Wounding patterns for U.S. Marines and sailors during Operation Iraqi Freedom, major combat phase

A Focus on Non-Amputation Combat Extremity Injury: 2001-2018

INTRODUCTION

Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports.

METHODS

The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented.

RESULTS

A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3.

CONCLUSION

This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.

How Common Are Civilian Blast Injuries in the National Trauma Databank, and What Are the Most Common Mechanisms and Characteristics of Associated Injuries?

BACKGROUND

Recent military conflicts have produced substantial improvements in the care of service members who experience blast injuries. As conflicts draw down, it is important to preserve and improve skills gained in combat. It is unknown whether civilian blast injuries can serve as a surrogate for military blast trauma. To guide further research, it is crucial to understand the volume, severity, and distribution of civilian blast injury in the civilian population.

QUESTIONS/PURPOSES

(1) What proportion of US trauma admissions are a result of blast injury? (2) What are the common mechanisms, and what is the demographic breakdown of civilian patients presenting to trauma centers after blast injuries? (3) What is the severity, and what are the characteristics of injuries sustained by civilian patients after blast injuries?

METHODS

We queried the American College of Surgeons National Trauma Databank (NTDB), a national aggregation of trauma registry data which captures robust mechanism of injury and wounding pattern information, for any patient admitted for trauma and an initial mechanism of injury corresponding to a predefined list of ICD-9 and ICD-10 external cause of injury codes related to blast injuries and reported as a proportion of all trauma-related admissions. Mechanisms were categorized into similar groups, and data were collected regarding demographics as well as location and intentionality of blast (that is, unintentional, the result of assault, or self-inflicted). Patient injuries were characterized by ICD-9 or ICD-10 diagnosis codes and sorted according to the body area affected and severity of injury, measured via the Injury Severity Score (ISS). The ISS is a measure of trauma severity, with scores ranging from 1 to 75 points based on injury severity, which is calculated according to injury scores in six separate body domains (head or neck, face, chest, abdomen or pelvis, extremities, external). A score of 1 represents a minor trauma to one region, while a score of 75 indicates injuries deemed nonsurvivable in one or more domains. Data were limited to trauma admissions in 2016.

RESULTS

Patients injured by blast mechanisms represented 0.3% (2682 of 968,843) of patients in NTDB-participating trauma centers who were treated after a blast injury in the year 2016; 86% (2315 of 2682) of these patients were men, and the mean ± SD age was 38 ± 21 years. Blast injuries most commonly occurred after detonation of fireworks (29% [773 of 2682]) or explosion of gas or pressurized containers (27% [732 of 2682]). The most commonly injured area of the body was the upper extremity (33% [894 of 2682]), followed by the face (28% [747 of 2682]), lower extremity (11% [285 of 2682]), thorax (10% [280 of 2682]), and head (10% [259 of 2682]). Fifty-eight percent (1564 of 2682) of patients had at least one burn injury. A total of 2% (51 of 2682) of the injuries were fatal, with a mean ISS score of 6 ± 8; 23% (608 of 2682) of patients presented with injuries classified as severe (ISS > 8).

CONCLUSION

Civilian blast-associated injuries are not common, but they can be severe, and in many (though not all) respects they seem similar to those described in published case series of military blast victims. Key differences include age and gender (civilian injuries more commonly involve women and older patients than do those in military studies). The potential of civilian blast patient care as a surrogate for study and clinical experience for military surgeons in the interwar period-as recommended by the National Academies of Sciences, Engineering, and Medicine report-is supported by our preliminary results. Future interventions or training programs would likely need to rely on multisite or targeted partnerships to encounter appropriate numbers of patients with blast injuries.

LEVEL OF EVIDENCE

Level IV, prognostic study.

The impact of delayed surgical intervention following high velocity maxillofacial injuries

Our study compares the number of postoperative complications of Syrian patients admitted to the Galilee Medical Center (GMC) over a 5-year period (May 2013-May 2018) for treatment after initial high-velocity maxillofacial injuries sustained during the Syrian civil war. Specifically, we evaluated complication rates of patients arriving "early," within 24 h, to the GMC versus those who arrived "late," or 14-28 days following high-velocity maxillofacial injuries. Both groups of patients received definitive surgical treatment within 48 h of admission to our hospital with a total of 60 patients included in this study. The mean age was 26 ± 8 years (range: 9-50) and all except one were male. Postoperative complications in the early group were found to be significantly higher compared to the delayed arrival group (p = 0.006). We found that unintentionally delayed treatment may have contributed to a critical revascularization period resulting in improved healing and decreased postoperative morbidity and complications. We discuss potential mechanisms for complication rate variations, including critical vascularization periods. Our study may add to a growing body of work demonstrating the potential benefit of delayed surgical treatment for high-velocity maxillofacial injuries.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation

PURPOSE

Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes.

