Review Article
Early Management of Ballistic
Maj W. G. P. Eardley, MB ChB,
MSc, MRCS (Ed) RAMC
Col M. P. M. Stewart, MB ChB,
QHS, FRCS (Glas), FRCS
(Tr & Orth), L/RAMC
From the Academic Department of
Military Surgery and Trauma, Royal
Centre for Defence Medicine,
Birmingham, West Midlands, UK
(Dr. Eardley), and the Department of
Orthopaedics and Trauma, James
Cook University Hospital,
Middlesbrough, UK (Dr. Stewart).
Neither of the following authors nor
any immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Eardley and
Dr. Stewart.
The opinions or assertions
contained herein are the private
views of the authors and are not to
be construed as official or as
reflecting the views of the Ministry of
Defence or Her Majesty’s
government. The authors are
employees of the Ministry of
Defence. No grant funding was
received for this study.
J Am Acad Orthop Surg 2010;18:
118-126
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
118
Hand Trauma
Abstract
Complex hand wounds are an unfortunate consequence of conflict.
Increased battlefield survival rates have resulted in an evolving
range of ballistic hand trauma encountered by deployed surgical
teams, requiring increased knowledge and understanding of these
injuries. In the civilian setting, the combined threats of gun crime
and acts of terrorism warrant appreciation for such injury among all
surgeons. Surgeons often have to relearn the management of
ballistic hand trauma and other aspects of war surgery under
difficult circumstances because the experiences of their
predecessors may be forgotten. Current evidence regarding these
injuries is scarce. Ballistic hand trauma is rarely isolated. The
demand on surgical resources from combat injury is significant,
and it is imperative that a phased strategy be followed in this
setting. Minimal, accurate débridement and decompression with
early stability are crucial. Delayed primary closure and an
awareness of future reconstructive options are fundamental.
M odern battlefield survival rates
are increasing,1 and one conse-
quence is that deployed surgical teams
of injured coalition forces survived,
compared with 76.4% and 69.7% in
the Vietnam conflict and World War
are encountering an evolving range of II, respectively.1 There is a trend of
ballistic hand trauma. To achieve the increased extremity injury and a
best outcome following significant hand decrease in the ratio of gunshot
injury, military surgeons must be famil- wounds to fragmentation injuries. In
iar with the options available for assess- recent conflict, gunshot wounds ac-
ment, early temporizing, and definitive count for 18% of extremity injuries
treatment. The increase in acts of ter- and fragmentation for 78%.4
rorism and the rise of gun crime,2 The United States Joint Theater
however, require that civilian clini- Trauma Registry recorded 6,609
cians also acquire experience with combat wounds in Iraq and Afghani-
ballistic hand trauma. A hand that is stan from 2001 to 2005.5 Of the
permanently deformed in the after- 3,575 wounds to the extremities,
math of injury may have lifelong
53% involved the soft tissues. Frac-
negative consequences for the af- ture complicated 26% (915) of the
fected person.3 extremity injuries; 83% (758) of
these were open. There was an even
Patterns of Injury distribution of wounds with and
without fractures in the upper and
Ballistic wounding and combatant lower extremities. Fractures to the
survivability have evolved over time. hand constituted 36% of upper limb
In Operation Iraqi Freedom, 88.2% fractures and 18% of overall extrem-
Journal of the American Academy of Orthopaedic Surgeons
Maj W. G. P. Eardley, MB ChB, MSc, MRCS (Ed), RAMC, and Col M. P. M. Stewart, MB ChB, QHS, FRCS (Glas), FRCS (Tr &Orth), L/RAMC
ity injuries; 87% of the hand frac-
tures were open. The impact of hand
trauma on attrition of combat troops
is significant, accounting for 15% of
troops evacuated to the United States
in World War II.6 In a recent conflict,
60% of wounding to the upper limb
occurred in the wrist and hand.7
Ballistic trauma wounds rarely
present in isolation, nor do the inju-
ries commonly involve one system.
The seriously injured hand in this
circumstance may be afforded a
lower surgical priority while life-
threatening hemorrhage is arrested.
