Initial management of upper extremity war injuries

Upper extremity war injuries are complex wounds that include a combination of bone, soft-tissue, and vascular injury, and nerve loss. Treatment begins in theater with initial wound care and provisional skeletal stabilization. Once in the continental United States at a tertiary-care facility, the wounds are further debrided, and definitive treatment is initiated. Definitive treatment involves a multidisciplinary approach to treat all associated injuries. After serial debridement and irrigation to remove all devitalized tissue and contamination, a coordinated plan is made for skeletal stabilization and definitive closure or soft-tissue coverage. Options for skeletal fixation include open reduction internal fixation, external fixation, intramedullary nailing, and cement spacer placement with delayed bone grafting for segmental bone loss. Soft-tissue coverage options include delayed primary closure, dermal substitutes, skin grafting, rotational flaps, pedicled flaps, and free flaps. Treatment decisions are dictated by injury location, size of wounds, and donor site availability. Associated nerve injuries often present with large segmental defects and cannot be repaired acutely. Treatment requires delayed autograft reconstruction, with or without nerve conduits.