CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 422, pp. 88–96

© 2004 Lippincott Williams & Wilkins

Treatment of the Mangled Lower Extremity after a

Terrorist Blast Injury
Michael J. Langworthy, MD*; Jeffrey M. Smith, MD†; and Mark Gould, MD*

Terrorist bombings, with resultant blast injuries, have been
increasing in frequency during the past 30 years. Injury to
the musculoskeletal system is common in victims who survive
such attacks. Substantial injury to the limbs may occur
through several different mechanisms, each of which may
affect prognosis and alter the treatment algorithm. An analy-
sis of the available literature on terrorism and blast events
revealed that resource use of the treating medical facility is
high during the initial hours after a blast attack, but usually
is manageable. A resource management protocol was devel-
oped to organize the treatment of limb salvage into four
phases. This management protocol may improve the medical
facility’s ability to manage system resources while treating
patients with severe blast injuries. The decision of whether to
salvage or proceed with limb amputation is one of the most
difficult in orthopaedic trauma. A basic education in the
mechanisms of blast damage, a methodical approach to re-
suscitation, and mangled extremity treatment, likely can im-
prove surgical success.
Injuries caused by terrorist bombings have taken place
with increasing frequency since the fall of the Berlin Wall.
Terrorist bombing campaigns have changed constantly in
response to organized policy changes such as formal coun-
terterrorism programs and increased security measures.21
One certainty is that the frequency of terrorist attacks and
the amount of casualties they generate have increased in
magnitude. An analysis of the literature concerning terror-
ist bombings was done to assess the mechanics of blast
phenomena and the musculoskeletal patterns of injury af-
ter a blast attack, and also to examine existing limb sal-
vage treatment protocols.
From the *Naval Medical Center San Diego, San Diego, CA; and the †Uni-
versity of California, San Diego, CA.
The authors did not receive outside funding, payments or other benefits from
a commercial entity.
The views expressed in this paper are those of the authors and do not reflect
the official policy or position of the Department of the Navy, the Department
of Defense, or the United States Government.
Correspondence to: CDR Michael J. Langworthy, MD, Naval Medical Cen-
ter San Diego, 34800 Bob Wilson Drive, Suite 112, San Diego, CA 92134-
1112. Phone: 619-532-8429; Fax: 619-532-8467; E-mail: lcdrlang@aol.com.
DOI: 10.1097/01.blo.0000129558.38803.c2
Although blast attacks can generate large numbers of
fatalities and injuries, most survivors are not wounded
severely and require only outpatient treatment.5,9,15,21,32,34
There is a small subset of patients after a blast attack who
will have injuries that may be life-threatening, limb-
threatening, or both.5,9,15,21,32,34 Our review of terrorist
blast attacks revealed that the treating institutions after a
blast terrorist attack seldom are overwhelmed in dealing
with life-threatening and limb-threatening trauma, and that
resuscitation and limb salvage procedures can proceed in a
methodical and timely manner. We used preexisting limb
salvage algorithms to synthesize a resource management
protocol termed the Balboa Blast Treatment Protocol. This
protocol details the ABCDs of resuscitation and wound
treatment in blast victims. Institutional resource use will
be outlined against this protocol template and its mechan-
ics will comprise a large segment of the discussion.
Examination of the available literature on clinical blast
experience reveals that, after a blast, there are different
patterns of injury for open air bombings versus bombings
in confined spaces.5,9,14,l5,21,32–34 Terrorist blast attacks on
buildings with subsequent structural failure also lead to
unique patterns of injury.5,14,l5,21,31,32,34 Victims generally
are taken to the hospital nearest the vicinity of the blast
attack.14,15,21,27,32,34 Data from Europe and Southwest
Asia indicate that a disorganized medical response may be
associated with unnecessarily higher rates of morbidity
and mortality.9,27,31,32,34 Trauma surgeons are faced with
victims who have sustained moderate to severe trauma and
have to use available resources wisely. With judicious use
of resources early in the period after the blast, aggressive
and methodical treatment of the mangled extremity may be
done without compromising the principles of limb salvage
treatment.
DISCUSSION
Injuries caused by explosions may be organized into sev-
eral groups.9,11,15 Primary blast injury occurs because of
the direct impact of the shock front and primary blast wave
on the extremity tissues. Secondary blast injury occurs

88
Number 422
May 2004
because of projectile penetration of the extremity tissue.
Tertiary blast injury occurs when the victim is thrown into
motion, and tissue damage occurs from the sudden accel-
eration followed by deceleration into a wall, a floor, or
another object. A miscellaneous category makes up the
fourth category, which includes burns and crush-type in-
juries that result from the damage to buildings or other
structures.
