Injuries From Roadside Improvised Explosive Devices

Hybrid III Manikin Lumbar Spine Loading Under Vertical Impact

INTRODUCTION

Clinical investigations have attributed lumbar spine injuries in combat to the vertical vector. Injury prevention strategies include the determination of spine biomechanics under this vector and developing/evaluating physical devices for use in live fire and evaluation-type tests to enhance Warfighter safety. While biological models have replicated theater injuries in the laboratory, matched-pair tests with physical devices are needed for standardized tests. The objective of this investigation is to determine the responses of the widely used Hybrid III lumbar spine under the vertical impact-loading vector.

MATERIALS AND METHODS

Our custom vertical accelerator device was used in the study. The manikin spinal column was mounted between the inferior and superior six-axis load cells, and the impact was delivered to the inferior end. The first group of tests consisted of matched-pair repeatability tests, second group consisted of adding matched-pair tests to this first group to determine the response characteristics, and the third group consisted of repeating the earlier two groups by changing the effective torso mass from 12 to 16 kg. Peak axial, shear, and resultant forces at the two ends of the spine were obtained.

RESULTS

The first group of 12 repeatability tests showed that the mean difference in the axial force between two tests at the same velocity across the entire range of inputs was <3% at both ends. In the second group, at the inferior end, the axial and shear forces ranged from 4.9-25.2 kN to 0.7-3.0 kN. Shear forces accounted for a mean of 11 ± 6% and 12 ± 4% of axial forces at the two ends. In the third group of tests with increased torso mass, repeatability tests showed that the mean difference in the axial force between the two tests at the same velocity across the entire range of inputs was <2% at both ends. At the inferior end, the axial and shear forces ranged from 5.7-28.7 kN to 0.6-3.4 kN. Shear forces accounted for a mean of 11 ± 8% and 9 ± 3% of axial forces across all tests at the inferior and superior ends. Other data including plots of axial and shear forces at the superior and inferior ends across tested velocities of the spine are given in the paper.

CONCLUSIONS

The Hybrid III lumbar spine when subjected to vertical impact simulating underbody blast levels showed that the impact is transmitted via the axial loading mechanism. This finding paralleled the results of axial force predominance over shear forces and axial loading injuries to human spines. Axial forces increased with increasing velocity suggesting the possibility of developing injury assessment risk curves, i.e., the manikin spine does not saturate, and its response is not a step function. It is possible to associate probability values for different force magnitudes. A similar conclusion was found to be true for both magnitudes of added effective torso mass at the superior end of the manikin spinal column. Additional matched-pair tests are needed to develop injury criteria for the Hybrid III male and female lumbar spines.

Combat Injury Profile in Urban Warfare

INTRODUCTION

Combat ground maneuvers consist of various platforms and have several environmental characteristics, influenced by the terrain, the operational mission, and the force's capabilities. This study assesses data on injuries sustained during urban warfare, aiming to evaluate the relationship between injury characteristics, maneuver platform, and personal protective gear on the battlefield.

MATERIALS AND METHODS

IDF soldiers injured infantry soldiers from the "Cast Lead" and the "Protective Edge" operations in the Gaza Strip (2008-2009 and 2014, respectively) were divided into four groups according to the maneuver platform and the environment: mounted infantry (armored and unarmored vehicle) and dismounted infantry (urban and open area). The primary outcome was the severity of the injury, and the secondary outcome was the injured body part.

RESULTS

Overall, 588 casualties were included in the final analysis, of whom 507 were dismounted infantry soldiers (265 in open terrain and 242 in urban area) and 81 were mounted infantry soldiers (20 in unarmored and 61 were injured in armored vehicles). The Injury Severity Score was similar in all subgroups. Open terrain subgroups were found to have fewer head injuries and higher levels of lower extremity injuries, similar to the unarmored vehicle group. More facial injuries were documented in the urban area group.

CONCLUSIONS

The Injury Severity Score was not influenced by environmental protection. Although we found differences in the injured body parts, further studies on the exact mechanism of injury are needed to elucidate further the relationship and differences between the various platforms used and injuries seen in urban warfare, aiming for tailor-made protection.

Human pelvis injury risk curves from underbody blast impact

INTRODUCTION

Underbody blast loading can result in injuries to the pelvis and the lumbosacral spine. The purpose of this study was to determine human tolerance in this region based on survival analysis.

METHODS

Twenty-six unembalmed postmortem human surrogate lumbopelvic complexes were procured and pretest medical images were obtained. They were fixed in polymethylmethacrylate at the cranial end and a six-axis load cell was attached. The specimens were aligned in a seated soldier posture. Impacts were applied to the pelvis using a custom vertical accelerator. The experimental design consisted of non-injury and injury tests. Pretest and post-test X-rays and palpation were done following non-injury test, and after injury test medical imaging and gross dissections were done. Injuries were scored using the Abbreviated Injury Scale (AIS). Axial and resultant forces were used to develop human injury probability curves (HIPCs) at AIS 3+ and AIS 4 severities using survival analysis. Then ±95% CI was computed using the delta method, normalised CI size was obtained, and the quality of the injury risk curves was assigned adjectival ratings.

RESULTS

At the 50% probability level, the resultant and axial forces at the AIS 3+ level were 6.6 kN and 5.9 kN, and at the AIS 4 level these were 8.4 kN and 7.5 kN, respectively. Individual injury risk curves along with ±95% CIs are presented in the paper. Increased injury severity increased the HIPC metrics. Curve qualities were in the good and fair ranges for axial and shear forces at all probability levels and for both injury severities.

