191

Medical Issues in the Care of the Combat Amputee

Chapter 10

MEDICAL ISSUES IN THE CARE OF THE 

COMBAT AMPUTEE

BRANDON J. GOFF, DO*; THANE D. McCANN, MD†; RUPAL M. MODY, MD‡; JOSHUA D. HARTZELL, MD§; PAIGE 

E. WATERMAN, MD¥; LUIS J. MARTINEZ, MD¶; ROBERT N. WOOD-MORRIS, MD**; CHARLOTTE CARNEIRO, 

RN, MS, COHN-S, CIC††;RICHARD F. TROTTA, MD‡‡; JULIE A. AKE, MD, MSC§§; AENEAS JANZE, MD¥¥; ALLISON 

FRANKLIN, DO¶¶; SHANE McNAMEE, MD***; GARTH T. GREENWELL, DO†††; VINCENT T. CODISPOTI, MD‡‡‡; 

KEVIN F. FITZPATRICK, MD§§§; MICHAEL DEMARCO, DO¥¥¥; and PAUL F. PASQUINA, MD¶¶¶

ISSUES IN INFECTIOUS DISEASES 

WOUND CARE MANAGEMENT 

DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM 

WEIGHT-BEARING PROGRESSION 

HETEROTOPIC OSSIFICATION 

ELECTRODIAGNOSTIC EVALUATION OF PERIPHERAL NERVE INJURIES IN 

COMBAT AMPUTEES/EXTREMITY TRAUMA

LONG-TERM EFFECTS OF LIMB AMPUTATION

SUMMARY
192

Care of the Combat Amputee

*Major, Medical Corps, US Army; Assistant Chief, Amputee Service, Integrated Department of Orthopaedics and Rehabilitation, National Naval Medical 

Center, 8901 Rockville Pike, Bethesda, MD 20889 and Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307; formerly, 

Director of Inpatient Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC

†Major, Medical Corps, US Army; Staff Physiatrist, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, Center for the Intrepid, 

3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234; formerly, Resident Physician, Department of Orthopaedics and Rehabilitation, Walter Reed 

Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC

‡Captain, Medical Corps, US Army; Physician, Department of Infectious Diseases, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, 

Washington, DC 20307

§

Captain, Medical Corps, US Army; Infectious Diseases Fellow, Department of Medicine, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307; formerly, Chief of Medical Residents, Department of Medicine, Walter Reed Army Medical Center, 6900 Georgia Avenue 

,NW, Washington, DC

¥

Major, Medical Corps, US Army; Infectious Diseases Fellow, Department of Medicine, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, 

Washington, DC 20307

¶

Major, Medical Corps, US Army; Infectious Diseases Fellow, Infectious Diseases Clinic, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307

** Major, Medical Corps, US Army; Infectious Diseases Fellow, Department of Infectious Diseases, Walter Reed Army Medical Center, 6900 Georgia 

Avenue, NW, Washington, DC 20307; formerly, Chief of Medicine, Wurzburg Medical Center, Wurzburg, Germany ††Infection Control Nurse Specialist, Department of Infection Control and Epidemiology, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307; formerly, Nurse Manager, Occupational Health, Marriott Wardman Park Hotel, 2660 Woodley Road NW, Washington, 

DC

‡‡Colonel, Medical Corps, US Army; Assistant Chief, Infectious Disease Service, Department of Internal Medicine, Walter Reed Army Medical Center, 

6900 Georgia Avenue, NW, Washington, DC 20307 §§ Captain, Medical Corps, US Army; Infectious Diseases Fellow, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 

20307; formerly, Chief of Medical Residents, Department of Medicine, Madigan Army Medical Center, Tacoma, Washington ¥¥ Captain, Medical Corps, US Army; Resident Physician, Department of Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, 

6900 Georgia Avenue, NW, Washington, DC 20307 ¶¶Captain, Medical Corps, US Army; Director of Inpatient Rehabilitation, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical 

Center, 6900 Georgia Avenue, NW, Washington, DC 20307; formerly, Resident, Department of Physical Medicine and Rehabilitation, Walter Reed 

Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 

***Medical Director, Polytrauma, Assistant Professor, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, 1201 

Broadrock Boulevard, Richmond, Virginia 23249 †††Captain, Medical Corps, US Army; Staff Physiatrist, Department of Physical Medicine and Rehabilitation Services, MCHK-PT, Tripler Army Medical Center, One Jarrett White Road, Tripler Army Medical Center, Hawaii 96859; formerly, Resident, Department of Physical Medicine, Walter Reed 

Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC ‡‡‡Captain, Medical Corps, US Army; Resident Physician, Department of Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, 

6900 Georgia Avenue, NW, Washington, DC 20307 §§§ Captain, Medical Corps, US Army; Staff Physiatrist, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia 

Avenue, NW, Washington, DC 20307 ¥¥¥ Major, Medical Corps, US Army; Director of Electrodiagnostic Medicine, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical 

Center, 6900 Georgia Avenue, NW, Washington, DC 20307 ¶¶¶Colonel, Medical Corps, US Army; Chair, Integrated Department of Orthopedics and Rehabilitation, Walter Reed Army Medical Center and National 

Naval Medical Center, Section 3J, 6900 Georgia Avenue, NW, Washington, DC 20307
193

Medical Issues in the Care of the Combat Amputee

ISSUES IN INFECTIOUS DISEASES 

wound sepsis will be presented. 

Initially, the wound should be grossly decontaminated without compromising hemostasis. The wound 

is then protected with a sterile or clean dressing and 

orthosis depending on the wound location (ie, wrist 

hand orthosis on an open distal ulnar fracture). The 

patient is triaged and transitions through higher levels 

of care with further wound management to include 

incision and drainage/debridement and definitive 

surgical treatment. Tetanus prophylaxis should be provided and documented if not up-to-date or unknown. 

Although it is mandatory for US service members to 

have up-to-date tetanus immunization before deployment, this may not be the case for allied soldiers or 

injured noncombatants.

Characteristics of a fracture determine the risk of 

infection. The commonly used Gustilo classification 

scheme for open fractures provides a useful tool for 

standardizing care, predicting potential complications, 

and comparing similar injuries in published reports.4

There is little value to culturing wounds early in 

the clinical course. In a series of 1,104 open fractures 

that were swabbed for aerobic/anaerobic culture before administration of antibiotics, 7% of the positive 

surveillance wound cultures developed infection with 

the same bacterium.5 Another series of 89 consecutive 

open fractures demonstrated 83% initial surveillance 

culture growth, but after debridement, 60% of repeat cultures were negative or grew nonpathogenic 

bacteria.6 Most wounds at presentation (before debridement/therapeutic irrigation) are colonized or 

contaminated, but rarely develop true infection. The 

authors recommend only obtaining wound cultures 

and initiating antibiotic treatment when clinical 

symptoms/findings indicate a true infection, such 

as fever, elevated white blood cell count, change in 

vital signs, purulent discharge, etc.

Pre- and perioperative antibiotic prophylaxis has 

repeatedly demonstrated reduced postoperative infectious complications.7

 Significant variation persists in 

antibiotic selection, timing, and duration of administration. The Surgical Infection Prevention Project 

guidelines address this topic8:

1. Timing of the first dose of antimicrobial therapy. 

The first dose should begin within 60 minutes 

of the incision. If a fluoroquinolone or vancomycin is used, infusion should begin within 

120 minutes of incision to reduce antibioticassociated reactions. If a proximal tourniquet 

is used, administering the full antibiotic dose 

before tourniquet application is desirable. 

Management of Infectious Issues in the Combat 

Amputee/Extremity Trauma Patient

Prophylactic Antibiotics for the Combat Amputee/

Extremity Trauma Patient

Throughout the history of warfare, open extremity 

fractures have been associated with significant morbidity and mortality. Field surgeons used therapeutic 

amputations as a last line of defense against sepsis and 

exsanguination with poor results. During the Franco–

Prussian War, management of these injuries accounted 

for 13,173 amputations with 10,006 reported deaths.1

During the American Civil War, the mortality rate for 

lower extremity fractures ranged from 14% to 32%, 

despite approximately 29,980 amputations reported. 

Early in World War I an open femoral fracture carried 

a mortality risk of 80%; however, mortality was reduced to 16% with the advent of the Thomas traction 

splint.2 Further advancement in fracture reduction, 

splinting, surgical debridement, and subsequent healing by secondary intention contributed to even better 

outcomes. The importance of debridement in decreasing septic mortality from wounds was demonstrated 

in both the Spanish Civil War and World War I. 2 The 

often-cited surgeon’s creed “cut to cure” should not be 

dismissed or maligned because this philosophy led to 

markedly improved survival rates during the preantibiotic era and continues to play a significant part of 

battlefield injury management in the modern age of 

broad-spectrum antibiotics and multidrug-resistant 

organisms (MDROs). 

With the discovery of penicillin and subsequently 

streptomycin and the sulfonamides, physicians anticipated that patient outcomes would improve. Yet, 

it became evident that even with antibiotics, closure of 

an infected wound was still prone to failure. Delayed 

primary closure of an infected wound has evolved into 

common practice of battlefield medicine. Although it 

is universally accepted to use antibiotics to treat an 

infected wound, its use to prevent wound infection is 

not as clearly defined and may contribute to antibioticresistant bacteria.

For 50 years, various prophylactic regimens have 

been used with varied success. A majority of the data 

comes from civilian literature and may not always 

apply to the combat injured. In 1974 Patzakis et al 

reported the first prospective randomized data demonstrating the effectiveness of prophylaxis in wound 

infections.3 Since this report several studies and guidelines have addressed it. In this chapter these data will 

be reviewed and a framework for the prevention of 
194

Care of the Combat Amputee

2. Duration of antimicrobial prophylaxis. No compelling evidence indicates that the use of 

antibiotics until all catheters and drains are 

removed will lower infection. Prophylactic 

antimicrobials should be discontinued within 

24 hours postoperatively.

Orthopaedic surgical prophylaxis regimens typically involve first or second generation cephalosporins 

(excellent coverage for anticipated community-based 

skin flora). Suggested regimens for total joint (hip 

and knee) arthroplasty are cefazolin 1 to 2 grams intravenous (IV) or cefuroxime 1.5 gram IV. These also 

would be appropriate for amputation prophylaxis. 

Vancomycin 1 gram IV may be used if a beta-lactam 

allergy/intolerance exists. These recommendations 

should be considered with each hospital’s antibiogram 

(local sensitivities and resistance patterns) because the 

presence of MDROs may influence the appropriate 

choice. Consultation with departments of infectious 

disease, infection control, and surgical services is 

recommended. 

Management of Infectious Issues in Combat 

Amputee/Extremity Trauma Patients at a Military 

Tertiary Care Center

War Wound Infections and Appropriate Antibiotic 

Therapy

The bacteriology of war wounds has changed significantly over the past 100 years. During World War 

I, Streptococcus spp and Clostridium spp predominated.

Wound infections in World War II showed anaerobic 

organisms and skin flora such as Streptococcus spp

and Staphylococcus aureus. With the advent of antibiotics and improved wound debridement techniques, 

there has gradually been a shift to gram-negative 

wound infections during the Vietnam and Korean 

wars. Organisms such as Enterobacter spp, Escherichia 

spp, Klebsiella spp, Pseudomonas spp, and present-day 

Acinetobacter baumannii-calcoaceticus complex (ABC) 

have begun to emerge as predominant pathogens of 

battle wounds.9,10

More than 18,000 service members were injured 

from 2001 to 2006 while serving in Afghanistan 

and Iraq. The prevalence of extremity wounds with 

concomitant infection has been high.9,10 Murray et al 

examined wound culture isolates from soldiers admitted to a combat support hospital in Baghdad, Iraq, at 

the time of initial injury.11 Of 61 soldiers, 30 (49%) had 

positive wound cultures, predominantly composed 

of less pathogenic gram-positive skin commensals (2 

cases of which were methicillin-resistant Staphylococcus 

aureus [MRSA]). Of the three gram-negative organisms 

isolated, all were drug sensitive. The lack of drug resistance and decreased pathogenicity supported the 

curtailment of the use of broad-spectrum prophylactic 

antibiotics in theater.11

In contrast to Murray’s findings within the theater, wound and blood cultures taken at tertiary care 

facilities showed increasing gram-negative bacteria, 

particularly MDROs.9,10 A report to the Centers for 

Disease Control and Prevention (CDC) in 2004 demonstrated increasing rates of drug-resistant ABC as 

a cause of bloodstream infections in 102 soldiers 

injured in Iraq, Kuwait, and Afghanistan that were 

treated at military medical tertiary care facilities.12

Petersen et al identified major pathogens isolated 

from war trauma-associated infections in 56 soldiers 

on the USS Comfort from March through May 2003.10

Of wound cultures obtained, 47% were polymicrobial with ABC the predominant organism (33%), 

followed by Escherichia coli (18%), and Pseudomonas 

spp (17%). Overall, 81% of organisms in wound 

cultures were gram-negative bacteria, whereas 19% 

were gram-positive bacteria. Aronson et al reported 

similar data from Walter Reed Army Medical Center 

(WRAMC) with ABC, Pseudomonas aeruginosa, E coli,

and Klebsiella spp accounting for a majority of war 

wound infections.9 Recent evidence suggests that the 

outbreak of multidrug-resistant ABC infection in the 

US military healthcare system likely results from environmental contamination of field hospitals coupled 

with broad-spectrum antibiotic use and transmission 

within healthcare facilities.13

According to the CDC/Healthcare Infection Control Practices Advisory Committee 2006 guidelines, 

MDROs are defined as resistant to one or more classes 

of antibiotics.14 MDROs such as MRSA, ABC, and 

extended-spectrum beta-lactamase (ESBL) producing 

organisms are being isolated from wound infections 

and other sterile body sites and fluids in soldiers.9,10,12

The incidence of multidrug-resistant ABC in all culture 

sites at WRAMC increased from 0.087 cases per 1,000 

admissions in 2002 to 0.3 cases per 1,000 admissions 

in 2005.

