Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIX: Wounds and Injuries of Bones and Joints

Management at the Forward Hospital

United States Department of Defense

Following resuscitation, antibiotics should be started immediately according to the principles outlined in Chapter XI.

At operation, a properly applied tourniquet is a definite aid in locating and controlling sites of major hemorrhage Attention to accepted tourniquet usage principles is mandatory. In almost every case, the tourniquet, if used, should be released after two hours. It is also an absolute necessity that any tourniquet used during the procedure be released at the conclusion of the procedure prior to dressing to ensure appropriate hemostasis. Wound debridement should be carried out through generous incisions generally in the long axis of the extremity, avoiding the crossing of flexion creases at right angles.

Incisions should be planned such that the option to extend them is maintained. One should attempt to place the incision such that later reconstructive surgery is not compromised. The full extent of the wound including the deep fascia, should be widely exposed to facilitate the complete removal of foreign material, devitalized muscle, and other nonviable tissue (Chapter XVI). Small fragments of bone without soft-tissue attachment should be discarded, but larger fragments, particularly those contributing to length and circumferential integrity and those with significant soft tissue attachments, should be retained. Large, completely detached fragments should be cleaned thoroughly and replaced as near to their anatomical positions as possible The wound should be copiously irrigated-with pulsatile lavage containing an antibiotic solution whenever possible. Irrigation is an extremely important aspect of wound debridement, and with major injuries should optimally consist of approximately 10 liters of solution. Vascular repairs are accomplished as indicated in the acute phase, but nerve and tendon repairs should not be performed at this stage of treatment of battlefield casualties.

As has been said, the wound must not be dosed. No attempt should be made to effect wound coverage. Relaxing incisions, pedicle flaps, or any other definitive plastic type of wound approximation techniques are contraindicated at this time.

The wound should be dressed with a single layer of fine-mesh gauze followed by bulky fluffed gauze, then wrapped. Packing of the wound, which impedes drainage and capillary flow, should be avoided (Chapter XVI).

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Operational Medicine 2001

Health Care in Military Settings

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