The current blast classification scheme is useful for
categorizing the mechanism of blast injury. However, it is
not useful as a guide to resuscitation or as a guide to soft
tissue or skeletal treatment. A mangled extremity from a
primary blast injury usually will denote a much higher
kinetic energy impact on the tissues than either missile
penetration or crush injury.15,21,23,24,33 Traumatic amputa-
tions are the most dramatic and serious injuries to the
musculoskeletal system, and occur in 1–3% of victims.21,24
Traumatic amputations from primary blast phenomena
are the most frequent mechanisms of limb amputation, and
are caused by the direct effect of shock waves. The waves
become coupled to the limb tissue and run along the long
bones, creating a powerful shearing force that acts in a
coaxial direction relative to the bone. The long bone frac-
tures into multiple fragments (comminution) and then the
flailing remnant limb soft tissue is avulsed by the ensuing
primary blast wave.23 Mellor and Cooper36 concluded that
traumatic limb amputation from a primary blast phenom-
enon carried a grave systemic prognosis. They reported on
52 victims, of whom only nine survived. Hull and Coop-
er24 and Hull23 examined the pathoanatomy of the result-
ant primary blast pattern and determined, through cadaver
and animal studies, that the prevalence of traumatic am-
putation was at the level of the tibial tuberosity in lower
extremity amputations, and through the more distal portion
of the upper extremity. Traumatic amputation seldom oc-
curred through a joint.
Secondary blast injury from debris fragments, shrapnel,
or bomb casings also can be a cause for the mangled
extremity, but this is a less frequent mechanism of ampu-
tation than primary blast injury. Fragments with sufficient
mass and velocity can strike the musculoskeletal tissue and
impart crushing and lacerating damage to the limb.23
Crush injuries also can result in traumatic amputation of
the extremity after a blast attack, with subsequent damage
to the limb from building debris. We were unable to locate
any case reports on limb reattachment or replantation after
traumatic blast amputations.
The physical destruction within tissue and along limbs
predominantly is dependent on the amount of total energy
transferred and subsequent energy released per unit length
of wound.9 An examination of the destruction generated
by penetrating projectiles reveals that damage along the
wound tract depends on numerous variables. The preim-
Terrorist Blast Injury 89
pact velocity and mass of the projectile account for the
total energy and are represented as 1/2MV.23 Other vari-
ables that affect the energy transfer to tissues include: the
drag and aerodynamic properties of the projectile before
impact, the inherent tissue resistance to penetration, the
fragility of the projectile once it has entered the tissue, and
the drag and tendency of the projectile to shimmy after
tissue penetration.9,23
Experimentally, it has been shown that missiles pos-
sessing irregular shapes have inherent ballistic instability,
and tend to deposit greater proportions of the total preim-
pact kinetic energy more rapidly and with greater tissue
destruction than symmetric missiles.9,12
During the past 30 years, the trauma community has
seen improvements in surgical techniques and our under-
standing of musculoskeletal trauma.38 Blast victims who
have sustained severely traumatized limbs with vascular
and nerve injuries may be candidates for limb salvage once
resuscitation criteria have been met. The medical treat-
ment of a blast victim with a mangled extremity begins
with the fundamental goals to save the patient’s life and to
maximize patient function through either limb salvage or
amputation.
Posttraumatic treatment of general trauma victims with
a mangled extremity is often broken down into periods of
resuscitation and extremity treatment.7 In our analysis of
terrorism events and blast injuries we considered the gen-
eration of polycasualties and the difference in the patho-
physiology of a blast-induced extremity wound and an
extremity wound caused by blunt force trauma. We have
organized this approach in the development of the Balboa
Blast Treatment Protocol: (A) acute resuscitation (1–4
hours); (B) bone stabilization (1–72 hours); (C) coverage
(3–7 days); and (D) disability treatment (after 7 days).
The A phase begins with the primary survey. An at-
tempt is made to identify life-threatening conditions and
begin their treatment. Airway, breathing, and circulation
are addressed during this phase. Resuscitation is most
critical during the first 4 hours but remains ongoing as
deemed necessary.
