Treatment of Blast

Injuries of the Extremity

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Marko Bumbaširević, MD Abstract

Aleksandar Lesic, MD
Milorad Mitkovic, MD
Vesna Bumbaširević, MD
Dr. M. Bumbaširević is Professor of
Orthopaedic Surgery and Traumatology,
and Director, Institute for Orthopaedic
Surgery and Traumatology, University
Clinical Center of Belgrade, Belgrade,
Serbia and Montenegro.
Dr. Lesic is Associate Professor of
Orthopedic Surgery, Institute for
Orthopedic Surgery and Traumatology,
University of Belgrade. Dr. Mitkovic is
Professor of Orthopedic Surgery,
Institute for Orthopedic Surgery and
Traumatology, Clinical Centre Nis,
Serbia and Montenegro. Dr. V.
Bumbaširević is Assistant Professor o
Anesthesiology, Institute for
Blast trauma is a complex event. Pathophysiologically, blast
injuries are identified as primary (caused solely by the direct effect
of blast overpressure on the tissue), secondary (caused by flying
objects or fragments), tertiary (caused by bodily displacement), or
quaternary (indirectly caused by the explosion). The range of
primary blast injuries includes fractures, amputations, crush injury,
burns, cuts, lacerations, acute occlusion of an artery, air embolism–
induced injury, compartment syndrome, and others. Secondary
injuries are the most common extremity blast injuries. Like
primary injuries, they may necessitate limb amputation, be life-
threatening, and produce severe contamination. Tertiary blast
injuries of the extremity may result in traumatic amputations,
fractures, and severe soft-tissue injuries. Quaternary injuries most
often are burns. Following treatment and stabilization of
immediate life-threatening conditions, all patients are given
antibiotic and tetanus prophylaxis. Débridement and wound
excision are started as early as possible, with repeat débridement
performed as necessary; fasciotomies also are performed to prevent
compartment syndrome. Well-vascularized muscular free flaps
provide soft-tissue coverage for blast-injured extremities. The
closed-open technique of flap closure allows reexamination of the
wound, further irrigation, débridement, and later bone and soft-
tissue reconstruction.

Anesthesiology, University of Belgrade.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. M. Bumbaširević, Dr. Lesic,
Dr. Mitkovic, and Dr. V. Bumbaširević.
J Am Acad Orthop Surg 2006;14:
S77-S81
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
B
last injuries represent more than
half of the total number of pen-
etrating war injuries in recent
conflicts.1-3 Previously used terms
for blast injury were “wind of shot,”
“reflex paralysis,” “air contusion,”
and “blast concussion.”3 These inju-
ries were caused, not by bullets, but
by bombs, missiles, hand grenades,
land mines, mortar/artillery shells,
and many different types of explo-
sives.4 Although blast attacks can
generate a large number of fatalities
and injuries, most survivors are not
seriously injured, and outpatient
treatment is sufficient.5,6
Injuries of the musculoskeletal
system are the most common
wounds seen in armed conflicts, rep-
resenting up to 70% of all inju-
ries.1,2,7,8 In the current conflict, 70%
to 80% of these injuries are the result
of explosive devices, such as im-
provised explosive devices, rocket-
propelled grenades, land mines, rock-
ets, and mortars. This rate of
musculoskeletal injury is explained
by the fact that, today, military per-
sonnel use modern vehicles, body ar-
mor, and helmets; these offer some,

