Vascular trauma to the lower extremity: the Lebanese war experience

Delivering trauma and rehabilitation interventions to women and children in conflict settings: a systematic review

Background

In recent years, more than 120 million people each year have needed urgent humanitarian assistance and protection. Armed conflict has profoundly negative consequences in communities. Destruction of civilian infrastructure impacts access to basic health services and complicates widespread emergency responses. The number of conflicts occurring is increasing, lasting longer and affecting more people today than a decade ago. The number of children living in conflict zones has been steadily increasing since the year 2000, increasing the need for health services and resources. This review systematically synthesised the indexed and grey literature reporting on the delivery of trauma and rehabilitation interventions for conflict-affected populations.

Methods

A systematic search of literature published from 1 January 1990 to 31 March 2018 was conducted across several databases. Eligible publications reported on women and children in low and middle-income countries. Included publications provided information on the delivery of interventions for trauma, sustained injuries or rehabilitation in conflict-affected populations.

Results

A total of 81 publications met the inclusion criteria, and were included in our review. Nearly all of the included publications were observational in nature, employing retrospective chart reviews of surgical procedures delivered in a hospital setting to conflict-affected individuals. The majority of publications reported injuries due to explosive devices and remnants of war. Injuries requiring orthopaedic/reconstructive surgeries were the most commonly reported interventions. Barriers to health services centred on the distance and availability from the site of injury to health facilities.

Conclusions

Traumatic injuries require an array of medical and surgical interventions, and their effective treatment largely depends on prompt and timely management and referral, with appropriate rehabilitation services and post-treatment follow-up. Further work to evaluate intervention delivery in this domain is needed, particularly among children given their specialised needs, and in different population displacement contexts.

PROSPERO registration number

CRD42019125221.

A decade of major vascular trauma: Lessons learned from gang and civilian warfare

INTRODUCTION Trinidad and Tobago is a trans-shipment point for the illegal trade of drugs, arms and ammunition and, as such, has a high incidence of gang-related warfare and drug-related crimes. This has led to a high incidence of gunshot and stab wounds, with associated major vascular injuries. We describe our management strategies learned from a decade of vascular trauma experience. METHODS A retrospective analysis of age, gender, type of trauma, vessel injured, procedure and outcome for all cases of vascular trauma between 2006 and 2015 at two surgical units in Trinidad and Tobago. RESULTS There were 198 vascular trauma cases (232 procedures), involving 159 (80%) males at a mean age of 33 years. Gunshots accounted for 103 (52%) cases, followed by stabs/chops (n=50; 25%) and lacerations (n=15; 8%). The most commonly injured vessels were the radial/ulnar arteries (n=39; 20%) and the superficial femoral artery (n=37; 19%). There were seven pseudoaneurysms and three traumatic arteriovenous fistulae. Repair techniques included primary (n=82; 35%), reversed vein (n=63; 27%), polytetrafluoroethylene (n=58; 25%), oversew (n=24; 10%) and endovascular (n=5; 2%) techniques. There were eight (4%) secondary amputations and eight (4%) deaths. CONCLUSIONS Major vascular trauma causes significant morbidity and mortality in Trinidad and Tobago, with the majority of cases due to gunshot injuries secondary to gang-related warfare and civilian violence. We compare our experience with that in the literature on the epidemiology and management of vascular trauma.

Prognostic Factors of Leg Amputation in Patients With Vascular Injury: A Systematic Review

Individual studies on the prognostic factors of leg amputation, due to vascular injury, have been small, and they have produced conflicting results. Reliable data are necessary so that surgery can be targeted more effectively. The authors carried out a systematic review from 1990 to 2002 to identify the high risk of patients to amputation. Meta-analysis was carried out. The authors found that patients with preoperative hypotension, popliteal artery injury, and associated bone and nerve injury had a significantly higher risk of leg amputation than those without these risk factors. Also, patients with postoperative infection had a higher chance of amputation than those without infection. This information is essential for an appropriate evaluation and the treatment of such patients.

The complete management of extremity vascular injury in a local population: A wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq

BACKGROUND

Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy.

METHODS

From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed.