Hypovolemia in a victim with a mangled extremity ne-
cessitates a rapid determination whether its cause is from
thoracic or abdominal bleeding, heart pump failure, or
exsanguinations from wounds. Neck vein distention likely
denotes pump failure, whereas collapsed neck veins indi-
cate hypovolemia. Resuscitation during this period is
aimed at restoration and maintenance of adequate cerebral
perfusion.48
The B phase begins once vital hemodynamic functions
and organs have been addressed. Diagnostic studies and
treatment protocols dealing with potentially life-
threatening injuries are handled during this time. Limb
ischemia from systemic causes already should have been

90 Langworthy et al
addressed. Localized ischemia of the mangled extremity
from vascular insufficiency is assessed and treated during
this phase. Open fractures and dislocations are treated with
irrigation and debridement, and fracture stabilization is
done during this phase.45,46 This phase is likely the most
important iatrogenic determinant of the success of limb
salvage.39,45–49,50,53 Methodical and competent wound
treatment can be done with simple tools if surgical prin-
ciples are respected. External fixation can be applied to
provide en route stabilization before transfer to definitive
care institutions if the initial treating facility is not set up
for long-term limb salvage treatment. Depending on the
specific bone injury and the associated injuries, fracture
reconstruction may be provisional or definitive.
The C phase includes wound closure and/or coverage
and definitive bony stabilization. Controlled debridement
and wound treatment is done temporally and pathoana-
tomically. Blast wounds should not be closed or covered
primarily. Peripheral thrombosis can occur as many as 72
hours after the index injury and early primary closure has
been reported to correlate with a high incidence of infec-
tion.5,9–11,21,24
Conversion of external fixation to intramedullary bony
stabilization may be done during this time if appropriate.
Decisions regarding the timing and execution of flaps
should occur within this 3- to 7-day period. Investigations
have shown that there is an increased infection rate in
wounds closed before 3 days and after 7 days if a bead
pouch has not been used.13,26,44 If the blast event has
occurred in a geographic location that does not provide
adequate free tissue transfer expertise, then transfer to a
tertiary care institution that does have reconstructive sup-
port services must be done. It is during this phase that the
blast wound pathophysiology may totally manifest and a
decision regarding delayed secondary amputation versus
continued limb salvage may need to be made.
The D phase begins soon after definitive extremity cov-
erage has been obtained and may last as many as 2 years.
This phase deals with the definitive surgical procedures
being done to accomplish bone union, limb length and
alignment, and other functional improvements for the sal-
vaged limb.8,18,35,40,52 Rehabilitation of the patient will be
done during this phase. This may include neuromuscular
education and edema control in the salvaged limb or pros-
thetic fitting and gait education after limb amputation.
Resource Use
Anxiety and manpower use of the treating facility are
highest during the acute resuscitation phase. Resource use
such as use of operating rooms, consumable orthopaedic
equipment, radiography, and hospital beds, peaks during
the bone stabilization phase. Logistically, the coverage and
disability treatment phases begin days after the event. If
Clinical Orthopaedics
and Related Research
the original treating medical facility does not have the
resources for long-term limb salvage, then transfer to an-
other facility is recommended. The initial tools for pres-
ervation of life and limb are simple during the first two
phases of the blast treatment protocol and become much
more sophisticated in the last two phases.
Limb Salvage
The goal of limb salvage in the mangled extremity is to
provide a sensate plantar area of the foot with sufficient
motor power to make the limb useful. Limb salvage is a
highly equipment-dependent type of procedure with spe-
cial tables, instruments, imaging machines, and implants
or external fixators being required. Operative strategies
need to be planned. However, the initial debridement can
be done with simple instruments at the initial treating fa-
cility with subsequent transfer to a definitive care facility
that specializes in long-term limb salvage. The initial pro-
cedure is without a doubt the most important determinant
in achieving a successful outcome in limb salvage surgery.
Gustilo and Anderson20 evaluated 1025 open fractures
of long bones in an attempt to prevent infection. They
classified the soft tissue component of these injuries to one
of three categories. A Type I injury was a fracture of the
long bone with a laceration less than 1 cm, with minimal
soft tissue damage and no gross contamination. A Type II
injury was one in which the soft tissue laceration was 1 cm
with moderate soft tissue damage. A Type III injury was
divided into subtypes A, B, and C. A Type III-A injury had
extensive soft tissue injury but the bone could be covered
adequately. A Type II-B injury not only had extensive soft
tissue injury but also had periosteal stripping and the bone
could be covered adequately. A Type III-C injury was one
in which there was extensive soft tissue damage and the
need for arterial repair. Although potentially useful for
predicting prognosis, the grading of blast injuries is not
critical to their treatment. It is the understanding that pa-
tients with blast injuries frequently have more occult tissue
damage than is apparent at the first debridement. Accurate
grading of the mangled extremity is difficult even with
assessment and classification schemes. Brumback and
Jones6 reported approximately a 60% interobserver agree-
ment when using the Gustilo and Anderson classification
of open fractures. The Lower Extremity Assessment Proj-
ect (LEAP) has shown that existing classifications do not
correlate with clinical outcome.11 The findings of the
LEAP study suggest that there is no significant difference
in outcomes between patients who have reconstruction or
amputation after severe trauma to the lower extremity.
