Surgical management of a gunshot comminuted forearm fracture with distal major vessel injury in a field hospital

INTRODUCTION

Modern armed conflicts, characterized by the widespread use of explosive ordnance, have led to a significant increase in the proportion of severe, combined, and complex injuries to the musculoskeletal system. A particularly prominent place in the structure of combat surgical trauma is occupied by mine-explosive injuries to the extremities. These are often accompanied by partial or complete avulsion of the limb, extensive soft tissue defects, comminuted fractures, and critical damage to major vessels [1][2]. According to an analysis of the casualty structure during the special military operation, the most complex and prognostically unfavorable are limb injuries involving damage to major vessels and nerves, placing the highest demands on the system of staged treatment and medical evacuation [3][4].

The critical importance of limb salvage in cases of near-complete traumatic avulsion complicated by vascular insufficiency extends beyond clinical to profound socio-psychological outcomes. Successful revascularization preserves function, prevents disability, and significantly improves the post-injury quality of life in a predominantly young, working-age patient population [5][6]. Historically, starting with the first successful limb replantation performed 64 years ago, microsurgical and reconstructive techniques have become the gold standard in such situations [6]. However, the implementation of these methods in a military field hospital, at the stage of qualified or specialized medical care, is associated with a number of extreme factors: limited resources, the continuous influx of wounded, and the need for rapid decision-making within the framework of the “damage control” concept (Damage Control Surgery) [7][8].

Ischemia resulting from major arterial trauma is the critical factor determining limb viability. The time to restoration of adequate blood flow directly correlates with the risk of irreversible necrobiotic changes and subsequent amputation [9][10]. In combat trauma, complicated by massive wound contamination and extensive zones of primary and secondary necrosis, the choice of revascularization method is critically important. Traditional approaches, such as primary vessel suture or autovenous bypass grafting, require adaptation to the realities of military field surgery [9][10]. Cases with an extended arterial defect present particular difficulty, necessitating the use of a vascular graft, most often an autologous vein [5][9]. The choice of donor site (most commonly the great saphenous vein of the leg) and the harvesting technique must take into account the overall condition of the wounded patient, the presence of concomitant injuries, and the potential risk of infectious complications [7].

Current publications based on experience in the Special Military Operation zone are actively addressing issues related to the organization of surgical care, injury pattern analysis, and the application of new technologies. These include military external fixation kits (MEFK) for fracture stabilization and negative pressure wound therapy systems [1][4][7][11]. However, each clinical case of severe incomplete limb avulsion, particularly of the upper limb, with successful restoration of blood flow in field conditions, represents a unique experience requiring detailed analysis of the tactical and technical decisions made. This allows for the refinement of clinical recommendations and action algorithms for surgeons working at forward stages of medical evacuation [12][13].

The presented article, based on a detailed analysis of a clinical case of a mine-explosive injury to the left upper extremity with near-complete avulsion of the hand and critical ischemia, analyzes the comprehensive surgical approach implemented in a Level 2 military field hospital. Particular attention is paid to the multidisciplinary consultative decision, which combined the principles of “damage control” (massive primary surgical debridement of the wound, external fixation using a MEFK) with the performance of a microsurgical revascularization operation — autovenous grafting of the radial artery using a reversed great saphenous vein from the leg. This analysis contributes to the development of limb salvage tactics for severe combat injuries and supplements current understanding of the possibilities of reconstructive surgery at the early stages of care in an armed conflict.

CASE DESCRIPTION

A 38-year-old serviceman sustained a mine-explosive injury to the left upper extremity due to a shell explosion during a combat mission in the Special Military Operation zone. Subsequently, hemorrhage developed from the wound, and the serviceman self-applied a tourniquet to his upper arm. He was then evacuated and hospitalized at a Level 2 military field hospital (separate medical detachment) 2 h after the injury.

Upon admission, the patient was alert (Glasgow Coma Scale score 15). The condition according to the military field surgery (MFS) scales:

• MFS-I (Military Field Surgery — Injury) — 2 points — severe injury;
• MFS-SA (Military Field Surgery — State after Admission) — 13 points — moderate condition.

