage of the wound's recesses, and by maintaining adequate capillary perfusion of the injured tissues. Early institution of systemic antibiotic therapy plays more than an ancillary role in the management of these contaminated war wounds. If these management objectives are achieved, the risk of further local tissue destruction and systemic invasion by pathogenic micro-organisms is reduced to a minimum.

The emphasis of this chapter is on the management of damaged muscle Surgical management of other soft tissue and bone injuries is dealt with in other chapters. Two separate mechanisms are responsible for the injury caused by the passage of missiles through tissues. As the projectile punches through muscle, it destroys the tissue in its direct path by crushing it. Temporary cavitation forces, which present about one millisecond after passage of the projectile, stretch the tissues adjacent to the permanent missile track and result in additional injury or destruction.

Crushed Muscle: The amount of crushed muscle resulting from a single bullet or single fragment is closely related to the presenting cross-sectional area of the projectile. The gross anatomy of muscle will be much more severely disrupted by multiple penetrating projectiles striking in close proximity to each other, as is the case with explosive device injuries, deforming or fragmenting rifle projectiles, or any rifle projectile that strikes bone. Some remnants of muscle crushed by penetrating projectiles will generally be seen as a frayed edge along the missile track. Detached pieces of muscle, partially detached muscle flaps, and muscle islands surrounded by perforations should be regarded as nonviable. They would most likely act as foreign bodies that will potentiate infection in an already contaminated wound.

Stretched Muscle: Temporary displacement of muscle by cavitation (see Chapter 11) can cause petechial hemorrhages from torn small vessels (contusion), thrombosis of other small vessels, and patchy broken muscle fibers. Cavitation follows the path of least resistance, which is most often to separate muscle between parallel fibers and bundles. Gross radial splits are sometimes seen in muscle but not nearly to the extent that they are seen in skin. Although both bullet yaw and bullet deformation appreciably increase the dimensions of both the permanent and the temporary cavities, the effects of bullet fragmentation are by comparison devastating, and may result in an injury that is multiplied by several orders of magnitude in muscle that has been weakened a millisecond earlier by the creation of multiple radial fragment tracks.

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Operational Medicine 2001

Health Care in Military Settings

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