Advances in the treatment of lower extremity wounds applied to military casualties.

A review of six patients with severe lower extremity injuries (four of six with grade IIIB tibia fractures), resulting from combat in Somalia, was undertaken to identify patterns of injury, treatment, and problems unique to combat injuries. An AK-47 gunshot was the mechanism of injury in five of six patients. Muscle flaps were required in all patients (four pedicled muscle flaps and three free vascularized flaps), with five of six patients undergoing flap closure during the subacute phase. Ilizarov devices were used in three of four grade IIIB tibia fractures. Five major nerve injuries were identified in three of six patients. The ballistic effect of an AK-47 to the soft tissues of the extremity is not a high-energy wound as seen in civilian blunt trauma. Knowledge of ballistics and the delay in definitive flap coverage secondary to evacuation allowed definition of zones of injury and successful use of local flaps in the majority of our patients. The high number of nerve injuries not commonly described with blunt trauma may prevent full rehabilitation.