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Timing of Wound Coverage in Extremity War Injuries

Dr. Sherman is The Audrey Skirball Kenis Professor and Chair, Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA. Dr. Rahban is Resident, Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California. Dr. Pollak is Associate Professor of Orthopaedics, University of Maryland School of Medicine, and Attending Orthopaedic Traumatologist, R Adams Cowley Shock Trauma Center, Baltimore, MD.

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. Sherman, Dr. Rahban, and Dr. Pollak.

Although several studies have been done on the timing of débridement of open fracture, none has specifically examined the effect of timing of soft-tissue coverage on outcome in the types of lower extremity injury being encountered in Iraq and Afghanistan, namely, injuries associated with the detonation of improvised explosive devices. Complex limb salvage requiring free tissue transfer or rotational flap coverage for soft-tissue defects has been commonly performed during the recent military conflicts in Iraq and Afghanistan. Current treatment protocols favor the inclusion of timely and stable axial limb fixation, radical débridement of all compromised soft tissues and osseous structures, and early wound closure with healthy, well-vascularized autologous tissue. In an attempt to minimize overall morbidity, a comprehensive plan must be made to sequentially reconstruct the involved extremity in order to achieve the highest level of function possible, with a durable construct, in the shortest period of time. Prospective studies are necessary to evaluate the effect of timing of coverage on outcome and on limb salvage.