Upper Extremity Coverage: Management of Combatrelated Soft Tissue Injury of the Upper Extremity

Extremity trauma has always been a demoralizing feature of warfare, and modern conflicts have seen even greater rates of extremity injuries.^1-5 Despite the progression of modern combat weaponry leading to the increased rate of extremity wounds, the fields of plastic, orthopedic, and vascular surgery have likewise progressed, leading to an overall decreased rate of extremity amputation with each major military conflict. The one exception to this generalization is the Vietnam War, which saw a dramatic increase in the destructive nature of high-velocity firearms, landmines, and booby-traps. These weapons along with increased patient survivability led to increasingly worse extremity injuries.^6,7 The introduction of body armor and improved medical evacuation capabilities were likely responsible for the increased survival as well as the increase in the amputation rates seen during the Vietnam War.^8,9 During Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF), despite another dramatic progression in the violence of modern weaponry, the major extremity amputation rate has little changed at between 7% and 10% for all combat casualties with extremity injuries who were unable to return to duty within 72 hours of injury.^8,10 This is in large part due to the continued advancement of battlefield medicine, body armor, and limb salvage surgery. Additionally, the ability to provide safe, vascularized wound coverage in the form of rotational, pedicled, and free tissue transfer in the subacute or late time periods are likely responsible for maintaining the current limb salvage rates.^11-14.