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Section 1: General Topics
Figure 43
strong opposition (B). O = opponens pollicis; APB = abductor pollicis brevis; FB = exor pollicis
brevis. +++ = maximum activity, ++ = mild activity, + = minimum activity.
as palmar, whereas for very precise
work, contact with the tip of the same
digits creates a tip type of grip. A lateral, or key, grip involves contact of the
pad of the thumb with the lateral aspect
of the corresponding finger in its distal
segment.
A power grip predominantly involves
the ulnar aspect of the hand with involvement of the little and ring fingers.
The radial three digits also participate
actively either in a pure power pattern
form or by adding an element of precision to the power grip. The power grip
can be divided into three subtypes: cylindrical, spherical, and hook. Despite
the many functions of the hand, any
prehensile act, when arrested instantaneously, might fit in one of these patterns in a pure or combined form.
In a cylindrical grip, all fingers are
flexed maximally, such as around the
handle of a tool, and the counterpressure to the flexing fingers is provided
by the thenar eminence. More power is
provided to this grip when the thumb
wraps around the flexed fingers. If an
element of precision is necessary, the
thumb will adopt a longitudinal position of adduction that allows for small
adjustments of posture. In general, the
pattern of the grip during prehension
Schematic drawings demonstrate muscle activity during weak opposition (A) and
is determined by the intention and not
necessarily by the shape of the object.24
Finger flexion is primarily powered by
the flexor digitorum profundus. The
flexor digitorum superficialis and the
interossei become involved if more
power is necessary. The thumb brings
its contribution with the thenar muscles
and the flexor pollicis longus.
The spherical grip is used to hold
objects such as a ball. It is similar to
a cylindrical grip in terms of motor
force, although the interossei are more
active as a result of the abduction of
the metacarpophalangeal joints. When
a large object is held, a power grip is
used with minimal flexion of the fingers,
which are abducted and rotated, and the
thumb participates at the opposite pole
by stabilizing the object and providing
the necessary counterpressure. With a
smaller spherical object, the fingers are
adducted and the thumb is in opposition; this pattern of prehension is of the
precision type.
The hook power grip involves flexion
of both interphalangeal joints, especially
the proximal interphalangeal joint, and
minimal participation of the metacarpophalangeal joint. The flexor digitorum
profundus and flexor digitorum superficialis are both involved. This pattern
is used in carrying a suitcase and can
be maintained for a prolonged period.
Summary
One of the important physical characteristics that distinguishes humans
from other mammals is the freeing of
the upper limbs from the task of weight
bearing, which allows the upper limbs
to perform as organs of prehension.
Understanding how the upper limbs
of humans have adapted to this task is
crucial in making treatment decisions
that affect the clinical care of individuals
with upper limb abnormalities, deformities, or losses.
References
1. Morrey BF, Itoi E, An KN: Biomechanics of the shoulder, in Rockwood
CA Jr, Matsen FA III, Wirth MA,
Harryman DT, eds: e Shoulder, ed
2. Philadelphia, PA, WB Saunders,
1998, pp 233-276.
2. Inman VT, Saunders J, Abbott LC:
Observations on the function of the
shoulder joint. J Bone Joint Surg Am
1944;26(1):1-30.
3. Howell SM, Imobersteg AM, Seger
DH, Marone PJ: Clarication of the
role of the supraspinatus muscle
in shoulder function. J Bone Joint
Surg Am 1986;68(3):398-404. Medline
4. American Academy of Orthopaedic
Surgeons: Joint Motion: Method of
Measuring and Recording. Chicago,
IL, American Academy of Orthopaedic Surgeons, 1965.
5. Boone DC, Azen SP: Normal range
of motion of joints in male subjects.
J Bone Joint Surg Am 1979;61(5):756-
759. Medline
6. Simon SR, Alaranta H, An KN, et al:
Kinesiology, in Buckwalter JA, Einhorn TA, Simon SR, eds: Orthopaedic
Basic Science: Biology and Biomechanics of the Musculoskeletal System,
ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 731-827.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
112
Chapter 8: Kinesiology of the Upper Limb
7. Morrey BF, Chao EY: Passive motion
of the elbow joint. J Bone Joint
Surg Am 1976;58(4):501-508. Medline
8. Long C II, Conrad PW, Hall EA,
Furler SL: Intrinsic-extrinsic muscle
control of the hand in power grip and
precision handling: An electromyographic study. J Bone Joint Surg Am
1970;52(5):853-867. Medline
9. Funk DA, An KN, Morrey BF, Daube
JR: Electromyographic analysis
of muscles across the elbow joint.
J Orthop Res 1987;5(4):529-538.
Medline DOI
10. Travill AA: Electromyographic study
of the extensor apparatus of the
forearm. Anat Rec 1962;144:373-376.
