Field hospital treatment of blast wounds of the musculoskeletal system during the Yugoslav civil war

Periarticular blast wounds without fracture a prospective case series

BACKGROUND

During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture.

METHODS

The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement.

RESULTS

Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01).

CONCLUSION

Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Negative-Pressure Wound Therapy Versus Standard Treatment of Adult Patients With Conflict-Related Extremity Wounds: Protocol for a Randomized Controlled Trial

Background

In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.

Objective

The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.

Methods

This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.

Results

The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.

Conclusions

To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.

Trial Registration

ClinicalTrials.gov NCT02444598; http://clinicaltrials.gov/ct2/show/NCT02444598 (Archived by WebCite at http://www.webcitation.org/72hjI2XNX)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12334

Blast Injuries

BACKGROUND

Blast injuries in the United States and worldwide are not uncommon. Partially due to the increasing frequency of both domestic and international terrorist bombing attacks, it is prudent for all emergency physicians to be knowledgeable about blasts and the spectrum of associated injuries.

OBJECTIVE

Our aim was to describe blast physiology, types of blast injuries associated with each body system, and manifestations and management of each injury.

DISCUSSION

Blast injuries are generally categorized as primary to quaternary injuries. Primary injuries result from the effect of transmitted blast waves on gas-containing structures, secondary injuries result from the impact of airborne debris, tertiary injury results from transposition of the entire body due to blast wind or structural collapse, and quaternary injuries include almost everything else. Different body systems are affected and managed differently. Despite previous dogma, multiple studies now show that tympanic membrane perforation is a poor predictor of other blast injury.

CONCLUSIONS

Blast events can produce a myriad of injuries affecting any and every body system. All emergency physicians should be familiar with the presentation and management of these injuries. This knowledge may also be incorporated into triage and discharge protocols guiding management of mass casualty events.

Outcomes of IED foot and ankle blast injuries

BACKGROUND

Improvements in protection and medical treatments have resulted in increasing numbers of modern-warfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome.

METHODS

U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms.

RESULTS

Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors of amputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury, and only nine (14%) of the service members were fit to return to their preinjury duties.

CONCLUSIONS

This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rate and frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population.

[Reconstruction of the elbow with the deep circumflex iliac artery. Multicomponent free flap plasty after a gunshot wound]

A 20-year-old woman sustained massive elbow trauma from a gunshot wound. After initial surgery soft tissue coverage, reconstruction of the proximal third of the ulna, of the ulnar collateral ligament and of the triceps tendon was performed by one multicomponent microvascular free flap. There were no complications, the elbow is stable and reached full weight bearing 11 months after trauma. Active range of motion for extension and flexion is 0-20°-80°.

Improvised explosive devices: pathophysiology, injury profiles and current medical management

The improvised explosive device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range from rudimentary home made explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as roadside explosives and blast mines, explosive formed pojectile (EFP) devices and suicide bombings. Each of these groups causeinjury through a number of different mechanisms and can result in vastly different injury profiles. The "Global War on Terror" has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma care may be required to manage casualties from similar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.

Unique complications of foot and ankle injuries secondary to warfare

This article discusses the common complications associated with lower extremity trauma and amputations secondary to combat injuries. The complications include retained fragments, soft tissue adhesions, poor wound healing, painful bursae, neuroma formation, heterotopic ossification, and depleted uranium. Although there is some literature on these topics, most is based on noncombat injuries, indicating a need for further research into the management of these devastating injuries.

War wounds of the foot and ankle: causes, characteristics, and initial management

Foot and ankle trauma sustained in the Global War on Terror have unique causes and characteristics. At least one-quarter of all battle injuries involve the lower extremity. These severe lower extremity wounds require specialized early treatment. Ballistic mechanisms cause almost all injuries, and as such, most combat foot and ankle wounds are open in nature. Wounds are characteristically caused by blast mechanisms, but high velocity gunshot injuries are also common. The severe and polytraumatic nature of injuries sustained frequently call for damage control orthopaedics to be utilized. Cautious early treatment of irregular and highly exudative ballistic wounds with subatmospheric wound dressings may ease their early management.

