What are the guidelines for prolonged field care of patients with joint trauma in a deployed setting?

Prolonged Field Care for Joint Trauma in Deployed Settings

In deployed settings with joint trauma, prolonged field care should follow the Joint Trauma System's tiered Role-based care model, prioritizing damage control resuscitation with whole blood within 30 minutes of injury, immediate stabilization at Role 1/2 facilities, and rapid evacuation to Role 3 surgical capabilities when feasible. 1, 2

Understanding the Deployed Trauma Care Framework

The military trauma system operates fundamentally differently from civilian systems due to austere conditions and evacuation challenges:

• Role 1 care encompasses point-of-injury treatment through battalion aid stations, approximating civilian EMS and freestanding emergency centers, but with significant limitations in provider training levels, bed capacity, and diagnostics 1
• Role 2 facilities provide the first surgical capability through Forward Resuscitative Surgical Detachments, approximating small community hospitals but with severely limited patient holding capacity and reduced diagnostic equipment 1
• Role 3 field hospitals represent the highest echelon of deployed care, approximating civilian Level II trauma centers but with smaller holding capabilities and diagnostics limited to CT scanning or less 1

The critical distinction in prolonged field care is that extremity wounds and fractures account for approximately 54% of all combat wounds, making joint trauma management a dominant concern 3

Immediate Resuscitation Priorities

Hemorrhage Control and Blood Product Administration

Low-titer group O whole blood is the resuscitation product of choice and must be available within 30 minutes of casualty wounding at all roles of care. 2

• Whole blood provides red cells, plasma, and platelets in a single unit, simplifying resuscitation in austere environments 2
• When whole blood is unavailable, component therapy should be available within 30 minutes 2
• All prehospital providers must be trained to screen donors, collect fresh whole blood, transfuse products, and recognize transfusion reactions 2
• The damage control resuscitation guideline implementation decreased mortality in massively transfused patients from 32% to 21% 4

Triage and Evacuation Decisions

Apply structured field triage to determine evacuation priority:

• Immediate (Red): Joint injuries with vascular compromise, open fractures with hemorrhage, or pulseless extremities require immediate surgical intervention 3, 5
• Delayed (Yellow): Stable joint fractures without neurovascular compromise can tolerate delayed evacuation 5
• Time-sensitive extremity injuries (open fractures, fractures with neurovascular compromise) trigger transport to trauma center capabilities 3

Specific Joint Trauma Management in Prolonged Field Care

Assessment and Stabilization

Penetrating injuries to extremities proximal to elbow or knee, two or more proximal long-bone fractures, crushed/degloved/mangled/pulseless extremities, and amputations proximal to wrist or ankle all mandate evacuation to surgical capabilities. 3

Critical assessment points:

• Check distal pulses and capillary refill in all joint injuries 3
• Document neurovascular status before and after splinting 3
• Recognize that 68.3% of battlefield wounds are penetrating mechanism, vastly different from civilian 11.1% 4
• 21.8% of military casualties have metabolic shock (base deficit ≥5), and 29.8% require blood transfusion 4

Damage Control Orthopedics

In prolonged field care scenarios where definitive surgery is delayed:

• Perform external stabilization of long bone fractures to reduce hemorrhage and enable safer evacuation 1
• Apply tourniquets for life-threatening extremity hemorrhage; all providers must be trained in tourniquet application 2
• Splint joint injuries in position of function to prevent further neurovascular damage 3
• Document all interventions for continuity of care across evacuation chain 4

Psychosocial Considerations in Prolonged Care

Orthopaedic trauma care must incorporate biopsychosocial assessment, as psychological and social factors significantly influence recovery trajectory and long-term outcomes. 3

• Combat-related extremity injuries account for approximately two-thirds of initial hospitalization costs and disability payments 3
• Interdisciplinary teams including behavioral health providers optimize outcomes 3
• Early identification of psychosocial risk factors prevents long-term disability 3

Critical Pitfalls to Avoid

Undertriage of joint trauma with occult vascular injury leads to preventable limb loss and mortality. 3

• Never assume a palpable pulse excludes significant vascular injury in penetrating extremity trauma 3
• Avoid delaying evacuation for patients with "stable" joint injuries if neurovascular status is uncertain 3
• Do not prioritize specialty-specific cases over life-threatening injuries in mass casualty scenarios 5
• Recognize that military survival rates have improved to 95.4%, but extremity wounds remain the dominant injury pattern requiring aggressive early management 3, 4

Performance Improvement Integration

The Joint Trauma System has implemented evidence-based clinical practice guidelines that improved battlefield survival to 5.2% mortality after hospital admission, comparable to civilian age-matched cohorts at 4.3% 4

• Track performance improvement indicators for all joint trauma cases 4
• Implement standardized documentation for registry participation 4
• Use systems-based methodologies to identify and remedy trauma system deficiencies 4