Hand injuries that would ordinarily
demand emergent dedicated surgical
attention are often subject to signifi-
cant delay unless the surgical team
can be configured in terms of staffing
levels and skill set to address this is-
sue.
Two studies3,8 discussed hand in-
jury in the Vietnam conflict in terms
of energy transfer, staged surgical
strategy, prompt decompression of
hematoma, and the significance of
carpal tunnel release. The authors
highlighted the importance of de-
layed primary closure of wounds and
the impact of rapid evacuation on
combat casualty survival. A strategy
of minimal, accurate sharp dissection
and removal of contaminants with
retention of tissues of doubtful via-
bility for assessment at subsequent
procedures is similarly encouraged
by Fackler and Burkhalter.9
Elton and Bouzard10 describe bal-
listic injuries to the metacarpus, em-
phasizing adequacy of débridement
and the use of Kirschner wires (K-
wires) in the stabilization of frac-
tures, corroborated by subsequent
experience in the Balkans conflict.11
The achievement of early, temporiz-
ing bony stability of the metacarpals
before the definitive procedure with
optimum alignment, apposition, and
rotation is encouraged. Retaining
metacarpal length is desirable; how-
February 2010, Vol 18, No 2
ever, Elton and Bouzard10 state that
heroic efforts to restore normal
length do not seem justified.
Metcalf12 identified the debilitating
effect on the hand resulting not only
from direct wounds but also second-
ary to proximal peripheral nerve le-
sions in World War I. Awareness of
this effect is fundamental and appli-
cable to current practice, and serial
clinical examination and awareness
of wounding patterns help prevent
proximal nerve injury from being
overlooked.
Anatomy and
Biomechanics
An awareness of the biomechanical
properties of the hand and functional
capacity following injury is crucial
for planning surgical and rehabilita-
tion strategies.13 A functioning hand
may be described as one comprising
a stable wrist joint and at least two
sensate, pain-free digits that can
achieve opposition.14 The hand has
four functional units: the opposable
thumb, the index and long fingers,
the ring and small fingers, and the
wrist. Prehension, the ability to grasp
and manipulate objects, may be pos-
sible even if only two sensate, mobile
digits remain.
Moran and Berger14 note that it is
the degree to which the hand adopts
the basic maneuvers of pinch, grip,
and grasp postoperatively that de-
fines ultimate outcome. In regard to
amputation, a recommendation for
early removal of the digit is made
when four of the six basic compo-
nents (ie, bone, joint, skin, tendon,
nerve, vessel) of the finger or thumb
are injured. Reconstructing a se-
verely damaged digit may result in a
chronically stiff and painful finger
that impedes, rather than improves,
hand function. It should be stressed
that although amputation of a digit
may improve ultimate function, re-
solving this dilemma is for the recon-
structing surgeon. At the first proce-
dure, retention of digits of doubtful
ultimate function is encouraged be-
cause they may serve as sources of
skin cover elsewhere in the hand in a
later procedure.
Retention of the thumb is the
greatest priority because of the
thumb’s unique ability to circumduct
and oppose. Loss of the thumb may
reduce hand function by more than
half. Second to the thumb in impor-
tance is the index finger, with its role
in precision and directional grip as
well as its extension independence.14
Loss of the index finger affects over-
all hand strength and leads to a 20%
decrease in power grip, key pinch,
and supination strength.15 Although
salvaging a damaged index finger is
desirable, heroic attempts may not
be warranted because an impaired
index finger is usually bypassed in
favor of an intact middle finger.16
The middle finger is often recruited
when the index is compromised, and
its position allows it to participate in
both power and precision grips. The
little finger, while contributing little
to overall power, plays an important
role in digitopalmar grip because of
the mobility of its carpal-metacarpal
joint. Highlighting the discrete con-
tribution of each digit to overall
hand function and the subject of de-
bate engendered when digit salvage
is in question, the little finger is con-
sidered by some to have the greatest
functional role after the thumb.17
Principles of Early
Surgery
Assessment and Initial
Management
Ballistic injury rarely affects the hand
alone. Because multiple injuries to
the extremities constitute 60% of
surgical cases, thorough assessment
is essential.18 In transfer from a for-
119
Early Management of Ballistic Hand Trauma
Figure 1
Photographs of a close-range gunshot wound to the hand demonstrating
entry, with tattooing from gunpowder (A), and exit (B) wounding.