CONCLUSIONS

This is the first study to develop axial and resultant force-based HIPCs defining human tolerance to injuries to the pelvis from vertical impacts using parametric survival analysis. Data can be used to advance military safety under vertical loading to the seated pelvis.

Injuries in Underbody Blast Fatalities: Identification of Five Distinct Mechanisms of Head Injury

Previous research has shown that injuries to the head and neck were prevalent in 73% of all mounted fatalities of underbody blast. The mechanisms that cause such injuries to the central nervous system (CNS) are not yet known. The aim of this study was to identify the head and spinal injuries in fatalities due to underbody blast (UBB) and then develop hypotheses on the causative mechanisms. All U.K. military fatalities from UBB with an associated head injury that occurred during 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Computed tomography post-mortems (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology classification. Pearson's chi-square and Fisher's exact tests were used to show a relationship between variables and form a hypothesis for injury mechanisms. There were 50 fatalities from UBB with an associated head injury. Of these, 46 had complete CTPMs available for analysis. Chi-square and Fisher's exact tests showed a relationship between lateral ventricle blood and injuries to the abdomen and thorax. Five partially overlapping injury constellations were identified: 1.multiple-level spinal injury with skull fracture and brainstem injury, 2.peri-mesencephalic hemorrhage, 3.spinal and brainstem injury, 4.parenchymal contusions with injury to C0-C1, and 5.an "eggshell" pattern of fractures from direct impact. These injury constellations can now be used to propose injury mechanisms to develop mitigation strategies or clinical treatments.

Blast Injuries by an Improvised Explosive Device in Japan: A Case Report

Blast injuries caused by an improvised explosive device (IED) are becoming more common in civilian settings. However, physicians may not be familiar with the treatment and management of blast-injured victims. To the best of our knowledge, this is the first case report of a blast injury caused by an IED in Japan. A 64-year-old man was admitted to our hospital's emergency department after sustaining a blast injury. His vital signs were stable, but he had multiple small wounds with embedded foreign bodies that were consistent with injuries sustained by IED victims. The patient was treated for his injuries and was moved to another hospital on day 37. Knowledge about blast injuries caused by IEDs and management strategies for mass casualties are both necessary.

Loading rate effect on tradeoff of fractures from pelvis to lumbar spine under axial impact loading

Objectives: The transmission of impact loading from the seat-to-pelvis-to-lumbar spine in a seated occupant in automotive and military events is a mechanism for fractures to these body regions. While postmortem human subject (PMHS) studies have replicated fractures to the pelvis or lumbar spine using isolated/component models, the role of the time factor that manifests as a loading rate issue on injuries has not been fully investigated in literature. The objective of this study was to explore the hypothesis that short duration pulses fracture the pelvis while longer pulses fracture the spine, and intermediate pulses involve both components.Methods: Unembalmed PMHS thoracolumbar spine-pelvis specimens were fixed at the superior end, and a six-axis load cell was attached. The specimens were mounted on a vertical accelerator, and noninjury and injury tests were conducted by applying short, medium, or long pulses with 5, 15, or 35 ms durations, respectively. Peak axial, shear and resultant forces were obtained. Injuries were documented using posttest x-ray and computed tomography images and scaled using the AIS (2015).Results: The mean age, stature, weight, body mass index, and BMD of twelve specimens were 64.8 ± 11.4 years, 1.8 ± 0.01 m, 83 ± 13 kg, 26.7 ± 5.0 kg/m², and 114.5 ± 21.3 mg/cc, respectively. For the short, long, and medium duration pulses, the mean resultant forces were 5.6 ± 0.9 kN, 5.9 ± 0.94 kN, and 5.4 ± 1.8 kN, and time durations were 4.8 ± 0.5 ms, 16.3 ± 7.3 ms, and 34.5 ± 7.5 ms, respectively. For the short pulse, pelvis injuries were more severe in 3 out 4 specimens, for the medium pulse, they were distributed between the pelvis and spine, and for the long pulse, spine injuries were more severe in 3 out of 4 specimens.Conclusions: While acknowledging the limitations of the sample size, the results of this study support the hypothesis of the time variable in the tradeoff between pelvis and spine injuries with pulse duration. The tradeoff pattern is attributed to mass recruitment: short pulse biases injuries to pelvis while limiting spinal injuries, and the opposite is true for the longer pulse, thus supporting the hypothesis. It is important to account for the time variable in injury analysis.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020

PURPOSE

Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs.

METHODS

This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis.

RESULTS

During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed.

CONCLUSIONS

Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

Development of a rodent high-energy blast injury model for investigating conditions associated with traumatic amputations

AIMS

In recent conflicts, most injuries to the limbs are due to blasts resulting in a large number of lower limb amputations. These lead to heterotopic ossification (HO), phantom limb pain (PLP), and functional deficit. The mechanism of blast loading produces a combined fracture and amputation. Therefore, to study these conditions, in vivo models that replicate this combined effect are required. The aim of this study is to develop a preclinical model of blast-induced lower limb amputation.

METHODS

Cadaveric Sprague-Dawley rats' left hindlimbs were exposed to blast waves of 7 to 13 bar burst pressures and 7.76 ms to 12.68 ms positive duration using a shock tube. Radiographs and dissection were used to identify the injuries.

RESULTS

Higher burst pressures of 13 and 12 bar caused multiple fractures at the hip, and the right and left limbs. Lowering the pressure to 10 bar eliminated hip fractures; however, the remaining fractures were not isolated to the left limb. Further reducing the pressure to 9 bar resulted in the desired isolated fracture of the left tibia with a dramatic reduction in the fractures to other sites.

