1. Thorough inspection of the wounds with liberal use of surgical wound extension is necessary to inspect all levels of tissue including examination of fascial planes. Wounds should be extended longitudinally rather than transversely around a limb when possible. If available, continuous wave Doppler examination and diagnostic arteriography can be used as adjuncts in cases where distal perfusion is a concern.4
2. Early control of active hemorrhage, gross decontamination, followed by a meticulous sharp debridement with a scalpel and/or scissors should be the starting point for wartime penetrating wounds.
3. Removal of all nonviable tissue, including skin, fat, fascia, muscle, and bone, is essential to reduce the load of contamination and necrotic tissue in the wound and is the hallmark of an adequate debridement.
4. Irrigation or lavage with normal saline is also important to decrease bacterial count and soiling. Irrigation or lavage of open wounds can be accomplished using various devices such as pulse lavage using a battery powered system or gravity irrigation using genitourinary tubing or bulb/syringe. Published clinical data is inconclusive as to which irrigation method is superior, however, additives, such as iodine or castile soap, should not be added to the irrigation solution (see JTS War Wounds: Debridement and Irrigation CPG for additional information).5
5. Confirmation of hemostasis is critical prior to evaluation for dressing or closure.
6. In the setting of an extremity amputation, appropriate vascular structures should be double-ligated (stick tie distal to a free tie) proximal to the bone resection but as distal as possible to ensure adequate tissue perfusion. Vascular structures should be separated from nerves prior to ligation. Avoid traction neurectomies when possible in patients who will have access to targeted muscle reinnervation treatment at the time of wound definitive closure.6
7. The amputation should be performed at the most distal level which provides viable bone and soft tissues for later closure. In select instances close to the proximal joint (e.g., knee, elbow), preservation of viable bone length in the absence of adequate viable soft tissue coverage is advocated in order to preserve options for either late free tissue transfer coverage and amputation level salvage or disarticulation. Ipsilateral fractures proximal to the level of viable tissue should be initially stabilized and should not be a determining factor for amputation level. These fractures can be stabilized with external fixation or splinting to facilitate evacuation.7
8. Be prepared to accept atypical skin and tissue flaps so long as the tissue is viable.
9. Do not perform primary closure of traumatic amputations. All wounds must be left open and re-evaluated with serial irrigation and debridements as the zone of injury declares itself.
10. Avoid open circular or guillotine amputations. These techniques are antiquated, sacrifice viable soft tissue, and relegate the casualty to more proximal revision, and are not that much faster than the open, length-preserving length of initial amputation advocated. All amputations should be performed at the most distal level possible with re-evaluation of the open amputation site within the first 24 hours.
11. Do not amputate through the most proximal fracture if stabilization of the fracture would result in an improved functional outcome and the associated wounds make salvage at the more distal level possible. For example, stabilizing a subtrochanteric femur fracture to allow for a more traditional above knee amputation or stabilizing a tibial plateau fracture to salvage a below knee amputation in what would otherwise be a knee disarticulation or above knee amputation can be performed when the injury pattern permits. Be aware, that these fractures can be associated with a high rate of infection and heterotopic ossification but can often be successfully treated to fracture union.7