We conducted a prospective study to evaluate bone bruises, or trabecular microfractures, associated with isolated medial collateral ligament injuries. Magnetic resonance imaging was performed on 65 patients with isolated medial collateral ligament injuries determined by physical examination and imaging studies. Of these 65 patients, 29 (45%) had associated trabecular microfractures. Follow-up images were completed at various intervals on 24 of these 29 patients (83%). Complete resolution of these lesions was observed in all cases. This process appears to occur as a result of gradual diffusion over a period of 2 to 4 months. Bone bruises associated with medial collateral ligament injuries are approximately one-half as common as bone bruises associated with anterior cruciate ligament injuries. However, medial collateral ligament-associated trabecular microfractures may be a better natural history model because these injuries are treated nonoperatively.

Disseminated fungal infections are normally opportunistic infections in the immunocompromised population. Current literature has documented a high mortality rate with these infections in civilian trauma or as complications of severe burns. There is only one published case of fungal infection in a combat-injured individual to date, which resulted in mortality despite aggressive debridement and appropriate antifungal agents. We present here three patients in whom aggressive debridement, antifungals, and the addition of dilute Dakin's solution with negative pressure wound therapy was used to treat angioinvasive mold. Angioinvasive fungal infection continue to be one of the most aggressive and devastating infections that our combat-injured patients face. With the addition of dilute Dakin's solution, we successfully managed three critically ill patients. Previous literature had shown close to 30% mortality associated with cutaneous mucormycosis and the mortality rate approaches 100% with disseminated angioinvasive fungal infections. These results provide hope not only for the combat-injured patients being treated for both local and disseminated angioinvasive fungal infections, but also for the civilian trauma and immunocompromised patients.

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.