Treatment of war wound infections primarily 

involves surgical debridement of devitalized tissue 

with adjunctive antibiotics. Antibiotic susceptibility 

testing must guide treatment for MDROs. Currently, 

ABC susceptibility testing has increased utilization of 

polymyxins, carbapenems, and aminoglycosides for 

treatment.9,10,12 Severely ill or immunocompromised 

patients with multidrug-resistant ABC infection 

have been treated with combination therapy based 

on in-vitro and some in-vivo reports of synergy with 

combinations of polymyxins with rifampin and/or 
195

Medical Issues in the Care of the Combat Amputee

carbapenems; however, the clinical relevance of these 

data remains uncertain.15,16 A carbapenem is typically 

the preferred drug for treating ESBL organisms.17,18 

Multiple drugs are available to treat MRSA infections 

such as vancomycin, linezolid, and trimethoprimsulfamethoxazole.

The decision to treat war wound cultures and the 

duration of treatment are challenging. These decisions 

are dependent on the clinical suspicion for infection 

and type of infection present (ie, superficial vs deep 

infection). When MDROs are isolated from sterile sites, 

an infectious disease specialist should be consulted for 

further treatment recommendations.

Management and Follow-Up of Surgical Infections 

for Combat Amputee/Extremity Trauma Patients

Colonization

In postsurgical patients, differentiating between 

colonization and true infection is critical. Colonization 

is defined as the isolation of microorganisms in culture 

without accompanying clinical signs and symptoms of 

infection. The presence of the organism is not pathogenic and treatment is usually not required because 

of the lack of active infection, although antimicrobial 

measures are sometimes undertaken to decolonize a 

patient for infection control purposes (discussed below). To avoid unnecessary antibiotic use, the authors 

recommend against culturing wounds and surgical 

sites without clinical signs or symptoms of infection.

Surgical Site Infections. Surgical site infections 

(SSIs) are the most common complication of hospitalized surgical patients.19 Risk for the development 

of SSIs is related to both patient and operation 

characteristics. Contaminated and high-risk surgeries are associated with higher frequency of SSI 

development, with amputations among the highest 

risk procedures.20 Organisms commonly causing 

orthopaedic procedure-associated SSIs include 

S aureus, coagulase-negative staphylococcal species, 

and gram-negative bacilli. Surveillance data demonstrate that the epidemiology of SSIs in critically ill 

patients has been changing: the percentage of SSIs 

associated with gram-negative bacilli decreased 

from 56.5% in 1986 to 33.8% in 2003. The distribution of gram-negative pathogens also has changed, 

with decreasing numbers of E coli and Enterobacter 

isolates and an increase in the frequency of Acinetobacter-associated SSIs.21 Acinetobacter spp and ESBLproducing organisms have presented a particularly 

difficult clinical challenge to US military hospitals 

because of high levels of antimicrobial resistance 

among those pathogens.

SSIs are categorized as follows:

	 •	 superficial incisional SSI,

	 •	 deep incisional SSI, and

	 •	 organ/space SSI.22

As defined for surveillance purposes, superficial 

incisional SSIs occur within 30 days of the operation, 

involve only the skin or subcutaneous tissue of the 

incision, and feature at least one of the following: (1) 

purulent drainage; (2) organisms isolated from culture 

of fluid or tissue from the incision; (3) local signs or 

symptoms to include pain or tenderness, swelling, erythema, and warmth; and (4) diagnosis by the surgeon 

or attending physician.

Deep incisional SSIs occur within 30 days of the 

operation (within 1 year if an implant is in place); involve the deep soft tissues (muscle and fascial layers) 

of the incision; feature at least one of the four characteristics listed in the previous paragraph; and involve 

the patient with a fever greater than 38o Celsius or 

evidence of abscess or other infection on examination, 

histopathology, or radiologic examination.

Organ/space SSIs occur within 30 days after the 

operation if no implant is in place or within 1 year if 

an implant is in place and involve part of the anatomy 

that was opened or manipulated. In patients undergoing amputations, the organ/space SSI includes joint 

or bursa infections and osteomyelitis. Organ/space 

SSIs are usually treated as infections related to the 

relevant organ and space, whereas the superficial and 

deep incisional SSIs are treated as skin and soft tissue 

infections.

The diagnosis of an SSI is made with emphasis on 

examination of the incision. Signs of infection include 

tenderness, swelling, erythema, and purulent drainage. Clinical manifestations of SSIs typically occur 5 

days postoperatively. Fever within the first 48 hours 

postoperatively is only rarely attributable to SSI.23

Exceptions include SSIs resulting from streptococci 

and clostridial organisms, which can be diagnosed by 

the Gram stain of incisional drainage, and staphylococcal toxic shock syndrome, which is accompanied 

by the early findings of fever, hypotension, elevated 

liver-associated enzymes, and diarrhea.24 In the presence of early postoperative fever, the incision should 

be examined thoroughly and any drainage should be 

sampled, and a thorough evaluation of all potential 

causes of common nosocomial infections should be 

conducted.

The Infectious Diseases Society of America has 

published guidelines for SSI treatment.25 The most important aspect of treating SSIs is to open the wound, remove infected material, and perform dressing changes 
196

Care of the Combat Amputee

until the wound heals by secondary intention. Following drainage of the wound, antibiotic administration is 

not recommended without evidence of invasive infection or systemic illness. However, in patients with fever 

( > 38.5o Celsius) or tachycardia, a short course of antibiotics may be indicated (24–48 hours). The choice of 

therapy is often empiric, but should be guided by Gram 

stain or culture results when available. S aureus and 

streptococcal species are the most common infecting 

pathogens in SSIs following clean procedures (those 

procedures not entering the gastrointestinal or genital tracts). Consequently, agents with gram-positive 

coverage such as cefazolin, oxacillin, and clindamycin 

are recommended. Surgical procedures involving the 

gastrointestinal and genitourinary tracts as well as incisions involving the axilla or perineum have a higher 

incidence of gram-negative organisms and anaerobic 

pathogen infections. In these circumstances, effective 

choices include cefotetan, ampicillin/sulbactam, or a 

fluoroquinolone plus clindamycin. In all cases in which 

the rate of MRSA infection is high, vancomycin or 

linezolid should be considered while awaiting results 

of culture and susceptibility testing. In the authors’ 

experience with patients returning from Operation 

Iraqi Freedom/Operation Enduring Freedom (OIF/

OEF), limited-spectra antibiotics have been less useful 

because of the prevalence of MDROs. Antimicrobials 

with broader spectra have been required for these 

wound infections and should be considered as empiric 

therapy in clinically severe infections.26

Implant Infections. SSIs may affect surgical implants. Implant-associated infections occur perioperatively by bacterial contamination during surgery, 

by hematogenous spread of pathogens through blood 

from a distant infectious focus, or contiguously from 

an adjacent infectious focus.27 Definitive diagnosis of 

implant-associated infection involves the presence of 

clinical manifestations, intraoperative signs of infection 

adjacent to the implant, and the growth of pathogens 

in cultures of surgical specimens.28 A full discussion 

of device-related infections is beyond the scope of this 

chapter but an overview is provided below.

For infections related to an implanted orthopaedic 

device, the surgical treatment has traditionally involved 

resection arthroplasty or removal of the fixation device. 

The surgical management of infected joint prostheses 

varies from debridement with prosthesis retention to 

two-stage replacement, which involves hardware removal, followed by the placement of an antimicrobialcontaining spacer. The patient undergoes a prolonged 

course of systemic antibiotics—typically 6 weeks—and 

subsequent implantation of a new prosthesis. The 

two-stage replacement approach is preferred over the 

one-stage approach because of improved cure rates 

and superior functional outcomes.29

Infections of fracture-fixation devices that involve 

bone, including pin-site infections, are treated as osteomyelitis with a 6-week course of systemic antibiotics. 

Superficial infections of these devices can be adequately treated with 10 to 14 days of antibiotic therapy once 

the possibility of deeper infection has been excluded. 

Surgical intervention depends on the type of device, 

the presence of bone union, and the clinical stability of 

the patient. Infection of intramedullary nails usually 

requires removal of the infected nail, use of externalfixation pins, and potentially subsequent insertion of 

a replacement nail. Surgical intervention of infected 

external-fixation pins28 involves removing infected 

pins and, if bone union has not occurred, inserting new 

pins at a distant site or fusion of the bones.

In the authors’ experience, a large number of patients with orthopaedic implant infections have not 

been able to undergo immediate device removal because of the extent of their injuries. In these patients, 

the authors recommend infectious disease consultation 

to determine the optimal antimicrobial regimen often 

involving an initial parenteral course of antibiotics followed by a long-term oral regimen. Cure rates in trials 

involving retention of the implant generally have been 

disappointing. A recent randomized controlled trial of 

rifampin in implant salvage among a selected group 

of patients with joint prosthesis or fracture-fixation 

device staphylococcal infections yielded promising 

results.30 Ongoing studies in OIF/OEF patients will 

hopefully provide valuable data on how to best manage these complex cases. 

Protocol for Management of Infections for Amputee/Extremity Trauma Patients

An axiom for the treatment of soft tissue or hardware infections is debridement of infected or devitalized tissues and removal of implanted hardware. 

Antibiotics serve a secondary role that is effective 

only with adequate debridement. Without sufficiently 

removing the infected source, most antibiotic regimens 

fail regardless of duration of treatment regimen. Recommendations for optimal duration of therapy vary 

and no standard consensus guidelines exist.

Treatment of osteomyelitis poses several clinical 

difficulties. No studies have addressed prospective 

randomized clinical trials assessing the length of antimicrobial therapy in these patients. In the setting of 

traumatic injury, osteomyelitis has a heterogeneous 

disease course and the optimal duration of antimicrobial therapy is unknown. In experimental models, 

4 weeks of therapy were more effective in sterilizing 

the bone than 2 weeks of therapy. Surgical debride-
197

Medical Issues in the Care of the Combat Amputee

ment was not part of these models; therefore, shorter 

courses of therapy may be as effective when paired 

with extensive surgical debridement.31 Although it 

typically takes approximately 6 weeks for vascularized 

soft tissue to cover the debrided bone and anecdotal 

experiences suggest a higher relapse rate with shorter 

durations of therapy, most experts recommend 4 to 6 

weeks of parenteral antimicrobial therapy.32

A similar problem exists for skin and soft tissue 

infections. The duration of antibiotics for infections 

involving only the skin and soft tissue has not been 

definitively proven. Most experts recommend 7 to 14 

days of therapy or until resolution of clinical signs and 

symptoms. Therefore, each patient should be followed 

closely to ensure adequate treatment and to prevent 

the spread of the infection to deeper tissues.

Principles of Management. It is difficult to compare 

the available literature because no standard case definitions, treatments, or patient populations exist, resulting 

in large discrepancies among outcomes that may not 

be based exclusively on treatment methods. In addition, small sample sizes in many studies preclude the 

ability to make definitive conclusions and the sample 

populations vary (civilian trauma vs combat injury).

The inoculating event is important in determining 

management. Posttraumatic osteomyelitis may occur 

as a direct result of bony injury following trauma or 

arise from nosocomial infection. Ideally, antibiotic selections are guided by wound culture and sensitivity 

results. Empiric antibiotic regimens should be chosen 

based on the medical center’s antibiogram (local sensitivities and resistance patterns). 

Patients with amputations/extremity trauma often 

have serial debridements (“washouts”) prior to wound 

closure. Interval surgical exams are important in 

monitoring for resolution of infection. Findings of new 

purulence, fluid collections, or necrotic tissue should 

be cultured because it may represent a new infection 

or an emerging resistant organism. Cultures should 

not be taken during serial washouts if no evidence of 

infection exists because positive culture results may 

represent colonization.

Quantitative operative cultures may be used as a 

marker of decreased or resolving bacterial burden. 

Quantitative culture requires weighing and careful 

preparation of the specimen for serial dilutions to 

determine whether the colony count is greater than 

105 colony-forming units per gram of tissue. Colony 

counts of this magnitude are correlated with a greater 

likelihood of infection associated with wound closure. 

Direct Gram smears of known quantities of specimen 

can be used to give an immediate assessment of organism load. Because quantitative cultures are time 

consuming and labor intensive, not all laboratories 

have procedures for performing these assays. The 

authors therefore recommend against performing 

such cultures.33

Different inflammatory markers can be used to 

monitor infection, but none have been studied in the 

authors’ particular patient population. These markers 

include C-reactive protein, erythrocyte sedimentation 

rate, and pro-calcitonin level. Unfortunately, these 

markers differ based on the specific patient’s inflammatory response to the initial trauma, surgical trauma, 

and underlying comorbidities. The most important 

concept in monitoring these parameters is the observance of trends. A significant increase in any of these 

serum studies may prompt further radiologic or surgical exploration for unresolved infection.

Orthopaedic consultants often obtain serial plain 

radiographs. Although plain films are insensitive for 

monitoring osteomyelitis, findings of osteopenia and 

thinning of cortical bone or sequestra should prompt 

closer monitoring or cross-sectional imaging studies. 

Serial cross-sectional imaging studies (computed tomography [CT], magnetic resonance imaging, etc) may 

be used, but they are significantly more expensive and 

patient transport may present challenges. To further 

complicate imaging study of osteomyelitis, noninfectious postoperative scarring or edema in traumatized 

bone can persist for up to 1 year.34 Heterotopic ossification (HO) has also been commonly seen in the OIF/

OEF population; however, it does not appear to pose 

an increased risk of infection.35

Infection Control and Surveillance in Returning 

Warriors

The emergence of MDROs is a worldwide dilemma 

and adds to the complexity of care for wounded and ill 

service members returning from theater. The predominant and troublesome MDRO that military personnel 

face returning from OIF/OEF is ABC.9,10,12,13 Several 

reports have focused on the ABC outbreak that appears to be related to contamination in field hospitals.13

Acinetobacter has been appreciated since the Vietnam 

War and it continues to be a significant problem for 

personnel returning from OIF/OEF.36

Other MDROs of concern in major military hospitals 

and in civilian hospitals are gram-negative organisms, 

Klebsiella pneumoniae, P aeruginosa, vancomycin-resistant enterococcus, and ESBL-producing organisms. 