Complaints. Pain in the wound area, numbness and lack of sensation in the left hand.

Local status of the left upper extremity. The left hand is cold and cyanotic. Palpation of the hand is painless; sensation is absent. In the middle third of the left forearm, there is an extensive soft tissue defect with the presence of foreign bodies and bone fragments. Upon loosening the tourniquet, there is no hemorrhage. Pathological mobility is present in the projection of the wound (indicating a fracture of the radius and ulna). The hand is connected to the forearm by a small skin flap on the medial surface of the forearm and the soft tissues on the lateral surface of the forearm. Muscle and tendon ruptures, as well as ruptures of the neurovascular bundles, are visualized in the wound (Fig. 1).

Radiography of the left upper extremity revealed multiple foreign bodies (metal fragments), comminuted fractures involving diaphysis of the radius and ulna (Fig. 2).

Complete Blood Count. Leukocytes 25.66 × 10⁹/L; erythrocytes 3.96 × 10¹²/L; hemoglobin 139 g/L; hematocrit 32.99%; platelets 267 × 10⁹/L.

Diagnosis established. Mine-explosive injury of the left upper extremity. Multiple fragment wounds of the left forearm with gunshot comminuted fractures of the diaphysis of the radius and ulna, with rupture of the neurovascular bundle, with an extensive soft tissue defect. Traumatic shock, grade 2.

Given the imminent risk of irreversible left-hand ischemia, the likelihood of hemorrhage, the need for fixation of bone fragments, and extensive primary surgical debridement of the wound, a military consultation (traumatologist, vascular surgeon, surgeon, anesthesiologist) decided on surgical treatment at the military field hospital (Level 2).

Course of the operation: under endotracheal anesthesia, extensive primary surgical debridement of the wound was performed with removal of foreign bodies and necrotic tissue. Subsequently, a MEFK was applied to the radius (Fig. 3).

Application of the MEFK to the left ulna was not performed due to large soft-tissue defects. Subsequently, the stumps of the ulnar and radial arteries were isolated, the arterial stumps were thrombosed. The diameter of the ulnar artery was less than 2 mm; it was decided not to proceed with reconstruction. The diameter of the radial artery was 4 mm (Fig. 4).

Resection of the non-viable arterial segments and thrombotic masses was performed down to healthy tissue, which yielded satisfactory retrograde blood flow. The diastasis between the stumps was 4 cm. 50 mL of heparinized solution (2,500 IU of unfractionated heparin + 50 mL of 0.9% NaCl) was injected into the distal stump, resulting in weak retrograde blood flow (venous). The arterial stumps were clamped. It was decided to use an autologous vein for further arterial grafting. Due to the deficit of preserved soft tissues in the forearm and wound infection, harvesting an autologous vein from the left forearm was ruled out to preserve the outflow pathways (from the hand). A 5 cm segment of the great saphenous vein (GSV) was isolated and resected in the distal third of the left leg. Subsequently, grafting of the radial artery was performed using the reversed GSV with an 8/0 polypropylene suture, creating two end-to-end anastomoses. Upon clamp removal, blood flow was restored, demonstrating satisfactory pulsation in both the autogenous graft and the radial artery (Fig. 5).

After blood flow restoration, pulse oximetry on the second finger of the left hand showed a heart rate of 86 bpm and SpO₂ of 90%. Additionally intraoperative Doppler ultrasound of the hand arteries visualized the main arterial blood flow in the superficial palmar arch, with a blood flow velocity of 100 cm/s (Fig. 6).

In the postoperative period, the left hand was warm and pink, with satisfactory pulsation in the radial artery. The following conservative therapy was administered: ceftriaxone 1.0 g IM; unfractionated heparin 5,000 IU SC; pentoxifylline 10.0 mL + 200.0 mL 0.9% NaCl IV drip; promedol 2.0 mL IM. Hemodynamic parameters were stable, and diuresis was satisfactory. Four hours after the operation, the patient was evacuated for further stages of treatment and rehabilitation.