CONCLUSION

In this paper, a rodent blast injury model has been developed in the hindlimb of cadaveric rats that combines the blast and fracture in one insult, necessitating amputation. Experimental setup with 9 bar burst pressure and 9.13 ms positive duration created a fracture at the tibia with total reduction in non-targeted fractures, rendering 9 bar burst pressure suitable for translation to a survivable model to investigate blast injury-associated diseases. Cite this article: Bone Joint Res 2021;10(3):166-172.

A Comparative Study Between Two Combat Injury Severity Scores

INTRODUCTION

In recent years, specific trauma scoring systems have been developed for military casualties. The objective of this study was to examine the discrepancies in severity scores of combat casualties between the Abbreviated Injury Scale 2005-Military (mAIS) and the Military Combat Injury Scale (MCIS) and a review of the current literature on the application of trauma scoring systems in the military setting.

METHODS

A cross-sectional, descriptive, and retrospective study was conducted between May 1, 2005, and December 31, 2014. The study population consisted of all combat casualties attended in the Spanish Role 2 deployed in Herat (Afghanistan). We used the New Injury Severity Score (NISS) as reference score. Severity of each injury was calculated according to mAIS and MCIS, respectively. The severity of each casualty was calculated according to the NISS based on the mAIS (Military New Injury Severity Score-mNISS) and MCIS (Military Combat Injury Scale-New Injury Severity Score-MCIS-NISS). Casualty severity were grouped by severity levels (mild-scores: 1-8, moderate-scores: 9-15, severe-scores: 16-24, and critical-scores: 25-75).

RESULTS

Nine hundred and eleven casualties were analyzed. Most were male (96.37%) with a median age of 27 years. Afghan patients comprised 71.13%. Air medevac was the main casualty transportation method (80.13). Explosion (64.76%) and gunshot wound (34.68%) mechanisms predominated. Overall mortality was 3.51%. Median mNISS and MCIS-NISS were similar in nonsurvivors (36 [IQR, 25-49] vs. [IQR, 25-48], respectively) but different in survivors, 9 (IQR, 4-17) vs. 5 (IQR, 2-13), respectively (P < .0001). The mNISS and MCIS-NISS were discordant in 34.35% (n = 313). Among cases with discordant severity scores, the median difference between mNISS and MCIS-NISS was 9 (IQR, 4-16); range, 1 to 57.

CONCLUSION

Our study findings suggest that discrepancies in injury severity levels may be observed in one in three of the casualties when using mNISS and MCIS-NISS.

Comparison of Human Surrogate Responses in Underbody Blast Loading Conditions

Impact biomechanics research in occupant safety predominantly focuses on the effects of loads applied to human subjects during automotive collisions. Characterization of the biomechanical response under such loading conditions is an active and important area of investigation. However, critical knowledge gaps remain in our understanding of human biomechanical response and injury tolerance under vertically accelerated loading conditions experienced due to underbody blast (UBB) events. This knowledge gap is reflected in anthropomorphic test devices (ATDs) used to assess occupant safety. Experiments are needed to characterize biomechanical response under UBB relevant loading conditions. Matched pair experiments in which an existing ATD is evaluated in the same conditions as a post mortem human subject (PMHS) may be utilized to evaluate biofidelity and injury prediction capabilities, as well as ATD durability, under vertical loading. To characterize whole body response in the vertical direction, six whole body PMHS tests were completed under two vertical loading conditions. A series of 50th percentile hybrid III ATD tests were completed under the same conditions. Ability of the hybrid III to represent the PMHS response was evaluated using a standard evaluation metric. Tibial accelerations were comparable in both response shape and magnitude, while other sensor locations had large variations in response. Posttest inspection of the hybrid III revealed damage to the pelvis foam and skin, which resulted in large variations in pelvis response. This work provides an initial characterization of the response of the seated hybrid III ATD and PMHS under high rate vertical accelerative loading.

Damage Control Resuscitation Supplemented with Vasopressin in a Severe Polytrauma Model with Traumatic Brain Injury and Uncontrolled Internal Hemorrhage

INTRODUCTION

Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of traumatic death worldwide and particularly on the battlefield. They are especially challenging when present simultaneously (polytrauma), and clear blood pressure end points during fluid resuscitation are not well described for this situation. The goal of this study is to evaluate for any benefit of increasing blood pressure using a vasopressor on brain blood flow during initial fluid resuscitation in a swine polytrauma model.

MATERIALS AND METHODS

We used a swine polytrauma model with simultaneous TBI, femur fracture, and HS with uncontrolled noncompressible internal bleeding from an aortic tear injury. Five animals were assigned to each of three experimental groups (hydroxyethyl starch only [HES], HES + 0.4 U/kg vasopressin, and no fluid resuscitation [No Fluids]). Fluids were given as two 10 mL/kg boluses according to tactical field care guidelines. Primary outcomes were mean arterial blood pressure (MAP) and brain blood flow at 60 min. Secondary outcomes were blood flows in the heart, intestine, and kidney; arterial blood lactate level; and survival at 6 hr. Organ blood flow was measured using injection of colored microspheres.

RESULTS

Five animals were tested in each of the three groups. There was a statistically significant increase in MAP with vasopressin compared with other experimental groups, but no significant increase in brain blood flow during the first 60 min of resuscitation. The vasopressin group also exhibited greater total internal hemorrhage volume and rate. There was no difference in survival at 6 hours.

CONCLUSION

In this experimental swine polytrauma model, increasing blood pressure with vasopressin did not improve brain perfusion, likely due to increased internal hemorrhage. Effective hemostasis should remain the top priority for field treatment of the polytrauma casualty with TBI.

