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

Introduction. Modern combat trauma, especially mine‑blast extremity injuries, often results in severe combined injuries with near-complete avulsions, critical ischemia, and extensive tissue defects. The relevance of limb salvage is determined by medical and socio‑psychological aspects. However, the implementation of complex reconstructive techniques in a field military hospital setting is associated with extreme factors and requires adaptation of the “damage control” principles (Damage Control Surgery).

Objective. To analyze a comprehensive surgical approach to limb salvage in cases of near-complete traumatic hand amputation complicated by vascular insufficiency, using a clinical case example in a level 2 field military hospital.

Case description. A clinical case of a mine-explosive injury to the left upper extremity in a 38-year-old serviceman is presented. The injury involved near-complete avulsion of the hand, comminuted fractures of the forearm bones, an extensive soft tissue defect, and critical ischemia. Treatment involved a multidisciplinary consultation and the execution of the following in a single surgical series: 1) extensive primary surgical debridement of the wound, 2) external fixation of the radius using a military external fixation kit, 3) microsurgical autovenous grafting of the radial artery with a reversed graft from the great saphenous vein of the leg. Intraoperative monitoring was performed using pulse oximetry and ultrasound angioscanning. As a result of the operation, main arterial blood flow to the hand was restored (pulsation in the radial artery, SpO2 90% on the finger, blood flow velocity in the superficial palmar arch 100 cm/s according to ultrasound angioscanning). The condition of the limb improved postoperatively: the hand became warm and pink. After 4 hours, the patient was evacuated for further staged treatment. Successful early revascularization was made possible by the sequential combination of Damage Control Surgery principles (radical primary surgical debridement and minimally invasive fracture stabilization) and complex microsurgical reconstruction. Key success factors included the short ischemia time, a carefully considered decision by the consultation, and the selection of a distant (lower leg) donor site for vein graft harvesting to reduce the risk of infection and preserve venous outflow in the injured limb. This case demonstrates the possibility of bringing elements of specialized surgical care to more forward stages of medical evacuation in modern armed conflicts.

Conclusions. This experience demonstrates that limb salvage in severe combat injuries with a vascular component is possible at the stage of qualified surgical care (Level 2 hospital), provided there is a multidisciplinary approach, readiness to perform microsurgical interventions, and strict adherence to the principles of staged treatment. The success of initial revascularization is critically important, but represents only the first step in a long process of subsequent reconstructive and rehabilitative measures aimed at restoring function.

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