MSS07: SURGICAL STABILIZATION BY EXTERNAL FIXATION OF FRACTURES SUSTAINED IN COMBAT DURING THE GLOBAL WAR ON TERROR
Michael D Cobler-Lichter, MD1; Jessica M Delamater, MD, MPH1; Ana M Reyes, MD, MPH1; Talia R Arcieri, MD1; Jonathan D Stallings, PhD2; Vincente S Nelson, MD, LTC1; Nicholas Namias, MD, MBA, FACS1; Kirby R Gross, MD, COLret3; Shawn Boomsma, DO, MAJ4; Mark D Buzzelli, MD, COLret1; Jennifer Gurney, MD, COL2; Kenneth G Proctor, PhD1; Paul J Wetstein, MD, LTC1; 1Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, Florida, USA; 2Joint Trauma System, Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, TX; 3Division of Trauma Surgery, Department of Surgery, Cooper University Hospital, Camden, NJ; 4Department of Orthopedic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, Florida, USA
OBJECTIVES: Role 2 (R2) U.S. military treatment facilities (MTFs) provide far forward damage control resuscitation and surgery. Despite many configurations of R2 surgical teams, each service defines external fixation (EF) as a requisite skill. To inform planners of potential needs for future conflicts, this study describes EF utilization in recent past conflicts.
METHODS: The Department of Defense Trauma Registry (DoDTR) was retrospectively reviewed from 2003 to 2023. U.S. Military combat casualties who underwent EF at U.S. MTFs were included. Early EF was defined as first EF performed at R2, or Role 3 (R3) in cases of R2 bypass. Rate of early EF was compared between military operation and time period by stratifying patients into continuous 3-year intervals and comparing these groups with chi-squared tests.
RESULTS: 6,111 patients received 7,801 EFs. There were 2,600 U.S. casualties, 1,630 foreign civilians, 275 NATO military casualties, and 1,605 non-NATO military casualties. Patients were predominantly young (median age 25) males (97.0%). The dominant injury type was penetrating (69.4%), the most frequent mechanism was explosion (56.4%), and the median ISS was 11 (IQR 9-18). 19.0% of all EFs were placed at R2, 67.7% at Role 3 (R3), 5.4% at Role 4 (R4), and 7.8% at R4-Continental US (R4C) MTFs (Figure 1). 60 patients (2.3%) died after undergoing EF. 71.9% of EFs met the definition of early EF. The rate of early EF varied significantly with both time period and military operation, though remained high (range 66.6%-82.2% for time period, 70.7%-85.5% for military operation, p<0.001). 66.7% of EFs were of the lower extremity and 19.9% were of the upper extremity. At both R2 and R3 MTFs, the lower extremity was the predominant site (75.9% and 67.9% respectively) and external pelvic fixation was rarely performed (0.3% and 0.1%).
CONCLUSION: This is the first analysis of EF by role of care in two decades of counterinsurgency operations. In the military, EF is expected as part of the expeditionary scope of practice for general surgeons, a unique requirement for U.S.-trained general surgeons. EF is a common means for early extremity fixation, though pelvic fixation is rarely performed early, likely due to ease of pelvic binder use, and the expertise and equipment required for pelvic EF. Time to capability is a balance in any trauma system, though given 71.9% of EFs in military combat casualties were performed early, it is imperative to maintain orthopaedic expertise close to the point of injury.