Medline DOI
11. Capener N: e hand in surgery.
J Bone Joint Surg Br 1956;38(1):128-
151. Medline
12. Hollister AM, Gellman H, Waters
RL: e relationship of the interosseous membrane to the axis of rotation
of the forearm. Clin Orthop Relat Res
1994;298:272-276. Medline
13. O’Driscoll SW, Horii E, Ness R,
Cahalan TD, Richards RR, An KN:
e relationship between wrist position, grasp size, and grip strength.
J Hand Surg Am 1992;17(1):169-177.
Medline DOI
14. Christensen JB, Adams JP, Cho KO,
Miller L: A study of the interosseous
distance between the radius and
ulna during rotation of the forearm. Anat Rec 1968;160(2):261-271.
Medline DOI
15. Halls AA, Travill A: Transmission of pressures across the elbow
joint. Anat Rec 1964;150:243-247.
Medline DOI
16. MacConaill MA, Basmajian JV, eds:
Muscles and Movements: A Basis for
Human Kinesiology. Baltimore, MD,
Williams &Wilkins, 1969.
17. Sarraan SK, Melamed JL, Goshgarian GM: Study of wrist motion in
exion and extension. Clin Orthop
Relat Res 1977;126:153-159. Medline
18. Radonjic D, Long C II: Kinesiology of the wrist. Am J Phys Med
1971;50(2):57-71. Medline
19. Littler JW: On the adaptability
of man’s hand (with reference to
the equiangular curve). Hand
1973;5(3):187-191. Medline DOI
20. Landsmeer JM: e anatomy of the
dorsal aponeurosis of the human
nger and its functional signicance. Anat Rec 1949;104(1):31-44.
Medline DOI
21. Littler JW: Hand structure and function, in Littler JW, Cramer LM, Smith
JW, eds: Symposium on Reconstruc-
tive Hand Surgery. St Louis, MO, CV
Mosby, 1974, pp 3-12.
22. Cooney WP III, Lucca MJ, Chao EY,
Linscheid RL: e kinesiology of
the thumb trapeziometacarpal joint.
J Bone Joint Surg Am 1981;63(9):1371-
1381. Medline
23. Forrest WJ, Basmajian JV: Functions
of human thenar and hypothenar
muscles: An electromyographic
study of twenty-ve hands. J Bone
Joint Surg Am 1965;47(8):1585-1594.
Medline
24. Napier JR: e prehensile movements
of the human hand. J Bone Joint Surg
Br 1956;38(4):902-913. Medline
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
113
Chapter 9
Wartime Amputations
Donald A. Gajewski, MD Paul J. Dougherty, MD
Abstract
Amputations are among the most severe limb injuries seen in military combat. Caring for
personnel with such severe traumatic injuries is a two-stage procedure involving initial
care at a forward medical facility to remove the damaged limb to prevent infection and
save the patient’s life and later denitive care provided aer the patient is transported to
another medical facility. Advances in care over decades of wars and conicts have led to the
increased survival of personnel with limb amputations. Specialized care centers staed by
surgeons, nurses, prosthetists, and therapists have been established by the US military to
provide a team approach to caring for combat personnel with amputations, with the goal
of returning each injured patient to the best possible health and function.
Keywords: combat amputations; Korea; Operation Enduring
Freedom; Operation Iraqi Freedom; US Amputee Care Program;
Vietnam; World War II
Introduction
Compared with the typical battle casualty, amputations represent a small but
important group of combat casualties
that require longer hospital stays, more
surgical care, and prosthetic fitting. The
wars of the 20th and 21st centuries have
found surgeons relearning the principles
of care for individuals with amputations
in a combat setting. The techniques and
special postoperative care for these patients are not routinely taught in surgical training programs in the United
States. Such personnel often are the
most severely injured patients seen on
the battlefield and require priority care
at forward surgical echelons.
Conflict can occur without warning,
and military surgeons could be treating
Neither of the following authors nor any immediate family member has received anything
of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Gajewski and Dr. Dougherty.
is chapter is adapted and updated from Dougherty PJ: Wartime amputee care, in Smith DG,
Michael JW, Bowker JH, eds: Altas of Amputations and Limb Deciencies: Surgical, Prosthetic,
and Rehabiliation Principles, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons,
2004, pp 77-97.
battle casualties with little or no preparation. It is the goal of any military surgeon to be prepared to treat any battle
casualty that arises, which means minimizing morbidity and mortality, even
with a large number of patients. Preparedness therefore involves the ability
to not only treat battlefield casualties
but also instruct others on the care of
such patients.
Personnel with amputations have
historically been a substantial clinical
problem for military surgeons because
of (1) the severity of injury, (2) high morbidity, and (3) long hospital stays. Very
few surgeons have extensive experience
caring for individuals with amputations
in civilian practice, thus making the
study of this type of injury paramount
for military surgeons to provide the best
care for their patients. During every
conflict in the 20th and 21st centuries,
there has been a steep learning curve
concerning the care of individuals with
amputations.