Nonfatal motor vehicle related injuries among deployed US Service members: Characteristics, trends, and risks for limb amputations

BACKGROUND

Motor vehicle-related (MVR) incidents are important causes of morbidity among deployed US service members (SMs). Nonbattle MVR injuries are usually similar to civilian MVR injuries, while battle MVR injuries are often unique due to the blast effects from precipitating explosive mechanisms. Our primary objective was to describe the characteristics and trends of nonfatal MVR injuries sustained by deployed US SMs. A second objective was to assess the association between mechanism of injury (i.e., explosive vs. nonexplosive) and limb amputation.

METHODS

We conducted a retrospective cross-sectional analysis using data from the Department of Defense Trauma Registry collected from October 2001 to December 2018. Descriptive statistics were reported stratified by mechanism of injury (explosive vs. nonexplosive). The association between mechanism of injury and limb amputation was assessed using logistic regression models.

RESULTS

There were 3,119 US casualties who sustained nonfatal MVR injuries, 2,380 (76.3%) SMs sustained nonexplosive MVR injuries while 739 (23.7%) sustained explosive MVR injuries. Of all MVR casualties, 2,085 (66.9%) were in Iraq or Syria and 1034 (33.1%) in Afghanistan. The annual prevalence of nonfatal MVR battle casualties was highest in Iraq and Syria from 2003 to 2009 and Afghanistan from 2009 to 2014, ranging overall 15 to 50 MVR casualties per 1,000 wounded in action. There were 92 limb amputations associated with MVR incidents. Compared with nonexplosive MVR mechanisms, explosive MVR mechanisms had higher association with limb amputation (adjusted odds ratio, 2.6; confidence interval, 1.7-3.9), even after adjusting for injury year and Injury Severity Score (AOR, 2.1; confidence interval: 1.4-3.4).

CONCLUSION

Motor vehicle-related incidents are an important cause of injury in US military operations. Compared with nonexplosive MVR incidents, explosive MVR incidents result in more severe injuries, and have a higher associated risk of limb amputation. Continued efforts to improve injury prevention through protective equipment and medical training specific to MVR injuries are needed.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, Level III.

Lower Limb Posture Affects the Mechanism of Injury in Under-Body Blast

Over 80% of wounded Service Members sustain at least one extremity injury. The 'deck-slap' foot, a product of the vehicle's floor rising rapidly when attacked by a mine to injure the limb, has been a signature injury in recent conflicts. Given the frequency and severity of these combat-related extremity injuries, they require the greatest utilisation of resources for treatment, and have caused the greatest number of disabled soldiers during recent conflicts. Most research efforts focus on occupants seated with both tibia-to-femur and tibia-to-foot angles set at 90°; it is unknown whether results obtained from these tests are applicable when alternative seated postures are adopted. To investigate this, lower limbs from anthropometric testing devices (ATDs) and post mortem human subjects (PMHSs) were loaded in three different seated postures using an under-body blast injury simulator. Using metrics that are commonly used for assessing injury, such as the axial force and the revised tibia index, the lower limb of ATDs were found to be insensitive to posture variations while the injuries sustained by the PMHS lower limbs differed in type and severity between postures. This suggests that the mechanism of injury depends on the posture and that this cannot be captured by the current injury criteria. Therefore, great care should be taken when interpreting and extrapolating results, especially in vehicle qualification tests, when postures other than the 90°-90° are of interest.

Environment at the time of injury determines injury patterns in pelvic blast

The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and loss of life, on a very large scale. The environment at the time of detonation is known to result in different injury patterns in casualties exposed to blast, which is highly relevant to injury mitigation analyses. We describe differences in pelvic injury patterns in relation to different environments, from casualties that presented to the deployed UK military hospitals in Iraq and Afghanistan. A casualty on foot when injured typically sustains an unstable pelvic fracture pattern, which is commonly the cause of death. These casualties die from blood loss, meaning treatment in these should focus on early pelvic haemorrhage control. In contrast, casualties injured in vehicle present a different pattern, possibly caused by direct loading via the seat, which does not result in pelvic instability. Fatalities in this cohort are from injuries to other body regions, in particular the head and the torso and who may require urgent neurosurgery or thoracotomy as life-saving interventions. A different strategy is therefore required for mounted and dismounted casualties in order to increase survivors.

Peacekeepers suffered combat-related injuries in Mali: a retrospective, descriptive study

PURPOSE

To describe the combat-related injuries cured by Chinese Level 2 medical treatment facility (CHN L2) in Mali from 1 March 2016 to 1 March 2018, including type of weapon, mortality, nature of injuries, degree and location of injuries and surgical procedures. METHODS : A retrospective, descriptive study of 176 injured cases that met the terrorist attacks was conducted. The medical data were collected by an electronic database system. All collected data were entered into an Excel spreadsheet for calculation.

RESULTS

We found that improvised explosive devices (114/176, 65%) were the most commonly used weapons of attack in Mali. 68.75% of the injuries (121/176) were classified as 'minor injuries according to Abbreviated Injury Scale score. As one patient may suffer multiple injuries, each location and nature of injuries was counted separately. Surface injuries were the top (116/197, 58.88%), followed by orthopaedic injuries (52/197, 26.39%) and internal injuries (29/197, 14.72%). The extremities were the most frequently injured body parts (144/197, 73.09%). We operated 175 surgeries to deal with the 176 combat-related injuries, which accounted for 40.05% of all 437 surgeries. The surgical debridement to remove fragments of explosive was the most frequently performed surgery. We also admitted 20 cases (18/176, 34%) into intensive care unit and transferred 40 cases to Level 3 medical facility. CONCLUSION : Peacekeepers taking protective measures for head and trunk frequently got surface injuries. And their unprotected extremities often got injured. The fragment removal was the top surgery and the damage control surgery was the highly technical nature surgery we performed. Chinese military should offer advanced surgical training course to military surgeons who carry out overseas operations.