DISCUSSION

The presented clinical case of incomplete traumatic avulsion of the hand due to a mine-explosive injury to the left upper extremity clearly illustrates the contemporary challenges and possibilities of military field reconstructive surgery in an active combat zone. The successful revascularization performed at a Level 2 hospital (separate medical detachment) is an indicator of a highly organized surgical care system and readiness to implement complex microsurgical technologies, even at the stage of qualified medical care. The treatment provided comprehensively addressed several interrelated objectives: saving the limb from inevitable amputation, preventing life-threatening complications, and creating conditions for subsequent rehabilitation. Analysis of this case in the context of current research on combat trauma allows for the identification of key tactical and technical aspects.

Epidemiology and severity of combat extremity injuries in modern conflicts

The structure of combat surgical trauma during the Special Military Operation (SMO) is characterized by a predominance of blast and fragment injuries, leading to severe combined injuries of the extremities [1][4]. As noted by Vasilchenko et al., up to 70% of all casualties are precisely such injuries, with a significant portion accompanied by damage to major vessels, massive blood loss, and shock [1]. In our case, the patient was diagnosed with traumatic shock, grade 2, which is fully consistent with data on the severity of such injuries. Kasimov et al. emphasize that in forward medical units, it is precisely limb injuries with a vascular component that require the most urgent and technically complex intervention, often under conditions of a continuing influx of wounded [4]. The assessment of the patient’s condition using military field surgery scales (MFS-I — 2 points, severe injury; MFS-AS — 13 points, moderate condition) confirms the high predictive value of these scales for triage and determining the scope of immediate measures [3].

Diagnosis and organization of care

The diagnostic algorithm begins on the battlefield within the framework of Tactical Combat Casualty Care (TCCC), where the key element is the rapid identification of life-threatening hemorrhage and the application of tourniquets. TCCC (literally “tactical combat casualty care”) is a tactical medicine protocol describing the actions a combatant must perform to provide aid to a comrade on the battlefield [14]. In a medical facility setting, diagnosis is based on the clinical picture (signs of acute ischemia) and instrumental methods. Angiography remains the gold standard; however, its performance is not always possible in the acute phase (within an hour). Ultrasonography is a rapid and effective screening method [15]. The clinical case reported by Yatsun et al.,
where a femoral vessel injury was diagnosed and managed 4 days post-injury, emphasizes the importance of constant vigilance even in cases of delayed presentation [15].

The organization of trauma care is a critical success factor. Priyadarshini et al. convincingly demonstrated that implementing a protocolized approach at all stages — from prehospital tourniquet application to standardized surgical algorithms — statistically significantly increases patient survival while concurrently reducing amputation rates [14]. The modern system is built on the principles of staged treatment with evacuation by purpose, where forward surgical teams (Level 2) perform life-saving interventions according to the principles of Damage Control Surgery (DCS), while definitive reconstruction is carried out in rear specialized centers (Role 4/5) [1].

Damage control surgery as a foundation for limb salvage

The fundamental principle in the treatment of this patient was the sequential application of the “damage control” concept (Damage Control Surgery). This approach, initially developed for abdominal trauma, has become a cornerstone of combat casualty care for patients with polytrauma, including limb trauma [7][8]. The primary surgical debridement of the wound with removal of foreign bodies, bone fragments, and non-viable tissues was aimed not at definitive reconstruction, but at the prevention of anaerobic and purulent infection — one of the main obstacles to successful limb salvage [7][8]. Batyrshin et al. emphasize that the use of negative pressure wound therapy (NPWT) systems after extensive primary surgical debridement in traumatic avulsions allows for effective wound management, reducing edema and bacterial contamination, thereby creating more favorable conditions for subsequent reconstructive stages [7]. Although NPWT was not indicated at this specific stage in the present case, the underlying philosophy of performing a radical yet rapid primary debridement fully aligns with the DCS principles.

The most important element of DCS for fractures within a contaminated wound is stable, but minimally invasive, fixation. The MEFK use for osteosynthesis of the radius is the standard approach in such a situation [4][11]. As Chupryaev et al. pointed out, external fixation with devices like the MEFK allows for reliable stabilization of bone fragments without implanting foreign bodies into the potential infection zone, while providing access to the wound for subsequent dressings and revisions [11]. The decision to forego osteosynthesis of the ulna due to large soft tissue defects was a pragmatic decision aimed at minimizing the risk of necrosis and infection around the implant, which is also consistent with the principles of staged treatment [5][8].