The latest surgical techniques from
civilian practice often are inappropriately applied to personnel who must be
transported from a combat zone. The
goals of initial care must take into account the deleterious effects of evacuation; thus, any initial surgery should
prepare the soldier (or civilian) for the
trauma of transportation. In the case
of personnel with amputations, wound
closure often is attempted to provide a
residual limb so that a prosthesis may
be fitted as soon as possible. As documented in World War I, World War II,
and the Vietnam War, early wound closure in battlefield hospitals was shown
to dramatically increase complication
rates.
During the recent past, the Army
Medical Department has assumed responsibility for other missions (for example, refugee care). The care of refugees
and patients who are not US or allied
soldiers, and therefore are not evacuated, has changed the traditional role
of military surgeons. For such patients,
both initial and definitive care currently occurs in the combat theater. Patient
factors also are variable, including being
of any age or sex and having a variety of
nutritional and health problems. Prosthetic fitting of the amputated limb also
is highly variable and depends on the
resources of the international community, involved nongovernmental organizations, and the healthcare resources of
the patient’s nation.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
115
Section 1: General Topics
Evolution of US
Military Care
Mechanisms of Injury
During the American Civil War, gunshot wounds were the main cause of injury leading to amputation (75%), with
the remainder of the injuries caused by
artillery projectiles (fragments or grape
1,2
shot).
By World War I, artillery shell
fragments were the most common cause
of injury leading to amputation. Artillery and shell fragments were the major
cause of injury during World War II, but
Hampton3 noted that the prevalence of
land mines contributed to the number
of patients with limb loss in Italy.
Indications for Surgery
Early in the Civil War, amputations
were recommended under the following
conditions: crush injury, nerve or blood
vessel injury, gunshot fracture with
extensive comminution, a major open
joint injury accompanied by a fracture,
or extensive soft-tissue injury.
was recommended as soon as possible
within the primary period of the first
day, before the development of sepsis.
By 1863, as surgical techniques
evolved and surgeons became more experienced, indications for amputation
became more refined. Gunshot fractures
of the femur were not always necessarily
an indication for amputation. In 1863,
Moses6 reported a 12.9% incidence of
amputation associated with long-bone
fractures for the battles near Chattanooga, Tennessee. Hodgen7 and Lidell8
reported good results in treating gunshot fractures of the lower limbs with
Hodgen splints. Hodgen himself, who
treated survivors of the long evacuation
from the battlefield to a large hospital in
St. Louis, Missouri, believed that amputation should be performed only for
those patients who had injuries to joints,
blood vessels, or nerves. Swinburne9 advocated amputation surgery for a partial or complete traumatic amputation,
extensive soft-tissue injury associated
with nerve or blood vessel injury and
4,5
Surgery
denuded bone, the loss of a major blood
vessel, or compound fractures of the
knee or ankle joint. Most gunshot fractures were treated nonsurgically during
the Civil War, and a variety of splints
were developed to treat these fractures.
7,8
During World War I, the indications
for surgery also changed. Speed,10 who
was with the Base Hospital (Chicago
Unit) in France in 1918, reported on
121 amputations. The indications for
surgery were severe fractures, gas gangrene, sepsis, secondary hemorrhage,
and trench foot. The most common
level was the transfemoral amputation
(58.6%). Speed10 recommended an open
circular amputation with longitudinal
skin slits up the side of the residual limb.
Evacuation Hospital No. 8 reported
151 amputations in 4,714 battle injuries
(3.2%) from September 13 to November
13, 1918. Of these, 62% were for gas
gangrene, 33.7% for trauma, and 10.5%
for sepsis. Again, transfemoral amputations were the most prevalent (39%).
11
By World War II, the indications
for surgery were primarily for the direct effects of trauma, with a partial or
complete traumatic amputation being
the most common reason for amputation; completion of the amputation was
the initial procedure performed. Major
vascular repair had not yet been developed, and up to 20% of limb losses were
caused by vascular injuries. Infection
had declined as a major indication for
surgery, possibly because of the widespread use of antibiotics.
3,12,13
Surgical Techniques
Various amputation techniques were reported during the Civil War. The Army
Medical Museum recorded 253,142
casualties in the Civil War; 20,559
patients (8.1%) had major limb amputations (those proximal to the wrist or
the ankle). In this series, transfemoral
amputation was the most common amputation level. The open circular (or
flapless) technique was most commonly
used. For transtibial amputations, flaps
were used in 1,720 patients (58.8%),
and the open circular technique was
used in 1,206 patients (41.2%). The total
overall mortality of these patients was
14
35.7%.
During World War I, various tech-
niques were attempted for amputation
surgery. The United States officially declared war in 1917, but the Red Cross
had been providing medical units to
France since the beginning of the war in
1914. In 1918, a hospital center was es-
tablished in Savenay, France, with Evacuation Hospital No. 8 as its core unit. An
amputation service was established at
that hospital to care for people with amputations who would be returning to the
United States. The goals of this service
were to provide skin traction, wound
care, and physical therapy. A program
of early ambulation with fitting of a temporary prosthesis, with a design based
on the experience of Belgian physicians,
also was instituted at Savenay, and approximately 20% of the returning personnel with amputations were initially
fitted there.