ward facility, the hand should be
dressed and immobilized with the
wrist extended, the metacarpopha-
langeal (MCP) joints flexed, and the
proximal and distal interphalangeal
(IP) joints extended.13 Intravenous
antibiotics and analgesia are admin-
istered, and tetanus status is ad-
dressed. The cause of injury should
be defined, although this is often dif-
ficult to do. An indication of the en-
ergy transfer and extent of bony and
soft-tissue compromise to be ex-
pected is gained from radiographs of
the injured limb taken in two planes,
with the addition of an oblique view
when possible.
Ballistic wounding is often dis-
cussed in terms of cavitation and en-
ergy.19 This is related to the construc-
tion of the projectile, its velocity, and
how it interacts with the soft tissue
in its path. Most important, how-
ever, the extent of damage occurring
as a result of ballistic injury is depen-
dent on how the projectile behaves
when it encounters bone and soft tis-
sue—its deformation. This is a valu-
able concept in the global apprecia-
tion of the nature of war wounds
and guides early surgery. This con-
cept, however, is not uniform for ev-
ery wound throughout the body, and
120
misconceptions of the pathophysiol-
ogy of ballistic injury arise as a re-
sult.20
Although awareness of the patho-
physiology of war wounding is fun-
damental, those who manage hand
trauma must be mindful of hand-
specific considerations. Cavitation in
the hand may be less evident than in
other sites because of a shortened,
narrow wound track.9 The hand con-
tains a dense concentration of struc-
tures vital to upper limb function
that may be compromised by over-
zealous initial débridement beyond
obvious contamination and nonvia-
ble tissue (Figure 1).
Augmented by radiographs, a clini-
cal survey of the extent of injury aids
surgical decision making. The ulnar
nerve is tested by function of the first
dorsal interosseous muscle and the
extent of sensation in the ulnar bor-
der of the little finger. Power in the
abductor pollicis brevis indicates an
intact recurrent median nerve. Test-
ing extension at the IP and MCP
thumb joints and thumb abduction
establishes continuity of the poste-
rior interosseous nerve. Combined
with a simple light-touch assessment
with the patient’s eyes closed, this
examination allows a rapid overview
Journal of the American Academy of Orthopaedic Surgeons
of function. Assessment of skin color,
skin loss, capillary refill, wound
contamination, and finger cascade
should be performed in comparison
with the uninjured limb. The pattern
of skin loss is relevant to the orienta-
tion of potential skin flaps. An in-
creased level of suspicion should al-
ways prevail in the assessment of
ballistic wounds with regard to the
presence of occult injury to more
proximal neurovascular structures.
Kleinert and Williams21 note that
mutilating hand injuries must be ad-
dressed promptly and with exacting
technique. As with all hand injuries,
a prime consideration is maximum
preservation of function. Correction
of compromised circulation is ur-
gent. Realignment of partially sev-
ered digits, splintage, and elevation
for transfer are recommended. Be-
cause of the risk of ischemia from
rapidly accumulating edema and
hematoma, prompt surgical inter-
vention should be considered.21 The
apparent decompression of hand
wounds resulting from open frac-
tures does not preclude the develop-
ment of hand compartment syn-
drome. Hand fasciotomy may still be
required because multiple compart-
ments are vulnerable to edema and
hematoma.