Rather, there are several variables that predict worse out-
come regardless of injury characteristics and most treat-
ment decisions.
Number 422
May 2004
None of the scoring tools have included blast victims as
part of their study population. The key decision on wheth-
er to proceed with limb salvage or limb amputation will
require clinical judgment and the understanding that every
case is unique. Factors such as comorbid trauma and
shock, comorbid medical conditions, age, limb ischemia
time, plantar sensation, and muscle viability all are impor-
tant factors, but they do not correspond to a particular limb
salvage algorithm. Coincident chest and abdominal hollow
and solid viscous injury may preclude limb salvage, espe-
cially if there is a corresponding vascular injury. Age may
not be a contraindication to limb salvage, but with increas-
ing age there is an increased chance of a comorbid medical
condition such as diabetes, which subsequently can reduce
the success of attempted limb salvage. Muscle viability
generally is assessed easily with blast injury, but noncon-
fluent hemorrhage in the dermis and overlying skin with
blast injury and crush injury denotes an area that may or
may not remain viable. Unless the posterior tibial nerve is
inspected physically and transected, prediction of the final
sensibility of the sole of the foot is almost impossible after
a blast injury.
Consultation with senior surgeons, vascular surgeons,
and plastic surgeons is strongly advocated and often is
beneficial, but may not always be available.12 We recom-
mend that mangled extremity treatment be evaluated on a
case by case basis and that the surgeon’s technical skill,
clinical judgment, and available primary and secondary
referral resources be the primary guides in choosing limb
salvage or amputation.
Initial Wound Treatment
Once the wound has been assessed in the triage area, our
treatment recommendations include simple lavage of the
wounds with saline from liter bottles over a large recep-
tacle, followed by sterile dressings with Kerlix (Tyco
Healthcare Group, Mansfield, MA) soaked in 0.9 normal
saline or less than half-strength Betadine (Purdue Freder-
ick, Stamford, CT) for exposed tissues. Avoiding the use
of circumferential or elastic bandages where possible may
be prudent so as not to constrict the extremity. A photo-
graph or a drawing of the wound should be placed in the
medical record. The wound should not be hidden from the
patient. Often, the patient better understands the reason for
amputation if he or she has been allowed to see the wound.
Once the sterile dressings have been placed, they should
not be removed until the patient is in the operating envi-
ronment for definitive debridement.
Patient evaluation and resuscitation should continue
throughout this process. Initial treatment of the patient and
the wound are important factors in optimizing the body’s
chemotactic response to the wound and mobilization of the
inflammatory response. Supplemental oxygen to aid wound
Terrorist Blast Injury 91
perfusion can optimize the patient’s natural immune mec-
hanism in dealing with foreign pathogens.41 By hydrating,
treating anxiety and pain with analgesics, and keeping
the patient warm, wound perfusion will be enhanced. Once
the patient is hemodynamically stable, radiographic ex-
amination of known and suspected sites of trauma should
be done.
Antibiotics and Tetanus
Open fractures generally are contaminated, or at least
colonized, at the time of presentation.44 The normal skin
flora includes streptococcus, staphylococcus, and coliform
bacteria. Clostridium tetani and Clostridium perfringens
are gram-positive rods that frequently are found in the soil
and may be blown into the wound. Primary and secondary
blast trauma wounds may not manifest the entire zone of
the injury to the limb for the first 72 hours.5,33 Infection
will develop unless necrotic tissue is debrided adequately
and the remaining tissue is irrigated thoroughly. This is the
most important factor in the attainment of a good result in
the treatment of these open fractures. Empiric antibiotic
coverage for open fractures should be initiated as soon as
the open injury is recognized. Patzakis et al43 showed an
infection rate of 13.9% in patients who received no anti-
biotics, a 9.7% incidence of infection in patients who re-
ceived only penicillin, and a 2.3% incidence in patients
who received Cephalthin (Keflin). Patzakis et al42 did a
prospective, randomized, double-blind study comparing
single-agent antibiotic therapy with ciprofloxacin, with
combination therapy consisting of cefamandole and gen-
tamicin in all types of open fractures. One hundred sixty-
three patients were enrolled during a 20-month period with
171 open fractures being treated. The infection rates for
Type I, Type II, and Type III open fractures were calcu-
lated. The infection rates for Type I and Type II open
fractures in the ciprofloxacin group were 5.8% and 6% in
the combination therapy group. The infection rates for
Type III open fractures for the ciprofloxacin group were
31% versus 7.7% for the combination therapy group.42
Because of the delayed nature in which blast wounds may
manifest disease, we think it is reasonable to proceed with
combination antibiotic therapy in which a cephalosporin
with an aminoglycoside or a synthetic penicillin with an
aminoglycoside is used in treating open fractures from
blast phenomena. The addition of ampicillin or penicillin
should be considered in wounds with gross contamination.