MATERIALS AND METHODS

Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status.

RESULTS

Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning.

CONCLUSIONS

Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

The application of bone marrow mesenchymal stem cells and biomaterials in skeletal muscle regeneration

Skeletal muscle injuries have bothered doctors and caused great burdens to the public medical insurance system for a long time. Once injured, skeletal muscles usually go through the processes of inflammation, repairing and remodeling. If repairing and remodeling stages are out of balance, scars will be formed to replace injured skeletal muscles. At present, clinicians usually use conventional methods to restore the injured skeletal muscles, such as flap transplantation. However, flap transplantation sometimes needs to sacrifice healthy autologous tissues and will bring extra harm to patients. In recent years, stem cells-based tissue engineering provides us new treatment ideas for skeletal muscle injuries. Stem cells are cells with multiple differentiation potential and have ability to differentiate into adult cells under special condition. Skeletal muscle tissues also have stem cells, called satellite cells, but they are in small amount and new muscle fibers that derived from them may not be enough to replace injured fibers. Bone marrow mesenchymal stem cells (BM-MSCs) could promote musculoskeletal tissue regeneration and activate the myogenic differentiation of satellite cells. Biomaterial is another important factor to promote tissue regeneration and greatly enhance physiological activities of stem cells in vivo. The combined use of stem cells and biomaterials will gradually become a mainstream to restore injured skeletal muscles in the future. This review article mainly focuses on the review of research about the application of BM-MSCs and several major biomaterials in skeletal muscle regeneration over the past decades.

Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017

BACKGROUND

Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown.

METHODS

We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis.

RESULTS

Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets.

CONCLUSIONS

Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.

Unrealized potential of the US military battlefield trauma system: DOW rate is higher in Iraq and Afghanistan than in Vietnam, but CFR and KIA rate are lower

LEVEL OF EVIDENCE

Observational/retrospective/historic controls, level IV.

Hydrodynamic rupture of liver in combat patient: a case of successful application of "damage control" tactic in area of the hybrid war in East Ukraine

Background

The hybrid war of Russia against Ukraine has been started in certain districts of Donetsk and Luhansk oblasts within the Donbas area in 2014.

Case presentation

We report a clinical case of a combat patient who was injured after the multiple launcher rocket system “Grad” shelling, diagnosed with hydrodynamic liver rupture followed by medical management with application of damage control (DC) tactic in conditions of hybrid war.

The patient underwent relaparatomy, liver resection, endoscopic papillosphincterotomy, endoscopic retrograde cholecystopancreatography, stenting of the common bile duct, and VAC-therapy. Applied treatment modalities were effective; the patient was discharged on the 49th day after injury.

Conclusions

To our best knowledge, this is the first report describing a successful application of DC tactic in the hybrid war in East Ukraine. From this case, we suggest that application of DC tactic at all levels of combat medical care could save more lives.

Amputation: Not a failure for severe lower extremity combat injury

INTRODUCTION

The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life.

PATIENTS AND METHODS

All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation.

RESULTS

In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery.

CONCLUSION

Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury.

Strength and histology of a nanofiber scaffold in rats

BACKGROUND

Full-thickness soft tissue defects from congenital absence or traumatic loss are difficult to surgically manage. Healing requires cell migration, organization of an extracellular matrix, inflammation, and wound coverage. PLCL (70:30 lactide:caprolactone, Purac), poly(propylene glycol) nanofibrous scaffolds enhance cell infiltration in vitro. This study compares strength and tissue ingrowth of aligned and unaligned nanofibrous scaffolds to absorbable and permanent meshes. We hypothesize that PLCL nanofibrous grafts will provide strength necessary for physiological function while serving as a scaffold to guide native tissue regeneration in vivo.

