The role of plastic surgeons in extremity reconstruction following mass casualty incidents

Abstract

Aim: Mass casualty incidents (MCIs) are a devastating source of morbidity and mortality, testing the infrastructure of acute care management and challenging the ability to reconstruct limbs. Herein, we look to further a discussion on upper and lower limb reconstruction following MCIs.

Methods: Review of the literature, including our institute’s experience with the 2013 Boston Marathon Bombings, the 2015-2016 Terror Attacks in Ankara, and the 2010 earthquake in Haiti, pertaining to extremity reconstruction following MCIs.

Results: The three aforementioned case profiles highlight extremity wounds associated with MCIs and the subsequent reconstructive role of plastic surgeons. Surgical intervention or temporization of extremity wounds is a critical responsibility of plastic surgeons in this setting. Limb salvage is possible and often the preferred option following disasters.

Conclusion: Intentional or naturally occurring MCIs are a grim reality. Successful response to these events requires prompt mobilization of emergency medical staff and hospital activation. Plastic surgeons play a paramount role in multidisciplinary management of trauma with a particularly important involvement in limb reconstruction.

Keywords

Upper extremity reconstruction / lower extremity reconstruction / mass casualty incidents / microsurgery

References

[1] Peleg K,Michael M.Patterns of injury in hospitalized terrorist victims..Am J Emerg Med2003;21:258-62

[2] Dussault MC,Osselton D.Blast injury and the human skeleton: an important emerging aspect of conflict-related trauma..J Forensic Sci2014;59:606-12

[3] Clover AJ,Redmond AD.The extent of soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response..World J Surg2014;38:2543-50

[4] Thakar HJ,Rohrich RJ.The role of the plastic surgeon in disaster relief..Plast Reconstr Surg2009;124:975-81

[5] Kolata G, Longman J, Pilon M. Doctors saved lives, if not legs, in Boston. The New York Times April 16, 2013. Retrieved August 28, 2015. Available from: http://www.nytimes.com/2013/04/17/us/physical-legacy-of-bomb-blasts-could-be-cruel-for-boston-marathon-victims.html. [Last accessed on 14 Jan 2019]

[6] Gates JD,Biddinger P,Burke P.The initial response to the Boston marathon bombing..Ann Surg2014;260:960-6 PMCID:PMC5531449

[7] Kim PS,Kirkham JC,Ibrahim AM.The Boston marathon bombings: the early plastic surgery experience of one Boston hospital..Plast Reconstr Surg2013;132:1351-63

[8] Caterson EJ,Weaver MJ.Boston bombings: a surgical view of lessons learned from combat casualty care and the applicability to Boston’s terrorist attack..J Craniofac Surg2013;24:1061-7

[9] İğde M.Plastic surgery management of victims of terrorist violence in Ankara, Turkey..Ann Plast Surg2017;79:600-5

[10] Clover AJ,Saeed W,Majumder S.Experience of an orthoplastic limb salvage team after the Haiti earthquake: analysis of caseload and early outcomes..Plast Reconstr Surg2013;127:2373-80

[11] Wolf Y,Mankuta D,Onn E.An earthquake disaster in Turkey: assessment of the need for plastic surgery services in a crisis intervention field hospital..Plast Reconstr Surg2001;107:163-8

[12] Gregory TM,Guigui P,Bouyer B.Terrorist attacks in Paris: surgical trauma experience in a referral center..Injury2016;47:2122-6

[13] Bosse MJ,Jones AL,Sims SH.The insensate foot following severe lower extremity trauma: an indication for amputation?.J Bone Joint Surg Am2005;87:2601-8

[14] Chunguang Z,Fuguo H,Yueming S.Characteristics of crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake..Emerg Med J2010;27:627-30

[15] Bosse MJ,Kellam JF,Webb LX.A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores..J Bone Joint Surg Am2001;83-A:3-14

[16] Barbier O,Choufani C,Ollat D.Surgical support during the terrorist attacks in Paris, November 13, 2015: experience at Bégin military teaching hospital..J Trauma Acute Care Surg2017;82:1122-8

[17] Bosse MJ,Kellam JF,Webb LX.An analysis of outcomes of reconstruction or amputation after leg-threatening injuries..N Engl J Med2002;347:1924-31

[18] Saddawi-Konefka D,Chung KC.A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia..Plast Reconstr Surg2008;122:1796-805 PMCID:PMC4410276

[19] Chung KC,Haase SC.A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures..Plast Reconstr Surg2009;124:1965-73 PMCID:PMC2788746

[20] Walsh NE.Rehabilitation of landmine victims--the ultimate challenge..Bull World Health Organ2003;81:665-70 PMCID:PMC2572531

