By Elizabeth Hofheinz, M.P.H., M.Ed., March 13, 2020
You don’t have to be in a war zone to experience a junctional injury, an event involving the root of an extremity and the adjacent torso to include the shoulder and thoracic outlet or the pelvis, lower part of the abdomen, and proximal part of the thigh.1 Captain Dana C. Covey, M.D., deployed many times to conflict zones, has been called upon to treat patients with such injuries.
Dr. Covey, previously chairman of
the Department of Orthopaedic Surgery at Naval Medical Center, San Diego, is
now a professor of orthopedic surgery at University of California San Diego.
Along with colleague Alexandra Schwartz, M.D., he recently published an article
titled, “Orthopaedic Junctional Injuries,” in the October 2, 2019 edition of The
Journal of Bone and Joint Surgery. 
Dr. Covey told OSN, “While a civilian orthopaedic surgeon may encounter a junctional injury in routine practice as a result of a stabbing or gunshot wound, military orthopedic surgeons tend to see many more of these injuries. Either way, the foremost danger in these situations is that the person could bleed to death.”
And these are no small numbers. Research has revealed that 19.3% of battlefield deaths from potentially survivable hemorrhage in Iraq and Afghanistan occurred in junctional anatomic regions.2 Other work found that when considering deaths that occurred after reaching a medical treatment facility, among 287 potentially survivable battle injuries in Iraq and Afghanistan, 21% of the deaths were from junctional injuries.3
But there is a serious gap in the literature when it comes to treating these injuries, explains Dr. Covey.
To his civilian orthopaedic colleagues, Dr. Covey says, “Because this is not something you routinely see in a stateside ER, orthopedic surgeons might not recognize the definitive signs of vascular injury. These may include an expanding hematoma, a cool extremity, and an audible bruit. Any of these can happen if you are dealing with, for example, a serious motorcycle accident or a military IED.”
So, what are the initial steps involved in treating someone with this type of injury?
If you suspect you are dealing with a junctional injury, states Dr. Covey, it is wise to consider the military’s CABC protocol—Catastrophic hemorrhage, Airway, Breathing, and Circulation.
“Because someone with these injuries can bleed to death very quickly, we begin with halting the hemorrhaging. While direct compression is vital, in a chaotic situation (a firefight) this may not be feasible. Although several devices have been developed in an effort to tamponade junctional bleeding, there is no reliable data pointing to the efficacy of one design over another.”
Let’s say that the temporary measures to halt the bleeding are largely successful and the patient can be flown to a more advanced level of care. Dr. Covey: “This person would arrive at a level two facility, the first one with a surgical capability – though not markedly robust.”
“The location of the injured vessel needs to be identified (in or out of the adjacent trunk). Bleeding may be controlled using digital or manual pressure, depending on the size of the wound. If manual pressure is unsuccessful, a Foley catheter may be inserted into the wound and the balloon inflated with saline to attempt tamponade. Proximal control of arteries in upper and lower extremities must be obtained via different measures. These include exposing the subclavian artery through either a supraclavicular or less hazardous infraclavicular approach. In the lower extremity a vertical midinguinal surgical approach may be used.”
“As for airway issues, the surgeon typically places a tube in the throat, uses a breathing mechanism, or performs CPR. As for the last step in the protocol, circulation, the care provider inserts an IV. Many of these steps occur simultaneously.”
Providing a glance into what military surgeons must contend with, Capt. Covey states, “There are times when a helicopter cannot land because it is under fire or there are severe dust storms in the area. Ideally, however, someone with a junctional injury can reach level three care, which has more advanced surgical and subspecialty care available. They would then be transferred the U.S. military’s single level four facility—Landstuhl, Germany. Ultimately, they will end up at one of the large U.S.-based military facilities such as Walter Reed National Medical Center or Naval Medical Center, San Diego.”
Dr. Covey can see a future where fewer patients will have to endure these traumas. Pointing to a number of new developments on the horizon, he says, “The use of tranexamic acid to aid in clotting has shown to decrease the morbidity and mortality of junctional injuries. Another innovation being explored is the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in junctional injuries. This involves feeding a catheter up the femoral artery and then inflating a balloon to help tamponade the artery from the inside — the goal being to get above the level of the injury.”
And there are wearable items that may reduce the frequency and severity of these injuries.
“Service members now wear Kevlar undergarments to protect their pelvic region. This covers the genitals, the proximal thigh and vessels.”
Alas, junctional injuries provide an interesting clinical junction of orthopaedics and trauma.
Beyond interesting, however, is the real-world impact that the proper treatment could have on patients and their families.
For additional information or questions, please contact Dr. Covey at Dana.Covey@va.gov
References:
1.) Tai NRM, Dickson EJ. Military junctional trauma. J R Army Med Corps. 2009 Dec; 155(4):285-92.
2.) Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH. Death on the battlefield (2001- 2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6)(Suppl 5):S431-7.
3.) Eastridge BJ, Hardin M, Cantrell J, Oetjen-Gerdes L, Zubko T, Mallak C, Wade CE, Simmons J, Mace J, Mabry R, Bolenbaucher R, Blackbourne LH. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011 Jul;71(1)(Suppl):S4-8.