The use of all three antibiotics for the first 24–48 hours
is appropriate in almost all of these injuries, except in the
rare circumstance where antibiotic supply is limited. Dis-
continuation of the aminoglycoside and penicillin usually
is based on the establishment of a stable wound, whereas
discontinuation of the broad-spectrum cephalosporin oc-
curs 24–48 hours after wound closure or coverage.
 Clinical Orthopaedics
92 Langworthy et al and Related Research

Tetanus prophylaxis depends on the available history of

tetanus immunization, and the available supply of tetanus
toxoid and immune globulin. The supply usually is not
limited, and patients with an uncertain history are given
both. However, in a mass casualty situation or if supply is
limited, prioritization first should go to wounds that are
greater than 24 hours old at initial presentation, followed
by wounds with greatest contamination, or soft tissue in-
jury, or both.

Operative Debridement and Stabilization

Once the patient has been hydrated adequately, is com-
fortable, is receiving supplemental oxygen, and antibiotics
and tetanus have been administered, formal surgical de-
bridement may proceed.
Because of the possibility of barotrauma to the lungs Fig 1. The photograph shows the medial aspect of a blast
and viscus organs after a blast injury, a regional or spinal wound 72 hours after a terrorist blast attack injured this victim.
anesthetic can be used in place of positive-pressure general The remote location of the blast location led to a delay in
anesthetic agents. A proximal limb tourniquet should be treatment.
placed but not inflated. The splint and dressing are taken
down, and the extremity is examined again for perfusion. the injured limb.41 Debridement of the blast injury wound
When time and resources allow for salvage of a limb with should be done serially and frequently until the identifi-
a vascular injury, an angiogram is done at this time in the cation and removal of all nonviable tissue has been
operating room. After gross debris, such as clothing, is achieved, and each debridement usually should err on the
removed from the wound, the patient’s extremity then is side of debriding marginal tissue.
prepared and draped.
Primary and secondary blast injuries with skeletal in- Irrigant
volvement typically have a zone of soft tissue injury that Isotonic solution should be used for irrigation. Ideally, a
is larger than the area of the fracture. Often, there is a low pressure pulse lavage with less than 70 psi with a
central zone of necrotic tissue surrounded by a zone with pulsation rate less than 1050 pulsations per minute is used
marginal stasis. All contaminated, necrotic tissue and and seems to be effective in removing bacteria from soft
minimal wound margins must be excised. Our preference tissues.19 There are isolated reports of high pressure lavage
is to start the debridement at the 12 o’clock position of the generating intramedullary bacterial contaminant seed-
wound, and proceed in a methodical and clockwise man-
ner from known tissue planes into the damaged tissue. The
initial injury generally creates a soft tissue shock wave that
produces severe soft tissue stripping. This damage may not
be appreciated unless extensile incisions are made. These
incisions should be made along the longitudinal axis of the
limb. Even modest-sized wounds in blast injuries may re-
veal extensive soft tissue stripping and deep foreign body
contamination once the extensile incisions give proper ex-
posure of the wound (Figs 1,2).
Necrotic muscle, fat, fascia, tendon, and skin all must
be removed. Muscle is tested for viability (the four Cs:
contractility, consistency, color, and the capacity to bleed).
A common error that occurs during initial debridement is
underestimating the amount of muscle damage. Local va-
soconstriction, thrombocyte clotting, and complement ac-
tivation will have occurred at the wound surface. There are
Fig 2. This photograph shows the lateral aspect of the leg in
no controlled studies to date that favor therapeutic strate- the same victim. The muscle is completely necrotic, and there
gies that inhibit peripheral wound thrombosis. Stasis and is confluent hemorrhage in the dermis and epidermis, which
retained nonviable tissue decrease phagocyte function in denotes the complete nonviability of the area.
Number 422
May 2004
ing.1,3 Infection and nonunion rates also seem to improve
with adequate lavage under low pressures.
Cultures
Specimens for culture are no longer thought to be useful
for guiding antibiotic prophylaxis in open fractures.
