Page 11 - Journal of Special Operations Medicine - Spring 2015

Return to Duty

After Severe Bilateral Lower Extremity Trauma

Andrew J. Sheean, MD; Johnny Owens, BS, MPT; Sean Suttles, PT, DPT;
Brett W. Crossland, MS, CSCS; Daniel J. Stinner, MD

ABSTRACT
Despite the preponderance of evidence demonstrating combat­injured Soldiers with type III open tibia frac­
poor outcomes as a result of combat­related orthopaedic ture and severe hindfoot injury have been shown to be
3,4
trauma, teams of medical professionals have remained 20.5% and 26%, respectively. Thus, the scenario in
undaunted in their pursuit of innovative techniques to which a Servicemember with a severe lower extremity
maximize the functional capacity of Servicemembers injury is able to return to his preinjury functional status
with devastating extremity injuries. We present the case remains more of the exception than the rule.
of an Active Duty Special Forces (SF) qualified senior
noncommissioned officer (NCO) with severely injured Case Presentation
extremities successfully salvaged with a multidisciplinary
program involving cutting­edge prosthetic technol ogy A 40­year­old active SF NCO was injured while mounted
and a novel approach to physical rehabilitation. in an up­armored tactical vehicle by an improvised ex­
plosive device blast while serving in support of Opera­
Keywords: ankle fusion, outcomes, limb salvage, rehabilitation tion Iraqi Freedom in 2005. He was evacuated to Balad
Air Base, where he was found to have sustained the
following orthopaedic injuries: a closed left distal tibia
fracture (OTA 43­C3); a closed left proximal third tibia
Introduction
fracture (OTA 41­C3) (Figures 1 and 2); a closed right
The burden of lower extremity trauma among those distal tibia fracture (OTA 43­C3) (Figure 3); a closed left
involved in recent combat operations is well described, tongue­type calcaneus fracture; a closed left iliac crest
with 82% of casualties having sustained extremity inju­ fracture; and open third and fourth lumbar vertebral
ries. Fifty­three percent of these injuries were penetrat­ body compression fractures with associated spinous
ing soft tissue wounds and 26% of all extremity injuries process fractures. His nonorthopedic injuries included
involved fractures. Moreover, the majority of these traumatic brain injury and significant soft tissue defects
1,2
injuries were related to explosions, and it is these high­
energy mechanisms that frequently involved complex Figure 1 Anteroposterior (A) and lateral (B) radiographs of
soft tissue defects, comminuted fracture patterns, and the left tibia/fibula on presentation to SAMMC.
associated neurovascular injuries. As a result, the treat­ (A) (B)
ment of these injury patterns commonly involves an as­
sessment as to the ultimate viability of the injured limb,
as both amputation and limb salvage are often reason­
able treatment approaches.

For those patients treated with limb salvage, their clinical
course commonly involves multiple, planned procedures
to restore the soft tissue envelope and reapproximate os­
seous length, alignment, and rotation, as the final goal
can often not be achieved with a single surgery. Many
advances have been made in the treatment of these limb­
threatening injuries during the previous decade of con­
flict; however, functional outcomes such as return to
duty (RTD) remain low. In fact, the RTD rates among

1