ORTHOPAEDIC CONSIDERATIONS

It is common for DCBI patients to present with traumatic bilateral lower extremity amputations at various levels from transtibial to very high transfemoral levels. These are often associated with extremely complex soft tissue blast wounds that include the perineal and gluteal region (see Figure 1). In addition to lower extremity amputations, these injury patterns are often associated with complex pelvis and acetabular injuries (see Figure 2). Traumatic amputation of the non-dominant upper extremity can also be seen in these complex patterns due to weapons holding stance.

Optimal orthopedic care entails:

1. Ensuring extremity hemorrhage control
2. Pelvic external fixation if there is hemorrhage from a pelvic fracture, especially with sacroiliac disruption
3. Stabilization of extremity fractures in salvageable limbs / limb remnants
4. Debridement of devitalized tissue

Once in the operating room, hemorrhage control in the wound can be accomplished by replacing field TQ with pneumatic TQ. Total TQ time should be recorded, and it is imperative to communicate with anesthesia when the TQs are being released. These patients can have profound hypotension when the TQs are released and anesthesia must be ready with blood, calcium, bicarb and be prepared to hyperventilate the patient to manage the large acid load from reperfusion of the ischemic limb as inflow is restored. It is important to note that examination of the pelvic ring should be performed to address stability. Pelvic fractures can be stabilized with the use of clamped sheets or commercial pelvic binders centered over the greater trochanters, or a pelvic external fixator if resources and ability allow for this.