Diffuse leakage of fluid from dam-
aged capillary beds is a major hazard
in hand injuries and may result in is-
chemia in an area distant from a
compartment already decompressed
by an associated open fracture.22 The
impact of the general condition of
the patient must be considered in the
context of preventing early complica-
tions, such as increasing compart-
ment pressures. Not only are injured
persons often obtunded during pre-
sentation and postoperative care,23
but their delay to treatment also may
be considerable. Both of these factors
may contribute to difficulty in injury
assessment and an increased risk of
early complications. Battlefield expe-
Maj W. G. P. Eardley, MB ChB, MSc, MRCS (Ed), RAMC, and Col M. P. M. Stewart, MB ChB, QHS, FRCS (Glas), FRCS (Tr &Orth), L/RAMC
rience has demonstrated that emer-
gent generous fasciotomy incorpo-
rating carpal tunnel decompression
is crucial in extensive injury of the
hand and forearm.13
With regard to infection risk, in par-
ticular tetanus vulnerability, wounds
may be stratified by extent of contam-
ination, time to débridement, and an-
tibiotic administration. The high-risk
wound group includes all ballistic hand
trauma and requires cover with tetanus
immunoglobulin for those with ques-
tionable immunity. A booster is given
to those whose immunization status is
known.24
Antibiotic administration in ballistic
wounding is recommended in addition
to thorough débridement and meticu-
lous wound care. Delay in antibiotic ad-
ministration and in initial débridement
can each significantly increase the in-
fection rates of war wounds.25 Early
administration of cephalosporin is
advised for prophylactic monother-
apy, continued for a maximum of 3
days. The routine use of prophylactic
gram-negative cover is not recom-
mended unless the patient has com-
plicating injuries, such as penetrating
abdominal trauma. In cases of pro-
longed evacuation, the use of oral
quinolones is recommended because
of the ease of administration in an
austere environment. By the stage of
reconstructive surgery (ie, 5 to 7
days from injury), clinically evident
infection is managed according to
sensitivities. For routine prophylax-
is during reconstructive procedures,
first-generation cephalosporin is used
at induction and continued for a
maximum of 24 hours.
These recommendations must be
seen in their context of rapid evacua-
tion of the injured to emergency
medical care.24 When treating refu-
gees, the recommendations of the In-
ternational Committee of the Red
Cross (ICRC) are intravenous peni-
cillin for 48 hours and then oral ther-
apy until delayed primary closure,
February 2010, Vol 18, No 2
with a total of 5 days of coverage.26
A patient who presents with wounds
after 72 hours or with injuries result-
ing from land mines receives addi-
tional metronidazole for a similar
duration.
Several classification systems have
been devised for ballistic injury and
wounds to the hand. The evacuation
chain is dynamic, and consistency in
record keeping and wound classifica-
tion is vital. Simple systems are best.
The ICRC system focuses on six fea-
tures of the injury: E (entry), the
maximum diameter of the entry
wound in centimeters; X (exit), the
maximum diameter of the exit
wound in centimeters; C (cavity), the
presence of cavitation sufficient to
accept two gloved fingers on explo-
ration; F (fracture), the presence of
an associated fracture; V (vital struc-
ture), injury to structures such as the
brain, viscera, and major vessels; and
M (metallic body), the presence of
retained ballistic material.27
The continuous data of the wound
measurements should be recorded,
along with the presence or absence
of associated injury or retained frag-
ments. Although this system has lim-
itations, the intent is to consider the
wounds as surgical entities rather
than weaponry phenomena, an ap-
proach that aids in communication
and reproducibility in the investiga-
tion of outcomes. We recommend
the use of the ICRC system aug-
mented with the notation of skin
loss, palmar skin viability, bone loss,
joint destruction, and nerve and ten-
don compromise.
Surgical Management
The surgeon who initially manages a
wound of the hand largely deter-
mines the subsequent course of
events for that injury. Initial surgery
in hand trauma is conservative;
Brown28 observed that “the hand
contains little that can be sacrificed
without significant consequence.”