Analysis of the Frequency and Mechanism of Injury to Warfighters in the Under-body Blast Environment

During Operation Iraqi Freedom and Operation Enduring Freedom, improvised explosive devices were used strategically and with increasing frequency. To effectively design countermeasures for this environment, the Department of Defense identified the need for an under-body blast-specific Warrior Injury Assessment Manikin (WIAMan). To help with this design, information on Warfighter injuries in mounted under-body blast attacks was obtained from the Joint Trauma Analysis and Prevention of Injury in Combat program through their Request for Information interface. The events selected were evaluated by Department of the Army personnel to confirm they were representative of the loading environment expected for the WIAMan. A military case review was conducted for all AIS 2+ fractures with supporting radiology. In Warfighters whose injuries were reviewed, 79% had a foot, ankle or leg AIS 2+ fracture. Distal tibia, distal fibula, and calcaneus fractures were the most prevalent. The most common injury mechanisms were bending with probable vehicle contact (leg) and compression (foot). The most severe injuries sustained by Warfighters were to the pelvis, lumbar spine, and thoracic spine. These injuries were attributed to a compressive load from the seat pan that directly loaded the pelvis or created flexion in the lumbar spine. Rare types of injuries included severe abdominal organ injury, severe brain injury, and cervical spine injury. These typically occurred in conjunction with other fractures. Mitigating the frequently observed skeletal injuries using the WIAMan would have substantial long-term benefits for Warfighters.

Porphyrins in troubled times: a spotlight on porphyrins and their metal complexes for explosives testing and CBRN defense

A critical perspective on (metallo)porphyrins in security-related applications: the past, present and future of explosives detection, CBRN defense, and beyond.

Mechanical characterization and finite element implementation of the soft materials used in a novel anthropometric test device for simulating underbody blast loading

Soft materials (e.g. polymers) are widely used in biomechanical devices to represent the nonlinear viscoelastic properties inherent in biological soft tissues. Knowledge of their mechanical properties is used to inform design choices and develop accurate finite element (FE) models of human surrogates. The goal of this study was to characterize the behavior of eight polymeric materials used in the design of a novel anthropomorphic test device (ATD) and implement these materials in an FE model of the ATD. Tensile and compressive tests at strain rates ranging from 0.01s^-1 to 1000s^-1 were conducted on specimens from each material. Stress-strain relationships at discrete strain rates were used to define strain rate-dependent hyper-elastic material models in a commercial finite element solver. Then, the material models were implemented into an FE model of the ATD. The performance of the material models in the FE model was evaluated by simulating experiments that were conducted on the ATD lower limb. The material characterization tests revealed viscoelastic strain rate-dependent properties in the flesh and compliant elements of the ATD. Higher modulus polymers exhibited rate-dependent, strain-hardening properties. A strong agreement was seen between the material model simulations and corresponding experiments. In component simulations, the materials performed well and the model reasonably predicted the forces observed in experiments.

[A new concept of organization and scope of neurosurgical care in the US army during armed conflicts in the early 2000s]

Military operations in various parts of the world in the early 2000s are becoming more regionalized; new warfare tactics emerge, which makes it necessary to review and modify the neurosurgical care system. The article reviews the results of original studies on this issue and summarizes the experience of the US Army medical service in Afghanistan and Iraq. The article discusses the structure of sanitary losses, organization and scope of medical and evacuation neurosurgical measures, types and techniques of surgical interventions, and the rate of complications. We describe five levels of neurosurgical care echelons and an implemented "injury control - neurosurgery" concept; particular attention is paid to the peculiarities of research and specialist training. We demonstrate that implementation of the new concept for organization and scope of neurosurgical care has improved treatment outcomes and reduced the mortality rate in the mentioned military conflicts of recent years compared to those in the Vietnam War. We may conclude that the described experience of the US Army can be used to improve the efficacy of neurosurgical care to the wounded and victims of armed conflicts.

A correlation analysis of metacarpal & phalangeal injury pattern from improvised explosive devices amongst armed force personnel

Injuries to the hand during military combat operations, particularly from improvised explosive devices (IEDs) have a significant impact on form, function, mental health and future employment but remain underreported amidst the life and limb-threatening emergencies that garner more attention. An understanding the patterns of hand injuries encountered from IEDs is crucial to optimizing reconstruction and rehabilitation. The aim of this study was to re-evaluate hand injury sustained from IED in order to understand the clinical burden for reconstruction and direct the focus for future hand protection. We identified 484 hand injuries in 380 patients sustained as a result of IEDs among military personnel service in Afghanistan between 2006 and 2013. 53% of all surviving military personnel injured by IEDs sustain injuries to the hand. Analysis of the 103 patients who sustained injury to the metacarpal, phalanges or digital amputation revealed that the middle and ring fingers are most commonly injured. Amputation to the ring finger is strongly associated with injury to the adjacent fingers and amputations to the middle, ring and little fingers concurrently is a commonly observed pattern. The proximal phalanges of the middle and ring fingers had a strong correlation for fracture together. These findings disprove the conventional belief in an ulnar focus of injury and support the quest for a development of combat hand protection that addresses the injury pattern seen.

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data

INTRODUCTION

Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.

METHODS

The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ² and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.

RESULTS

We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).

CONCLUSION

Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

What does the literature say about the needs of veterans in the areas of health?