Microsurgical revascularization under military field conditions: criteria and technique

The key decision that ensured hand viability was the performance of autovenous grafting of the radial artery, elevating the treatment from simple damage control to complex reconstructive surgery. Although the first successful limb replantation was performed over half a century ago [6], their execution in a field hospital remains an extraordinary event. Successful management of such cases requires specialized equipment combined with advanced training of the surgical team [5][10].

Criteria for the decision on revascularization. In our case, the surgical consultation opted for limb salvage. This choice was based on several factors: a relatively short ischemia time (approximately 2 hours prior to hospitalization plus the time required for preoperative preparation), the preservation of a partial soft-tissue bridge connecting the hand to the forearm, and, most importantly, the satisfactory condition of the patient (stable hemodynamics after shock resolution). Amonov et al., in their study, noted that primary dilemma in managing near-complete avulsions lies in the conflict between the angiosurgical task (restore blood flow as quickly as possible) and the osteoplastic task (perform high-quality fixation and defect reconstruction) [5]. In the described case, this issue was resolved in favor of primary vascular reconstruction after rapid yet adequate bone stabilization and primary surgical debridement.

Choice of revascularization method and vascular graft. The detected extended (4 cm) radial artery defect with thrombosed stumps precluded the possibility of a direct anastomosis. In such situations, autogenous vein grafting is the gold standard of care [9][10]. In a review of combat-related revascularization, Merkulov et al. indicated that an autologous vein, specifically the GSV of the leg, is the optimal graft due to its availability, diameter match, and relative resistance to infection compared to synthetic prostheses [10]. The decision to use a vein from the leg, rather than from the injured forearm, was fully justified. Firstly, the injured limb had an extensive soft-tissue deficit, and additional damage could have impaired venous outflow. Secondly, the vein harvest site should be as far as possible from the primary contamination zone to reduce the risk of graft infection, a principle reflected in the study by Kholmatov et al. on the treatment of false aneurysms [9].

Intraoperative monitoring. The use of intraoperative pulse oximetry and Doppler ultrasound to confirm blood flow restoration is a modern requirement that significantly increases the accuracy of assessing surgical success [10][16]. Visualization of blood flow in the superficial palmar arch at a velocity of 100 cm/s objectively confirmed the technical patency of the anastomoses and the adequacy of the distal vascular bed. Klimovich et al. noted the increasing role of ultrasound methods, including UAS, not only in diagnosis but also in intraoperative monitoring of vascular injuries of the extremities [2].

Postoperative risks and rehabilitation prospects

While successful intraoperative revascularization represents a critical milestone, it is merely the initial step in a long recovery process. The primary immediate threats during the postoperative period encompass anastomotic thrombosis, wound infection, and necrotic changes within the area of severe trauma.

Risk of thrombosis. Despite the satisfactory blood flow achieved, the risk of autovenous graft thrombosis remains substantially elevated due to the extensive soft-tissue trauma, edema, and possible hypercoagulation. This requires the administration of full anticoagulant therapy in the postoperative period, which was carried out in this patient.

Risk of infection and necrosis. The extensive soft tissue defect of the forearm, the presence of bone fragments, and foreign bodies create ideal conditions for the development of infection. Studies dedicated to the treatment of polytrauma emphasize the need for repeated, staged debridements and wound revisions, often with the use of NPWT, to control infection and prepare for definitive skin plasty [7][8][11]. The management of the ulna without osteosynthesis will also require a future decision: either its stabilization after wound cleaning, or resection followed by bone grafting material.