11,15
Of the 550 individuals
with amputations examined at Savenay,
58% were treated using the open circular technique, 30% using the flap technique with delayed primary closure, and
11% using pri mary or delayed primary
closure alone.11 Of the residual limbs
that were closed, 25% needed to be reopened because of infection.
After patients were stabilized, they
were evacuated to the United States. In
the continental United States, five hospitals were designated as amputation
centers to consolidate the resources of
surgeons, prosthetists, physical therapists, and nurses. The team approach,
which is common today, had its origin
at these specialty centers during World
16
War I.
Kirk,17 who became the US Army
Surgeon General during World War II,
wrote about his experiences in caring for
personnel with amputations at two hospitals, where he treated approximately
1,700 patients. He advocated the open
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
116
Chapter 9: Wartime Amputations
circular technique for war casualties for
two reasons: (1) its simplicity and (2)
preservation of the maximum residual
limb length, both of which allowed wide
drainage to treat infection and enabled
earlier transport of the patient. Surgical
procedures were staged, and definitive
surgical closure was performed when
the patient was stable and in a stable
environment. Kirk17 noted that at least
95% of the patients who arrived from
overseas with open residual limbs
needed additional care before prosthetic
fitting. Most residual limbs were edematous and had unhealed areas. Other
problems included bony protrusion and
infection (most often from Streptococcus,
Staphylococcus, Proteus, and Klebs Loffler
bacillus species).
17
Early in World War II, military surgeons relearned the lessons from previous conflicts. Patients who did not have
skin traction after open circular amputations experienced bony protrusion and
needed reamputation, with the resultant
loss of residual limb length. Amputations in which the skin had been closed
were seldom successful because of infection. After the attack on Pearl Harbor,
Hawaii, amputated limbs treated with
delayed primary or primary closure became infected and required amputation
at a higher level (LT Peterson, MD, unpublished data, 1946).
Early in World War I, because of his
experience, Kirk was instrumental in
developing policies to care for personnel with amputations. In 1942, the lack
of success with early wound closure led
Kirk (before becoming surgeon general)
to reemphasize the open circular amputation technique.18 The technique at
this time was characterized by amputating at the lowest level of viable soft
tissue, allowing the skin to retract, and
successively cutting layers of muscle
and bone more proximally to produce
a concave residual limb. The open residual limb permitted wide drainage
to prevent infection. Postoperatively,
the patient was to be maintained in
continuous skin traction to prevent the
retraction of soft tissues. A repair or
plastic closure of the residual limb was
then performed for patients with an ad
herent scar. In a later article, Kirk and
McKeever12 emphasized that the open
circular technique was a two-stage procedure that required a second surgery
for wound closure.
Prosthetic Devices
There was no standardized prosthetic
fitting or rehabilitation for Civil War soldiers with amputations. Minor19 recommended that the artificial limb should
have the following characteristics: have
the same size and shape as the limb
being replaced; be constructed of light,
strong, and durable materials; and be
“well fitting to the residual limb.” Minor19 felt that the Anglesey and Bly legs
(patented in 1805 and 1858, respectively) were most appropriate because both
had an ankle joint. Palmer legs (created
by Benjamin Palmer in 1846), which
had a solid ankle, also were popular. It
is not known how many soldiers used
prostheses because many people with
lower limb amputations walked with
ambulatory aids, such as crutches, rather than wearing a prosthesis. During
the Civil War, Otis and Huntington14
reported that 40 to 60 patients with
knee disarticulations were fitted for a
prosthesis.
During World War I, several improvements were made in the care and
prosthetic fitting of soldiers with limb
loss. First, a program of early fitting with
a plaster temporary prosthesis was tried
in France.15 Wilson,15 who was in charge
of the amputee service at Savenay where
a limited program of early walking was
instituted for people with lower limb
amputations, believed that if the wound
was clean, a patient could begin ambulating after 2 to 3 weeks. At this time,
the patient was fitted with a temporary
prosthesis consisting of a socket and a
frame. The frame could be prefabricated and needed a minimum of fitting,
and the socket was generally made from
plaster of Paris and molded to relieve
wound pressure. Wilson15 believed
-
that early ambulation promoted wound
healing, caused residual limb shrinkage, improved morale, and decreased
the time to permanent prostheses. For
upper limb amputations, body-powered
grasping hooks were developed and
17,20,21
used.
Prior to World War II, no national
research program, either military or civilian, existed to investigate the quality
of artificial limbs. Initially, the military
believed that such a program was the
responsibility of the Veterans Administration, which had long-term responsibility for personnel with amputations.
However, the Veterans Administration
procured nearly all its prostheses from
commercial manufacturers and therefore lacked its own experienced prosthetists and engineers.
At the request of the US Surgeon
General in February 1945, the National Research Council established a
Committee on Artificial Limbs. Paul E.