These MDROs have a predilection for transmission in 

healthcare facilities and persist unless diligent control 

and containment measures are undertaken. Wounded 

service members, particularly those with open nonhealing wounds or burns, are at risk for bacterial 

colonization and/or infection. Treating these infections 
198

Care of the Combat Amputee

with broad-spectrum antimicrobials leads to depletion 

of normal gut flora, increasing the risk for Clostridium 

difficile-associated disease. 

Measures for successful control of MDROs, which 

have been documented in the United States and 

abroad, consist of a variety of combined interventions.14 These interventions include hand hygiene 

by all healthcare providers, the use of active surveillance cultures for MDRO colonization, contact 

precautions, infectious control education, enhanced 

environmental cleaning, and improvements in 

communication between healthcare providers/

facilities about patients with MDRO infections. 

Each of these measures should be customized for 

application within each healthcare facility and the 

local community under the guidance of an active and 

informed infection control committee of specialists 

in infectious disease, occupational health, preventative medicine, pharmacy, and clinical laboratory services. However, it is the responsibility of individual 

healthcare providers to play an active role in the 

successful elimination of MDROs in their patients, 

their hospital, and their community.

Initiation and Surveillance of Contact Precautions

Active surveillance of MDROs, particularly with 

MRSA, is being widely conducted in the United States. 

In 2003 major military medical treatment facilities 

began surveillance cultures of groin and axillae for 

ABC and nares for MRSA on all soldiers directly admitted from theater. Population and need determines 

targeted surveillance. Contact precautions are used as 

a containment measure before MDRO isolation from 

culture when there is a high suspicion for infection (eg, 

on hospital admission and/or in patients with open 

draining wounds not contained in a dressing). Methods for determining colonization are not standardized 

among institutions. CDC guidelines should be used as 

a reference when making decisions regarding colonization surveillance methods.14 Any healthcare provider 

can initiate contact precautions, but they should be 

removed in conjunction with infection control practitioners and hospital policy.

CDC defines contact precautions as the wearing 

of gown and gloves when in contact with the patient 

or anything that has touched the patient.14 Although 

visitors who touch the patient do not always need 

to comply with these measures, the rationale for 

healthcare providers to wear protective gear is to 

prevent the transmission of bacteria from one patient 

to another. In some circumstances it is not feasible for 

each patient to have a private room. In these cases patients with the same MDROs can be located together. 

At WRAMC family members are required to wear a 

gown and gloves only if they will come into contact 

with blood or body fluids. Other institutions require 

family members to wear a gown, gloves, and masks 

(when concern for airborne transmission exists) at all 

times. The efficacy of any of these strategies requires 

strict adherence. 

Discontinuing Contact Precautions

Few data support standardized criteria for removing contact precautions for patients colonized or 

infected with MDROs. The clearing protocol shown 

in Table 10-1 is used in two major military medical 

treatment facilities to clear patients and to reduce 

their social isolation.37 Providers should know their 

patients’ status and be involved in a clearing protocol 

as soon as antibiotic therapy has ceased for 72 hours 

and wounds are healed. 

Environmental Cleaning

The environment plays an increasingly significant 

role in the transmission of nosocomial MDROs. ABC 

and MRSA can live for weeks on surfaces, especially 

“high-touch” surfaces.38 Daily housecleaning of such 

surfaces, particularly IV poles and bedrails, is critical. 

Hospital-grade disinfectants with high kill while drying should be used in patient rooms, especially during 

patient turnover. Assiduous environmental cleaning by 

hospital housekeeping staff has been shown to reduce 

the frequency of vancomycin-resistant enterococcus 

cross contamination.39

Once the colonized patient is discharged and returns for rehabilitation in outpatient clinics, the risk 

for transmission is decreased but not eliminated. 

Patients with amputations and other combat-related 

injuries often require multiple readmissions and clinic 

visits for rehabilitation. They are continually at risk for 

acquiring a new infection or spreading their colonized 

microbes. In WRAMC’s outpatient clinics patients 

with open wounds or undergoing dressing changes 

must be treated in designated areas. In therapy gyms 

the healthcare provider monitors and cleans mats and 

other equipment used by patients with the appropriate germicide.

Hand Hygiene

Hand hygiene remains the cornerstone of infection 

prevention and control in healthcare and community 

settings; therefore, hospital administrators should give 
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Medical Issues in the Care of the Combat Amputee

it the highest level of attention.40 Soap and water may 

be as effective as antimicrobial soap. Alcohol hand 

gels with moisturizer have been shown to be effective against all organisms except C difficile and spores. 

Hand hygiene for healthcare workers is required before 

and after any patient care and after removing gloves. 

Routine surveillance of handwashing is recommended 

to enforce its importance and identify areas for intervention within an institution. 

Communication and Education

Providers communicating to bed control managers, discharge planners, and others have been very 

successful in alerting others of a patient’s MDRO 

status. Healthcare providers have a critical role in 

educating patients of the significance of MDRO 

colonization or infection. To prevent feelings of 

isolation and anxiety, simple language should be 

TABLE 10-1

CLEARING PROTOCOL SUMMARY CHART

To Clear For When Obtain These Cultures Order as Repeat Clear

Acinetobacter Off antibiotics 72 

hours, clinically improved, 

hardware sites 

clean and dry

Groin, axillae, nasal swabs

Original site if sputum, 

urine, or open/draining 

wound

Rule out Acinetobacter 

(ACI), choose 

site from pick list 

(groin, axilla, nares, 

wound, sputum, 

other)

Same cultures 

two more 

times, each 

72 hours 

apart

If all cultures 

are negative 

and approved by 

ICES

MRSA Off antibiotics 72 

hours, clinically improved, 

hardware sites 

clean and dry

Nares

Original site if sputum, 

urine, or open/draining 

wound

Rule out MRSA, 

select nasal swab 

and other sites from 

pick list

Same cultures 

two more 

times, each 

72 hours 

apart

If all cultures 

are negative 

and approved by 

ICES

VRE Off antibiotics 

72 hours, 

clinically 

improved, 

hardware sites 

clean and dry

Stool cultures or rectal 

swab

Original site if sputum, 

urine, or open/draining 

wound

Rule out VRE,

 choose sites from 

pick list

Same cultures 

two more 

times, each 

72 hours 

apart

If all cultures 

are negative 

and approved by 

ICES

MDRO/ESBL 

Gram negs 

(Klebsiella, 

Pseudomonas)

Off antibiotics 

72 hours, 

clinically 

improved, 

hardware sites 

clean and dry

Urine or peri-anal/rectal 

swab

Original site if sputum, 

urine, or open/draining 

wound

Rule out MDRO 

choose sites from 

pick list

Same cultures 

two more 

times, each 

72 hours 

apart

If all cultures 

are negative and 

approved by 

ICES

Clostridium difficile Completed 72 

hours of treatment

No cultures necessary NA NA If clinically 

improved 

and no diarrhea for 24 

hours

ESBL: extended spectrum beta-lactamase

ICES: Infection Control and Epidemiology Service

MDRO: multidrug-resistant organism

MRSA: methicillin-resistant Staphylococcus aureus

VRE: vancomycin-resistant enterococcus 

Initiate clearance cultures when off effective* antibiotics for 72 hours, wounds are healing, hardware is clean, and patient is clinically healing. For long-term patients readmitted, initiate clearance cultures prior to restart of antibiotics.

Do not culture blood, cerebrospinal fluid, or scabbed/healed wounds if these were originally positive.

*Effective antibiotic = one to which the organism is proven susceptible
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Care of the Combat Amputee

used to convey the type and significance of infection/colonization to each patient placed on contact 

precautions. 

Fever in the Returning Service Member 

Fever in the returning service member should be 

recognized for its similarities to routine travelers and 

for its uniqueness related to the combat environment.9

Rates of disease and nonbattle injury casualties historically exceed battle injuries in most conflicts. Rates have 

remained high for conflicts within the past decade, 

although preventive medicine interventions have 

dramatically reduced the nonpsychiatric and nonbattle 

injuries. Nevertheless, certain infections should remain 

high on the physician’s differential when treating a 

returning service member. 

Systemic illness, followed closely by diarrheal 

and respiratory illnesses, constitutes the majority of 

syndromes in all travelers when studied across six 

continents.41 Diarrheal illness is common in deployed 

personnel with up to 66% of troops reporting diarrhea, 

but it is an unlikely cause of fever the longer a patient 

has been back from theater.9 Physicians should consider more common etiologies of diarrhea and fever 

(C difficile) for patients who have been out of theater 

for more than 1 week. 

Malaria remains a consideration with travel to 

endemic areas outside the United States. Malaria is a 

common etiology of fever in the returning traveler, yet 

it has attack rates of only 10% in most areas of Afghanistan. Malaria from Iraq is rare with few cases directly 

attributable to travel there.42 Most of the malaria cases 

have been caused by Plasmodium vivax (80% to 90% 

in Afghanistan and 95% in Iraq) with the remainder 

caused by the more life-threatening strain, Plasmodium 

falciparum.43 Fever secondary to P vivax infection, which 

can occur months after exposure, should be considered 

as a potential etiology in at-risk patients for up to 1 

year after return from deployment. 

Q fever, caused by Coxiella burnetii, has been diagnosed in returning service members, with more than 

30 cases diagnosed during OIF/OEF.9,44,45 Classically, 

patients have been exposed to animals, such as cows 

and sheep, but several of the cases from OIF/OEF did 

not have known direct exposure. Q fever, which has 

a variable clinical course, often presents as a nonspecific febrile flu-like illness with pneumonia and/or 

hepatitis. Chronic infection most commonly involves 

the heart, and specific recommendations have been 

developed to monitor for chronic disease.46

Leishmaniasis, spread by the sand fly, represents 

another potential cause of fever in the returning 

service member. More than 1,200 cases of cutaneous 

leishmaniasis and four confirmed cases of visceral 

leishmaniasis have occurred.47 Cutaneous leishmaniasis is characterized by a nonhealing skin ulcer, 

without systemic symptoms. Visceral leishmaniasis is a 

systemic illness that manifests as a syndrome of fever, 

fatigue, night sweats, weight loss, gastrointestinal upset, hepatosplenomegaly, impaired liver function tests, 

and pancytopenia. Patient travel to endemic areas will 

increase one’s suspicion of leishmaniasis, and diagnosis can be made with a serologic assay.9

Apart from wound-specific infections, service 

members are at risk for infections transmitted via 

blood transfusion. Many service members receive 

massive transfusions (greater than 10 units of blood 

products). Although screening of the prepared blood 

supply is adequate, wartime often necessitates the use 

of field-expedient donors that may not have had recent 

screening for potentially newly acquired diseases such 

as human immunodeficiency virus and viral hepatitis. 

Unlike hepatitis A, which is rarely acquired via transfusion, hepatitis B and hepatitis C are associated with 

blood transfusions. One study from 1996 estimated 

nonwar-related transmission rates of 1 per 64,000 units 

transfused for hepatitis B virus. Hepatitis C virus was 

estimated to have transmission rates of 1 per 103,000 

per donor exposure in the United States. Human immunodeficiency virus transmission rates have been 

reported at 1 per 493,000 units transfused in the United 

States.48 Although rates are not yet known for deployed 

service members, new infections have been identified 

in returning OEF/OIF service members. 

Providers caring for hospitalized service members 

who have sustained injuries during a deployment 

should be aware of all potential causes of infections. 

Although it is the tendency to focus on the areas of 

trauma, potential travel-related infections must also 

be considered. Using the methods discussed in this 

section and reviewing the infections that are endemic 

to a deployed area will help the provider make an 

expedient diagnosis and decrease morbidity.

WOUND CARE MANAGEMENT 

Introduction

Wound care management is a critical component of 

military medicine, especially in the traumatic amputee’s 

care. Combat injuries often require complex wound care 

at multiple sites throughout the body. Because of the 

advances in body armor, fewer wounds are being seen to 

the chest and abdomen than had been reported in prior 
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Medical Issues in the Care of the Combat Amputee

wars. Furthermore, given the combination of immobilization, peripheral nerve injuries, and sedating effects of 

multiple medications, these patients are at even greater 

risk of developing problems such as pressure ulcers or 

compressive neuropathies. Therefore, proper positioning of the patient at all times throughout the echelons 

of care will likely reduce the risk of iatrogenic injuries. 

Judicious application of a standardized algorithm may 

reduce morbidity and mortality associated with wound 

management as well as economic burden.

Although it would seem reasonable that the amount 

of training a medical professional receives in wound 

care management would be commensurate with its degree of overall medical significance, this is not the case. 

Wound care tends to be an area of healthcare where 

outdated dogma often supersedes current medical 

knowledge. In addition, it is often mistakenly judged 

to be a subject, rather than a required dedicated field 

of medicine within itself. 

A provider cannot make competent decisions 

regarding the “how” of treatment when there is an 

incomplete understanding of the “why.” In this section a focused discussion of the essential principles 

of wound care will be presented. Unfortunately, a 

detailed analysis of wound types, their corresponding nomenclature, and specific treatment algorithms 

is beyond the scope of this section. Therefore, the following review will address normal wound healing, 

factors that negatively affect outcomes, and general 

principles to optimize wound healing. 

The Phases of Wound Healing

The four stages of wound healing are 

1. hemostasis, 

2. inflammation, 

3. proliferation, and 

4. remodeling.

Hemostasis

The hemostatic phase starts when the skin is first 

broken and stops when blood loss is controlled. The 

most immediate reaction to vascular injury occurs at 

the level of the vessel itself that reflexively vasoconstricts when damaged. The two primary means of 

hemostasis, however, involve initiation of the coagulation cascade and the formation of a platelet plug. 

These events are elegantly triggered when normally 

extraluminal materials such as collagen, thrombin, and 

tissue factor are exposed to the intraluminal milieu. 

The time required depends on the wound size and 

intrinsic factors associated with the patient’s health.