RESULTS

During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n=134), neck and great vessel 17% (n=33), and thoracoabdominal 13% (n=25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n=21). Surgical wound infection occurred in 3.7% (n=5), and acute anastomotic disruption in 3% (n=4). Graft thrombosis occurred in 4.5% (n=6), and early amputation and mortality rates during the study period were 3.0% (n=4) and 1.5% (n=2), respectively.

CONCLUSIONS

To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.

In-Theater Management of Vascular Injury: 2 Years of the Balad Vascular Registry

BACKGROUND

Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts.

STUDY DESIGN

Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed.

RESULTS

During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 31; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%.

CONCLUSIONS

This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage.

Trauma epidemiology and outcome in a developing country: perspectives from a university teaching hospital in Beirut

This study aims at evaluating trauma care at the American University of Beirut Medical Centre (AUB-MC) and comparing it to the norms established by the Major Trauma Outcome Study (MTOS). From January 2001 until January 2003, data necessary to calculate probability of survival using the Trauma Injury Severity Score methodology were collected. M, W, Z, Ws and Zs statistics were calculated to compare outcome at AUB-MC to the MTOS dataset. A total of 873 patients were included in the study. W statistics was calculated at 0.35 with Z score for the overall sample of 0.081 indicating that there was no statistically significant difference in survival between this group and the MTOS group. In a developing country a hospital achieves trauma outcomes similar to the MTOS dataset. Further studies looking at trauma care in Lebanon as a whole are needed.

Is staged external fixation a valuable strategy for war injuries to the limbs?

High-energy weapons or blast injuries usually result in substantial tissue damage and are serious medical and public health problems. We report our experience with staged external fixation for war injuries to the extremities. Forty-seven patients with 64 high-energy limb fractures caused by war weapons were retrospectively reviewed. The fractures were associated with severe soft tissue damage. There were 14 Gustilo-Anderson Type IIIA fractures, 40 Type IIIB fractures, and 10 Type IIIC fractures. Soft tissue débridement followed by axial realignment of the fractured bones with immediate skeletal stabilization using the AO/ASIF unilateral tubular external fixator was performed on the day of admission. The primary tubular fixators were exchanged 5 to 7 days later for Ilizarov frames. Delayed primary closure, skin grafts, or flaps were used for soft tissue coverage. The mean followup was 40 months, and the Ilizarov/hybrid external fixator was the definitive treatment in all patients. Bone union was achieved at an average of 8 months in 58 (90.6%) fractures. Three patients had nonunions and one patient required an amputation. Two patients were lost to followup. Staged external fixation is a valuable strategy for treatment of war injuries to the extremities.

LEVEL OF EVIDENCE

Therapeutic study, Level IV. See the Guidelines for Authors for a complete description of levels of evidence.

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group (n = 372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 +/- 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery (n = 73), and the deep femoral vein (n = 41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was 'organ dysfunction' in 37 (9.9%) and 'organ loss' in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.

An historical tour of vascular injury management: from its inception to the new millennium

Advances have been made in times of war. Lessons learned from these experiences should be studied in order to avoid the costly mistakes made previously. Fortunately, major conflicts have not been common recently. Therefore, military surgeons depend on the stable environment of civilian trauma and research to lead the way. Documentation and careful record keeping such as the Vietnam Vascular Registry are vital in assisting surgeons with lessons to be learned.

Surgical approach to military vascular injuries

PURPOSE OF THIS STUDY

Vascular injuries caused by high-velocity military missiles are associated with bone fracture, soft-tissue, nerve and tendon injuries. In this study we will discuss the surgical strategy and results of vascular injuries, which require a different approach from primary and elective surgical procedure.

BASIC METHODS

Surgical interventions were performed in 116 patients. Vascular lesions were localized on the lower extremity in 53, upper extremity in 55, and nine were in other regions. Vascular injuries were concomitant with bone fracture in 46 and nerve injuries in 36 patients. Vascular repair was performed after orthopedic stabilization in vessels with an ischemic period of less than 4 hours.

PRINCIPAL FINDINGS

Fasciotomy was performed after vascular repair in the 22 cases that had arrived after 8 hours. Amputation was required in two cases. There was one mortality.

CONCLUSIONS

The best results are obtained when a multidisciplinary and emergency approach are used by the team of vascular, orthopedic, plastic and neurosurgeons who are experienced in military injuries.