Hand fasciotomy is a rarely performed procedure which should be considered by military surgeons, and performed where necessary. Maximising hand function is vital in all military patients, but is even more significant in those who have lost multiple limbs and require maximal function from remaining hands, which are commonly injured too. It is vital that compartments are decompressed expediently to minimize muscle ischaemia. Cases were identified from the JTTR from March 2003. Data were collected prospectively from Aug 2009 to Feb 2010. Patient notes were analysed and the following recorded –demographics, mechanism of injury (MOI), associated injuries, echelon of care at which fasciotomy was performed, indication recorded by operating surgeon, and specialty of operating surgeon. 9 patients were identified, median age was 23, MOI was IED in 8/9 and mine in 1/9/. All were multiply injured. 4/9 (44%) were performed at R3 and 5/9 (56%) at R4. All fasciotomies at R4 were performed at the first debridement, intrinsic muscles were found to be necrotic in 1 case. At R3 3/4 were performed by orthopaedic surgeons and 1/4 by a plastic surgeon, at R4 all were performed by hand surgeons, either orthopaedic or plastic. All fasciotomies performed at R4 were at the first debridement, and 1 revealed necrotic intrinsic muscles. This implies that some of these patients may have benefited from earlier procedures. In upper limb injury where it is not possible to passively flex the metacarpophalangeal joints to 90 degrees, decompressing the hand should be considered.
Topical Negative Pressure Therapy (TNPT) has gained increasing acceptance as a useful tool in wound management. Since 2002, the Royal Centre for Defence Medicine (RCDM) in South Birmingham has gained considerable experience with managing complex combat trauma with TNPT. The mainstay of managing high-energy combat wounds has changed little over the last century of conflict and remains early debridement, wound lavage, fracture stabilisation and delayed closure. Over the last 10 years the use of TNPT has proved to be a useful adjunct in promoting delayed primary and secondary closure, and is now common practise in the US and UK military medical services. There is however, little level 1 evidence to support the use of TNPT in military trauma. All military patients admitted to Selly Oak Hospital between April 2007 and March 2008 that were treated with TNPT were identified, those whose notes were available were included. 37 cases were included. There was a strong correlation between ISS, NISS, and antibiotic use during TNPT use and the total duration of secondary care. However, we found no correlation between delay to first TNPT application, the frequency or location of TNPT dressing changes and any of our surrogate markers of outcome. TNPT is just one of a number of techniques for managing military high-energy injuries and should not be seen as an alternative to the established principles. The high frequency of TNPT dressing changes is not supported by this research and this should be reflected in the clinical management of patients requiring prolonged TNPT.