Inflammation

The inflammatory phase, under normal circumstances, lasts 3 to 5 days and is defined by the presence of neutrophils. The role of the neutrophils in a 

wound bed is context dependent and under certain 

conditions it can be disadvantageous. As a member of 

the body’s innate immune response, neutrophils are 

critical but their actions are nonspecific. Neutrophils 

act by releasing cytokines and chemokines within the 

wound bed, leading to free radical production and 

creating an unfriendly environment for both pathogens, as well as often the body’s own tissue-healing 

cells. Neutrophils also release the enzymes collagenase and elastase into the wound bed to break down 

the remaining extracellular matrix in preparation for 

subsequent wound-healing stages. By preventing 

pathogens from establishing foci and removing the 

detritus of an injured wound bed (extracellular matrix, dead pathogens, and native cells), an accessible 

route of entry for the body’s incoming regenerative 

cells is created.

Neutrophils will generally persist until most 

of the bacteria and necrotic tissue are removed. 

Neutrophils are vital acutely following injury, but 

they become a deficit in subsequent healing stages. 

Wound debridement at this later stage is therefore 

vital. The transition to the proliferative phase of 

wound healing is facilitated by manually cleaning 

a wound bed of bacteria and necrotic tissue. The 

success of wound debridement depends on proper 

technique. Excessive force may lead to renewed 

involvement of the neutrophils and only reinitiate 

the wound-healing cascade.

Proliferation

Just as the inflammatory phase was defined by the 

neutrophil, the proliferative phase is defined by the 

macrophage. Macrophages consume bacteria and nonviable material, and release enzymes to break down the 

existing extracellular matrix. However, macrophages, 

which are more sophisticated and multidimensional 

than neutrophils in their overall function, can be considered the orchestrators of wound healing. The release 

of growth factors and cytokines leads to the migration 

of keratinocytes and fibroblasts into the wound bed 

to initiate reepithelialization and granulation tissue 

formation, respectively.

Three steps in the proliferative phase include

1. reepithelialization, 

2. granulation tissue formation, and 

3. wound contraction.
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Care of the Combat Amputee

Reepithelialization. The first step in the proliferative phase, reepithelialization begins as early as 

24 hours postinjury. When an area of skin is broken, 

the loss of contact inhibition that occurs between 

epidermal cells stimulates replication and migration 

into the wound bed. This migration is coordinated by 

macrophages. 

Granulation Tissue Formation. The second step, 

the granulation tissue formation, can begin as early 

as 3 days postinjury and is visually the hallmark of 

the proliferative phase. The wound bed begins to take 

on a shiny, reddish-pink, cobblestone appearance. 

Macroscopically, each red cobblestone represents a 

burgeoning new capillary, and the shiny texture is 

imparted by the loose extracellular matrix, which is 

produced by fibroblasts. When the intricate processes 

of reepithelialization and granulation tissue formation 

are not coordinated, they can work in opposition. For 

example, a wound will stop granulating once it is 

epithelialized, even if the wound has not yet filled in. 

Similarly, if epithelialization never occurs, granulation may continue unabated until a heaping mound 

of granulating tissue towers over the surrounding 

periwound skin. The etiology and treatment of these 

conditions will be discussed later in this chapter.

Wound Contraction. The third step in the proliferative phase is wound contraction. When a wound is 

mature enough, fibroblasts are signaled to alter their 

gene expression, the synthesis of actin filaments is 

upregulated, and the fibroblast transforms into a myofibroblast. Myofibroblasts link up across the wound 

bed and over time pull the wound closed.

Remodeling

The remodeling phase, the final and longest woundhealing phase, frequently lasts more than 2 years. It is 

largely mediated by fibroblasts and consists primarily 

of collagen deposition along the lines of stress. Remodeling is a dynamic process and increases the tensile 

strength of the wound where it needs it most.

Abnormal Wound Healing

Abnormal wound healing occurs when a chronic 

wound fails to proceed through the aforementioned 

phases, resulting in a wound that is deficient in its 

anatomic and/or functional integrity. Wound healing 

is simplified and described in phases; however, it is a 

continuum involving countless cells, cytokines, and 

yet to be identified factors. A wound can be further 

complicated by extrinsic factors, such as infection, or 

intrinsic factors specific to the patient such as malnutrition or defined genetic-dependent characteristics. 

The wound-healing mechanisms are overwhelmed, 

and intervention is required to facilitate recovery. 

The differential diagnosis for a nonhealing wound is 

relatively narrow and for the vast majority of cases will 

be related to at least one of the following intrinsic or 

extrinsic factors. Intrinsic factors may include chronic 

inflammation, excessive granulation or insufficient 

epithelialization, excessive fluid (maceration) within 

the wound bed, poor nutritional status, etc. Extrinsic 

factors may include insufficient or excessive debridement and/or inadequate infection management.

Chronic Inflammation

Chronic inflammation in the presence of infection, 

for example, is an appropriate and necessary bodily 

response. The appropriate clinical action in this situation would clearly be to treat the infection and not 

the inflammation. Conversely, if a wound appears 

persistently inflamed yet not infected, other etiologies 

must be sought. 

Insufficient versus Excessive Debridement

Aside from infection, the most likely causes for 

persistent inflammation within the wound come from 

repeated trauma or necrotic tissue. As discussed previously, fixing one issue can often exacerbate the other. 

To clear a wound of its necrotic tissue, for example, 

the wound must be debrided. An aggressive debriding 

schedule, such as wet-to-dry dressing changes every 

4 hours, may cause excessive trauma and a situation 

of diminishing returns. Likewise, in an exudative or 

otherwise wet wound, applied dressings are unable 

to dry and therefore debridement would not be accomplished with subsequent removal. Wounds with 

substantial eschar may require sharp debridement, 

whereas wounds with less eschar may respond to autolytic or enzymatic debridement. The clinician should 

choose the most appropriate means of debridement 

depending on the wound characteristics.

Granulation versus Epithelialization

Complications associated with granulation are often compounded with problems of epithelialization. 

Specifically, a hypogranulating wound often localizes 

the problem to the wound bed. Conversely, a hypergranulating wound often indicates a problem with 

epithelialization (ie, the periwound skin). 

Consider the following: A wound bed is chronically inflamed from necrotic tissue. The surrounding 

skin, however, is supple and healthy. Because of the 

persistent inflammation, the wound bed granulates at 
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Medical Issues in the Care of the Combat Amputee

a very slow pace, but the surrounding skin continues 

to migrate in at a normal pace. As a result, the edges 

of the wound margins are opposed over an insufficient 

wound bed. 

Consider a wound that has a very healthy wound 

base, but has persistently macerated wound edges. 

The wound will granulate at a normal pace but the 

wound margins will fail to oppose secondary to insufficient epithelialization. The granulating tissue, with 

no signal to stop, will therefore grow unabated, rising 

above the level of the surrounding skin. This would 

be referred to as a hypergranulating wound, although 

a more accurate characterization would be a “hypoepithelializing” wound. 

A wound may fail to epithelialize properly for several reasons. One reason is the rolled edge or epiboly. 

Under normal circumstances, periwound skin divides 

and migrates down into the wound bed. Occasionally, however, these cells can become misdirected and 

like the crest of a breaking wave curl up underneath 

themselves. Because of contact inhibition, the cells stop 

dividing and epithelialization fails. A close inspection 

of the wound can identify this phenomenon. Sharp 

debridement is usually the quickest and most effective 

solution. The remaining reasons for insufficient epithelialization are simply related to unhealthy periwound 

skin, the most common etiologies being a macerated 

wound edge, unrelieved pressure, persistent inflammation, or infection. 

A slowly granulating wound—more often than 

not—indicates an unhealthy wound base. Desiccation, persistent inflammation, infection, a cold wound 

bed, and tightly packed gauze are all common causes. 

Whatever the etiology, it is critical to remember that 

if epithelialization has already occurred, the wound 

bed will not granulate even if the underlying problem 

is corrected. It is therefore occasionally necessary to 

cauterize the surrounding wound edges with silver 

nitrate to prevent epithelialization while the wound 

bed recovers. 

Desiccation versus Maceration

The task of balancing optimal moisture levels between wound and skin is often the most challenging 

aspect of wound care. Depending on age, sex, and body 

fat, the amount of water in human bodies ranges from 

50% to 70%. Moisture is essential for wound healing. 

Without moisture, migrating cells and chemical signals 

have no medium in which to travel, and the viability of 

enzymes and growth factors cannot be maintained.

Although humans need water, they are unable to 

live in it. The keratinized stratum corneum of human 

epidermis keeps excess moisture from penetrating to 

deeper levels; however, this attribute is negated with 

an open wound. Once upper stratum corneum and 

basilar layers are interrupted, epidermal cells become 

exposed to a hypotonic solution and will gradually 

swell and burst. The desmosomes that anchor the 

epidermal cells to the dermis and to each other will 

eventually become disrupted, and the wound will 

become larger.

A skilled wound care specialist will consider the 

periwound skin as part of the wound environment 

because it is from this healthy rim of tissue that most of 

the regenerative epithelial cells originate. Management 

of the periwound fluid balance is critical. Through the 

judicious use of dressings, emollients, and barriers, 

the wound bed may be kept moist without causing 

maceration of the wound margin. Likewise, the wound 

must be kept dry enough without causing desiccation 

of the wound bed. 

Infection versus Antibiotics 

By definition a wound is infected when the bacterial 

load exceeds 100,000 organisms per gram. A clinical 

diagnosis may be made based on signs and symptoms of infection to include purulence, erythema, or 

evidence of advancing cellulites. As discussed in the 

previous section, determination of colonization versus 

active infection is critical in determining appropriateness of antibiotic management. Additional signs and 

symptoms of infection include

	 •	 induration,

	 •	 pain,

	 •	 fever,

	 •	 changes in color,

	 •	 persistently foul odor,

	 •	 increased drainage,

	 •	 friablegranulationtissue that easilybleeds,and

	 •	 delayed healing.

The indiscriminate use of topical antibiotics has 

led to bacterial resistance and the alteration of normal 

skin flora. In addition, the nonselective nature of these 

antibiotics also causes damage to native cells. Some 

bactericidal agents such as hydrogen peroxide and 

iodine are more toxic to human cells than to bacteria. 

These characteristics warrant judicious use of topical 

agents in wound management. 

Impaired Healing Response

Thus far, the discussion of abnormal wound healing has revolved around direct extrinsic factors, 

but an equally important aspect is the health of the 
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Care of the Combat Amputee

wound-healing machinery itself. If a patient’s system 

is already stressed from sepsis, for example, the body 

simply cannot allocate the resources necessary for 

wound healing. Broadly speaking (and with some 

overlap) there are five main categories of problems 

that can cause an impaired healing response: 

1. a diseased state, 

2. an impaired immune system, 

3. malnutrition, 

4. toxins, and 

5. medications. 

In the inpatient setting special attention should be 

paid to the patient’s nutritional status and medication 

profile. Immunosuppressants such as corticosteroids 

and nonsteroidal antiinflammatory medications 

(NSAIDs) are frequent culprits. Cytotoxic topical 

agents as discussed above can also slow things down 

considerably. For a patient whose nutritional status is 

compromised, weekly prealbumin levels are indicated 

and a certified nutritionist should be involved as 

early as possible. Tobacco use also can seriously retard 

wound healing. Patients must be educated about this 

and offered a tobacco cessation program. This is an 

especially important point among traumatic amputees 

whose wounds have a tenuous blood supply and associated tissue viability; the success of limb preservation 

depends on optimizing the wound environment.

Wound Treatment

Thousands of wound care products are available 

and likely an equal number of institution-specific treatment algorithms. To the uninitiated, this abundance of 

choice can spuriously equate with degree of complexity. Developing expertise in wound care takes years of 

hands-on experience. Basic proficiency depends on 

pattern recognition and determining the why, when, 

and how of the main interventions. 

Debridement

Debridement attempts to remove all unwanted 

elements from a wound such as eschar, slough, fibrin, 

pus, and bacteria. Because of their common yellow 

color slough, fibrin and pus are occasionally confused. 

Slough is loosely adherent, partially solubilized dead 

tissue that can be stringy or soupy in its texture and 

usually lacks a persistent foul odor. Fibrin is a very 

adherent, almost rubbery substance that is formed as 

a result of fibrinogen leaking into the inflamed wound 

bed. Pus, which has a milky texture, is usually accompanied by other signs of infection and ominously 

indicates the presence of purulent organisms.

So why debride? The most direct answer is that by 

not debriding a patient is at increased risk for infection, impaired wound healing, and potentially further 

surgical revisions. For an amputee this may have a 

significant impact on his or her functional capabilities if this revision leads to a shorter residual limb. An 

undebrided wound cannot be properly visualized and 

therefore cannot be properly assessed. What may initially look like a partial thickness wound, for example, 

could be deep enough to involve both muscle and bone 

and could be obscuring a deep infection. In addition, 

nonviable tissue takes up space and acts as a barrier 

against further cell entry. In this way, regenerative cells 

are thwarted from repopulating the wound bed and 

immune cells are denied access to the growing number 

of bacteria in the eschar and slough. Chronic inflammation results when nonviable tissue causes persistent 

neutrophil accumulation that may prohibit cellular 

progression to granulation and reepithelialization. 

Debridement is a necessary and powerful tool that can 

rapidly effect change in a relatively short period.

There are four main techniques to debride a 

wound: 

1. sharp, 

2. autolytic, 

3. enzymatic, and 

4. mechanical.

Sharp Debridement. Sharp debridement involves 

the use of a cutting instrument, such as a scalpel or 

scissors, and can be performed at the bedside by qualified personnel. It is the most rapid—and often the most 

effective—method of debridement. Large wounds that 

are completely covered in adherent fibrin or eschar are 

prime candidates for sharp debridement, and depending on patient tolerance may occasionally require more 

than one session to complete the bulk of the debriding 

process. The ultimate goal is to expose a healthy pink 

tissue base, remove all barriers to granulation, and 

ensure accurate staging and assessment. 