Klopsteg of Northwestern University in
Evanston, Illinois, chaired the committee. The goals of the committee were to
assist the Army, the Navy, and the government in procuring the best prostheses to meet the demands of World War II
personnel.
22,23
In addition, the committee sponsored studies on the mechanical
behavior of both normal and artificial
limbs; studied existing prostheses; and
directed research toward improving,
simplifying, and standardizing artificial
limbs as much as possible. This included
investigating potential new materials to
manufacture limbs, studying the art of
limb fitting, and training the patient in
its use. These studies and research resulted in improvements in upper limb
prostheses, including improvements in
the use of plastics; the testing of many
different joints; and the use of rubber,
fabric, and bonding methods that were
recommended by the National Bureau
of Standards.
22-24
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
117
Section 1: General Topics
At the University of California, basic research was conducted on gait and
the use of muscles to power an upper
limb prosthesis; the latter was known
as a cineplastic operation. Lower limb
studies focused on identifying the elements of normal gait, principles that are
still used today. This research, started
during World War II, was ongoing for
several years and led to substantial improvements in prostheses.
22-26
The Vietnam Experience
The experiences of World War II and the
Korean War were not routinely taught to
surgeons before they were deployed to
Vietnam. Consequently, the treatment of
personnel with amputations in forward
hospitals was not standardized and occasionally compromised patient care,
especially in the earlier stages of the
Vietnam War. As casualties increased,
amputation centers in the continental
United States slowly began to handle
the specialized care required by these
patients.
The incidence of amputations at surgical hospitals in Vietnam ranged from
4.5% to 5.6%. Most patients had either
partial or complete traumatic amputations that were caused by their injuries,
necessitating only completion of the residual limb. Trauma was the primary
indication for amputation in more than
90% of the patients in Vietnam, followed
by vascular complications (6%), and infection (3%).
Late amputations were performed in
cases of infection, from either an open
fracture or a failed vascular repair.
Schmitt and Armstrong29 reported that
186 of 485 amputations (38%) performed at Clark Air Force Base in the
Philippines were late amputations. The
precise number of late amputations performed because of osteomyelitis is not
known.
The Wound Data and Munitions Effectiveness Team recorded 98 significant
amputations in their series (RF Bellamy,
MD, personal communication). Of these,
27-31
35 patients died before reaching medical
care, and 1 patient died of wounds after
reaching medical care alive, a mortality
rate similar to that caused by land mine
injuries in the Bougainville Campaign
during World War II.
Valley Forge Army General
Hospital Experience
Amputations caused by land mines and
booby traps occurred in 62% of the
patients who were examined at Valley
Forge Army General Hospital (Alcide
M. LaNoue, MD, Ft. Leavenworth, KS,
unpublished data, 1971). Land mines in
Vietnam were unconventional devices
made from other ordnance or improvised from local materials. Transtibial
(40%) and transfemoral (27% to 31%)
amputations were the most common.
According to data of the Wound Data
and Munitions Effectiveness Team, patients who had lost more than one limb
comprised 16% of the battlefield casualty admissions at Valley Forge Army
General Hospital and 19% of the patients who were received alive at a medical treatment facility. It is unknown if
this increase was the result of improved
medical care, which preserved the most
severely injured, or if there was a change
in the type of weapons used against
American troops.
Although the recommended technique at this time was an open circular amputation with postoperative
skin traction, as in previous wars, this
technique was not always used. In his
series of 410 patients received at Valley
Forge Army General Hospital between
1969 and 1970, LaNoue reported that
41% of the transtibial amputations had
skin closure before evacuation, and this
group incurred a 56% failure rate because of gross infection. He also found
that the time from injury to the prosthetic fitting increased from 9 to 11
months when closure was performed
before evacuation (Alcide M. LaNoue,
MD, Ft. Leavenworth, KS, unpublished
dat a, 1971).
LaNoue also reported an 88% failure rate for Syme ankle disarticulations
performed in the combat theater, necessitating conversion to amputation
at the transtibial level. This failure occurred because the heel pad was par
tially devascularized by removal of the
hindfoot. Rather, LaNoue recommended
that the hindfoot be left intact and that
simple wound débridement be performed for forefoot injuries, leaving the
choice of definitive amputation to the
receiving physician. The devascularized
heel flap did poorly when a patient was
transferred from Vietnam to the United
States.
LaNoue concluded that initial amputations in the combat theater should
follow three principles: (1) Maximum
length should be preserved, and definitive procedures should be ignored until
a stable environment can be provided;
(2) if a definitive procedure was necessary, the environment must be stabilized and the evacuation deferred; and
(3) skin traction must be maintained on
all residual limbs wherever possible.
A substantial number of US Army
personnel from Vietnam received treatment at Letterman, Fitzsimons, Walter
Reed, Brooke, and Valley Forge Army
General Hospitals.32 Only Valley Forge
Army General Hospital, however, established an amputation service that
combined the skills of a physical therapist, a surgeon, and a prosthetist on one
team. A staff psychiatrist was added to
the team in January 1971.33 The goals of
treatment in these hospitals were to provide residual limb healing, ambulation
training (for lower limb amputations) or
training in activities of daily living (for
upper limb amputations), an initial prosthesis, and a medical board that would
allow for medical retirement.