Volume 14, Number 10, 2006 S77

Treatment of Blast Injuries of the Extremity
although not absolute, protection to
the head, thorax, and abdomen, leav-
ing the limbs unprotected.9-11
Pathophysiology of
Blast Injuries
The biophysics of the blast wave has
been well described.1,3-5,9,11,12 Because
blast trauma is a complex event,
it can cause complex injuries to
several organ systems, with dif-
ferent symptoms.11 Prospective
studies would be the ideal method to
understand the human pathophysi-
ology of blast injuries, but this is im-
possible. Therefore, most previous
reports have focused on epidemio-
logic analysis13-15 or the pathophysi-
ology of primary blast injuries of
vital organs.14,16,17 Cernak et al2 ana-
lyzed pathophysiologic responses to
blast extremity injury, and Hayda et
al11 studied blast injury effects on in-
strumented cadavers. In addition,
blasts produce different patterns of
injury in an open space compared
with the effects that occur in a con-
fined space.13,14,18
The Mechanism of
Blast Injury
The sudden pressure change
caused by a blast wave can dam-
age tissue by four mechanisms:
spallation, implosion, acceleration-
deceleration, and pressure differen-
tials.1,3,11,19,20 In their study of the ef-
fects of blast overpressure of the
extremities, Cernak et al2 showed
significant elevations in levels of
plasma arachidonic acid metabo-
lites, thromboxane A2, prostacyclin,
and sulfidopeptide leukotrienes.
Their findings suggest that transmis-
sion blast and stress wave energy
also can cause extensive, measurable
pathophysiologic alterations, leading
to late effects of blast injury.
Classification of Blast
Injuries
On a pathophysiologic basis, blast
injuries and the effects of blast inju-
S78
ries are divided into four general
types:4
1. Primary blast, or blast wave, in-
jury is caused solely by the direct ef-
fect of blast overpressure on the tis-
sue and typically is experienced by
casualties close to the explosion.
These injuries are caused by interac-
tion of the shock front with air-
containing organs (eg, middle ear,
lung, bowel).6 The extremities also
can be involved.
2. Secondary blast injuries are
caused by flying objects that, ener-
gized by the explosion, become pro-
jectiles. Most explosive devices con-
tain metallic and other kinds of
fragments that create penetrating in-
juries when the device disintegrates.
These fragments are the most com-
mon cause of injury and even death
in military attacks.4
3. Tertiary blast injuries are
caused by displacement, in which
the whole body or the limbs are pro-
pelled by a shock wave. Usually in-
dividuals are thrown against fixed
objects, such as a wall, or against the
ground.
4. Quaternary or miscellaneous
blast injuries refer to all explosion-
related injuries, illnesses, and diseas-
es not resulting from the mecha-
nisms of primary, secondary, or
tertiary blast injuries. They are indi-
rectly caused by the explosion.
Extremity Blast Injuries
Musculoskeletal blast trauma oc-
curs most frequently as a conse-
quence of one or more types of blast
injury; the most serious result from
the primary blast. Physical destruc-
tion within the tissue and along the
limbs is predominantly dependent
on the amount of total energy trans-
ferred and the subsequent amount of
energy released per unit length of the
wound. Thus, the destruction can be
a manifestation of one type of blast
injury or some combination of
them.11
The literature indicates that pri-
mary blast injuries affecting only the
Journal of the American Academy of Orthopaedic Surgeons
extremities are rare. An antiperson-
nel mine injury is an example of a
primary injury.1,11,12 The range of
primary blast injuries confronted by
orthopaedic, trauma, and plastic sur-
geons includes fractures, amputa-
tions, crush injury, burns, cuts, lac-
erations, acute occlusion of an
artery, air embolism–induced injury,
compartment syndrome, and others.
Blast waves are able to fracture
bones and avulse parts of an extrem-
ity,5,6 making the very broad zone of
the injury unrecognizable during
initial physical examination. Com-
plete or incomplete traumatic ampu-
tation can be particularly problemat-
ic; Mellor and Cooper12 reported that
only 5 of 52 patients with severe
blast injury survived after initial
traumatic amputation.
Secondary blast injuries are the
most common extremity blast inju-
ries.21 Like primary blast injuries,
they may necessitate primary or sec-
ondary limb amputation and even be
life-threatening. The extent of the
injury depends on the secondary
fragment mass, shape, velocity, and
angle to the body.3 It is well known
that secondary blast injuries are
more severe than the injuries result-
ing from low-velocity bullets8,22,23
and that they are prone to infection
because fragments can produce se-
vere contamination.
Tertiary blast injuries of the ex-
tremity are caused by high-energy
explosions displacing individuals
into the air, with resultant injury on
impact. Traumatic amputations,
fractures, and severe soft-tissue inju-
ries are possible.12
Quaternary or miscellaneous in-
juries most often are burns as a con-
sequence of thermal effects.
Diagnosis
An initial diagnosis may be offered
in the battlefield, but the most accu-
rate assessment likely is made in a
hospital setting. Most commonly
used biochemical blood tests are of
little value in the diagnosis of blast
injury.
 Marko Bumbaširević, MD, et al

Figure 1

Patient with severe extremity and abdominal injury from a land mine explosion. He was treated by external fixation of both lower
legs and the right femur (A) and with musculocutaneous free latissimus dorsi flap coverage of both lower legs (B). C, Complete
survival of the flaps, removal of external fixators, and healing of the open fracture wounds and bone fractures at 11 months.
D, Final result, at 2-year follow-up.