Autolytic and Enzymatic Debridement. If a wound 

contains more than a mild to moderate amount of debris, sharp debridement is usually a necessary initial intervention. After the bulk of necrotic tissue is removed, 

however, the need for continued debridement must be 

weighed against the tradeoffs of excessive tissue handling, trauma, and risk of contamination. Under these 

circumstances and when the wound is otherwise healthy 

and uninfected, autolytic debridement (with or without 

exogenous enzymatic debridement) becomes ideal.
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Medical Issues in the Care of the Combat Amputee

Autolytic debridement relies on the body’s endogenous enzymes and phagocytes. Toward this end, an 

occlusive dressing is used that is usually changed no 

sooner than 72 hours. The occlusive dressing provides 

a warm, moist, and unperturbed environment that is 

ideal for wound healing. Because the dressing is not 

changed multiple times per day, the body’s enzymes 

accumulate in the wound and break down nonviable 

tissue. To augment this process, exogenous enzymes, 

such as collagenase, papain, and urea, are occasionally 

applied to the wound bed. When the dressing is finally 

changed, much of the debris has become loosened and 

is easily removed with limited patient discomfort.

Because this method of debridement relies on 

occlusion, however, presence of active infection is a 

contraindication to use of this technique. In addition, 

those that change the dressing should be aware that 

it is not uncommon for occlusive dressings to have a 

strong odor. In contrast to infected wounds, however, 

the odor will not persist once the wound is cleaned.

Mechanical Debridement. Although inferior to 

sharp debridement at removing recalcitrant fibrin or 

eschar, mechanical debridement can be a very effective 

and appropriate means of removing less adherent necrotic tissue from a wound. In addition, most forms of 

mechanical debridement can be performed with relatively little training. Examples include simple manual 

scrubbing with gauze, irrigation with pulsatile lavage, 

and wet-to-dry dressings. The drawback of mechanical 

debridement is that it nonselectively removes both viable and necrotic tissue from a wound bed. Judicious 

use of this technique is required.

Wet-to-dry dressing is often a first-line treatment 

in wound management. However, it may not be appropriate in every clinical situation. In light of the 

biomechanics of wound healing, this technique may 

be deleterious to wound healing. The recurrent trauma 

to the wound bed beyond that necessary for adequate 

debridement of nonviable tissue may further complicate wound management. 

The technique necessary for successful use of wetto-dry dressings depends on the dressing changes 

every 12 hours. This frequent inspection of the wound 

leads to significantly more wound exposure than 

when using an occlusive dressing, causing inflammation and increasing the risk for contamination. 

In addition, regular cotton gauze sheds particulate 

matter when allowed to dry into a wound bed, which 

can be another source of irritation and inflammation. 

Wet-to-dry management of wounds is one of the more 

painful and (additively) time-intensive debridement 

methods. One benefit of using wet-to-dry dressings 

is the ability to perform frequent wound inspections 

particularly between surgical washouts. The disadvantage is the increased risk of excessive moisture 

leading to maceration of the surrounding skin, with 

inadequate drying thereby losing the debridement 

function. Debriding occurs as the adherent gauze is 

removed from the wound; if the gauze is unable to dry 

(or, alternatively, if it is remoistened before removal), 

no debriding occurs.

Another critical point (and this applies to all dressings) is that wounds should not be “packed,” but 

instead they should be “filled.” Gauze should be 

trimmed to an appropriate size, and the wound should 

be gently filled with the material. Tightly pushing an 

oversize dressing into the wound or “packing” leads 

to impaired wound healing. A tightly packed wound 

creates a pressure gradient that impedes the migration 

of regenerative cells and prevents adequate perfusion 

of the wound bed. Furthermore, untrimmed gauze 

may protrude from the wound bed and macerate the 

surrounding skin. 

When Not To Debride

Although a discussion of specific wound types and 

their management is beyond the scope of this section, 

there are a few contraindications to debridement. 

	 •	 Dry Gangrene: Dry gangrene occurs as a

consequence of arterial insufficiency and the 

wound is poorly perfused. The necrotic tissue 

under these circumstances is actually protecting the wound underneath from infection. 

Once this barrier is broken, bacteria can more 

freely penetrate into the wound bed and cause 

resistant infection. 

	 •	 Stable Heel Ulcers: Stable heel ulcers do

not need to be debrided and should be left 

alone.

	 •	 Pyoderma Gangrenosum: The pathophysiology of pyoderma gangrenosum is linked to 

immune system dysregulation, although its 

specific mechanism remains incompletely 

understood. An apparently small ulceration 

can become significantly more problematic 

following debridement. 

Restoring Moisture Balance

The majority of dressings and products fall into 

one of two major categories: (1) those that wet and (2) 

those that dry. Moisture balance of the wound bed and 

surrounding margin is critical and often the greatest 

challenge when treating a wound.
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Care of the Combat Amputee

A wound can be thought of as two populations 

of cells living side by side, each requiring an environment that is toxic to its neighbor. As previously 

noted, erring too much on the side of moisture for the 

sake of the wound bed causes the surrounding skin 

to become macerated and the wound to ultimately 

grow. Erring too much on the side of dryness for the 

sake of the surrounding skin causes the wound bed 

to become desiccated and prematurely arrests the 

healing process. 

The strategy used to obtain balance depends on 

the character of the wound. A venous stasis ulcer, for 

example, is notoriously weepy, such that all efforts are 

aimed at controlling drainage. Because of the failure of 

venous return, the wound bed of a venous stasis ulcer 

is essentially supplied with its own “ground water” 

making it virtually impossible to dry out. Although 

wound bed desiccation is unlikely, periwound maceration is a major concern. Barrier creams applied to the 

periwound skin can help protect against maceration 

but drainage control is critical. If conventional moisture 

wicking products such as alginates and hydrofibers 

fail to be effective, tampons are sometimes used with 

good results. If all wicking measures fail, the frequency 

of dressing changes must be increased until the periwound skin is adequately protected. 

In contrast to venous ulcers, ulcers caused by 

arterial insufficiency require the opposite approach. 

Under these circumstances, venous outflow is not the 

underlying problem, but rather arterial inflow. Without 

a healthy blood supply to the skin, the wound bed 

is easily desiccated and needs to be moistened with 

products such as hydrogels or impregnated gauze. 

Barring overzealous hydration, periwound maceration 

is rarely an issue in this situation. 

Similar strategies are used for wounds in between 

these extremes but to a more graded and balanced degree. For a wound that is producing a modest amount 

of exudate, for example, highly absorbent materials 

such as tampons or supersponges should be avoided 

because they excessively dry out the wound bed. 

Regardless of the initial strategy, the key is frequent 

inspection with each dressing change and modifications as the wound matures.

DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM 

Introduction

Despite advancements in prophylaxis and treatment, deep venous thrombosis (DVT) remains a serious 

complication in combat casualties with polytrauma and 

amputation. Consequences of DVT include prolonged 

hospital stay, delay in rehabilitation, secondary thrombophlebitis, or death from secondary pulmonary embolism. The incidence of DVT in trauma patients without 

prophylaxis has been estimated at 10% to 65%.49–52 This 

variability of incidence rates is likely related to the variety of injury patterns seen in polytrauma and combat 

amputees. Previous reports have demonstrated that 

patients with spinal cord injuries (SCIs) have the highest 

rate of DVT among trauma patients.53

Although, in general, prophylaxis greatly reduces 

the risk of DVT, the choice and method of prophylaxis 

remain complex, especially in polytrauma and combat 

amputees.54–58 Current methods of prophylaxis include 

adjusted doses of oral warfarin, fixed doses of low 

molecular weight heparin, subcutaneous heparin, 

aspirin, TED hose (Tyco Healthcare/Kendall Products, Mansfield, Mass), and sequential compressive 

devices (SCDs). Each of these methods except TED 

hose/SCDs carries an increased bleeding risk that 

presents a particular problem to trauma patients, 

especially those who require frequent returns to the 

operating room.59 The use of TED hose and SCDs in 

trauma patients—especially those with orthopaedic 

injuries and amputations—is limited when fractures 

or wounds involve the extremities. Prevention is the 

best treatment because the medical therapies to treat 

venous thromboembolic events are controversial and 

may have associated risk and complications. DVT/

pulmonary embolisms are a severe and life-threatening 

complication of injury.

Risk factors for DVT include 

	 •	 immobilization,

	 •	 trauma,

	 •	 malignancy,

	 •	 abnormal coagulation factors,

	 •	 obesity,

	 •	 estrogen therapy,

	 •	 advanced age, and

	 •	 prior history of DVT.60–63

Given the nature of combat injuries and the (often) 

lengthy evacuation process required to transport these 

injured service members through increasing echelons 

of care, it would appear that this patient population 

would be at even greater risk for developing venous 

thromboembolic events.

Incidence and Diagnosis from the Walter Reed 

Experience

Experience in caring for returning combat amputees 

from OEF/OIF at WRAMC have shown thrombosis 

diagnosed in about 30%, with about 60% being DVTs 
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Medical Issues in the Care of the Combat Amputee

and 40% being pulmonary embolisms. Twenty percent 

of DVTs were in the arms and 40% were in the leg. 

The location of the amputation has not been shown to 

correlate with the location of thromboembolism. The 

number of days of missed anticoagulation medications 

did not correlate with clot formation. The number of 

trips to the operating room correlated highly with clot 

formation, with more trips to the operating room correlating to a higher incidence of clots. Patients who had 

a planned trip to the operating room would have medical prophylaxis held the night before and the morning 

of surgery. In a population of patients undergoing 

surgery every other day or every third day, the number 

of days off medical prophylaxis quickly increases. In 

combination with other accepted prothrombotic factors, including venous stasis, hypercoagulability, and 

injury to the vascular endothelium, these patients are 

at increased risk of thrombosis development. Combat 

amputees with concomitant fracture are more likely to 

develop a venous thromboembolism (VTE). Comorbid 

traumatic brain injury (TBI) doubled the likelihood of 

being diagnosed with a VTE.

For the diagnosis of VTE, computed tomography 

(CT) was the best screening method for pulmonary 

embolisms with 100% sensitivity and specificity. The 

next best screening method was ultrasound, followed 

by angiography. However, for DVTs, CT scan had 100% 

sensitivity and 80% specificity, whereas ultrasound 

demonstrated 100% sensitivity and 91% specificity and 

angiography was the least sensitive for DVTs. In this 

young, relatively healthy patient population, physical 

symptoms of DVT are often vague and rarely readily 

apparent. Therefore, medical vigilance is critical and providers should have a low threshold for routine screening.

Physical Prophylaxis

Polytrauma and combat amputees are often unable 

to wear TED hose and SCDs because of their extremity injuries. From the authors’ experience at WRAMC, 

patients able to wear TEDs were less likely to develop 

a thrombus. A larger number of patients used SCDs, 

but this higher number may be deceiving. Although 

the treating physicians order many devices, in practice, 

patients do not tolerate them or wear them for much 

of the day and at night. This magnifies the importance 

of medical prophylaxis.

Medical Prophylaxis

Medical prophylaxis in this population remains 

debatable. Lovenox (Sanofi-aventis US, Bridgewater, 

NJ), a low molecular-weight heparin, tends to be the 

preferred agent within this population because of the 

ease in stopping and restarting for procedures. It is also 

simple to convert from prophylactic dosing to therapeutic dosing. Within the monitored setting of the intensive care units, heparin is often used, in part because 

of the reversibility of its action with protamine.

Minimizing Immobilization

The air evacuation process also must be considered. 

Antecedent trauma or surgery followed by prolonged 

air evacuation may be related to the development of 

VTE in more than half of those service members evacuated from deployments to the Middle East. Any injured 

patient who must travel via air evacuation faces several 

flights lasting approximately 6 hours each and additional ground transport time and other transport time to 

the evacuation sites. This long period of transportation 

immobilization should lead the provider to evaluate 

the need for earlier initiation of medical prophylaxis, 

although risk of bleeding complications must also be 

considered. The recognition of complications associated 

with severe polytrauma and combat wound-related 

amputations requires careful consideration before initiating anticoagulation and should be made on a caseby-case basis. Upon arrival to a tertiary care hospital 

(level 4 or 5 echelon), every effort should be given to 

facilitate early patient mobilization. This may include 

simple passive range of motion of the extremities for the 

patient restricted to bed or early transfers and ambulation, whether by wheelchair or other assistive device. 

Although no clear evidence indicates when medical 

prophylaxis should be discontinued, it is generally 

considered necessary to continue it until significant 

independent mobility is achieved.

WEIGHT-BEARING PROGRESSION 

Amputations sustained from high-energy combat 

trauma generally produce significant comorbidity.64

Femoral and pelvic fractures with coexisting lower 

extremity amputation present a significant rehabilitation challenge. These complex fractures must be given 

an appropriate amount of time protected from large 

distracted forces to allow proper healing. Operationally this is accomplished by implementing various 

degrees of weight-bearing restrictions that must be 

balanced with the well-known negative physical and 

psychological consequences of bed rest and inactivity.65–68 Unfortunately, little standardized information 

exists to guide the temporal parameters and advancement of weight-bearing restrictions. 

Because of advances in military medicine, timely and 

thorough evaluations of the musculoskeletal system are 
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Care of the Combat Amputee

standard. This generally includes aggressive orthopaedic surgical reduction and fixation as part of fracture 

management. After initial surgical management, fractures progress through a standard sequence of healing 

that includes inflammation, repair, and remodeling.69,70

Initial injury characteristics greatly affect the process. In 

particular, damage to the blood supply and soft tissue 

is common and lengthens the course of healing.

Generally the orthopaedic surgeon establishes a 

guide to the rehabilitation team on a patient’s weightbearing status. Therefore, an individual’s weightbearing status should not be advanced without the 

surgeon’s direct consultation. The determination of 

weight-bearing tolerance and internal fracture stability, 

which is multifactorial, includes fracture location, type, 

apposition of fracture fragments, method of fracture 

fixation, severity of soft tissue damage, blood supply 

integrity, nutritional status, and associated injuries. 

Given the numerous patient-specific variables, no 

standard guidelines are available for return to full 

weight bearing. 

