22.1

Soft-Tissue Injuries

Chapter 22

Soft-Tissue Injuries

All war wounds are contaminated and should not be

closed primarily.

The goal in treatment of soft-tissue wounds is to save lives,

preserve function, minimize morbidity and prevent infections

through early and aggressive surgical wound care far forward

on the battlefield.

Presurgical Care

 Prevent infection.

ο Antibiotics:

♦ Antibiotics are not a replacement for surgical

treatment.

♦ Antibiotics are therapeutic, not prophylactic, in war

wounds.

♦ Give antibiotics for all penetrating wounds as soon as

possible.

ο Sterile dressing.

♦ Place a sterile field dressing as soon as possible.

♦ Leave dressing undisturbed until surgery. A one-look

soft-tissue examination may be performed on initial

presentation. Infection rate increases with multiple

examinations prior to surgery. Initial wound cultures

unnecessary.

Surgical Wound Management Priorities

 Life-saving procedures before limb and soft-tissue wound care.

 Save limbs.

ο Vascular repair.

ο Compartment release.
22.2

Emergency War Surgery

 Prevent infection.

ο Wound surgery within 6 hours of wounding.

ο Antibiotics.

ο Sterile dressing.

ο Fracture immobilization.

 Superficial penetrating fragment (single or multiple)

injuries usually do not require surgical exploration. Simply

cleanse the wounds with antiseptic and scrub brush.

Nonetheless, depending on location and clinical presentation,

maintain high suspicion for vascular injury or intraabdominal

penetration.

ο Avoid “Swiss cheese” surgery (in an attempt to excise all

wounds and retrieve fragments).

Wound Care

Primary Surgical Wound Care

 Limited longitudinal incisions.

 Excision of foreign material and devitalized tissue.

 Irrigation.

 LEAVE WOUND OPEN—NO PRIMARY CLOSURE.

 Antibiotics and tetanus prophylaxis.

 Splint for transport (improves pain control).

 Longitudinal incisions.

ο Wounds are extended with incisions parallel to the long

axis of the extremity, to expose the entire deep zone of

injury. At the flexion side of joints, the incisions are made

obliquely to the long axis to prevent the development of

flexion contractures.

ο The use of longitudinal incisions, rather than transverse

ones, allows for proximal and distal extension, as needed,

for more thorough visualization and debridement.

 Wound excision (current use of the term debridement).

ο Skin.

♦ Conservative excision of 1–2 mm of damaged skin edges

(Fig. 22-1a).

♦ Excessive skin excision is avoided; questionable areas

can be assessed at the next debridement.
22.3

Soft-Tissue Injuries

ο Fat.

♦ Damaged, contaminated fat should be generously

excised.

ο Fascia.

♦ Damage to the fascia is often minimal relative to the

magnitude of destruction beneath it (Fig 22-1b).

♦ Shredded, torn portions of fascia are excised, and the

fascia is widely opened through longitudinal incision

to expose the entire zone of injury beneath.

♦ Complete fasciotomy is often required as discussed

below.

ο Muscle.

a b

c d

Fig. 22-1. (a) Skin excision, (b) removal of fascia, (c) removal of avascular

tissue, (d) irrigation.
22.4

Emergency War Surgery

Removal of dead muscle is important to prevent

infection. ACCURATE INITIAL ASSESSMENT OF MUSCLE VIABILITY

IS DIFFICULT. Tissue sparing debridement is acceptable if

follow-on wound surgery will occur within 24 hours.

More aggressive debridement is required if subsequent

surgery will be delayed for more than 24 hours.

♦ Sharply excise all nonviable, severely damaged,

avascular muscle (Fig. 22-1c).

♦ The “4 Cs” may be unreliable for initial assessment of

muscle viability (color, contraction, consistency,

circulation).

◊ Color is the least reliable sign of muscle injury.

Surface muscle may be discolored due to blood under

the myomesium, contusion, or local vasoconstriction.

◊ Contraction is assessed by observing the retraction

of the muscle with the gentle pinch of a forceps.