Churchill29 in 1944 introduced the
notion of a staged surgical strategy for
managing the ballistically injured hand,
establishing the requirement for an ini-
tial procedure and subsequent second
examination as standard care. Current
conflicts may provide distinctive chal-
lenges in the management of the war-
wounded hand, but the principle of a
staged surgical strategy remains para-
mount. The pattern of injury in these
conflicts has not been dissimilar to that
reported in other counterinsurgency
wars, in which 60% to 70% of wounds
are to the extremities and 70% to 80%
of wounds are inflicted by explosive
and fragmentation weapons.30 Such
wounds are multiple and complex,
the result of any combination of
avulsion, laceration, blast, and crush
that tears and shreds tissues; all are
compounded by heavy contamina-
tion with dirt and debris driven deep
into the tissues (Figure 2).
Overall surgical management may
be dictated by life-threatening inju-
ries, and the hand may be given a
lower priority for treatment. Our ex-
perience has highlighted the need to
buy time for the injured hand, to
have staff with expertise in hand sur-
gery present at the initial procedure,
and to maintain awareness of the
principles of reconstructive surgery
throughout. It is not uncommon for
the injured person to have sustained
traumatic amputations to one or
each lower limb and complex injury
to one or each hand. When a func-
tioning hand or hands will be crucial
to successful rehabilitation of injured
lower limbs, there is no compromise
in treatment, and the wounded hand
is afforded greater priority. When an
estimated 2 hours or more of
damage-control surgery of the ab-
dominal cavity or a lower limb sur-
gery is anticipated, we use a team of
three surgeons, one of whom has ex-
pertise in the hand and operates
solely on the injured hand.
121
Early Management of Ballistic Hand Trauma
Figure 2
Oblique radiograph (A) and clinical photographs (B and C) of a hand with fragmentation injury.
Figure 3
Intraoperative photograph of
débridement of a hand wound with
the use of a “flossing” technique
with simple dressing gauze.
Initial Surgery
The initial procedure for a ballistic
wound is an opportunity to preserve
and protect vital structures, restore
viability, and prevent sepsis. The
pressure of evolving hematoma
should be relieved, contaminants re-
moved, and vital structures inspect-
ed.8 The importance of the initial
procedure cannot be overstated.
Kleinert and Williams21 advise that
the first operation should conserve
all living tissue and should be per-
122
formed with the goal of obtaining
maximum function with as few sec-
ondary procedures as possible be-
cause “later reconstruction cannot
compensate for the poorly planned
and executed first procedure.”
For surgery, the patient is anesthe-
tized and placed supine on the oper-
ating table with an arm board at-
tached. A large bowl is used to aid in
cleaning, which involves removal of
grease and dirt, trimming the finger-
nails, and cleansing the undamaged
skin. Blood loss is minimized by use
of a padded pneumatic tourniquet,
which, depending on the level of the
lesion, may be placed over the distal
forearm. Elevation is preferred to ex-
sanguination before application of
the tourniquet. After the initial
cleaning, all gloves, drapes, and
equipment used in the cleaning are
discarded, and the surgical team and
the patient are reprepped and tow-
eled appropriately. The limb is fur-
ther prepared with iodoform or chlor-
hexidine disinfecting agents. The
wound is then copiously irrigated
with warmed 0.9% saline solution in
preparation for débridement.
The history of débridement is well
reported;31 the term (from the French
Journal of the American Academy of Orthopaedic Surgeons
débrider, to unbridle) was associat-
ed with observations that injured tis-
sue within constricting fascial com-
partments becomes compromised
through expansion, ischemia, and
necrosis. This idea was pursued by
Depage, a Belgian military surgeon
of World War I and a key figure in
developing this most vital facet of
wound care, progressing from simple
incision to exploration and excision
of devitalized tissue and contami-
nants.32
Débridement should be adequate
but not excessive; retaining tissue of
marginal viability for reassessment at
the next stage of surgery is recom-
mended33 (Figure 3). As noted by
Brown,28 débridement of ballistic
wounds of the hand has a dual pur-
pose: to remove from the wound
anything that may be detrimental to
healing, without damaging intact or
salvageable parts, and to decompress
the wounded area.
The War Injury Committee recom-
mends minimal skin débridement,
generous fascial incisions, excision of
all nonviable muscle, and preserva-
tion of bone and periosteum when
possible.6 Arterial injury is assessed,
and hematomas are decompressed.