Existing evidence indicates that fracture healing 

is optimized through loading of the repair tissue and 

decreased loading negatively impacts healing time.71,72

Furthermore, evidence exists that even immediate controlled loading may promote healing.71,73–78 In the rehabilitation setting, controlled loading is accomplished 

through the use of tilt tables, parallel bars, and aquatic 

therapy.79 Care must be taken to prevent excessive, distracting motion and development of pseudoarthroses 

or nonunion. Serial radiography to assess evidence of 

healing (and evidence of nonunion) is recommended. 

Frequent reassessment of patient symptomatology 

should be undertaken with particular emphasis on 

the quality of pain. Changes in quality should prompt 

further evaluation. The interdisciplinary team of rehabilitation professionals and an orthopedist is critical to 

ensure successful functional return.

Energy requirements are highest during the first 

two phases of bone healing, where the need for aggressive early nutritional support is critical.80–82 Caloric, 

protein, vitamin C, and vitamin D supplementation 

are required to meet the anabolic demand of wound 

healing.82 The presence of electronegativity at fracture 

sites has lead to the use of bone stimulators to expedite healing.83–85 Numerous case reports support their 

implementation in cases complicated by delayed bone 

union and nonhealing.83,86–89 Similarly, ultrasound offers a safe, noninvasive modality that may promote 

fracture healing.90–93 Yet, rigid research evidence is still 

lacking to determine the treatment characteristics of 

bone stimulation.

During the healing process, the sequelae of combat 

trauma must be actively managed to promote healing 

and early functional return. This includes decreasing 

the metabolic demand of infections and open wounds. 

TBI, which has a high prevalence in the polytrauma 

patient, presents numerous barriers including its association with HO development.94–96 The standard treatments for HO rely on the use of bisphosphonates and 

NSAIDs. These two pharmacological classes should be 

avoided with concomitant fractures because of their 

negative impact on healing. Similarly, nicotine intake 

should be actively discouraged given its inhibition of 

fracture healing.97,98

In the rehabilitation of the combat-acquired amputation novel plans and individualized recovery trajectories are required. Coexisting lower extremity fractures 

should be closely followed for appropriate healing 

and management of potential negative sequelae. The 

return of full weight bearing and ambulatory function 

depends on a series of patient-specific variables and 

ultimately it is decided by collective clinical judgment. 

Rapid advancement of stable fractures and close multidisciplinary monitoring are preferred in contrast to 

long periods of inactivity.

HETEROTOPIC OSSIFICATION 

Introduction

Among recent military amputees returning from 

combat in Iraq and Afghanistan, a high rate of HO 

has been seen in amputated residual limbs.99 HO is 

the abnormal formation of bone in soft tissues (Figure 

10-1). HO develops when pluripotent mesenchymal 

cells are inappropriately transformed into osteoblasts 

that contribute to bone production.100 The precise 

cause for this transformation in pluripotent cells is 

unknown.100 HO is commonly seen and has been well 

documented in the setting of SCIs, TBIs, burns, after 

total joint replacements (especially hips), and with 

severe soft tissue damage. Before the current military 

conflict there were few HO reports in amputees’ 

residual limbs.

Bone formation in amputees’ residual limbs 

presents numerous rehabilitation challenges. Bone 

formed in soft tissues of a weight-bearing limb can 

result in high-pressure areas, creating a risk for skin 

breakdown. Skin breakdown can have devastating 

effects on rehabilitation because it often requires 

prolonged periods of nonweight bearing and presents a risk for infection. In addition, HO in residual 
209

Medical Issues in the Care of the Combat Amputee

limbs can result in complex residual limb shapes 

and multiple pressure-sensitive areas that can make 

prosthesis fitting difficult or impossible. Increased 

pain, limitations in range of motion, and limitations 

in ambulation are also complications from HO in 

residual limbs.

Current diagnosis methods are acceptable. Patients 

often report changes in pain characteristics, range of 

motion restrictions, warmth, and socket fitting in their 

residual limbs. HO is diagnosed by plain radiograph, 

CT, magnetic resonance imaging, and/or triple phase 

bone scan. Blood studies such as alkaline phosphatase 

may also be followed throughout HO development 

and correlated to bone formation, maturity, and ultimately quiescence.

Current HO treatment methods are less than optimal. Prophylactic measures, which have shown some 

efficacy, include NSAIDs, bisphosphonates, and/

or radiation therapy.101–105 Once mature, however, 

treatment of symptomatic HO is limited to surgical 

resection.

Historical Perspective on Heterotopic Ossification 

in the Combat Amputee

A thorough literature review reveals few studies 

describing HO in combat-related traumatic amputees. 

Those studies are single case reports that demonstrate 

HO occurring in the amputees’ residual limb.106,107 Prior 

reports of combat casualties from the Civil War and 

World War I do not suggest a significant association 

with HO formation and traumatic amputation.108–110 A 

report by Colonel (Retired) Paul Brown, looking at 88 

residual limbs in Vietnam combat amputees, reported 

only 4 limbs (0.5%) as having “bone spur formation” 

that required surgical excision.111 Furthermore, Lieutenant General (Retired) Alcide LaNoue, who was 

chief of orthopaedics at Valley Forge General Hospital 

in Pennsylvania, reported seeing only a “few cases 

of ectopic bone in residual limbs” in more than 410 

amputations that were treated under his command 

during Vietnam.112

Heterotopic Ossification from the Walter Reed 

Experience

WRAMC saw a greater than 50% incidence of HO 

formation in combat amputees returning from OEF/

OIF. This is consistent with an estimated 62% incidence 

noted by Potter et al in a 2006 observational review of 

a similar patient population.113

It is, therefore, important to determine how the identified risk factors from this patient population might 

differ from those of prior conflicts. Service members 

with traumatic amputation from the Vietnam War had 

injuries complicated by retained metal fragments, other 

fractures, wound infections, and skin grafts.111 Some factors that do appear to differ from past populations are 

a b

Figure 10-1. (a) Plain radiograph showing heterotopic 

ossification in a transfemoral amputee and (b) photo showing heterotopic ossification manifesting superficially in the 

limb of an above-knee amputee.
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Care of the Combat Amputee

	 •	 causative pathogens of wound infections,

	 •	 overallincreasedseverityof secondaryinjuries,

	 •	 increased incidence of brain injuries,

	 •	 increased numbers, and

	 •	 types of surgical procedures/debridements.

One major differentiating factor is modern technology and training of initial responders (ie, the combat 

medic). Advances in forward care and prompt aeromedical evacuation with better technology in combat 

personal protective gear have allowed service members to survive injuries that would have been fatal 

in the past. This has intensified the incidence, type, 

and severity of secondary injuries and complications. 

Wound care in the highly advanced surgical arena 

has changed significantly over the past 40 years. The 

majority of Vietnam amputees received at Valley Forge 

General Hospital had open residual limbs, which were 

debrided with wet-to-dry dressings and rarely required 

more than one revision.111 In the current conflict with its 

emphasis on limb preservation and rapid movement 

of injured personnel through ascending echelons of 

care, service members are presenting to continental 

US tertiary care centers with increased severity of 

wounds, secondary injuries, and antibiotic-resistant 

wound infections that necessitate an increased number 

and complexity of surgical interventions. 

Surgical advances such as pulsed lavage debridement and vacuum-assisted wound closure have revolutionized soft tissue injury management and allowed 

a higher percentage of successful limb preservation 

attempts. However, the emphasis on limb preservation, 

which starts at wound triage, leads to tissue preservation with micro- and macro-trauma. This traumatized 

tissue, which most likely would have been removed 

in a similarly injured Vietnam War service member, 

may contribute to the triggering mechanism of cellular 

differentiation and HO formation. 

Another contributing factor is the type and severity 

of wound infections. Modern weaponry coupled with 

nontraditional projectiles such as the types of material 

used in improvised explosive devices appear to cause 

more contaminated and fragmented wounds. This 

has contributed to the increased quantity of wound 

infections and the increased virulence of microorganisms. Approximately 75% of amputee patients with 

HO at WRAMC had a wound infection. Acinetobacter

baumanni was the responsible microorganism in half 

of those infected. Before OIF/OEF A baumanni was 

primarily a hospital-acquired infection and not a common cause of wound infection. Prior studies have also 

shown A baumanni to be more difficult to treat because 

of increased antimicrobial resistance.114 The authors’ 

experience in treating this microorganism is consistent with these findings. Patient infection secondary 

to this pathogen often required multiple weeks of 

intravenous antibiotics and multiple wound debridements. Wounds infected with A baumanni significantly 

increased the risk of HO development; however, the 

mechanism is unclear. HO development may be attributed to factors associated with the bacteria, but 

the etiology of HO is most likely multifactorial and 

includes factors intrinsic to the patient. HO development warrants further study. 

A comorbidity of TBI was found to have the greatest correlation with HO development. Nearly 40% of 

the WRAMC OEF/OIF patient population had some 

degree of brain injury. This incidence is markedly 

increased compared to the 12% to 14% reported from 

the Vietnam War.111 The increased incidence attributed 

to decreased mortality from brain injury is secondary 

to technological advances and acute management. 

Mortality from brain injuries among US combatants 

in Vietnam was reported at 75% or greater.115 Studies 

show that brain injury alone can cause HO in 15% to 

40% of patients.116 Studies also suggest that having a 

brain injury in combination with structural trauma has 

an additive effect on HO frequency.116 

The decisions to use prophylactic medications by 

the primary medical teams were determined largely by 

extrapolating evidence from other disorders. An abundance of evidence supports the efficacy of multiple 

types of NSAIDs to prevent HO, especially involving 

traumatic injuries.117 Banovac et al118 showed treatment 

with the cyclooxygenase (COX)-2 inhibitor, Rofecoxib, 

to be clinically significant in preventing HO in patients 

with SCI. The advantage of a COX-2 inhibitor versus a 

traditional NSAID is based on the gastrointestinal protective properties of the COX-2 inhibitors. It is believed 

that these medications inhibit prostaglandin synthesis 

and thus reduce the inflammation and proliferation 

of mesenchymal cells.119 Etidronate is in the class of 

medications known as bisphosphonates. Numerous 

studies show its efficacy in preventing HO in SCIs and 

TBIs.120,121 However, some studies have demonstrated 

HO recurrence with treatment cessation.122 Etidronate 

is thought to decrease HO formation by inhibiting the 

conversion of amorphous calcium phosphate compounds into hydroxyapatite crystals, which is one of 

the final steps in bone formation.123

Radionuclide bone imaging roentgenographic 

studies have shown that the onset of HO—regardless 

of etiology—ranges from 3 to 12 weeks postinjury. 

It peaks at about 2 months and then evolves for an 

average of about 6 months. Then it reaches maturity 

and metabolic activity ceases.124 The authors’ patients 
211

Medical Issues in the Care of the Combat Amputee

treated with either Etidronate within 3 weeks or Rofecoxib at any time were less likely to develop HO 

compared to those who took no prophylactic medication. The standard dose of Etidronate was 20 mg/kg 

per day for 2 weeks followed by 10 mg/kg per day 

for 10 weeks based on the original dosing scheme 

used by Stover et al120 in their study on prophylaxis 

after SCI. Standard doses of Rofecoxib, Valdecoxib, 

and Celecoxib were 25 mg/20 mg/200 mg per day, 

respectively, for 8 to 12 weeks.

HO incidence appears to be markedly increased in 

OIF/OEF compared to prior military conflicts. Additionally, risk factors for HO development have been 

elucidated from the WRAMC population. Five of the 

risk factors are associated with increased structural 

trauma to soft tissue and bone. The sixth risk factor 

(brain injury) is neurogenic in nature and appears to 

have an additive effect on HO incidence when combined with structural trauma. Prophylactic medical 

treatment with Etidronate and Rofecoxib (no longer 

available) appears to decrease the probability of developing HO if started within 3 weeks of injury. To 

better determine a risk-benefit analysis, randomized 

controlled studies are needed to further determine 

the long-term effectiveness of both Etidronate and 

Celecoxib (the only COX-2 available) and identify 

complicating side effects, optimal dosage, and duration. However, if a decision is made to use any class of 

medication based on data from the Stover et al study 

and historical knowledge of HO’s natural evolution, 

the authors recommend starting the medication as soon 

as is feasible, preferably within 3 weeks of injury. 

In the authors’ experience, most HO manifestations 

can be treated conservatively with treatments such as 

range-of-motion exercises and appropriate prosthetic 

prescription to include liner and socket modifications. 

However, the definitive treatment for mature HO that 

fails conservative therapy is surgical removal.

Heterotopic Ossification and Three-Dimensional 

Modeling

Because of the number and severity of the complications associated with HO, surgical excision of 

the abnormal bone may become necessary. Excision 

is an accepted treatment for symptomatic HO when 

conservative treatment measures fail.116,125–127 Excision 

is frequently a difficult procedure because of the often intimate relationship of ectopic bone with native 

muscles, blood vessels, and nerves (Figure 10-2), and 

complications resulting from excision are common.128

Excision of HO requires careful planning to ensure that 

all ectopic bone is identified and excised, to minimize 

the resection of muscle and soft tissue surrounding the 

ectopic bone, and to prevent injuries to nearby nerves 

and blood vessels. 

Currently accepted imaging techniques, such as CT 

and magnetic resonance imaging, do not adequately 

provide a useful representation of the ectopic bone for 

planning and performing HO excision and for designing and fabricating prosthetic sockets. The emergence 

of technology that allows for the construction of threedimensional models to display a patient’s anatomy 

based on CT scans can now be used to plan for HO 

excisions and socket design. 

The process that makes the construction of these 

models possible combines high-resolution CT, software rendering technology, and three-dimensional 

modeling. When construction of a model is indicated to 

facilitate prosthetic socket construction or surgical excision of HO, a CT scan of the residual limb is obtained 

using 1.5-mm slices throughout the area to be modeled. The digital data from CT images are imported to 

software that allows for the selection of tissues to be 

modeled based on pixel density (Hounsfield values). 

The resulting images are delivered to the 3D Systems 

Inc. SLA-7000, which constructs a three-dimensional 

Figure 10-2. Intraoperative view of heterotopic ossification 

excision.
212

Care of the Combat Amputee

resin model of the patient’s anatomy (Figure 10-3). 

