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Page 2 of 10 Crystal et al. Plast Aesthet Res 2019;6:1 I http://dx.doi.org/10.20517/2347-9264.2018.69

INTRODUCTION
Initiated intentionally or as a result of natural disaster, mass casualty incidents (MCIs) continue to pose
a significant challenge for emergency medical resources and multidisciplinary trauma teams. From
earthquakes to landslides, geographical disasters frequently highlight multi-national relief efforts in resource
constrained environments. In an era of domestic and international terrorism, deliberate episodes of mass
violence utilizing explosives and firearms have disturbed the core of social intimacy and tested the resilience
of regional care centers. Of particular concern in MCIs are crush and blast injuries to the upper and lower
extremities, etiologies of which are rooted in the diversity of disaster types.

Specifically, the polytrauma associated with explosions results from a primary high-pressure blast wave and
secondary discharge of fragmented projectiles causing injuries ranging from soft tissue loss to complete
[1,2]
[2]
traumatic amputation . In a clinical review of conflict and terrorist related trauma, Dussault et al.
[3]
found that on average, 54% of blast injuries affect the extremities. Similarly, a review by Clover et al.
concluded that 60% of earthquake injuries are thought to localize to extremities, with 8%-13% associated
with significant open fractures. The broad mechanisms of injury and bodily involvement seen within MCIs
suggests an indispensable role for plastic surgeons in multidisciplinary teams comprised of colleagues from
[4]
various specialties including orthopedic and trauma surgery . As disasters become unfortunately more
unexceptional, plastic surgeons need to prepare for and respond to civilian MCIs.

With the evolution of extremity reconstruction from skin grafts to local tissue rearrangements and
microvascular free flap transfer, painstaking decisions regarding limb salvage efforts in MCIs must be
determined by plastic surgeons. This concept is further influenced by resource constrains particular to the
region where a disaster occurs. The purpose of this study is to highlight the various means of upper and
lower limb reconstruction following MCIs.

METHODS
A review of the literature was performed using the following MEDLINE search terms: (“Limb
Salvage”[Mesh] OR Extremity Reconstruct*[tiab] OR “Surgery, Plastic”[MeSH] OR “Trauma Surgery”[Tiab]
OR “Orthoplastic”[tiab]) AND (Mass Casualty[tiab] OR Terrorism[tiab] OR Earthquake[tiab] OR Blast
Injur*[tiab] OR Explosion[tiab] OR Triage[tiab]). Titles and abstracts were screened for relevance. The
initial search was limited to English-only articles and constrained to the past 30 years. Citations of assessed
manuscripts were screened for applicable articles.

RESULTS
Three events including our institution’s experience with the 2013 Boston Marathon Bombing, the 2015-2016
Ankara Terrorist Attacks, and the 2010 Earthquake in Haiti were specifically chosen to highlight extremity
wounds associated with MCIs and the subsequent reconstructive role of plastic surgeons.

Boston bombing
On 15 Apr 2013, two pressure cooker bombs exploded along the route of the 117th Boston Marathon. The
[5]
ground-level positioning and shrapnel components of the explosives lead to significant extremity trauma .
[6]
In total, 66% of admitted patients had lower extremity soft tissue and/or bony injuries .
Our institution received 24 patients, 11 of whom were cared for by the plastic surgery service. All 11 patients
[7]
had lower extremity injuries, while 4 had concomitant upper extremity injuries . Wounds were grossly
contaminated by foreign bodies, foreign tissue, and weaponized debris deliberately intended to inflict
secondary damage on patients. Three patients required lower extremity flap reconstruction in the acute to
subacute setting.