MATERIALS AND METHODS

Abdominal wall defects were created in 126 rats followed by underlay implantation of Vicryl, Gore-Tex, aligned, or unaligned PLCL Nanofiber mesh. Specimens were harvested at 2, 6, and 12 wk for strength testing and 2, 12, and 24 wk for histopathologic evaluation. Specimens were graded for cellular infiltration, multinucleated giant cells (MNG), vascularity, and tissue organization. Mean scores were compared and analyzed with non-parametric testing.

RESULTS

The PLCL grafts maintained structural integrity until at least 12 wk and exhibited substantial tissue replacement at 24 wk. At 12 wk, only the aligned PLCL had persistent cellular infiltration of the graft, whereas both aligned and unaligned PLCL grafts showed the presence of MNG. The presence of MNGs decreased in the aligned PLCL graft by 24 wk.

CONCLUSIONS

The aligned PLCL nanofiber mesh offers early strength comparable to Gore-Tex but breaks down and is replaced with cellular ingrowth creating a favorable option in management of complex surgical wounds or native soft tissue defects.

Plastic Surgery Challenges in War Wounded II: Regenerative Medicine

Background: A large volume of service members have sustained complex injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF). These injuries are complicated by contamination with particulate and foreign materials, have high rates of bacterial and/or fungal infections, are often composite-type defects with massive soft tissue wounds, and usually have multisystem involvement. While traditional treatment modalities remain a mainstay for optimal wound care, traditional reconstruction approaches alone may be inadequate to fully address the scope and magnitude of such massive complex wounds. As a result of these difficult clinical problems, the use of regenerative medicine therapies, such as autologous adipose tissue grafting, stem cell therapies, nerve allografts, and dermal regenerate templates/extracellular matrix scaffolds, is increased as adjuncts to traditional reconstructive measures. Basic and Clinical Science Advances: The beneficial applications of regenerative medicine therapies have been well characterized in both in vitro studies and in vivo animal studies. The use of these regenerative medicine techniques in the treatment of combat casualty injuries has been increasing throughout the recent war conflicts. Clinical Care Relevance: Military medicine has shown positive results when utilizing certain regenerative medicine modalities in treating complex war wounds. As a result, multi-institution clinical trials are underway to further evaluate these observations and reconstruction measures. Conclusion: Successful combat casualty wound care often requires a combination of traditional aspects of the reconstructive ladder/elevator with adoption of various regenerative medicine therapies. Due to the recent OIF/OEF conflicts, a high volume of combat casualties have benefited from adoption of regenerative medicine therapies and increased access to innovative clinical trials. Furthermore, many of these patients have had long-term follow-up to report on clinical outcomes that substantiate current treatment paradigms and concepts within regenerative medicine, reconstructive, and rehabilitation care. These results are applicable to not only combat casualty care but also to nonmilitary patients.

Plastic Surgery Challenges in War Wounded I: Flap-Based Extremity Reconstruction

Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.

Immunomodulatory capacity of the local mesenchymal stem cells transplantation after severe skeletal muscle injury in female rats

CONTEXT

Cell therapy technique with stem cells is a very attractive strategy for the treatment of muscle disorders.

OBJECTIVE

The objective of this study was to investigate the mechanism of local transplantation of mesenchymal stem cells (MSCs) which could contribute to skeletal muscle healing.

MATERIALS AND METHODS

Female rats were divided into three equal groups as the following: group 1, the negative control group (untreated group), group 2, sham-treated group, rats with muscle injuries involving volumetric muscle loss (VML) of adductor brevis muscle and injected locally with phosphate-buffered saline (PBS) 0.5 ml without stem cells after 7 d of muscle injury, group 3, treated group, rats with VML and injected locally (intramuscular) with 1.5 × 10⁶ bone marrow MSCs suspended in PBS 0.5 ml (1) after 7 d of muscle tissue injury. All animals were sacrificed after 4 weeks of stem cell transplantation.