Several benefits and advantages result from using 

CT-based three-dimensional models for prosthetic 

socket design and surgical HO excision planning. 

When used for prosthetic socket design, the models 

improve the anatomical contouring of the socket and 

assist in identifying anatomic anomalies for avoidance 

of stress to those areas.129 When used for planning surgical HO excision, the models helped allow for limited 

surgical incisions by preventing the need for complete 

takedown and revision of the amputation. In addition, 

they permitted preoperative planning of skin incisions 

and soft tissue revision, thereby allowing for complete 

HO excision while preserving enough soft tissue to 

adequately close the wound. The models provided a 

three-dimensional understanding of the ectopic bone’s 

anatomy and, therefore, the relationship of the HO to 

the patient’s native anatomy, which helped prevent 

damage to nearby nerves and blood vessels. Patients 

can use these models to localize pain areas in the 

residual limb that is attributed to specific spicules of 

the ectopic bone. The models also allowed for threedimensional documentation of the extent of the HO 

to permit excision of all troublesome ectopic bone.130

In addition to being a tool for planning surgical HO 

excision, CT-based three-dimensional models have 

other uses in managing amputees and the combat 

wounded. Amputees returning from combat in Iraq 

and Afghanistan often have other traumatic injuries, 

many of which can hinder their progress more than the 

amputation. Comminuted fractures of the long bones 

of the extremities and pelvic fractures are common 

comorbid injuries. Because of the complexity of pelvic 

and acetabular fractures, the anatomical details and full 

extent of the damage are not easily demonstrated by 

routine radiographs. It is vital to assess the integrity 

of the anterior and posterior columns, hip joint spaces 

for debris, and the medial walls of the acetabula.33

This assessment can often be achieved with routine 

CT (Figure 10-4). However, CT in conjunction with 

three-dimensional imaging can provide information 

regarding the extent of the fractures, help determine 

the spatial arrangement of fracture fragments, and assist the radiologist and physician understand complex 

fracture patterns (Figure 10-5).131,132 

Damage to the bony structure of the pelvis often 

can be extensive as a result of gunshot wounds or 

shrapnel, forcing the patient to remain on bed rest 

until the fracture heals. Management consists mainly of 

reestablishing a joint congruence to allow for adequate 

weight bearing and to prevent early coxarthrosis.133

CT-based three-dimensional models can greatly assist 

with assessing fracture healing because they can help 

monitor bony deficits in the pelvic ring until adequate 

continuity is established. These models, which provide 

accurate information on callus formation and potential areas of poor healing, can also help the patient to 

visualize the nature and extent of his or her injuries 

(Figure 10-6). 

Although patients with extensive pelvic fractures 

remain on bed rest, it is essential for them to receive 

Figure 10-3. Three-dimensional resin model of heterotopic 

ossification in a combat amputee.

Figure 10-4. Computed tomography axial images of com Computed tomography axial images of comminuted L5 and sacrum fractures 2 weeks postinjury.
213

Medical Issues in the Care of the Combat Amputee

bedside physical and occupational therapy to maintain upper extremity strength, lower extremity range 

of motion, and bed mobility. In addition, they should 

receive proper bowel and bladder management and 

their medical needs should be closely managed. Once 

callus formation is sufficient as indicated on CT imaging and three-dimensional models, the patient can 

advance to weight bearing. Training is initiated using 

a tilt table for improved orthostasis and the patient 

can ultimately progress to full weight bearing and ambulation.134 In lower extremity amputees, fitting and 

casting for an initial prosthetic limb can begin while 

they are on bed rest. They can begin bearing weight 

on the prosthetic limb once improved orthostasis is 

achieved and they can bear weight on the intact or 

residual limbs.

Figure 10-5. Graphic representation of three-dimensional model of the pelvis 2 weeks postinjury. (a) anterior view (b) posterior view.

a b

ELECTRODIAGNOSTIC EVALUATION OF PERIPHERAL NERVE INJURIES 

IN COMBAT AMPUTEES/EXTREMITY TRAUMA

Patient Identification

Peripheral nerve injuries are not always apparent at 

the time of injury. The primary and secondary surveys 

are focused on life and limb preservation. Severely 

injured patients will be obtunded on arrival and may 

remain so for days to weeks. Some neurologic deficits 

are subtle and the diagnosis is not entertained until the 

patient fails to meet therapy goals or has unexplained 

limb pain.

All patients should have a complete neurologic 

exam at regular intervals for several reasons: 

	 •	 It increases the likelihood that the nerve injuries will be diagnosed, especially the more 

subtle injuries, in the individuals who are 

regaining consciousness. 

	 •	 It provides several data points to track the

patient’s recovery or failure to recover. 

	 •	 These data points provide temporal context in

the patient with a prolonged hospital course 

exposed to numerous complications. 

Patients with peripheral nerve injuries can present 

with symptoms of pain, numbness, paresthesias, or 

weakness in a region or extremity. Any losses of muscle 

strength, sensation, or reflexes are signs of nerve injury. Swelling, increased warmth, deepened color, or 

lack of sweating in the distal extremity may indicate 

autonomic signs of nerve injury. These findings do not 

necessarily localize the injury to the peripheral nervous 

system. Central nervous system injuries can mimic or 

coexist with peripheral nervous system injuries. 

Clinical Evaluation

The goals of the clinical evaluation are to (a) define 

the distribution of nerve(s) injured, (b) determine 

the severity of injury, and (c) localize the presumed 

site of injury. Nerve injuries can cause deficits in 

the distribution of nerve roots, multiple peripheral 

nerves, or individual peripheral nerves. In brachial 

plexus lesions, trunk injuries will appear as deficits 

in multiple dermatomes and myotomes, whereas cord 

injuries present as multiple peripheral nerve injuries. 
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Care of the Combat Amputee

For example, an upper trunk injury will present with 

shoulder abduction and elbow flexion weakness, and 

impaired sensation in the lateral forearm and thumb. 

A posterior cord lesion will appear as coexistent radial 

and axillary nerve injuries.

Different clinical and electrophysiologic severity 

scales exist. The initial clinical evaluation should define 

complete versus incomplete motor and sensory loss 

in a particular nerve because operative intervention 

is rarely required for initially incomplete injuries. 

When intact motor function exists in the most distal 

muscles innervated by a particular nerve, the injury 

is considered “incomplete.” Key muscles in the upper 

extremity include the flexor digitis indicis, abductor 

pollicis brevis, and extensor indicis proprius for the 

ulnar, median, and radial nerves, respectively. In the 

lower extremity, the extensor hallucis longus is easily 

demonstrated with great toe extension for deep peroneal nerve function and palpating the adductor hallucis during great toe abduction or flexion demonstrates 

tibial nerve function. It is helpful to palpate the muscle 

being tested because substitution can sometimes create 

the same movement. 

All patients should receive a detailed sensory exam 

of autonomous zones. This information can be used 

to support or refine the diagnosis and to help formulate an electrodiagnostic further work-up. A bedside 

sensory examination is very subjective and considerable anatomic variation may exist. Furthermore, after 

an injury adjacent nerves can expand to previously 

anesthetic areas. For example, if there is no motor 

function in median-innervated muscles but sensation 

is present in the palmar thumb, the injury should not 

be immediately categorized as incomplete.

Inspection of the trunk and extremities can provide 

a presumed injury site. All entry and exit wounds 

and surgical scars should be documented. Sometimes 

extensive soft tissue damage and scars exist in the 

distal extremity with only a single entry wound more 

proximal. Both must be entertained as potential injury 

sites. Fasciotomy scars, which are also very common 

in combat casualties, are usually done at the time of 

injury prophylactically because of vascular disruption. If the fasciotomy was performed to decompress 

an acute compartment syndrome, there may have 

been nerve injury from the compartment syndrome. 

Atrophy is also important because disuse atrophy is 

mild and more generalized, whereas denervation atrophy is profound and focal. Documentation of limb 

circumferences, while not validated, is a reasonable 

objective measurement. In the fully recovered patient 

with significant axonal disruption, atrophy may persist 

despite symmetric clinical strength. The exact location 

of a Tinel’s sign should be documented. Distal progression of the Tinel’s sign supports spontaneous recovery 

before return of muscle function. 

A detailed history should uncover the mechanism of 

injury and a timeline of when nerve deficits appeared. 

Sometimes patients can recall immediate loss of motor 

function on the battlefield. Surgical reports might comment on the continuity of nerves encountered during 

exploration. If the nerve is found not in continuity, 

the ends may have been tagged and fixed to adjacent 

structures for future reattachment. This level of detail 

is often difficult to find in the medical records during 

medical evacuation. Patients occasionally report to 

Figure 10-6. Three-dimensional model of the pelvis from Figure 10-5, 2 weeks postinjury. (a) anterior view, (b) posterior 

view.

a b
215

Medical Issues in the Care of the Combat Amputee

the surgeon that the “nerve is bruised” or that it is 

a “neuropraxia.” The conclusions drawn from these 

particular historical reports generally mean that nerve 

continuity is intact. 

Electrodiagnostic Evaluation

The goals of any electrodiagnostic examination are 

to (a) determine the presence or absence of nerve injury, 

(b) rule out confounding diagnoses, (c) localize the lesion, (d) characterize the nerve lesion and determine 

severity, and (e) establish prognosis. 

Goals of the Electrodiagnostic Examination

1. Determine the presence or absence of nerve 

injury. Usually, the first sentence of the conclusion of an electrodiagnostic consultation 

is whether the study is normal or abnormal. 

Many individual abnormalities exist in the 

exam components: abnormal spontaneous 

potentials, abnormal motor unit morphology 

or recruitment, low amplitude compound 

muscle action potentials or sensory nerve 

action potentials, and conduction slowing. 

There are two major themes when determining an abnormal examination: (1) having 

multiple internally consistent abnormalities 

and (2) surrounding abnormalities with 

normality. These principles help prevent 

both false positive and false negative studies. 

False positive studies arise when conclusions 

are drawn on limited data. There are usually 

abnormalities of motor unit morphology or 

recruitment used to support a presumed diagnosis, ie, the self-fulfilling prophecy. False 

negatives arise when insufficient adjacent 

nerves and muscles are tested, eg, a diagnosed ulnar neuropathy that is really a lower 

trunk plexopathy.

2. Rule out confounding diagnoses. Similar 

to excluding a cervical radiculopathy in a 

patient with carpal tunnel syndrome, care 

must be taken to exclude more proximal or 

more systemic nerve lesions in patients with 

peripheral nerve trauma. The concept of a 

“double crush” nerve injury is important 

here. The assumption is that a nerve injury 

in one location has a causal relationship with 

a nerve injury elsewhere along a common 

pathway, perhaps resulting from impaired 

axoplasmic flow. Despite this, it is important 

to exclude entrapment neuropathies along an 

injured peripheral nerve. These represent easily treatable conditions that would otherwise 

interfere with recovery.

3. Localize the lesion. There are two ways to 

localize an injury on the electrodiagnostic 

examination. The first is to demonstrate conduction slowing or conduction block across 

a lesion. The second is the evaluation of the 

distribution of needle electromyography 

abnormalities. Using the second technique, 

there is always the possibility that “selective 

fasicular vulnerability” of a more proximal 

lesion explains the distribution of findings, 

eg, a sciatic injury involving only the fibers 

destined for the deep peroneal nerve. The 

electrodiagnostic localization also should be 

correlated with the mechanisms of injury. 

Both open penetrating wounds and closed 

blunt force injuries should be considered. 

This presumed site of injury is important in 

determining the progress.

4. Characterize the lesion and determine severity. The first characterization is whether 

the nerve injury is complete or incomplete. 

“Complete” does not imply nerve transection; 

it simply connotes that all axons are involved. 

However, demonstrating intact voluntary 

motor units in the most distal muscles of the 

injured nerve confirms incompleteness and 

at least partial nerve continuity. It is mandatory that those motor units have a rise time 

of less than 500 microseconds to ensure one 

is not looking at volume conducted motor 

units from nearby intact muscles. When the 

needle electrode exam shows positive sharp 

waves and fibrillations, with no voluntary 

recruitment of motor units, one is tempted 

to assume a complete injury. Performing motor and sensory nerve conductions on that 

nerve, distal to the presumed site of injury, 

allows one to demonstrate conduction block 

if present. A recordable response will appear 

if the conduction-blocked nerve is stimulated 

below the lesion. The partial axonal disruption 

explains the abnormal spontaneous potentials, 

and the conduction block of the remaining axons explains the inability to voluntarily recruit 

any motor units. The net effect is a muscle that 

will not activate. This demonstration of conduction block is important because it improves 

the patient’s prognosis. The conduction block 

should resolve fully within 3 months. 

 If the lesion is incomplete, an attempt should 

be made to approximate the degree of axon loss 

with primarily motor amplitude measurement. 
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Care of the Combat Amputee

Preinjury motor amplitudes would be most 

reliable, but are rarely available. Total body 

electrodiagnostic exams are not yet part of 

the predeployment examinations. Comparisons can be made to the contralateral limb. 

Although an up to 50% side-to-side motor 

amplitude variation exists in nonamputees, 

they should be considered equivalent in a patient with clear nerve injury for estimation of 

axon loss. This technique will underestimate 

the degree of axon loss after 2 to 3 months because of collateral sprouting. Unfortunately, 

most combat casualties do not have a true 

“sound side” for comparison. The contralateral limb is frequently injured or frankly absent. In those cases, amplitude comparisons 

with normal values with standard deviations 

provide a rough estimate. The utility of percentage amplitude preservation in prognosticating eventual outcome is unclear. One 

assumes the lower the percentage the worse 

the prognosis, but the real question is at what 

percentage is treatment altered? The answer 

to this typically lies with the peripheral nerve 

surgeon’s threshold for nerve exploration. At 

one of the authors’ institution, most incomplete injuries, regardless of percentage axon 

disruption, are treated conservatively.