This paper reports on a systematic review undertaken in 2013 aimed at identifying evidence and dismissing some of the myths surrounding the needs of the veteran community. Papers were retrieved from a wide range of sources to ensure that literature covered the key areas of health concerns and focused also on time spent in service. Of the twenty eight papers reviewed categories relating to mental health (including PTSD and suicide), the use of alcohol, trauma, hearing loss, cancer and obesity were identified. Outcomes from the review established that while early service leavers were the most vulnerable there were also aspects within service that had an impact on future life events such as the type of leadership experienced, the cohesion of the unit and facing combat situations. The use of alcohol as a coping mechanism is also considered prevalent with adverse effects as is the worry of family situations at home. The impact of service life on the veteran, especially if suffering trauma will have long lasting psychological and physical outcomes, although it is recognised that veterans in the main have excellent physical and psychological strength and many physical illnesses are not greatly exaggerated from that of the general public.

Blast Injuries: From Improvised Explosive Device Blasts to the Boston Marathon Bombing

Although most trauma centers have experience with the imaging and management of gunshot wounds, in most regions blast wounds such as the ones encountered in terrorist attacks with the use of improvised explosive devices (IEDs) are infrequently encountered outside the battlefield. As global terrorism becomes a greater concern, it is important that radiologists, particularly those working in urban trauma centers, be aware of the mechanisms of injury and the spectrum of primary, secondary, tertiary, and quaternary blast injury patterns. Primary blast injuries are caused by barotrauma from the initial increased pressure of the explosive detonation and the rarefaction of the atmosphere immediately afterward. Secondary blast injuries are caused by debris carried by the blast wind and most often result in penetrating trauma from small shrapnel. Tertiary blast injuries are caused by the physical displacement of the victim and the wide variety of blunt or penetrating trauma sustained as a result of the patient impacting immovable objects such as surrounding cars, walls, or fences. Quaternary blast injuries include all other injuries, such as burns, crush injuries, and inhalational injuries. Radiography is considered the initial imaging modality for assessment of shrapnel and fractures. Computed tomography is the optimal test to assess penetrating chest, abdominal, and head trauma. The mechanism of blast injuries and the imaging experience of the victims of the Boston Marathon bombing are detailed, as well as musculoskeletal, neurologic, gastrointestinal, and pulmonary injury patterns from blast injuries.

Improvised explosive device-related lower genitourinary trauma in current overseas combat operations

BACKGROUND

The use of improvised explosive devices (IEDs) has had a profound effect on battlefield trauma in the 21st century. Historically, wounds to the genitourinary (GU) structures have been less common than extremity and penetrating abdominal trauma in combat operations. GU injury incidence, severity, and associated injuries secondary to the use of this weapon in Operations Iraqi and Enduring Freedom has not been described.

METHODS

Data from the Department of Defense Trauma Registry was reviewed for combat-related GU injuries in Operations Iraqi and Enduring Freedom from 2001 to 2011. All wounded US armed service members are included in this database. Subjects were selected by a query of current procedural terminology and DRG International Classification of Diseases-9th Rev. codes related to traumatic injury of the penis, scrotum, testicles, and urethra. A retrospective chart review was performed for each patient to identify the date of injury, the mechanism of injury, and the associated traumatic wounds. Subjects' follow-up records were reviewed until present time or separation from active duty.

RESULTS

A total of 501 soldiers sustained lower GU trauma, with a total of 729 injuries. Of these casualties, 448 (89%) were wounded by IEDs. Dismounted injuries (87%) made up more of the cohort than did vehicular. Specific trauma sites include 149 (20%) penile, 260 (36%) testicular, 284 (39%) scrotal, and 36 (5%) urethral injuries. The 180 limb amputations (36%) and 86 fractures (17%) were the most encountered concomitant skeletal wounds among service members with GU injuries.

CONCLUSION

This is the first review of all lower GU trauma sustained by all US armed service members in current overseas combat operations. Combat-related lower GU trauma is primarily caused by IEDs in the spectrum of complex dismounted blast injuries. The mechanism primarily results in multisystem injury, with isolated GU involvement being uncommon. Continued evaluation of long-term sequelae, including sexual, urinary, and reproductive dysfunction, is needed.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

Deaths due to Intentional Explosions in Selected Governorates of Iraq from 2010 to 2013: Prospective Surveillance

INTRODUCTION

The aim of this study was to describe the most recent trends and epidemiologic patterns of fatal injuries resulting from explosions in Iraq, one of the countries most affected by violence from explosive devices.

METHODS

Iraqi Ministry of Health (MoH) routine prospective injury surveillance collects information on all fatal injuries recorded by coroners from physical examinations, police reports, and family members in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. This study analyzed explosive-related fatal injuries that occurred from January 1, 2010 through December 31, 2013.

RESULTS

Analysis included 2,803 fatal injuries. The number of fatal injuries declined from 2010 through 2012, followed by an increase in 2013. One-thousand one-hundred and one explosion-related fatalities were documented in 2013, more than twice as many as in 2012 or in 2011. Most fatalities were among men aged 20-39 years. Of all causalities, 194 (6.9%) were among females and 302 (10.8%) were among children aged less than 18 years. The majority of fatalities were caused by improvised explosive devices (IEDs): car bombs (15.3%), suicide bombs (4.0%), and other IEDs (29.6%). The highest number of fatalities occurred in streets and roads. Of all deaths, 95.6% occurred in three governorates: Baghdad, Ninevah, and Al-Anbar.

CONCLUSIONS

Explosives continue to result in a high number of fatal injuries in Iraq. Following a period of declining violence from explosives, in 2013, fatalities increased. Most explosion-related injuries resulted from IEDs; males aged 20-39 years were at greatest risk.