By 1969, the number of people with
amputations had become large enough
to justify a separate service at Valley
Forge Army General Hospital. Patients
evacuated from Vietnam were placed
with other amputees, evaluated, and
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
118
Chapter 9: Wartime Amputations
started on a program of residual limb
healing and physical therapy. Later,
patients were fitted with a temporary
prosthesis to walk or perform activities
of daily living. Because the numbers
were substantial, these individuals
were widely studied. The treatment of
individuals with amputations generally
followed a series of successive stages,
as follows: (1) wound healing, (2) preprosthetic training, (3) the fitting of
provisional prostheses, and (4) the fitting of permanent prostheses. Patients
generally progressed from one stage
to the next in sequential order. Each
member of the treatment team was responsible for a specific stage. During
wound healing, the surgeon provided
most of the care. During preprosthetic
training, therapists worked primarily with the patient. The prosthetist
gradually became involved during the
provisional and permanent prosthetic
34
stages.
An innovative early ambulation
program was initiated at Valley Forge
Army General Hospital to shorten
the stages of rehabilitation, based on
the program used by Wilson15 during
World War I. Patients ambulated earlier, even on open residual limbs, which
allowed them to become upright sooner in an effort to attain an earlier proprioceptive sense. Moreover, weight
bearing on lower limb amputations
reduced swelling. The hard socket allowed for compression of the residual limb and decreased edema, which
was thought to allow earlier prosthetic fitting. The psychological benefits
associated with being upright sooner
and earlier independence were well
documented. The team approach of
the amputation service at Valley Forge
Army General Hospital was not always
possible for the general orthopaedic
service. The entire team followed a
patient’s progress from admission to
discharge, providing comprehensive
care to the patient and, ultimately, better patient functionality.
Long-Term Follow-up
A review of the records of 484 personnel
with battlefield amputations who were
treated at Valley Forge Army General
Hospital was performed to document
the level of amputation, indication for
initial surgery, and mechanism of in-
34 -36
jur y.
The most common level of
limb loss seen was a unilateral transtibial amputation, a trend that started
in World War II, but there was a higher
proportion of those with multiple limb
loss (15.9%) than other studies, probably because Valley Forge Army General
Hospital was a referral hospital where
the more severely wounded patients
were concentrated.
Sixty-four percent of the patients with
a transtibial amputation were injured by
land mines or booby traps. Small arms
fire, exploding munitions, and rocketpropelled grenades accounted for the
other amputations. Trauma was the
indication for amputation in 89.5% of
the patients, followed by vascular injury
(8.4%) and infection (1.9%).
34
To determine the lifetime effects of
wartime limb loss (approximately 28
years after injury), patients from Valley Forge Army General Hospital were
surveyed regarding their prosthetic history and family life, including marriage
and children; the number of additional
surgeries since the initial amputation;
psychiatric history, including membership in Alcoholics Anonymous and
marriage counseling; other injuries; and
work history.
34-36
Transtibial Amputations
Of the 123 patients with transtibial amputation eligible for the follow-up study,
72 (59%) were available for follow-up
and divided into two groups.34 One
group had isolated transtibial amputations, and the second group had at
least one other major injury (polytrauma), defined in this study as a major
lower limb long-bone fracture; burns
over more than 20% of the body surface area; and/or substantial head, face,
chest, or abdominal wounds. Most of
the patients (44) were in the second
group. A comparison of employment,
marriage, and family factors showed
no significant difference between the
two groups. However, the reported incidence of psychological care differed
significantly (P < 0.001) between the two
groups, with only 21% of the first group
seeking help compared with 50% of the
second group.
34
All respondents were presently wearing prostheses, with the first group
averaging 15.9 hours per day and the
second group, 15.7 hours. Most respondents reported that they had changed
prostheses, specifically 78.5% of the first
group and 72% of the second group. The
most commonly reported changes were
in the foot (n = 22), suspension (n = 20),
liner (n = 18), and socket (n = 8). The
average number of prostheses used since
the first permanent prostheses were fitted was 7.89 (range, 3 to 30) in the first
group and 8.84 (range, 4 to 30) in the
second group. Patients reported an average of 1.94 surgical procedures since
their initial amputation (range, 0 to 13),
with 1.36 in the first group and 2.32 in
the second group.
34
The use of an osteoplastic technique
(Ertl technique) for transtibial limb loss
has been advocated for young, active patients. An Ertl osteoplasty produces an
end-bearing residual limb by creating a
bony synostosis between the tibia and
the fibula at the distal end of the residual limb. The technique was originally
described as creating a periosteal sleeve
bridge or tube between the most distal
end of the tibia and fibula, then filling
this tube with bone graft to create a
“bone bridge” at the distal bone of the
residual limb. Proponents of this technique believe that it produces a better
end-bearing residual limb, with better
prosthetic wear. Subsequent modifications to this technique include using a
fibular strut and orthopaedic hardware
for fixation of the bone. One important aspect of the technique, which is
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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Section 1: General Topics
often ignored, is that it provides good
soft-tissue coverage of the residual limb,
including myodesis and/or myoplasty.