Maj W. G. P. Eardley, MB ChB, MSc, MRCS (Ed), RAMC, and Col M. P. M. Stewart, MB ChB, QHS, FRCS (Glas), FRCS (Tr &Orth), L/RAMC
Frayed tendon ends are trimmed
smooth and preserved. Nerves in the
vicinity of wounds are carefully in-
spected and their condition noted.
Careful tagging and approximation
with a fine suture of the nerve ends
to the soft tissue of the palm is ad-
vised.34 Early skeletal stabilization is
beneficial when it can be achieved,
although it can be done at the next
surgical visit. Additional incisions
are made for carpal tunnel release
and decompression of muscular com-
partments. Caution should prevail in
creating fasciotomy incisions so as
not to compromise surgical ap-
proaches or flap coverage that may
be required later. Diligent attention
to hemostasis with the tourniquet re-
leased marks the end of initial sur-
gery.
Under the protocol of delayed pri-
mary closure (DPC), all wounds are
left open. The hand is dressed with a
nonadherent base layer, and bulky,
fine absorbent gauze is applied. The
forearm and hand are splinted with a
below-elbow backslab in the posi-
tion of function, with the wrist be-
tween 30° and 60° of extension and
the MCP joints in 70° of flexion with
the IP joint in extension, thus keep-
ing the ligamentous structures under
tension with the intention of mini-
mizing contractures.35
Postoperatively, the limb is ele-
vated and antibiotics are continued.
Dressings are left undisturbed until
the patient returns to the operating
room for the next phase of treat-
ment. The only indications for inter-
vention between these times are un-
explained increasing pain and heavy,
continual staining, or odorous drain-
age, in which case the wound is im-
mediately examined under anesthesia
as an emergency.
Reparative Surgery
Reparative surgery, also referred to
as delayed primary surgery, is per-
formed 3 to 5 days following the ini-
February 2010, Vol 18, No 2
tial procedure. This phase includes
reassessment of the wound with re-
gard to tissue viability, allowing for
further débridement if indicated. It is
an opportunity to obtain skeletal
alignment and stability, nerve repair,
and DPC. Because of the evacuation
chain, this phase may be performed
by a different surgical team. Thus, it
is imperative to keep clear records,
including injury classification.
An important part of injury man-
agement is the use of “spare parts”
in the later, reconstructive proce-
dure.36 Tissues that are nonfunc-
tional but viable should be retained
because they may provide valuable
soft-tissue and bone grafting options.
There is an opportunity to preserve
tissues that may prove to be valu-
able, such as innervated palmar skin
for reconstructive surgery.3
Skeletal stabilization is achieved
primarily by 1.1- or 1.6-mm K-wire
fixation.11 Fracture reduction and
stabilization help control pain, limit
the extent of “dead space” within a
wound, inhibit infection, and allow
for hand therapy to progress with a
greater intensity. Skeletal stability is
the foundation for subsequent recon-
struction, and obtaining this during
the second procedure affords the sur-
geon increased dedicated surgical
time in a physiologically more opti-
mized patient. Stability may also be
afforded by external fixators.37 In
dire circumstances, this can be
achieved with multiple K-wires and a
syringe barrel (Figure 4). Following
stabilization of the bony architecture
and further débridement as required,
DPC of wounds may be possible.
The balance between early closure
with associated septic complications
and late closure that may lead to
scarring and contractures should be
appreciated; this balance forms the
basis for modern wound care.38
Closure of all surgical wounds is
performed at reparative surgery ei-
ther directly or with local, regional,
Figure 4
Clinical photograph of a gunshot
wound to the hand temporarily
stabilized with the use of
rudimentary external fixation with
Kirschner wires and a syringe
barrel.
or distant flaps augmented with skin
grafting, as required (Figure 5). Fine
drains may be placed in the wound
and then removed, as appropriate.