Functional recovery and rehabilitation. Despite successful hand salvage, the patient will have a severe combined injury to the nerves (numbness and anesthesia were noted on admission). Damage to the median, radial, and ulnar nerves at this level of trauma is almost inevitable. Contemporary research by Gaivoronsky demonstrated progress in peripheral nerve surgery for combat injuries, including methods of single-stage reconstruction with muscle-tendon transposition and the development of entire concepts for providing neurosurgical care [17–19]. However, the restoration of sensory and motor function will span months to years, requiring multi-stage surgical interventions and intensive rehabilitation. The experience of rehabilitating military personnel with amputated limbs, accumulated in recent years as described by Momotov et al. [14], shows that even when a limb is successfully salvaged, the recovery program must be equally comprehensive, multidisciplinary, and prolonged to maximize the patient’s potential to return to an active life and work.

Comparison with civilian injuries and other mechanisms

Evaluating this case alongside injuries sustained in civilian settings, such as trauma caused by operating electric meat grinders described in the review by Suprunov and Skryabin [15], highlights critical distinctions. Although both mechanisms result in severe crush injuries, fractures, and often near-complete avulsions, there are fundamental differences between them that affect surgical tactics:

• nature of contamination: a blast injury involves massive primary contamination with soil, clothing debris, and multiple small foreign bodies, carrying an immeasurably greater risk of anaerobic (especially clostridial) and pyogenic infection compared to a relatively “clean” household injury from a meat grinder [2][15];
• zone of injury: blast trauma creates an extensive zone of primary and secondary necrosis due to the shock wave and thermal component, which complicates the assessment of tissue viability during primary surgical debridement [2][16];
• concomitant pathology: combat trauma is often part of polytrauma, accompanied by shock, and requires treatment within a staged evacuation system with time constraints at each stage [3][4][12].

All of these factors make the decision to perform complex reconstruction under military field conditions significantly riskier, but, as the described case shows, possible with clear organization.

Preventive measures and the importance of the correct prehospital stage

The success of the subsequent treatment was largely predetermined by competent actions at the prehospital stage. The serviceman’s self-applied tourniquet to the upper arm stopped life-threatening hemorrhage, which is a key factor for survival in major vessel injuries [1][4]. It is important to note that the tourniquet was applied according to modern protocols (high on the upper arm). Upon admission and clinical assessment, a decision was made to perform tourniquet conversion, a maneuver that effectively prevented irreversible ischemia and amputation driven by prolonged ischemia. Korol, in his study of medical evacuation, emphasizes that correctly performed first aid, including temporary hemorrhage control, and rapid evacuation (in this case, 2 h) are critically important steps for limb salvage [12]. The organization of such evacuation, as noted by Trishkin, is one of the key tasks of the medical service [3].

Selection of the level of care for reconstructive interventions

The performance of such a complex microsurgical operation in a Level 2 hospital raises important considerations regarding the adequacy of conditions and appropriateness. According to Kasimov et al., forward medical units (Level 2) today are equipped significantly better than in previous conflicts, concentrating specialists capable of performing not only urgent but also delayed primary interventions [4]. The consultation’s decision to operate on-site rather than evacuating the patient further was based on an understanding of the “golden window” for revascularization. Additional evacuation to a better-equipped hospital (Level 3) would have taken precious hours, thereby increasing the ischemia duration and making hand salvage impossible. As Amonov et al. note, when navigating the clinical conflict between vascular and orthopedic priorities, absolute precedence should always be given to restoring blood flow within the shortest possible timeframe, even if this means performing the intervention under sub-optimal conditions [5]. This case confirms the thesis put forward by Ivchenko and Ovchinnikov that the experience of the Special Military Operation is stimulating the shift of elements of specialized care to earlier stages of evacuation [13].

Long-term outcomes and multidisciplinary follow-up

Although a clinical case description usually focuses on emergency surgical care, it is important to analyze the probable further stages of the patient’s treatment. Even with the successful survival of the hand, the medical team will face extremely complex tasks:

• Wound and bone defect management. Once the patient is stabilized and the vascular graft is carefully monitored, a series of staged debridements will be required, followed by reconstruction of the extensive soft-tissue defect of the forearm. The experience described in works on the treatment of polytrauma [8][11] shows that rotational or free microsurgical flaps may be necessary to achieve this. The ulna, left without fixation, will require either delayed osteosynthesis or bone grafting to achieve consolidation.
• Neurosurgical rehabilitation. The absence of sensation in the hand indicates a severe, likely irreversible, injury to the median, radial, and ulnar nerves, representing the most prognostically unfavorable factor for functional recovery. Contemporary research, in particular by Gaivoronsky et al. and Isengaliev et al., shows that innovative methods are used in specialized centers, including single-stage reconstruction of the nerve trunk with tendon-muscle transposition, autologous nerve transplantation, and others [18][19]. However, the results always remain limited, and recovery will be partial at best.
• Orthopedic rehabilitation and prosthetics. Intensive rehabilitation aimed at preventing contractures, maintaining passive joint mobility, and, if possible, restoring active movements will be required for many months. Even if the motor function of the hand is lost, preserving a sensitive stump (with successful reinnervation) has enormous psychological and functional significance, allowing for the future use of myoelectric prostheses. The experience of amputee rehabilitation, described by Momotov et al. [14], demonstrates a comprehensive approach that includes not only prosthetics but also psychological, social, and vocational adaptation, which is equally applicable to patients with salvaged but deeply damaged limbs.

Ethical and economic aspects

The decision to pursue limb salvage, associated with multi-stage, costly, and lengthy interventions, always has an ethical and economic dimension. While the imperative to preserve a limb at any cost remains a natural guiding principle for the surgeon and a primary wish of the patient, it must be balanced against the risk of surgical futility, where a patient is subjected to numerous major surgeries for an ultimately unsatisfactory functional result. Research dedicated to rehabilitation [14] and analysis of long-term outcomes are important for forming clear criteria for selecting patients for such programs. In wartime, the issue of resources is also acute. However, as noted in the report on the activities of the medical service [3], the provision of high-tech care, including reconstructive plastic surgery, is a priority aimed at maximizing the restoration of combat capability and returning service members to an active life.

Limitations

Due to the conditions of care provision (surgical treatment in a frontline hospital followed by urgent evacuation), as well as difficulties in organizing follow-up (limited communication, impossibility of long-term monitoring), the authors do not have information on functional outcomes in the long-term period. This absence of long-term monitoring constitutes the primary limitation of the present study.

CONCLUSION

The presented clinical observation serves as a vivid illustration of the evolution of military field surgery, which, based on the classical principles of staged treatment and “damage control,” has integrated high-tech microsurgical methods into its practice. Successful autovenous grafting at the stage of a separate medical detachment was the result of highly coordinated efforts of a multidisciplinary team, including a traumatologist, a vascular surgeon, and an anesthesiologist.

Comparing these findings with current research confirms that the implemented strategy aligns with advanced trends, specifically prioritizing vascular reconstruction following rapid stabilization and debridement, harvesting an autogenous vein graft from a distant donor site, and utilizing intraoperative ultrasound monitoring. This case demonstrates that limb salvage in near-complete avulsion under combat conditions is no longer the exclusive prerogative of large tertiary centers but becomes a task solvable at earlier stages of medical evacuation, provided appropriate training and equipment are available. This directly relates to the tasks set for the medical service to improve the provision of surgical care during the Special Military Operation.

However, the success of the initial stage represents merely the beginning of a long recovery. The long-term viability of the salvaged limb will depend on the prevention of delayed complications (thrombosis, infection, necrosis), the success of subsequent reconstructive stages (soft tissue plasty, fracture treatment), and, no less importantly, on the capabilities of modern neurosurgery and rehabilitation to restore the function of damaged nerves.

Thus, this case is a model for the contemporary management of severe combat extremity trauma, demonstrating that staged treatment, interdisciplinary collaboration, and the integration of technology from the field hospital to the rehabilitation center are key not only to saving life but also to maximizing the post-injury quality of life.

Authors’ contribution. All authors confirm that their authorship meets the ICMJE criteria. The primary contributions are distributed as follows: Anton N. Kazantsev — surgical intervention, manuscript drafting and editing; Aron I. Chaava — literature search and analysis, preparation of illustrations; Dmitry Yu. Neskoromny — concept and design, literature analysis; Oleg V. Alekseev — literature analysis, manuscript editing. Approval of the final version of the article — all authors.