The severity of extremity damage
can be graded using many well-
known classifications, including the
Red Cross Wound Classification24-27
(see Table 1 in Covey, “Combat Or-
thopaedics: A View From the
Trenches.”) Although these classifi-
cations may have value, surgeon ex-
perience is the main determinant for
decision making in regard to defini-
tive treatment.
Radiographic findings of blast in-
juries are characteristic, typically
demonstrating severe bone commi-
nution and soft-tissue destruction.
The absence of metallic fragments
and bone comminution does not ex-
clude blast injury.
Treatment of Blast Injuries
Initial Assessment: Life Before
Limb
Once the immediate life-
threatening conditions have been
treated and stabilized (eg, pneu-
mothorax, colon injuries) and the ex-
tremity injury has been stabilized, a
plan for reconstruction of bone and
soft tissue can be formulated.
It is sometimes very difficult to
assess the viability of the extremity.
The so-called five P’s (pain, pulseless-
ness, pallor, paresis, paralysis) and
capillary refill in a severely injured
patient can be difficult to interpret;
therefore, in certain cases, urgent
Doppler examination and arteriogra-
phy should be performed to make
sure that the limb has adequate cir-
culation.28 Although the Balboa Blast
Treatment Protocol5 is the logical
procedure for treatment of a blast-
injured patient, personal experience
is again of prime importance. All pa-
tients are given antibiotic prophy-
laxis and tetanus prophylaxis.
Débridement and wound excision
should be performed as soon as pos-

Volume 14, Number 10, 2006 S79

Treatment of Blast Injuries of the Extremity
sible; early débridement significantly
reduces the infection rate in war-
injured limbs.29,30 Before initiation of
débridement, a tourniquet should be
placed and the wound copiously irri-
gated. Thorough débridement is crit-
ical; it is the most important step in
preventing complications, especially
infection. All avascular tissue should
be excised, including bone and throm-
bosed blood vessels. Skin, peripheral
nerves, and tendons, unless detached,
should not be débrided radically. Fas-
ciotomies should be performed to
prevent compartment syndrome.
Usually there is a need for repeat dé-
bridement 24 to 48 hours after the
initial procedure.
Only after complete débridement
should the decision regarding recon-
struction or amputation be made.
Although contemporary classifica-
tions have some value, the surgeon
usually makes the decision based on
his or her own experience and the
possibilities available for reconstruc-
tion. In our experience in the recent
wars in the former Yugoslavia, a pre-
requisite for lower extremity recon-
struction was continuity of the tibial
nerve and the ability to reconstruct
the main arteries when they were
damaged.31,32
External fixation is the method of
choice for skeletal stabilization in
most patients with blast injuries
and/or fractures.33-35 Hand and foot
fractures can be stabilized with
Kirschner wires. In patients with
vascular injury, vascular repair
should be done after fracture stabili-
zation.28
Wound Closure-Cover
In the Vietnam conflict, Colonel
Paul V. Brown36 obtained very good
clinical results and a low rate of in-
fection with the open wound tech-
nique; however, current concepts
suggest that these wounds may be
closed earlier when conditions are
optimized.31 The reconstruction lad-
der should start with the simplest
procedures, such as direct closure.
Depending on the soft-tissue defect,
S80
different techniques of wound cover-
age can be applied.
Although it is possible to use
many local and pedicle flaps, well-
vascularized muscular free flaps,
such as the latissimus dorsi or rectus
abdominis, have contributed to the
favorable results obtained in the
treatment of extremity blast injuries
(Figure 1).
In spite of the well-established be-
lief that open fracture wounds
should be left open for a long period,
early free-flap coverage is possible.37
The closed-open technique, a proto-
col of early free-flap coverage of se-
verely injured limbs, can be used.
With this procedure, the war wound
is closed completely as soon as pos-
sible with a free muscle or skin flap.
The microvascular anastomosis is
performed outside the zone of inju-
ry.38,39 After 12 hours, the flap is par-
tially elevated and the wound bed is
reexamined, allowing for further ir-
rigation and débridement. Addition-
al bone and soft-tissue reconstruc-
tion can be performed at a later
time.
Summary
When blast injury occurs, the pre-
vention of complications is difficult,
especially in view of the tremendous
destructive capabilities of modern
weapons. Nevertheless, with a well-
organized team approach, encourag-
ing results can sometimes be ob-
tained, even in the most severe
cases. Débridement and wound exci-
sion should be started as soon as pos-
sible; early débridement significant-
ly reduces the infection rate in
war-injured limbs. Thorough dé-
bridement is critical; all avascular
tissue should be excised, including
bone and thrombosed blood vessels.
Fasciotomies should be performed to
prevent compartment syndrome.
Repeat débridement should be done
24 to 48 hours later. The surgeon
should rely on personal experience
in deciding between reconstruction
or amputation. In our experience,
Journal of the American Academy of Orthopaedic Surgeons
gained during the recent wars in the
former Yugoslavia, a prerequisite for
lower extremity reconstruction was
the presence of tibial nerve continu-
ity and the possibility of recon-
structing the main arteries when
they were damaged. External fixa-
tion is the method of choice for limb
stabilization in most patients with
blast injuries. The reconstruction
ladder should start with the simplest
procedures, such as direct closure.
Well-vascularized muscular free
flaps provide favorable results in the
treatment of extremity blast inju-
ries, particularly when used with the
closed-open technique.
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