Staged management of ballistic hand
injuries during the Vietnam conflict
demonstrated the success of this ap-
proach.3,8,39 The timing of delayed
closure is not uniform; if at a second
examination the wound is still con-
taminated, closure is delayed another
48 hours. How quickly combat hand
wounds are closed is less important
than ensuring that they stay closed
and heal without infection. Recent
developments in wound care include
the application of negative-pressure
wound therapy. Advantages of this
approach include potential improve-
ment in wound healing, optimization
of the potential recipient grafting
bed, and a decrease in both wound
surface area and overall duration of
therapy.40 The authors have used this
approach both in the pre- and post-
application phases of split-thickness
skin grafting to the hand (Figure 6).
Reconstructive Surgery
The objective of early, staged man-
agement of hand wounds is to pro-
duce a noninfected, stable environ-
ment suitable for definitive closure
or reconstruction with bone, tendon,
or nerve grafting, depending on the
123
Early Management of Ballistic Hand Trauma
Figure 5
Metacarpal fractures associated with fragmentation injury stabilized with
Kirschner wires. A, AP radiograph demonstrating wire placement. B, Clinical
photograph following initial débridement and stabilization, demonstrating
significant dorsal skin loss. C, Photograph of radial forearm flap used to
afford cover for skin loss following satisfactory débridement.
situation. This stage of surgical inter-
vention occurs around 7 to 10 days
following the original injury. Defini-
tive reconstruction is done at the ear-
liest point possible, although the ulti-
mate outcome of such reconstruction
depends primarily on the success of
the initial emergency treatment de-
scribed previously.
Robust data regarding timing of skin
coverage and definitive reconstruction
in the upper limb are lacking. Accurate
débridement and proper temporary
wound closure with a reasonable delay
in flap coverage, however, have been
noted to provide a better chance of de-
finitive success compared with a rushed
earlier procedure.41 The complex na-
124
ture of the definitive reconstructive
options available in ballistic hand
trauma is beyond the scope of this
paper.
Rehabilitation
The process of rehabilitation and
splinting associated with reconstruc-
tive surgery similarly takes place
away from the conflict zone, al-
though it is essential that the initial
treating surgeon be aware of the im-
portance of rehabilitation of ballistic
injuries. Complications from extrem-
ity injury must be anticipated, and it
is essential that clinicians and thera-
Journal of the American Academy of Orthopaedic Surgeons
pists have an awareness of the fea-
tures of neuropathic pain and the im-
portance of secondary deformity
following proximal nerve injury. Per-
sistent pain and joint contractures
threaten the outcome of any inter-
vention regardless of its technical
complexity. A thorough understand-
ing of the pathophysiology of neuro-
pathic pain and a sensitive approach
to dynamic and static splinting and
to physiotherapy make an optimal
outcome more likely.
Hand injury rehabilitation passes
through several phases: early (pro-
tective), intermediate (mobilization),
and late (strengthening). Through
graduated exposure to activities of
daily living, the patient works to re-
gain as much preinjury activity as
possible.42 The number of upper limb
ballistic injuries requiring hand ther-
apy has increased.43 The require-
ments of modern combat casualties
in regard to reintegration into the
armed forces and the community as
a whole have changed with the ad-
vent of modern prostheses, raising is-
sues of care on the part of those co-
ordinating occupational services.44
The need for expansion of such ser-
vices is apparent in light of the close
relationship between warfare, ad-
vances in physical therapy, and the
genesis of the specialty of hand sur-
gery itself.45 The psychological im-
pact of severe hand injury in combat
must be addressed in addition to the
hand therapy needs of the individual.
The functional result gained through
surgical intervention and therapy is
heavily influenced by early, skillful
intervention that may prevent psy-
chological sequelae.46
Summary
Ballistic hand trauma is encountered
by military and civilian medical staff
either acutely or in encounters with
casualties repatriated from theaters
Maj W. G. P. Eardley, MB ChB, MSc, MRCS (Ed), RAMC, and Col M. P. M. Stewart, MB ChB, QHS, FRCS (Glas), FRCS (Tr &Orth), L/RAMC

Figure 6
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