|Amputation for War Wounds (ICRC, 30 p.)|
Severe limb injury or traumatic amputation produces different levels of tissue damage within the limb; skin, fat and muscle have variable resilience to injury. The most striking example is the extreme form of compartment syndrome produced within the leg by antipersonnel mines (figure 2); skin may be preserved distal to the muscle damage. Therefore, the wound excision element of the primary amputation is complicated; it is not achieved by amputating through viable tissue as distal as possible. A guillotine amputation may not even fulfil the first operative objective.
*BE AWARE OF EXTENDING COMPARTMENTAL INJURY, ESPECIALLY IN THE ANTEROLATERAL COMPARTMENT OF THE LEG*
Antibiotic prophylaxis is an essential part of the management but does not allow for leaving dead or contaminated tissue on the stump. All patients admitted with open wounds to an ICRC hospital receive 5 millon units of benzyl penicillin intravenously; this antibiotic is the drug of choice because the more serious pathogens i.e. streptococci and clostridia, remain sensitive to it.
When there is a long delay in the patient reaching medical care, putrid wounds are common but clinical gas gangrene is rare (6) (figure 3). A common and dramatic syndrome is the fever, confusion and anaemia associated with infected wounds. This may be labelled toxaemia or septicaemia (7). It is rarely encountered outside war surgery and its lack of description in medical literature is due, not to its benign nature, but to the adverse conditions in which it arises. Incomplete excision of dead tissue at primary amputation results in the same syndrome and when overlooked, if not fatal, results in a higher amputation (figure 4).
*STUMP INFECTION IS VERY DANGEROUS*
Field tourniquets which have been applied to the proximal limb present the surgeon with a dilemma if they have been in place and completely occlusive for two hours or more. Does he release the tourniquet and risk renal failure from myoglobinaemia or does he amputate above the tourniquet? A reasonable guideline might be that if such a tourniquet has been in place for more than six hours, the limb should be amputated proximal to it. However, if less time has elapsed, the limb is still in danger; the surgeon should observe the patient carefully and be prepared to amputate at a later date.