Should the extremity become infected later, cultures at that
time will be specific for the organism. Covey and Peter-
son10 reported that Pseudomonas was the most frequent
pathogen infecting amputations in patients who had pri-
mary closure.
Vascular Compromise
Once initial debridement and irrigation have been com-
pleted in an extremity with vascular compromise, the or-
thopaedic surgeon and the vascular surgeon must coordi-
nate the sequence of bone stabilization and reconstitution
of limb perfusion.48,50,51 In some cases, collateral flow
produces enough perfusion to allow skeletal fixation be-
fore arterial repair. Direct arterial repair rarely is done
before fracture stabilization, because attempts at fracture
reduction can damage the repair. If flow must be restored
immediately, then a shunt can be used to restore perfusion
distal to the arterial lesion. Once fracture stabilization has
been accomplished, exploration of the zone of injury and
direct repair of the vessel may be done. In the calf, the
arterial trifurcation is tethered to the interosseous mem-
brane and frequently is the site of occlusion. The more
distal the arterial repair, the higher the secondary ampu-
tation rate. Secondary amputation rates for the mangled
extremity with vascular injury and subsequent repair ap-
proaches 60–80%.20
Potential for vascular repair and limb salvage are based
on the feasibility of later definitive fracture repair, the
overall soft tissue injury, the associated foot injuries, the
patient’s associated injuries and the available resources for
vascular repair. Mass casualties will require the implemen-
tation of triage strategies.30 Because the number of survi-
vors from these terrorist attacks is hard to predict, initial
resources can be directed to treatment of wounds in limbs
that are clearly salvageable. Once resources begin to be
stressed, patients with questionable limb viability may
need to undergo amputation if stabilization and transport
to an alternate facility are not possible.
Reconstruction for vascular injuries usually is done
with a reverse saphenous vein graft with subsequent fas-
ciotomy of the extremity being done to prevent compart-
ment syndrome during the reperfusion phase. Changes to
the capillary endothelium may be seen after only 3 hours
of limb ischemia, with resultant postischemic swelling of
the soft tissue. Irreversible muscle damage likely occurs
after 6 hours of warm limb ischemia time, and irreversible
nerve damage occurs after 12 hours.37,48
Terrorist Blast Injury 93
Bone Stabilization
Skeletal stabilization techniques are based on which bone
is injured, the location of injury, and the degree of soft
tissue injury. Articular involvement needs to be fixed as
accurately as possible,2,25 but may need to be done at
secondary procedures. Mechanical stability of the fracture
fragments is a primary principle in obtaining osseous im-
munity and wound healing. Worlock54 investigated osteo-
myelitis rates with stable versus unstable fixation and re-
ported that the infection rate almost doubled in the un-
stable group. Fracture stabilization with intramedullary
nailing of open Grades I to IIIA diaphyseal fractures has
shown acceptably low rates of infection. However, exter-
nal fixation is the treatment of choice for most blast inju-
ries, primarily because the amount of bone and soft tissue
viability often is overestimated and contamination is un-
derestimated. This leads to the retention of necrotic or
contaminated material, which is harder to see and debride
with intramedullary fixation in place. External fixation
also may be applied without the use of radiography. Span-
ning of pathologic tissue or involved joints may be done
with subsequent return to the operating room and defini-
tive fixation after the soft tissue disorders have been ad-
dressed. Staged external fixation followed by intramedul-
lary nailing may be done if the time to conversion is short,
such as less than 7–10 days.24
Antibiotic Bead Pouch
Once the soft tissue debridement, bony stabilization, and
reperfusion of the extremity have been completed, then
consideration may be given to the addition of an antibiotic
bead pouch. Henry et al22 reported on the overall results of
845 open fractures treated with systemic antibiotics versus
systemic antibiotics with an antibiotic bead pouch. The
infection rate with just systemic antibiotics was 12%. With
a combination of systemic antibiotics and a bead pouch,
the infection rate was reduced substantially to 3.7%. Keat-
ing et al28 and Kelly et al29 reported a 16% deep infection
rate in open tibias treated without a bead pouch and 4%
with open injuries treated with an antibiotic bead pouch.