◊ Consistency of the muscle may be the best predictor

of viability. In general, viable muscle will rebound to

its original shape when grasped by a forceps, while

muscle that retains the mark has questionable viability.

◊ Circulation is assessed via bleeding tissue from a

fresh wound. Transient vasospasm, common with

war wounds, may not allow for otherwise healthy

tissue to bleed.

ο Bone.

♦ Fragments of bone with soft-tissue attachments and

large free articular fragments are preserved.

♦ Remove all devitalized, avascular pieces of bone smaller

than thumbnail size that have no soft-tissue attachment.

♦ Deliver each of the bone ends of any fracture independently, clean the surface and clean out the ends of the

medullary canal.

ο Nerves and tendons.

♦ Do not require debridement, except for trimming frayed

edges and grossly destroyed portions.

♦ Primary repair is not performed. To prevent desiccation,

use soft-tissue or moist dressings for coverage.
22.5

Soft-Tissue Injuries

ο Vessels.

♦ Only minimal debridement of vessel is required for a

successful repair.

ο Irrigation.

♦ Following surgical removal of debris and nonviable

tissue, irrigation is performed until clean (Fig. 22-1d).

♦ While sterile physiologic fluid is preferred, do not

deplete resuscitation fluid resources. May use potable

water as an alternative. The last liter of irrigant should

be a sterile solution with antibiotics.

ο Local soft-tissue coverage.

♦ The development and rotation of flaps for this purpose

should not be done during primary surgical wound care.

♦ Local soft-tissue coverage through the gentle mobilization

of adjacent healthy tissue to prevent drying, necrosis,

and infection is recommended. Saline-soaked gauze is

an alternative.

No Primary Closure of War Wounds.

ο Dressing.

♦ Do not plug the wound with packing as this prevents

wound drainage. Leaving the wound open allows the

egress of fluids, avoids ischemia, allows for unrestricted

edema, and avoids the creation of an anaerobic

environment.

♦ Place a nonconstricting, nonocclusive dry dressing over

the wound.

Wound Management After Initial Surgery

 The wound undergoes a planned second debridement and

irrigation in 24–72 hours, and subsequent procedures until a

clean wound is achieved.

 Between procedures there may be better demarcation of

nonviable tissue or the development of local infection.

 Early soft-tissue coverage is desirable within 3–5 days, when

the wound is clean, to prevent secondary infection.
22.6

Emergency War Surgery

 Delayed primary closure (3–5 days) requires a clean wound

that can be closed without undue tension. This state may be

difficult to achieve in war wounds.

 Soft-tissue war wounds heal well without significant loss of

function through secondary intention. This is especially true

of simple soft-tissue wounds.

 Definitive closure with skin grafts and muscle flaps should

not be done in theater when evacuation is possible. These

techniques may be required, however, for injured civilians

or prisoners of war.

Crush Syndrome

 When a victim is crushed or trapped with compression on

the extremities for a prolonged time, there is the possibility

for the crush syndrome (CS), characterized by ischemia and

muscle damage or death (rhabdomyolysis).

ο With rhabdomyolysis there is an efflux of potassium,

nephrotoxic metabolites, myoglobin, purines, and

phosphorous into the circulation, resulting in cardiac and

renal dysfunction.

ο Reperfusion injury can cause up to 10 L of third-space fluid

loss per limb that can precipitate hypovolemic shock.

ο Acute renal failure (ARF) can result from the combination

of nephrotoxic substances from muscle death (myoglobin,

uric acid) and hypovolemia resulting in renal low-flow state.

 Recognition.

ο History.

♦ Suspect in patients in whom there is a history of being

trapped (eg, urban operations, mountain operations,

earthquakes, or bombings) for a prolonged period (from

hours to days).

♦ Clear history is not always available in combat, and the

syndrome may appear insidiously in patients who

initially appear well.

ο Physical findings.