Deffer et al37 reported that the Ertl
procedure resulted in a more stable and
durable residual limb. Comparison with
other transtibial amputations was not
documented, however, and the definitive benefits of this level of amputation compared with the conventional
transtibial amputation remain unclear.
The Ertl procedure was performed in
42 patients (63%), 19 in the first group
and 23 in the second group.34 One patient reported undergoing bone block
removal because of pain. The Medical
Outcomes Study 36-Item Short Form
(SF-36) scores for the first group were
not significantly different (P < 0.01)
from the controls. Patients in the second group were significantly different
in all areas (P < 0.01). Currently, results
are inconclusive regarding whether
this technique should be used in every
young patient undergoing transtibial
amputation.
34,38,39
Transfemoral Amputations
A review of records by Dougherty36
showed that 59% of the patients with
transfemoral amputations were injured by land mines and booby traps.
Indications for surgery were trauma in
61.8% of the patients, failed vascular
repair in 29.2%, and infection in 8.7%.
The average time to Valley Forge Army
General Hospital was 4.4 weeks and to
pylon fitting was 4 weeks, with permanent prosthetic fitting at an average of 7
months. At follow-up, an average of 28
years after injury, 51% of those alive and
eligible for the study agreed to answer
the questionnaire. Of those, 93% are or
were married, 91.3% are or have been
employed, and 85% have children.
The average number of surgical procedures on the residual limb since the
initial amputation was 2.4.36 Six patients (13%) did not presently wear a
prosthesis; the others wore a prosthesis
an average of 13.5 hours per day and
have owned an average of 13.8 prostheses since their initial fitting. Of those
who wore a prosthesis, half had changed
their prescription since the initial fitting.
Twenty-four patients (52%) reported
seeking psychological care, including
Alcoholics Anonymous and marriage
counseling. The SF-36 scores were significantly lower than those of a control
group (P < 0.05) in all categories except
mental health.
Bilateral Transfemoral Amputations
Thirty patients (6.2%) in the follow-up
study were identified as having bilateral transfemoral amputations.35 Of these
patients, 26 were injured by land mines
or booby traps. Other mechanisms of
injury included artillery or mortar fire
(three patients) and machine gun fire
(one patient). The indications for surgery
were trauma in 53 (88%) of 60 residual
limbs and infection in the remaining
7 limbs. The medical records indicated that postoperative skin traction was
used in fewer than 50% of the patients.
Three patients also sustained an upper
limb amputation, with one at the wrist,
one above the elbow, and one below the
elbow. Documentation of shock and resuscitation attempts was incomplete, but
the records of 14 patients indicated that
an average of 23.7 units of blood had
been transfused.
Patients arrived at Valley Forge Army
General Hospital an average of 4.5 weeks
after injury. The records of 23 patients
showed that they were fitted with pylons
or stubbie feet an average of 8.3 weeks
after injury (range, 3 to 20 weeks). The
records of 17 patients showed that they
were fitted with permanent prostheses
an average of 6.5 months after injury
(range, 3 to 12 months).
Three patients died since leaving
Valley Forge Army General Hospital,
and 23 of the remaining 27 (85.2%)
agreed to answer the questionnaire and
complete the SF-36 form. Sixteen of the
23 (69.5%) are employed outside the
home even though they have adequate
compensation from the Veterans Administration to maintain a modest lifestyle. Twenty-one (91.3%) are or were
married, and 20 (87%) had children.
Five patients (21.7%) reported the use
of mental health services.
35
Five patients (21.7%) reported that
they still wear a prosthesis for an average of 7.7 hours per day. Ten others
(43.4%) reported using their prostheses
an average of 12.8 years after leaving
Valley Forge Army General Hospital.
Five patients reported using prostheses
primarily for “going out.”
The SF-36 scores of those with bilateral transfemoral amputations did not
differ significantly from those of a control group except in the area of physical
function. It is not clear why the SF-36
scores for this group were higher than
those of the other groups. One explanation might be the small number of
patients. Another explanation might be
the lower proportion of patients in the
other groups who were eligible to participate in the study. Finally, an error in
the methodology is a possibility.
Operations Iraqi and
Enduring Freedom
The wars in Iraq and Afghanistan have
seen the lowest fatality rate from combat wounds of any conflict in American
history.40 Although much of this can be
attributed to improvements in protective equipment, the development of an
in-theater trauma system has undoubtedly contributed to improved outcomes
for service members injured on the
battlefield.41 In addition, all deploying
surgical teams prepare themselves for
combat casualty care at the Army, Navy,
or Air Force Trauma Training Centers,
which are associated with renowned civilian level 1 trauma hospitals. Tactical
combat casualty care and emergency
war surgery courses also are available
to deploying surgeons. Operations Iraqi
Freedom and Enduring Freedom also
saw the development of far-forward surgical resuscitation teams that provide
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Chapter 9: Wartime Amputations
surgical and critical care to the most
severely wounded service members as
close to the point of injury as possible.
