|Amputation for War Wounds (ICRC, 30 p.)|
In hospitals of the International Committee of the Red Cross (ICRC) surgical amputation of lower and upper limbs at every level is common. Many of the severe limb injuries and traumatic amputations result from antipersonnel mines which, in modern warfare, are widely used and remain after the conflict (1) (figure 1).
Failure to appreciate the disparities between amputation in war surgery and civilian practice results in unhealed stumps, bone exposure and serial proximal amputations; these are the most disheartening aspects of working in a hospital for war injured. These complications arise from the dilemma of having to amputate according to war surgery principles but with only civilian techniques at hand; the pathology and variation of the injuries may render these techniques inappropriate.
*AMPUTATION FOR WAR WOUNDS IS DIFFICULT AND DIFFERENT*
The three objectives of primary amputation for war wounds, in order of priority, are:
i) to excise dead and contaminated tissue;
ii) to be able to perform delayed primary closure;
iii) to leave a stump that is acceptable for fitting a prosthesis i.e. preparation of the wounded part for a new function.
A primary amputation for war wounds which achieves all three objectives avoids complications.
*THE AMPUTATION MUST INCLUDE ALL DEAD, CONTAMINATED AND CONTUSED TISSUE*
This review is aimed at the civilian surgeon with little experience of war wounds; it is intended to rationalize and facilitate surgical amputation for war wounds, whether immediate or after attempted limb salvage. The Medical Division of the ICRC feels that this review is justified for three reasons: first, the ICRC surgeons treat a large number of war wounded; second, the same surgeons receive prompt feedback about their techniques because, in contrast to military surgeons, the patients remain under their care; third, standard texts give peripheral and inconsistent advice about primary amputation (2-5).
Any surgeon who treats war wounded must recognise that some cultures take a different view of limb amputation (6). The patients may prefer a useless limb to a functioning prosthesis, whilst others may prefer to die from their wounds rather than suffer amputation. Such views must be accepted and accomodated in decision making.