A thorough examination must be done with attention to

extremities, trunk, and buttocks. The physical findings

depend on the duration of entrapment, treatment

rendered, and time since the victim’s release.
22.7

Soft-Tissue Injuries

♦ Extremities.

◊ May initially appear normal just after extrication.

◊ Edema develops and the extremity becomes swollen,

cool, and tense.

◊ May have severe pain out of proportion to examination.

◊ Anesthesia and paralysis of the extremities, which

can mimic a spinal cord injury with flaccid paralysis,

but there will be normal bowel and bladder function.

♦ Trunk/buttocks: may have severe pain out of proportion

to examination in tense compartments.

ο Laboratory findings.

♦ Creatinine phosphokinase (CK) is elevated with values

usually > 100,000 IU/mL.

♦ The urine may initially appear concentrated and later

change color to a typical reddish–brown color, so called

“port wine” or “iced tea” urine. The urine output

decreases in volume over time.

♦ Due to myoglobin, urine dipstick is positive for blood,

but microscopy will not demonstrate red blood cells

(RBCs). The urine may be sent to check for myoglobin,

but results take days and should not delay therapy.

♦ Hematocrit/hemoglobin (H/H) can vary depending on

blood loss, but in isolated crush syndrome H/H is

elevated due to hemoconcentration from third spacing

fluid losses.

♦ With progression, serum potassium and CK increase

further with a worsening metabolic acidosis. Creatinine

and BUN will rise as renal failure ensues. Hyperkalemia

is typically the ultimate cause of death from cardiac

arrhythmia.

 Therapy.

ο On scene while still trapped.

♦ The primary goal of therapy is to prevent acute renal

failure in crush syndrome. Suspect, recognize, and treat

rhabdomyolysis early in victims of entrapment.

♦ Therapy should be initiated as soon as possible,

preferably in the field, while the casualty is still trapped.

Ideally it is recommended to establish IV access in a

free arm or leg vein.
22.8

Emergency War Surgery

◊ Avoid potassium and lactate containing IV solutions.

◊ At least 1 L should be given prior to extrication and

up to 1 L/h (for short extrication times) to a

maximum of 6–10 L/d in prolonged entrapments.

♦ As a last resort, amputation may be necessary for rescue

of entrapped casualties (ketamine 2 mg/kg IV for

anesthesia and use of proximal tourniquet).

ο Hospital care.

♦ Other injuries and electrolyte anomalies must be treated

while continuing fluid resuscitation, as given above, to

protect renal function.

♦ Foley catheter for urine output monitoring.

♦ Establish and maintain urine output > 100 cc/h until

pigments have cleared from the urine. If necessary, also

◊ Add sodium bicarbonate to the IV fluid (1 amp/L

D5W) to alkalinize the urine above a pH of 6.5.

If unable to monitor urine pH, put 1 amp in every

other IV liter.

◊ Administer mannitol, 20% solution 1–2 g/kg over 4

hours (up to 200 g/d), in addition to the IV fluids.

♦ Central venous monitoring may be needed with the

larger volumes (may exceed 12 L/d to achieve necessary

urine output) of fluid given.

♦ Electrolyte abnormalities.

◊ Hyperkalemia, hyperphosphatemia, hypocalcemia,

hyperuricemia must be addressed.

♦ Dialysis.

◊ ARF requiring dialysis occurs in 50%–100% of those

with severe rhabdomyolysis.

♦ Surgical management centers on diagnosis and

treatment of compartment syndrome—remember to

check torso and buttocks as well.

◊ Amputation: consider in casualties with irreversible

muscle necrosis/necrotic extremity.

♦ Hyperbaric oxygen therapy: may be useful after surgical

therapy to improve limb survival.
22.9

Soft-Tissue Injuries

Compartment Syndrome (see Chapter 27, Vascular Injuries)

 Compartment syndrome may occur with an injury to any

fascial compartment. The fascial defect caused by the injury

may not be adequate to fully decompress the compartment,

and compartment syndrome may still occur.

 Mechanisms of injuries associated with compartment

syndrome.

ο Open fractures.