 Another characterization is the presence 

of ongoing reinnervation. This can be a 

powerful conclusion to report to the referring 

physician. Documenting “reinnervation” 

implies an improved prognosis, even if not 

necessarily proven. “Reinnervation” is usually documented based on the presence of 

polyphasic motor unit potentials. Polyphasia, 

however, is a normal finding in all muscles, 

up to a certain percentage. Quantitative 

techniques may add objectivity and likely 

improve specificity. Polyphasic motor unit 

potentials should also be assessed for stability. An immature polyphasic potential, either 

from a collateral sprout or a regenerating 

axon, will show instability on conventional 

needle electromyography. Triggering on the 

potentials and then superimposing them will 

demonstrate the stability. “Instability” is the 

manifestation of increased jitter and blocking seen on single fiber electromyography. 

When looking for stability, it may be helpful 

to use the “apparent single fiber” technique. 

Distant motor unit activity is excluded when 

using a concentric needle electrode and a low 

frequency filter of 500 Hertz. 

5. Establish prognosis. No studies provide 

Class I evidence of electrodiagnostic findings 

and eventual outcomes. Generally, the purely 

neuropraxic lesions usually do well, whereas 

more severe nerve injuries rarely spontaneously recover. Electrodiagnostics cannot 

distinguish between a moderate and severe 

nerve injury. The diagnosis of a higher grade 

lesion can be based on one of four things:

a. Direct visualization of a nerve transection.

b. Direct visualization of a nerve lesion in 

continuity, but failure to conduct an action potential across the lesion site and 

entirely below the lesion site. 

c. Imaging, using either magnetic resonance 

neurography or ultrasound. Both are 

promising, but not readily available, and 

unvalidated. 

d. Failure to progress (most common). Identify the most proximal muscle that has no 

voluntary motor units. If axons regenerate 1 to 5 mm per day, then the maximum 

recovery time is 1 inch per month. One 

can then predict, in months, when the 

most proximal nonfunctioning muscle 

should begin working based on its distance from the presumed site of injury. 

Assume a median nerve injury in the distal brachium with no voluntary units in 

the pronator teres. If no voluntary motor 

units are seen in the pronator by 3 months 

(3 inches), then the injury is unlikely to 

recovery spontaneously. Assume a sciatic 

nerve injury in the proximal thigh. The 

peroneal division is complete and the 

tibial division demonstrates incompleteness in all muscles including the foot 

intrinsics. One would predict the short 

head of the biceps femoris would begin 

functioning by 12 months. The tibial division injury is incomplete from outset and 

will likely be followed clinically. 

Mechanisms of Recovery

A nerve injury that is incomplete recovers by several 

mechanisms: 

	 •	 resolution of conduction block (typically 0–3

months); 

	 •	 collateral sprouting from the nerve terminals

to innervate nearby muscle fibers that have 

lost their axons; and 

	 •	 regeneration of the axons from the injury site.
217

Medical Issues in the Care of the Combat Amputee

The complete nerve injury can only recover by axonal regeneration. Once the target muscle is reached, 

then collateral sprouting also occurs. Muscles with 

some innervations may undergo muscle hypertrophy 

to increase strength. All patients also improve using 

adaptive techniques. This manifests as improvements on scales such as the functional independence 

measure. 

Surgical Intervention

There are several types of surgical procedures to 

repair peripheral nerve injuries. An external neurolysis 

involves removal of necrotic and scar tissue from the 

outside of a neuroma. An internal neurolysis includes 

splitting the fascicles and resecting necrotic fascicles 

and those that cannot conduct an action potential. 

Those resected fibers can then be reapproximated or 

grafted. If no recordable action potential exists, then 

the entire neuroma can be resected and the nerve can 

be reapproximated or grafted. Neurotization involves 

taking fascicles from an intact nerve and performing 

an end-to-end or end-to-side anatamosis into the distal 

nonfunctioning nerve, eg, taking fascicles from the 

anterior interosseous nerve distal to the flexor pollicis 

longus and anastamosing it to the ulnar nerve near 

the wrist.

Nerve repairs can be immediate, early, delayed, 

or late. Immediate repair is done within the first 

hours to days for sharp, complete, but otherwise 

uncomplicated transections. The ends are mobilized 

and reapproximated. An early repair is performed 

several weeks after a complete injury to allow time 

for demarcation of the necrotic tissue to be removed. 

A graft may be required to achieve a tension-free 

repair. A delayed repair is performed between 3 and 

6 months. These patients have complete deficits, 

but the initial Sunderland grade is unclear. They do 

not show recovery in the most proximal muscles as 

predicted by the 1 inch per month estimation. A late 

repair is a salvage procedure or performed for pain 

control. Tendon transfers are also a viable option for 

patients with forearm and lower leg injuries, and they 

are usually performed late.

Once a nerve repair—with or without graft—is 

performed, it must recover by axonal regeneration. Sufficient time must be given to reach the target muscles. 

In denervated muscle, the motor end plate degenerates 

sometime between 12 and 24 months. Using 18 months 

as a time frame will help dictate the latest a delayed 

repair can be performed.

Rehabilitation Intervention

The initial rehabilitation intervention is to ensure 

the appropriate diagnosis has been made. Repeat 

testing and second opinions are sometimes necessary. 

Patient and family education about the treatment 

plan and goals is important to express that progress 

is measured in weeks and months rather than days. 

Providing symptomatic treatment for neuropathic 

pain is covered elsewhere in this textbook (see Chapter 

11, Pain Management Among Soldiers With Amputations). Interval examinations will help detect the 

development of complex regional pain syndrome as 

early as possible.

Emphasizing the importance of maintenance of 

range of motion is imperative. Nerve regrowth to a 

contracted hand is of little use. If patients are unable 

to demonstrate their home exercise program, then they 

require closer supervision. Physical and occupational 

therapy can assist with modalities before range-ofmotion exercises, pain control, adaptive mobility, and 

activity of daily living strategies.

LONG-TERM EFFECTS OF LIMB AMPUTATION

The connection between health and disease is a 

dynamic process of salutogenesis and pathogenesis, with the individual’s health dependent on the 

delicate balance of homeostasis.135 The trauma associated with the combat amputee can be seen as a 

powerful disturbance of homeostasis because effects 

are experienced long after the initial injury. Longitudinal studies of traumatic amputees suggest that 

this population ages differently than age-matched 

uninjured individuals. These differences not only 

may be attributed directly to the amputation (altered anatomy and physiology), but also may be 

related to disturbance of homeostatic mechanisms. 

Throughout OIF/OEF, military amputee clinics 

have continued to focus on short-term and intermediate goals for its service members that focus on 

rapid function recovery and reducing impairment 

through adaptive techniques or assistive equipment. 

The main focus of the acute interventions is wound 

healing, pain control, prosthesis optimization, and 

return to high-level activities. The long-term goals 

of amputee rehabilitation are either return to duty or 

transition to the civilian community with reintegration. Regardless of initial disposition, the eventual 

separation of the service member from the military 

requires that special attention be given to the aging 

combat amputees and their associated greater vulnerability to certain medical complications.
218

Care of the Combat Amputee

Musculoskeletal Topics of Concern

Osteoarthritis has occurred in the unilateral lower 

extremity amputees with higher incidence than predicted 

based on age alone, with osteoarthritic changes found in 

both the ipsilateral and contralateral hips. This incidence 

is increased threefold in the individual with a transfemoral as compared to transtibial amputation.135 The 

prevalence of symptomatic osteoarthritis of the knees has 

been found to be greater in amputees compared to agematched, uninjured individuals. Factor analysis of the 

amputees suggests that biomechanical changes and body 

weight alone do not account for increased osteoarthritis 

incidence. In the unilateral lower extremity amputee, 

forces transmitted through the intact limb can be three 

to five times greater than total body weight (transfemoral greater than transtibial).136 In an age-matched comparison of healthy athletic amputees and nonamputees, 

the incidence of contralateral knee osteoarthritis and 

pain was 65% greater in the amputee population.137

Back pain has also been shown to be a chronic and 

significant issue in amputees, much more than in the 

nonamputee population. It has been referred to as a 

secondary disability because 57% of amputees claimed 

it to be persistent and bothersome, with pain ratings 

of greater than 5 of 10 on the Visual Analogue Scale.138 

Functional limitations were found to be more significant in the lower extremity amputee with low back 

pain.139 Bone density testing in amputees shows significant early and sustained loss over time in amputees. 

This is important because some studies indicate scores 

commonly in the range of osteopenia and often osteoporosis. The bone loss is throughout the whole body 

but much worse in the amputated limb.140,141 A study 

by Leclercq et al correlated the loss of bone mass etiology of amputation (traumatic vs dysvascular), level of 

amputation (more severe bone loss when above-knee 

amputation), and prosthesis fit and use.142 

Osteoarthritis and decreased levels of bone density 

in amputees are multifactorial. However, steps may be 

taken to reduce functional limitations, such as socket 

fit, prosthetic fit and suspension, and prescription of 

components, for the appropriate associated activity 

(eg, a multiaxial energy-storing foot for ambulating on 

uneven terrain). It is also vital to evaluate gait through 

both clinical observation and formal gait laboratory 

analysis. An improved understanding of the kinetics 

and kinematics will help the clinician and rehabilitation team provide an appropriate prescription for both 

prosthetic and assistive equipment and associated 

therapies. When feasible, eligible amputees should be 

referred for a formal gait and motion analysis. 

Cardiovascular and Metabolic Topics of Concern

The aging amputee population has significantly 

worse cardiovascular and metabolic issues that 

appear to be directly related to their traumatic 

amputation and not accounted for by obesity, 

sedentary lifestyle, or tobacco use.142–144 Reports 

demonstrate a positive correlation between a rise 

in norepinephrine and mean arterial blood pressure after walking in a prosthesis, a phenomenon 

attributed to mechanical irritation of the residual 

limb.145 Studies of traumatic amputees compared to 

a cohort sample of the general population identify 

increased hypertension, ischemic heart disease, and 

diabetes mellitus.The traumatic amputee has a 65% 

greater risk of death from coronary and peripheral 

vascular diseases.146,147 Rose et al hypothesized that 

insulin may be a causative factor in maturity-onset 

obesity-hypertension in his study of Vietnam War 

veterans who had undergone bilateral traumatic 

leg amputation.148 In this study, the differences that 

were observed in insulin response between obese 

and lean bilateral above-knee amputees could not 

be attributed to lean body mass or physical fitness, 

inferring that these differences may be related to 

factors such as insulin-induced renal salt retention, 

increased sympathetic nervous stimulation, or increased cardiac inotropy. 

Evidence also suggests that lower extremity amputees should be monitored for aortic aneurysms; 

occurring at a reported rate of 6% versus 1% in the 

nonamputee population. It is postulated that the 

asymmetric blood flow changes in the lower limb 

amputee lead to an unbalanced mechanical stress 

on the aortic wall with eventual asymmetric degeneration of the aortic wall elastic elements, resulting in 

an aneurysm.149 Additionally, the metabolic costs of 

ambulation are substantially higher compared to the 

nonamputee, with much greater energy required for 

dysvascular amputees as compared to traumatic amputees. With aging and the aforementioned increased 

risk of cardiovascular disease and peripheral vascular 

disease in amputees, many of these demonstrate the 

metabolic derangements typically described in the 

dysvascular amputee.

The issues above underlie the importance of 

comprehensive nutritional, exercise, and wellness 

counseling for amputees. Wellness promotion and 

preventive measures should be part of one’s lifestyle. 

Vigilant medical monitoring for cardiovascular diseases, including aortic aneurysms, should be routine 

in amputee clinics.
219

Medical Issues in the Care of the Combat Amputee

Endocrine Topics of Concern

The blast injuries sustained by service members in 

Iraq and Afghanistan are best described as polytrauma 

because all organ systems are affected. Comorbidities 

in this patient population often include TBIs, visceral 

organ damage, large soft tissue defects, concomitant 

fractures, and peripheral nerve injuries. Service 

members with multisystem injury are often managed 

acutely in the intensive care unit and require prolonged 

hospitalization for multiple surgical and medical issues. Previous studies in the critical care literature have 

elucidated the posttraumatic inflammatory response 

and the negative systemic effects of critical illness and 

polytrauma on hypothalamic-pituitary function.150,151

Studies in patients with isolated SCI and TBI have identified associated chronic endocrinologic deficiencies, 

most notably hypogonadism. Total serum testosterone 

levels are significantly reduced in those with SCIs or 

TBIs.152–155 The specific etiology of these hormonal 

deficiencies is multifactorial, but the question for the 

clinician is: once a deficiency is identified, should it 

be addressed through supplementation? Androgen 

supplementation has been beneficial in maintaining 

skeletal muscle following SCI155 and has been used to 

augment wound healing in severe burns.156 Deficiency 

of testosterone and growth hormone in the individual 

with TBI has been theorized to result in the observed visual-spatial impairment memory and neurovegetative 

symptoms such as depression. Studies evaluating the 

utility of hormone supplementation in TBI are pending.

The issue of sexual function and fertility in the 

polytrauma patient—specifically the traumatic 

amputee—requires evaluation. The long-term effect 

of endocrine derangements on reproductive health in 

the male and female traumatic amputee has not been 

described in the literature. Impaired fertility has been 

documented in SCI,157 and recent animal models of SCI 

demonstrate that sperm integrity and genetic structure are altered following injury with an associated 

fertility reduction.158 From these findings about SCIs, 

service members with traumatic amputations should 

be screened early in their periprosthetic rehabilitation 

to identify hormonal deficiencies and consider appropriate supplementation. In those service members 

considering procreation, the consultation of a fertility 

specialist may be appropriate in those couples having 

difficulty with conception.

SUMMARY

This chapter has shown that there are a number 

of important medical issues that must be considered 

in the trauma care and eventual rehabilitation of the 

combat amputee. Following lifesaving surgical stabilization, these issues rise in their importance and cannot 

be ignored. In addition to the orthopaedic and vascular surgeons, these medical issues require teamwork 

among a host of nonsurgical specialists from infectious 

diseases, physical medicine and rehabilitation, neurology, internal medicine, and hematology. In summary, 

whether reading for initial knowledge or review, this 

chapter provides an overview of basic approaches to 

some of the more prominent medical issues encountered in the care of the combat amputee.

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