The antibiotic bead pouch can be added to span osseous
defects and to provide a local depository of antibiotics. By
placing the bead pouch in the osseous defects, a space is
left for subsequent bone grafting. The bead pouch gener-
ates local antibiotic concentration levels that are 10–20
times higher than those achieved with systemic antibiotic
infusion alone.28 The side effects from this practice seem
to be low. The disadvantage of using a bead pouch is that
a foreign body is left within the soft tissue space, which
may require another operation for removal. There also is
the theoretical possibility of generating resistant organ-
isms. Studies that have analyzed the geometric configura-
tion of beads versus spacer blocks have shown that beads

94 Langworthy et al
elute antibiotics more readily than spacers, smaller beads
elute better than larger beads, and tobramycin elutes more
readily than vancomycin.17,28,29
There is controversy over whether vancomycin should
be added to the initial bead pouch because of the possi-
bility of creating resistant organisms. The use of vanco-
mycin probably should be discouraged unless an organism
has been identified in the wound that is sensitive only to
vancomycin. A typical bead pouch construct has been out-
lined in Table 1.
The tobramycin and cement are hand mixed. In 3–4
minutes, the cement cures to a consistency that allows it to
be rolled into 6-mm to 8-mm balls, which then can be
skewered with a stainless steel wire. The ends of the wire
are looped so that the beads do not slip. Once the beads
harden, they may be placed into the soft tissue or bone
defect. The number of beads should be recorded to assist
with subsequent removal.
Ioban (3M Health Care, St Paul, MN) then is wrapped
over the wound to achieve a good seal. The Ioban is per-
meable to oxygen, so it allows for aerobic wound metabo-
lism. The Ioban and the wound are not drained. The local
concentrations of antibiotics are allowed to elute from the
beads. The maximum concentration occurs at 3 days, but
effective killing concentrations last as many as 3 weeks.28
With blast injury treatment, the bead pouch usually is ex-
changed in the operating room every 48 hours, or until the
soft tissues and bone have shown the extent of their injury.
Wound Closure
Mangled extremity wounds and fasciotomies should be
left open after the index surgical debridement. Surgical
wounds that were created for exposure may be closed if
they do not create tension. The tremendous energy that is
imparted by a blast wound likely warrants routine fasci-
otomy and compartment release. This likely would give
already damaged muscle the best chance of surviving.
Routine fasciotomy in blast victims also should be seen as
a resource management technique. If the fasciotomy is
done at the index surgery, then compartment pressures are
one less thing to monitor in an already stressed environ-
ment.
Wound desiccation must be prevented. Exposed ten-
dons should be covered with adjacent soft tissue if pos-
sible. Ioban is a better temporary dressing than sponges
TABLE 1. Antibiotic Bead Pouch Construction
24-Gauge wire 20 inches long
One package (40 g) methylmethacrylate
Tobramycin (powder) 1.2–3.6 g
Ioban
Clinical Orthopaedics
and Related Research
soaked in isotonic saline. Alternatively, wound vacuum-
assisted closure might be effective in many of these
wounds.
Repeat irrigation and debridements should be done ev-
ery 24–48 hours until all necrotic or pathologic tissue is
eliminated. Primary blast wounds may continue to un-
dergo peripheral thrombosis for as many as 72 hours after
the blast event. Closure of the wound or wound flap cov-
erage after a blast injury ideally is done within 5–7 days.
This allows for complete expression of the zone of injury.
The soft tissue reconstruction ladder consists of possible
delayed primary closure, split-thickness skin graft, local
flap, or free flap.
Amputation versus Salvage
After a blast injury, the surgeon may be confronted with a
mangled extremity that is so damaged about the soft tissue
envelope that salvage, even with an intact arterial supply,
is questionable. The best example of this situation would
be a mangled extremity with a disrupted posterior tibial
nerve with ipsilateral foot trauma. Lange31 proposed a
decision tree for amputation in patients with lower extrem-
ity trauma based on absolute and relative criteria. Absolute
indications for amputation were a limb ischemia time
greater than 6 hours, and, if after anatomic inspection, the
tibial nerve has been disrupted completely. His relative
indications for amputation of the lower extremity were
polytrauma that precluded attempted limb salvage and se-
vere ipsilateral foot trauma. Anticipated protracted soft
tissue and osseous reconstruction should not be considered
as a sole reason for amputation.
Even with amputations the soft tissue injury usually is
more important than the bone injury. If a decision has been
made for primary amputation, it is important to spare vi-
able skin and soft tissue, even if they do not follow classic
patterns for surgical amputation.16 Usually, the first pro-
cedure involves amputation of the nonsalvageable part and
routine debridement and irrigation of the remaining limb.
Gentle partial closure can be considered if the sutures are
nonconstricting to the remaining tissue. Ultimately, clo-
sure of the amputation will depend on the stability of the
tissues. A durable supple soft tissue envelope that is not
adherent or scarred to bone often is just as important to
maintenance of bone length.16
Foot
If the forefoot is damaged, then consideration should be
given to a short transmetatarsal amputation rather than
relying on scarred forefoot soft tissue that will be painful.