[21] Yang C,Zhong HJ,Jiang DM.The epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake..Injury2009;40:488-92

[22] Harrison BL,Lee MR.Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report..Plast Reconstr Surg2013;132:591-6

[23] Parrett BM,Pribaz JJ.A review of local and regional flaps for distal leg reconstruction..J Reconstr Microsurg2009;25:445-55

[24] Griffin M,Malahias M,Juma A.Flap decisions and options in soft tissue coverage of the upper limb..Open Orthop J2014;8:409-14 PMCID:PMC4235084

[25] Choudry UH,Li S.Soft-tissue coverage of the elbow: an outcome analysis and reconstructive algorithm..Plast Reconstr Surg2007;119:1852-7

[26] Ho T,Carson K,Manley K.Radial forearm free flap donor site outcomes comparison by closure methods..Otolaryngol Head Neck Surg2006;134:309-15

[27] Rasheed MZ,Tan KC.The extended lower trapezius flap for the reconstruction of shoulder tip defects..Ann Plast Surg2009;63:184-7

[28] Pierce TD.Use of the pedicled latissimus muscle flap for upper-extremity reconstruction..J Am Acad of Orthop Surg2000;8:324-31

[29] Lee KT.A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer..Plast Reconstr Surg2014;134:303-14

[30] Sood A,Russo G.Functional latissimus dorsi transfer for upper-extremity reconstruction: a case report and review of the literature..Eplasty2017;17:51-63 PMCID:PMC5317028

[31] Ong YS.Lower limb salvage in trauma..Plast Reconstr Surg2010;125:582-8

[32] Kramers-de Quervain IA,Käch K,Stüssi E.Functional donor-site morbidity during level and uphill gait after a gastrocnemius or soleus muscle-flap procedure..J Bone and Joint Surg Am2001;83-A:239-46

[33] Sugg KB,Concannon MJ,Brown DL.The reverse superficial sural artery flap revisited for complex lower extremity and foot reconstruction..Plast Reconstr Surg Glob Open2015;3:1-9 PMCID:PMC4596444

[34] Pu LL.Further experience with the medial hemisoleus muscle flap for soft-tissue coverage of a tibial wound in the distal third of the leg..Plast Reconstr Surg2008;121:2024-8

[35] Follmar KE,Baumeister SP,Erdmann D.The distally based sural flap..Plast Reconstr Surg2007;119:58-62

[36] Yazar S,Lin YT,Wei FC.Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures..Plast Reconstr Surg2006;117:2468-75

[37] Derderian CA,Baux G,Gurtner GC.Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience..J Reconstr Microsurg2003;19:455-62

[38] Wang HT,Erdmann D.Use of the anterolateral thigh free flap for upper-extremity reconstruction..J Hand Surg2005;30:859-64

[39] Yildirim S,Aköz T.Soft-tissue reconstruction using a free anterolateral thigh flap: experience with 28 patients..Ann Plast Surg2003;51:37-44

[40] Kimura N,Hasumi T.Clinical application of the free thin anterolateral thigh flap in 31 consecutive patients..Plast Reconstr Surg2001;108:1197-208

[41] Meyer A,Schoengart E,Taeger CD.Results of combined vascular reconstruction by means of AV loops and free flap transfer in patients with soft tissue defects..J Plast Reconstr Aesthet Surg2016;69:545-53

[42] Chan JK,Williams G.Soft tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps..Plast Reconstr Surg2012;130:284-95e PMCID:PMC3408595

[43] Stranix JT,Jacoby A,Mirrer J.Forty years of lower extremity take-backs: flap type influences salvage outcomes..Plast Reconstr Surg2018;141:1282-7

[44] Sabino J,Tintle S,Fleming M.A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction..Plast Reconstr Surg2015;135:895-902

[45] Cho EH,Carney MJ,Bauder AR.Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis..Plast Reconstr Surg2018;141:191-9

[46] Godina M.Early microsurgical reconstruction of complex trauma of the extremities..Plast Reconstr Surg1986;78:285-92

[47] Qiu E,Ghaznavi AM.Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing..J Plast Surg Hand Surg2018;1-6:

[48] Gabriel A,Kirk J,Beck B.The Haiti earthquake: the provision of wound care for mass casualties utilizing negative-pressure wound therapy..Adv Skin Wound Care2011;24:456-62

[49] Prasarn ML,Kloen P.Management of the mangled extremity..Strategies Trauma Limb Reconstr2012;7:57-66 PMCID:PMC3535134

[50] Pinzur MS.Outcomes-oriented amputation surgery..Plast Reconstr Surg2011;127:241-7S