ο Closed fractures.

ο Penetrating wounds.

ο Crush injuries.

ο Vascular injuries.

ο Reperfusion following vascular repairs.

 Early clinical diagnosis of compartment syndrome.

ο Pain out of proportion.

ο Pain with passive stretch.

ο Tense, swollen compartment.

 Late clinical diagnosis.

ο Paresthesia.

ο Pulselessness and pallor.

ο Paralysis.

 Measurement of compartment pressures: Not recommended,

just do the fasciotomy.

ο The diagnosis of a compartment syndrome is made on

clinical grounds.

ο Measurement of compartment pressures is not recommended

in the combat zone.

 Consider prophylactic fasciotomy.

ο High-energy wounds.

ο Intubated, comatose, sedated.

ο Closed-head injuries.

ο Circumferential dressings or casts.

ο Vascular repair.

ο Prolonged transport.

ο High index of suspicion.
22.10

Emergency War Surgery

Fasciotomy Technique

 Upper extremity.

ο Arm: The arm has two compartments:

The anterior flexors (biceps, brachialis) and the posterior

extensors (triceps).

♦ Lateral skin incision from the deltoid insertion to the

lateral epicondyle.

♦ Spare the larger cutaneous nerves.

♦ At the fascial level the intermuscular septum between

the anterior and posterior compartment is identified,

and the fascia overlying each compartment is released

with longitudinal incisions.

♦ Protect the radial nerve as it passes through the

intermuscular septum from the posterior compartment

to the anterior compartment just below the fascia.

♦ Compartment syndrome in the hand is discussed in

Chapter 26, Injuries to the Hands and Feet.

ο Forearm: The forearm has three compartments:

The mobile wad proximally, the volar compartment, and

the dorsal compartment (Fig 22-2).

♦ A palmar incision is made between the thenar and

hypothenar musculature in the palm, releasing the

carpal tunnel as needed.

♦ This incision is extended transversely across the wrist

flexion crease to the ulnar side of the wrist, and then arched

across the volar forearm back to the ulnar side at the elbow.

♦ At the elbow, just radial to the medial epicondyle, the

incision is curved across the elbow flexion crease. The

deep fascia is then released.

♦ At the antecubital fossa, the fibrous band of the lacertus

fibrosus overlying the brachial artery and median nerve

is carefully released.

♦ This incision allows for soft-tissue coverage of the

neurovascular structures at the wrist and elbows, and

prevents soft-tissue contractures from developing at the

flexion creases.

♦ A second straight dorsal incision can be made to release

the dorsal compartment, reaching proximally to release

the mobile wad if necessary.
22.11

Soft-Tissue Injuries

 Lower extremity.

ο Thigh: The thigh has three compartments:

The anterior (quadriceps), the medial compartment

(adductors), and the posterior compartment (hamstrings).

♦ A lateral incision is made from greater trochanter to

lateral condyle of the femur.

♦ Then iliotibial band is incised, and the vastus lateralis

is reflected off the intermuscular septum bluntly,

releasing the anterior compartment.

♦ The intermuscular septum is then incised the length of

the incision, releasing the posterior compartment.

♦ This release of the intermuscular septum should not be

made close to the femur, because there are a series of

perforating arteries passing through the septum from

posterior to anterior near the bone.

♦ The medial adductor compartment is released through

a

b

Volar Compartment

Medial

Dorsal Compartment

Mobile Wad

Lateral

Fig. 22-2. Forearm compartments.
22.12

Emergency War Surgery

a separate anteromedial incision.

ο Calf: The calf has four compartments:

The lateral compartment, containing peroneal brevis and

longus; the anterior compartment, containing extensor

hallucis longus, extensor digitorum communis, tibialis

anterior, and peroneus tertius; the superficial posterior

compartment, containing gastrocnemius and soleus; and

the deep posterior compartment, containing the flexor

hallucis longus, flexor digitorum longus, and the tibialis

posterior (Fig. 22-3).

♦ Two-incision technique.