If the hindfoot is damaged, then a below-the-knee ampu-
tation done at the musculotendinous junction will perform
better than a salvaged but scarred hindfoot pad. Midtarsal
amputations probably should be avoided because there fre-
Number 422
May 2004
quently is a muscle imbalance with resultant equinus de-
formity.
Ankle
If there is sufficient posterior skin and a patent posterior
tibialis artery, then a Syme’s amputation through a two-
stage technique may be appropriate for some patients.52
The first operation involves the disarticulation of the
ankle, with careful sharp subperiosteal dissection to pre-
serve the mechanical integrity of the heel pad. Inadvertent
penetration of the fluid-filled compression chambers
makes the weightbearing purpose of this flap unusable.
The cartilage cap of the plafond is left in place initially to
avoid bacterial seeding of cancellous bone. Once the risk
of infection is minimized, the second stage of the proce-
dure may be completed with the removal of retained car-
tilage, malleoli, and metaphyseal flare. Anchoring of the
Achilles tendon is mandatory to stabilize the heel pad in
place under the tibia.52 The average shortening of the ex-
tremity after this procedure is 10 cm, and weightbearing is
possible on the stump end for short distances. An anterior
flap also is described for patients in whom there is insuf-
ficient heel pad.49,52
Tibia
As stated earlier, preservation of bone length is desirable if
not at the expense of producing a scarred or insensate
stump flap. There is biomechanical value in the longer
transtibial amputation.26,31,37,44,48 The distal 1⁄4 of the tibia
should not be amputated because there is no suitable soft
tissue padding, and this also limits the space for shock
absorbing components and elastic response components.26
Obtaining full knee extension is more important than ob-
taining full knee flexion.
Knee
The knee should be salvaged if possible. The energy re-
quirements for an above-the-knee amputation are twice as
high as those of a transtibial amputation.26,31,37,48 The
functional outcome and prosthetic use of a salvaged knee
depends on whether there is significant articular destruc-
tion, and also whether there is an intact quadriceps mecha-
nism. The longer lever arm balances the thigh musculature
and the prosthesis can be suspended from the femoral
condyles. A higher amputation in the supracondylar area is
warranted if the flap otherwise is likely to become scarred
and adherent. The cartilage covering the distal femur
should be left on at the index surgery to avoid bacterial
seeding of the metaphyseal bone. A myoplasty to the bone
can help with the retention of muscular function. A knee
disarticulation with a good soft tissue envelope was
thought to be better biomechanically than a transfemoral
amputation. However, the LEAP study has shown that
Terrorist Blast Injury 95
through-the-knee amputations were a predictor of poor
outcome based on the Sickness Impact Profile.4
Femur
The Grade IIIB and Grade IIIC open femur fracture ini-
tially should receive an external fixator for skeletal stabi-
lization. Arterial repair in the thigh usually does very well.
Every attempt should be made to preserve length. If the
sciatic nerve is intact, every effort should be made to sal-
vage the limb if the soft tissues are viable.
Surgical amputation for blast-induced extremity injury
traditionally has been done for the immediate preservation
of life during war. Recent domestic-directed and foreign-
directed terrorism has exposed the civilian and military
population to high-energy blast phenomena. Every effort
should be made to first save the patient’s life and then save
the limb. Experience has shown that limb salvage has in-
herent risk for continued morbidity and even mortality.
Recent quantitative scoring systems have not assisted the
trauma surgeon in accurately predicting the success of
limb salvage versus amputation. The critical decision-
making to determine whether to salvage a limb or to am-
putate still has to be made based on the surgeon’s clinical
judgment and experience, available resources, and the
presence of multiple survivors with lower extremity
trauma. The treatment of open wounds from blast-related
extremity trauma differs from the treatment of blunt
trauma of the lower extremity. Wound closure should most
likely not be attempted until after 72 hours have elapsed.
Closure earlier than 72 hours seems to have high subse-
quent infection rates. The hospital environment after a
terrorist blast attack is chaotic. A terrorist blast attack can
generate large numbers of fatalities and orthopaedic inju-
ries, but most of the survivors are not wounded severely
and likely can be treated on an outpatient basis. A minority
of surviving blast victims will have injuries that are life
threatening, limb threatening, or both. The hospital re-
sources and personnel are strained; however, with good
resource management and surgical technique, attempted
limb salvage of the mangled extremity can be done in a
methodical and principled manner. Application of the Bal-
boa Blast Protocol may improve the medical facility’s
ability to manage the system resources required to treat
patients with these severe injuries, especially if there are
multiple surviving blast victims.
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