MICROSURGERY OF WAR

MICROSURGERY

HERIDA MANO
HERIDA CARA
HERIDA PIERNA
AMPUTACION

As Sergeant Surgeon to King Charles II, Richard Wiseman (1622-1676) was present at many of the battles of the Civil War and he described the war wounds as follows: " Wounds made by gun-shot are the most complicate sort of wounds that can be inflicted: For they are not only solution of continuity, but have joined with them contusion. Attrition, and dilaceration, in a high and vehement kind. To this we may add all sorts of fractures and accidents, as haemorrhagia, inflammation, erysipelas, gangrene, and sphacelus; besides the extraneous bodies which are violently carried into the wound, and multiply indications".
Still now the war wounds are the most complicated. The times have changed; today we have more powerful weapons (the worst of them the high velocity weapons); in the other hand we have the antibiotics, a more advanced orthopedic surgery and the microsurgery.

In Colombia we have faced almost a civil war; I would not be able to exactly define in what kind of war  we are living now. At the Military Hospital in Bogotá, we have to deal with war wounds caused mainly by: Fragmentation missiles (mortar, grenade shells), Solid missiles (low and high velocity bullets) and antipersonnel mines. With microsurgery we are able to transplant almost any kind of tissue to reconstruct difficult wounds, it is not an easy surgery but is the best way and some times the only way.
The ironic issue is: this kind of lesions are created by the man, the ethiology is the human being, so logically it would be easier to prevent them than prevent diseases like cancer. Probably men will find the way to prevent cancer but won't be able to stop the war.


CLINICAL CASE 1.
HIGH VELOCITY GUNSHOT WOUND IN THE FOREARM

HERIDA MANO DORSO

Preoperative picture: palmar view of the wound.

HERIDA PALMAR

Preoperative picture: dorsal view of the wound.

COGAJO

Picture of the free flap, in fact there are to flaps (latissimus dorsi and scapular) with one pedicle (subscapular vessels). The radial artery and comitant veins are used as recipient vessels; the latissimus dorsi muscle is used to cover the palm and the scapular skin the dorsum.

COLGAJO EN DORSO

Four month postoperative picture, palmar view. (Grafted Latissimus Dorsi muscle flap).

COLGAJO EN PALMA

Four month postoperative picture, dorsal view. (Scapular skin flap).


CLINICAL CASE Nº 2.

HERIDA Y AMPUTACION

Picture 1. Left leg amputation and open fracture of right leg. It is very important to save the right leg, in order to rehabilitate the patient. 

RX FRACTURA

Picture 2. X Rays of the exposed tibia and fibula fracture.

ANTIPERSONNEL MINE IN THE LEGS

COLGAJO PIERNA
Picture 3. Late operative picture. After soft tissue reconstruction and open fracture coverage with Latissimus dorsi free flap and skin grafts.
POP COLGAJO

Picture 4. Postoperative picture 4 months after surgery.


CLINICAL CASE Nº 3.


FRAGMENTATION MISSILE IN THE LOWER EXTREMITY

HERIDA GRANDE
Picture 1. Huge skin and muscle defect, with exposed tibia fracture and maleolar fracture.
COLGAJO LISTO
Picture 2. X Rays of the tibia fracture.
RX FRACTURA PIERNA
Picture 3. Latissimus dorsi free flap once it has been transferred, just before bone coverage.
COLGAJO PIERNA LISTO
Picture 4. Once the free flap has been completely sutured to cover both the tibia and maleolar fracture. The muscle is covered with skin grafts
COLGAJO POP
Picture 5. Five months postoperative picture.


CLINICAL CASE Nº 4.
HIGH VELOCITY GUNSHOT WOUND IN THE FACE

HERIDA CARA
Picture 1. Severe damage of soft tissues in the lateral aspect of the face. Destruction of skin, parotid gland, facial nerve, mandible, and zygoma.
TAC CARA
Picture 2. CT Scan shows the zygomatic arch and body destruction, mandible conminutive fracture with anterior displacement of the condile out of its place.
RX CARA
Picture 3. The zygoma body and zygomatic arch are reconstructed with a costal graft and AO microplates and screws. The mandible with an AO reconstruction plate from the condyle to the symphysis.
POP BASAL
Picture 4. The soft tissue defect was reconstructed with a parascupular free flap. The facial nerve was reconstructed with sural nerve grafts.
POP LATERAL
Picture 5. The zygoma is in acceptable position.


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