Superficial

Posterior Cmpt.

Gastrocnemius M.

Tibialis Posterior

Posterior Medial

Incision

Anterolateral

Incision

G. Saphenous V.

Tibia

Anterior Tibial 

Artery, Vein, 

Peroneal Nerve

Tibialis Anterior Anterior

Cmpt. EDL EHL

FHL in the

Deep Posterior

Cmpt.

Peroneus Brevis

and Longus in

Lateral Cmpt.

Fig. 22-3. Calf compartments.

◊ Incisions must extend the entire length of the calf to

release all of the compressing fascia and skin (Fig. 22-4).

◊ A lateral incision is made centered between the fibula

and anterior tibial crest.

◊ The lateral intermuscular septum and superficial

peroneal nerve are identified, and the anterior

compartment is released in line with tibialis anterior
22.13

Soft-Tissue Injuries

muscle, proximally toward the tibial tubercle, and

distally toward anterior ankle.

◊ The lateral compartment is then released through this

incision in line with the fibular shaft, proximally

toward the fibular head, distally toward the lateral

malleolus.

◊ A second incision is made medially at least 2 cm medial

to the medial-posterior palpable edge of the tibia.

◊ A medial incision over or near the subcutaneous

surface of the tibia is avoided, preventing exposure

of the tibia when the tissues retract.

◊ The saphenous vein and nerve are retracted anteriorly.

◊ The superficial compartment is released through its

length, and then the deep posterior compartment

over the FDL is released. Then identify the tibialis

posterior and release its fascia.

turn

Fig. 22-4. Anteromedial incision of the calf.
22.14

Emergency War Surgery

ο Foot: See Chapter 26, Injuries to Hands and Feet.

 Fasciotomy wound management.

ο Following the fasciotomy, the fasciotomy wound undergoes

primary surgical wound management, removing all

devitalized tissue.

ο As with all war wounds, the fasciotomy is left open, and

covered with sterile dressings.

 Vacuum Wound Closure Systems.

o Vacuum assisted wound closure is an important adjunct

to modern combat wound care.

o Only one device is currently approved for this application:

the Wound Vacuum Assisted Closing (VAC) Therapy

System.

o Field expedient vacuum assisted wound closure is an

alternative. Field expedient vacuum dressings are easily

created with standard issue items, including the following:

♦ Laparotomy sponges.

♦ Jackson-Pratt (JP) drains.

♦ Ioban.

♦ Benzoin.

♦ Adaptec (nonadherent gauze, for skin grafts).

♦ Sterile perforated IV bags.

◊ For wounds of the soft tissue and extremities, layer

laparotomy sponges with JP drains sandwiched

between the sponges and covered with Ioban. Apply

benzoin to the skin edges to prevent leaks.

◊ Attach the JP drains to the standard vacuum pump,

adjusted to 125 mm Hg suction. This dressing

eliminates the need for skin traction in amputations.

◊ For skin grafts, staple the graft to the edges of the

wound. Apply nonadhering gauze, and apply to

field-expedient vacuum dressing. Do not remove for

3 days. Grafts can be dressed with Silvadene when

the field-expedient vacuum dressing is removed.

◊ For open abdominal wounds, place sterile

perforated IV bags on the bowel, and sew the IV bag

to the fascia, or underlay the fascia with the IV bag.

Place laparotomy sponges on the IV bags and layer
22.15

Soft-Tissue Injuries

with JP drains. Apply benzoin to the skin edge and

cover with Ioban. Attach the drains to suction. This

dressing prevents leaking of abdominal fluids during

transport.

Many surgeons consider this an important part of wound

management because the use of vacuum systems may improve

and accelerate wound healing in a variety of conditions to

include: pressure ulcers, partial thickness burns, orthopaedic

wounds with large soft tissue defects, open abdominal wounds,

and assistance with skin graft viability.

The treatment of soft tissue injury is the most common

denominator in the management of war wounds. This chapter

summarizes some principles of this mangement.
22.16

Emergency War Surgery