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Combat Orthopaedics: A View From the Trenches

Dr. Covey is Chairman, Department of Orthopaedic Surgery, Naval Medical Center, San Diego, CA, and the Navy’s Orthopaedic Surgery Specialty Leader and Consultant to the Surgeon General.

Neither Dr. Covey nor the department with which he is 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.

The views expressed in this paper are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. Most orthopaedic wounds in Iraq are caused by exploding ordnance—frequently, improvised explosive devices, or IEDs. Because of advances in care, rapid medical evacuation, and modern body armor, many casualties have survived in Iraq who would not have done so in previous wars. Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.