Penetrating missile injuries during the Iraqi insurgency

INTRODUCTION

Since the invasion of Iraq in 2003, the conflict has evolved from asymmetric warfare to a counter-insurgency operation. This study investigates the pattern of wounding and types of injuries seen in casualties of hostile action presenting to a British military field hospital during the present conflict.

PATIENTS AND METHODS

Data were prospectively collected on 100 consecutive patients either injured or killed from hostile action from January 2006 who presented to the sole coalition field hospital in southern Iraq.

RESULTS

Eighty-two casualties presented with penetrating missile injuries from hostile action. Three subsequently died of wounds (3.7%). Forty-six (56.1%) casualties had their initial surgery performed by British military surgeons. Twenty casualties (24.4%) sustained gunshot wounds, 62 (75.6%) suffered injuries from fragmentation weapons. These 82 casualties were injured in 55 incidents (mean, 1.49 casualties; range 1-6 casualties) and sustained a total 236 wounds (mean, 2.88 wounds) affecting a mean 2.4 body regions per patient. Improvised explosive devices were responsible for a mean 2.31 casualties (range, 1-4 casualties) per incident.

CONCLUSIONS

The current insurgency in Iraq illustrates the likely evolution of modern, low-intensity, urban conflict. Improvised explosive devices employed against both military and civilian targets have become a major cause of injury. With the current global threat from terrorist bombings, both military and civilian surgeons should be aware of the spectrum and emergent management of the injuries caused by these weapons.

A review of casualties during the Iraqi insurgency 2006--a British field hospital experience

BACKGROUND

Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated.

METHOD

Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database.

RESULTS

There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%).

CONCLUSIONS

Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.

Musculoskeletal injuries in terrorist attacks--a comparison between the injuries sustained and those related to motor vehicle accidents, based on a national registry database

Terror-related injuries are becoming more prevalent. The predominant mechanism of damage is related to blast effects. These include penetrating injury due to material in the explosives and blunt trauma due to objects falling after detonation. However, the more commonly encountered severe trauma in civilian centres is related to motor vehicle accidents. A comparison between the two, although problematic, might enhance the knowledge of orthopaedic traumatologists dealing with these injuries. Thus 1072 in-patients, treated in levels I and II centres in Israel for orthopaedic injuries due to terrorist attack from November 2000 to December 2003, were compared with 9714 similar in-patients injured in motor vehicle accidents (controls). Analysis included age, gender, severity of injuries, diagnoses, lengths of intensive care unit and hospital stay, operations and mortality. The victims of terrorist attack included significantly more young adults, males, severe associated injuries and operations, and increased lengths of stay and mortality. Prompt recognition and awareness of the unique character of terror-related injuries is required.

Blast injuries: from triage to critical care

Injuries from explosions are multilayered. Although blast injuries are thought of most often in a military context, all nurses need to be prepared to care for these casualties. Awareness of the multiple levels of injuries and the need to modify care based on the underlying pathology have reduced morbidity and mortality in patients who have complex and very critical injuries.

Combat orthopaedics: a view from the trenches

Approximately 70% of war wounds involve the musculoskeletal system, and military orthopaedic surgeons have assumed a pivotal role in the frontline treatment of these injuries in Iraq. Providing battlefield orthopaedic care poses special challenges; not only are many wounds unlike those encountered in civilian practice, but patients also must be triaged and treated in an austere and dangerous environment, undergo staged resuscitation and definitive surgery, and endure prolonged medical evacuation, often involving ground, helicopter, and fixed-wing transport across continents. Most orthopaedic wounds in Iraq are caused by exploding ordnance--frequently, improvised explosive devices, or IEDs. Because of advances in care, rapid medical evacuation, and modern body armor, many casualties have survived in Iraq who would not have done so in previous wars. Treatment of war wounds, many of which are devastating in the scope of soft-tissue and bony injury, requires a team approach using hypotensive resuscitation, damage-control orthopaedics, new or rediscovered techniques of hemostatic and intravenous hemorrhage control, vacuum-assisted wound closure, and advanced reconstruction. Current challenges include prevention of infection, a better understanding of heterotopic ossification as a sequela of blast injury, and the need for a comprehensive, joint service database that encompasses the multilevel spectrum of orthopaedic care.