Dermal Fenestration With Negative Pressure Wound Therapy: A Technique for Managing Soft Tissue Injuries Associated With High-Energy Complex Foot Fractures

Military casualties can sustain complex foot fractures from blast incidents. This frequently involves the calcaneum and is commonly associated with mid-foot fracture dislocations. The foot is at risk of both compartment syndrome and the development of fracture blisters after such injuries. The amount of energy transfer and the environment in which the injury was sustained also predispose patients to potential skin necrosis and deep infection. Decompression of the compartments is a part of accepted practice in civilian trauma to reduce the risk of complications associated with significant soft tissue swelling. The traditional methods of foot fasciotomy, however, are not without significant complications. We report a simple technique of dermal fenestration combined with the use of negative pressure wound therapy, which aims to preserve the skin integrity of the foot without resorting to formal fasciotomy.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma

OBJECTIVE

To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts.

BACKGROUND

FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan.

METHODS

Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management.

RESULTS

A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%.

CONCLUSIONS

FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

The use of urinary bladder matrix in the treatment of trauma and combat casualty wound care

Treatment of combat injuries and resulting wounds can be difficult to treat due to compromised and evolving tissue necrosis, environmental contaminants, multidrug resistant microbacterial and/or fungal infections, coupled with microvascular damage and/or hypovascularized exposed vital structures. Our group has developed surgical care algorithms with identifiable salvage techniques to achieve stable, definitive wound coverage often with the aid of certain regenerative medicine biologic scaffold materials and advanced wound care to facilitate tissue coverage and healing. This case series reports on the role of urinary bladder matrix scaffolds in the wound care and reconstruction of traumatic and combat wounds. Urinary bladder matrix was found to facilitate definitive soft tissue reconstruction by establishing a neovascularized soft tissue base acceptable for second stage wound and skin coverage options within traumatic and combat-related wounds.

Steroid-Loaded Hemostatic Nanoparticles Combat Lung Injury after Blast Trauma

In response to the lack of therapeutics for internal bleeding following a traumatic event, we synthesized hemostatic dexamethasone nanoparticles (hDNP) to help alleviate internal hemorrhaging. hDNP consist of a block copolymer, poly(lactic-co-glycolic acid)-poly(l-lysine)-poly(ethylene glycol) conjugated to a peptide, glycine-arginine-glycine-aspartic acid-serine (GRGDS). These particles were evaluated as treatment for primary blast lung injury in a rodent model. Animals were randomly placed into test and control groups, exposed to blast and given immediate injection. Recovery was assessed using physiological parameters and immunohistochemistry. We found that dexamethasone-loaded hemostatic nanoparticles alleviate physiological deprivation caused by blast injury and reduce lung injury damage.

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster

OBJECTIVE

We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions.

BACKGROUND

Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes.

METHODS

A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack.

RESULTS

A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity.

CONCLUSIONS

Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation

BACKGROUND

Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation.

PATIENTS AND METHODS

The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for.

RESULTS

Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management.

CONCLUSIONS

The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.

What's new in operative trauma surgery in the last 10 years

PURPOSE OF REVIEW

This article reviews the latest operative trauma surgery techniques and strategies, which have been published in the last 10 years. Many of the articles we reviewed come directly from combat surgery experience and may be also applied to the severely injured civilian trauma patient and in the context of terrorist attacks on civilian populations.

RECENT FINDINGS

We reviewed the most important innovations in operative trauma surgery; the use of ultrasound and computed tomography in the preoperative evaluation of the penetrating trauma patient, the use of temporary vascular shunts, the current management of military wounds, the use of preperitoneal packing in pelvic fractures and the management of the multiple traumatic amputation patient.

SUMMARY

The last 10 years of conflict has produced a wealth of experience and novel techniques in operative trauma surgery. The articles we review here are essential for the contemporary care of the severely injured trauma patient, whether they are card for in a level 1 trauma center or in a field hospital at the edge of a battlefield.

Lower genitourinary trauma in modern warfare: the experience from civil violence in Iraq

BACKGROUND

Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war.

PATIENTS AND METHODS

A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs.

RESULTS

Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53-67% of cases and by individual firearms in 33-47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17-22% of cases and by firearms in 78-83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died.

CONCLUSIONS

Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury

PURPOSE

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

METHODS

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

RESULTS

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

CONCLUSIONS

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.

Incidence and morbidity of concomitant spine fractures in combat-related amputees

BACKGROUND CONTEXT

High-energy blasts are the most frequent cause of combat-related amputations in Operations Iraqi and Enduring Freedom (OIF/OEF). The nondiscriminating effects of this mechanism often result in both appendicular and axial skeletal injuries. Despite this recognized coincident injury pattern, the incidence and consequence of spine fractures in trauma-related combat amputees are unknown.

PURPOSE

This study sought to determine the incidence and morbidity of the associated spine fractures on patients with traumatic lower extremity amputation sustained during OIF/OEF.

STUDY DESIGN/SETTING

Retrospective case control.

PATIENT SAMPLE

Two hundred twenty-six combat-related lower extremity amputees presenting to a single institution and injured between 2003 and 2008 were included for analysis.

OUTCOME MEASURES

Physiologic and functional outcome measures were used to determine the influence of spine fractures on combat amputees. Physiologic measures included intensive care unit (ICU) admission rates, injury severity score (ISS), rate of narcotic/neuropathic pain use, and heterotopic ossification (HO) rates. Functional outcome measures included return-to-duty rates and ambulatory status at final follow-up.

METHODS

Data from 300 consecutive combat-related lower extremity amputations were retrospectively reviewed and grouped. Group 1 consisted of amputees with associated spine fractures, and Group 2 consisted of amputees without spine fractures. The results of the two groups were compared with regard to initial presentation and final functional outcomes.