In addition, these operations saw the
implementation of the Critical Care
Aeromedical Transport Team, which has
the capability of evacuating stabilized,
critically ill patients while providing en
route care and continued resuscitation.42
These advances have unarguably led to
the increased survival of personnel with
amputations who may have succumbed
to their injuries in previous conflicts.
43
In these recent military operations,
the most common mechanism of injury for major limb amputations was a
blast injury, mostly in the form of improvised explosive devices. Of all the
military casualties in Operations Iraqi
Freedom and Enduring Freedom, 70.5%
of individuals sustained a major limb injury, with amputation comprising 7.4%
of all major limb injuries.44 Transtibial
amputations were the most common,
accounting for 41.8% of all amputations,
followed by transfemoral amputations at
35.5%. Thirty percent of military personnel sustained multiple amputations,
and 14% of all amputations involved the
upper limbs. Ten percent of all military
personnel underwent amputation more
than 90 days after the date of injury,
either because of patient wishes or complications with attempted limb salvage.
45
In 2001, the US Army, under the
guidance of the Army Surgeon General, consolidated the care of personnel
with amputations in specialized centers
located at Walter Reed Army Medical
Center in Washington, DC, and Brooke
Army Medical Center in San Antonio,
Texas. The US Navy established a third
center at the Balboa Naval Hospital in
San Diego, California, with the intent of
providing care to personnel who were
from the West coast. At each center, a
multidisciplinary team from more than
a dozen specialties was brought together
to address not only the physical needs of
the wounded service member but also
the psychological, social, vocational,
and spiritual needs of soldiers, sailors,
airmen, and marines.46 Because of this
specialized care, soldiers from these
recent conflicts have seen the highest
return to duty rate (16.5%) in recent
47
history.
Current Concepts
In-eater Care
The initial goal of the combat surgeon
in treating a traumatic battlefield amputation is to prevent infection and save
the patient’s life while preserving as
much residual length as possible. The
indications for immediate amputation in
the combat theater are near-complete or
partial amputation, irreparable vascular
injury or failed vascular repair with an
ischemic limb, life-threatening sepsis
because of local infection, or a patient
in extremis with severe soft-tissue and
bone injury to the limb.48 If a patient
has a catastrophic limb injury but has a
viable limb and is physiologically stable,
amputation should not be performed in
the combat theater solely because of predicted limb dysfunction. In this case,
serial débridement of the wounds to
prevent infection and stabilize the limb
should take place until the patient arrives in the continental United States.
At that time, the patient can participate
in the decision for amputation, which
psychologically may help the patient
accept his or her limb loss.
The most common mechanism of
injury for a traumatic amputation is a
blast injury, and the high energy of this
mechanism should be respected. The
zone of injury is much more proximal
and broader than appreciated at first
glance. Thorough débridement should
be performed, which includes extending
wounds with longitudinal incisions to
check for debris that may have traveled
proximally through tissue planes. The
treating physician should have knowledge of standard amputation incisions
to facilitate future definitive closure. An
improperly placed incision for initial
débridement may change the definitive
closure when the patient returns to the
continental United States for continued
care. Guillotine amputations should
not be performed; rather, open, lengthpreserving amputations, preserving all
healthy tissue, should be performed to
leave the maximum number of treatment options for the surgeon providing
definitive care. Any distal tissue can be
considered a “flap of opportunity” and
can aid in the definitive closure, saving
not only length but also potentially a
joint level.
48
Amputation length should not be determined by proximal ipsilateral fractures. All proximal fractures should be
stabilized before patient transport for
potential salvage of optimum residual
limb length.49 Antibiotic beads should
be considered in heavily contaminated,
deep wounds. Invasive mold infection
should be suspected in patients who
sustain high transfemoral amputations
while on foot patrol and have received
large volumes of blood transfusion
during resuscitation.50 These wounds
should be packed open with a topical
adjunct, such as Dakin solution (dilute
sodium hypochlorite solution).
Evacuation Care
Although the transport times between
echelons of care are predictably small,
the accepting surgeon should always
consider a repeat débridement after the
patient’s arrival at his or her facility.
The zone of injury, which may initially
have been limited, can rapidly declare
itself during transfer of the patient from
one treatment facility to another and
between serial procedures. The application of a negative-pressure wound
dressing should be at the discretion
of the surgeon and should be avoided
in complex, massive wounds in which
the seal would be difficult to maintain
(Figure 1). Otherwise, this dressing has
been shown to be not only feasible in an
intercontinental air evacuation system
but also preferred by both flight crews
and patients.
51
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
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