Blast and penetrating fragment injuries to the extremities

Blast injury to the extremities is the most common form of injury in recent military campaigns and in civilian terror attacks. Most orthopaedic trauma is caused by the secondary effect of blast--penetrating fragment injury. Timely wound débridement and excision of contaminated or avascular tissue, along with prevention of sepsis, are crucial to managing extremity injury. Late reconstruction and functional results are very challenging for the surgical team to achieve.

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.

The Revised ???Reconstructive Ladder??? and Its Applications for High-Energy Injuries to the Extremities

In this report, we tried to evaluate the merits of the classic "reconstructive ladder" and other reconstructive tools, such as acute shortening followed by distraction osteogenesis and a vacuum-assisted closure device, for the treatment of high-energy injuries. Thirty-seven patients suffering from high-velocity injuries to the extremities caused by war weapons and blast terror attacks were treated at our institution. The fractures were initially stabilized by the Association for the Study of Internal Fixation (AO/ASIF) unilateral tubular external fixator, which was changed 2-3 days later to a circular Ilizarov frame for 19 patients. Temporary acute shortening was performed for 5 patients. Skin grafts were performed for 21 patients, local or regional flaps for 14 patients, and free flaps for 6. Vacuum-assisted closure was selected for 8 patients. The wounds were successfully closed in all the patients. Two patients with upper-limb injuries had nonunion. Motor nerve injuries recovered in 7/10 patients. Due to hypergranulating tissue, 2 patients treated with vacuum-assisted closure (VAC) had to stop treatment early. Their wounds were closed with skin graft or local flap. The classic reconstructive ladder, starting from direct closure and ending with a free flap, should be extended for limb traumas and include acute shortening with or without angulation, followed by distraction osteogenesis and the VAC system on the same step as the free flap.

Planning for mass civilian casualties overseas: IMSuRT-International Medical/Surgical Response Teams

The increased likelihood of mass casualties involving Americans living abroad has prompted the development of a mobile, civilian medical and surgical unit available for rapid deployment overseas. Using past experience derived from the National Disaster Medical Service, and from recent rescue efforts following the African embassy bombings in 1998, an International Medical-Surgical Response Team was developed. Organized under the Department of Homeland Security, it is staffed by civilian professionals from medical and bioengineering fields. Initial deployments to the World Trade Center (2001) and Guam (2002) have shown the ability to rapidly mobilize appropriate manpower and equipment to a mass casualty site, whether domestic or international. The goals of this organization are to work in cooperation with local authorities at the mass casualty site to provide rapid assessment and medical stabilization of injured persons. When the mass casualty is overseas, rapid evacuation of casualties is accomplished by the responding military air evacuation service.

Orthopaedic injuries among survivors of USS COLE attack

The objective of this article is to describe the range of orthopaedic injuries and outcomes of acute treatment regimens among survivors of the USS COLE terrorist attack and to reemphasize basic treatment principles for blast injuries. With the current geopolitical environment, the average community orthopaedic surgeon may be involved in treating injuries due to an explosive terrorist attack. This is a retrospective review of a consecutive series of the 39 patients who were injured during the USS COLE attack on October 12, 2000, and were received at Naval Medical Center, Portsmouth, Virginia, from the MEDEVAC (Medical Evacuation) system. The 17 casualties from the attack were not included in this study. Data were retrospectively collected from patient charts for all patients who survived the USS COLE attack. The 39 patients who survived the USS COLE attack sustained 81 injuries. Fourteen patients sustained 32 orthopaedic injuries, of which 61% were lower extremity injuries. Of the 10 patients who required hospitalization, 6 had orthopaedic injuries (60%). Three of five open fractures (60%) became infected, and two of two (100%) open fracture wounds treated with primary closure in the initial setting were infected. Lower extremity orthopaedic injuries may predominate in a shipboard blast scenario. Even minor injuries require prolonged time before patients return to active duty. Complex wounds have high infection rates and should be treated according to previously established protocols for wartime injuries. Principles of provisional fracture stabilization prior to transport, adequate wound débridement, and delayed wound closure are reviewed.