RESULTS

A total of 226 patients sustained 300 lower extremity amputations secondary to combat-related injuries, the most common mechanism being an improvised explosive device. Twenty-nine of these patients had a spine fracture (13%). Group 1 had a higher ISS than Group 2 (30 vs. 19, p<.001). Group 1 patients were also more likely to be admitted to the ICU (86% vs. 46%, p<.001). Furthermore, Group 1 patients had a significantly higher rate of HO in their residual limbs (82% vs. 55%, p<.005).

CONCLUSIONS

The incidence of spine fractures in combat-related amputees is 13%. The results suggest that combat-related amputees with spine fractures are more likely to sustain severe injuries to other body systems, as indicated by the significantly higher ISS and rates of ICU admission. This group also had a significantly higher rate of HO formation, which may be attributable to the greater local and/or systemic injuries sustained by these patients.

Urethral and penile war injuries: The experience from civil violence in Iraq

Objective

To determine the incidence, mechanism of injury, wounding pattern and surgical management of urethral and penile injuries sustained in civil violence during the Iraq war.

Patients and methods

In all, 2800 casualties with penetrating trauma to the abdomen and pelvis were received at the Al-Yarmouk Hospital, Baghdad, from January 2004 to June 2008. Of these casualties 504 (18%) had genitourinary trauma, including 45 (8.9%) with urethral and/or penile injuries.

Results

Of 45 patients, 29 (64%) were civilians and 16 (36%) were Iraqi military personnel. The injury was caused by an improvised explosive device (IED) in 25 (56%) patients and by individual firearms in 20 (44%). Of the patients, 24 had penile injuries, 15 had an injury to the bulbar urethra and six had an injury to the posterior urethra. Anterior urethral injuries were managed by primary repair, while posterior urethral injuries were managed by primary realignment in five patients and by a suprapubic cystostomy alone in one. An associated injury to major blood vessels was the cause of death in eight of nine patients who died soon after surgery (P < 0.001).

Conclusion

Urethral and penile injuries were caused by IEDs and individual firearms with a similar frequency. Most of the casualties were civilians and a minority were military personnel. Injuries to the anterior urethra can be managed by primary repair, while injuries to the posterior urethra can be managed by primary realignment. An associated trauma to major blood vessels was the leading cause of death in these casualties.

Combat injury coding: a review and reconfiguration

BACKGROUND

The current civilian Abbreviated Injury Scale (AIS), designed for automobile crash injuries, yields important information about civilian injuries. It has been recognized for some time, however, that both the AIS and AIS-based scores such as the Injury Severity Score (ISS) are inadequate for describing penetrating injuries, especially those sustained in combat. Existing injury coding systems do not adequately describe (they actually exclude) combat injuries such as the devastating multi-mechanistic injuries resulting from attacks with improvised explosive devices (IEDs).

METHODS

After quantifying the inapplicability of current coding systems, the Military Combat Injury Scale (MCIS), which includes injury descriptors that accurately characterize combat anatomic injury, and the Military Functional Incapacity Scale (MFIS), which indicates immediate tactical functional impairment, were developed by a large tri-service military and civilian group of combat trauma subject-matter experts. Assignment of MCIS severity levels was based on urgency, level of care needed, and risk of death from each individual injury. The MFIS was developed based on the casualty's ability to shoot, move, and communicate, and comprises four levels ranging from "Able to continue mission" to "Lost to military." Separate functional impairments were identified for injuries aboard ship. Preliminary evaluation of MCIS discrimination, calibration, and casualty disposition was performed on 992 combat-injured patients using two modeling processes.

RESULTS

Based on combat casualty data, the MCIS is a new, simpler, comprehensive severity scale with 269 codes (vs. 1999 in AIS) that specifically characterize and distinguish the many unique injuries encountered in combat. The MCIS integrates with the MFIS, which associates immediate combat functional impairment with minor and moderate-severity injuries. Predictive validation on combat datasets shows improved performance over AIS-based tools in addition to improved face, construct, and content validity and coding inter-rater reliability. Thus, the MCIS has greater relevance, accuracy, and precision for many military-specific applications.

CONCLUSION

Over a period of several years, the Military Combat Injury Scale and Military Functional Incapacity Scale were developed, tested and validated by teams of civilian and tri-service military expertise. MCIS shows significant promise in documenting the nature, severity and complexity of modern combat injury.

Wound outcome in combat injuries is associated with a unique set of protein biomarkers

Background

The ability to forecast whether a wound will heal after closure without further debridement(s), would provide substantial benefits to patients with severe extremity trauma.

Methods

Wound effluent is a readily available material which can be collected without disturbing healthy tissue. For analysis of potential host response biomarkers, forty four serial combat wound effluent samples from 19 patients with either healing or failing traumatic- and other combat-related wounds were examined by 2-D DIGE. Spot map patterns were correlated to eventual wound outcome (healed or wound failure) and analyzed using DeCyder 7.0 and differential proteins identified via LC-MS/MS.

Results

This approach identified 52 protein spots that were differentially expressed and thus represent candidate biomarkers for this clinical application. Many of these proteins are intimately involved in inflammatory and immune responses. Furthermore, discriminate analysis further refined the 52 differential protein spots to a smaller subset of which successfully differentiate between wounds that will heal and those that will fail and require further surgical intervention with greater than 83% accuracy.

Conclusion

These results suggest candidates for a panel of protein biomarkers that may aid traumatic wound care prognosis and treatment. We recommend that this strategy be refined, and then externally validated, in future studies of traumatic wounds.