RESULTS

In vitro culture the morphology of MSCs reached confluence and appeared as long spindle in shape on 9-14 d. Most of the cells did not express the hematopoietic cell marker, CD34 and CD45 but expressed MSCs marker CD44, CD90 and CD105. The remarkable increase of proliferating cell nuclear antigen positive nucleus was recorded in MSCs group as compared to PBS group. After 28 d of injection, administration of only PBS into the site of muscle injury caused up-regulation in the levels of interleukins IL-1β, IL-6, tumor necrosis factor alpha (TNF-α), transforming growth factor beta (TGF-β1), interferon alpha (IFN-α) and down-regulate the level of IL-10 in muscular tissue comparing to the untreated control. Bone marrow MSCs + PBS injected at the site of muscle injury significantly down-regulate the inflammatory cytokines levels IL-1β and IL-6 and TNF-α, TGF-β1 and IFN-α and up-regulate the level of IL-10. Collagen concentrations in the injured skeletal muscle estimated by enzyme-linked immuno sorbent assay and stained with Masson trichrome stain were increased with PBS group and decreased after transplantation of bone marrow MSCs in the site of injury. Muscle sections stained with H&E showed a higher number of centronucleated regenerating myofibers in the stem-cell-treated group than in the (PBS) and untreated control group. Microvasculature of skeletal muscle was decreased as demonstrated by immunostaining technique for CD34 in PBS group from untreated control. The MSCs group showed angiogenesis and marked increase of skeletal muscle microvasculature than PBS group.

CONCLUSION

MSCs can modify the local immunological responses and improve muscle regeneration by suppressing of inflammatory cytokines, activating of the anti-inflammatory cytokine, restoration of muscle fibers and angiogenesis. By means of increase in TGF-β production in response to muscle injury prevent the repair of injured fibers and increase connective tissue production (collagen fibers), thus propagating skeletal muscle weakness and fibrosis whereas MSCs + PBS injected at the site of muscle injury significantly down-regulate (TGF-β1) and hence the level of collagen (fibrosis or scar areas). MSCs are able to block the fibrotic signaling cascade by declining TGF-β1 and scar areas in the injured muscle.

Regional Variation in Causes of Injuries among Terrorism Victims for Mass Casualty Events

The efficient allocation of medical resources to prepare for and respond to mass casualty events (MCEs) attributable to intentional acts of terrorism is a major challenge confronting disaster planners and emergency personnel. This research article examines variation in regional patterns in the causes of injures associated with 77,258 successful terrorist attacks that occurred between 1970 and 2013 involving the use of explosives, firearms, and/or incendiaries. The objective of this research is to estimate regional variation in the use of different conventional weapons in successful terrorist attacks in each world region on variation in injury cause distributions. Indeed, we find that the distributions of the number of injuries attributable to specific weapons types (i.e., by cause) vary greatly among the 13 world regions identified within the Global Terrorism Database.

Clinical and post mortem analysis of combat neck injury used to inform a novel coverage of armour tool

INTRODUCTION

There is a requirement in the Ministry of Defence for an objective method of comparing the area of coverage of different body armour designs for future applications. Existing comparisons derived from surface wound mapping are limited in that they can only demonstrate the skin entry wound location. The Coverage of Armour Tool (COAT) is a novel three-dimensional model capable of comparing the coverage provided by body armour designs, but limited information exists as to which anatomical structures require inclusion. The aim of this study was to assess the utility of COAT, in the assessment of neck protection, using clinically relevant injury data.

METHOD

Hospital notes and post mortem records of all UK soldiers injured by an explosive fragment to the neck between 01 Jan 2006 and 31 December 2012 from Iraq and Afghanistan were analysed to determine which anatomical structures were responsible for death or functional disability at one year post injury. Using COAT a comparison of three ballistic neck collar designs was undertaken with reference to the percentage of these anatomical structures left exposed.

RESULTS

13/81 (16%) survivors demonstrated complications at one year, most commonly upper limb weakness from brachial plexus injury or a weak voice from laryngeal trauma. In 14/94 (15%) soldiers the neck wound was believed to have been the sole cause of death, primarily from carotid artery damage, spinal cord transection or rupture of the larynx. COAT objectively demonstrated that despite the larger OSPREY collar having almost double the surface area than the two-piece prototype collar, the percentage area of vulnerable cervical structures left exposed only reduced from 16.3% to 14.4%.

DISCUSSION

COAT demonstrated its ability to objectively quantify the potential effectiveness of different body armour designs in providing coverage of vulnerable anatomical structures from different shot line orientations. To improve its utility, it is recommended that COAT be further developed to enable weapon and tissue specific information to be modelled, and that clinically significant injuries to other body regions are also incorporated.

Role 2 military hospitals: results of a new trauma care concept on 170 casualties

INTRODUCTION

In recent military conflicts, military surgeons encounter more high-energy injuries associated with explosives. Advances in the field care and shorter evacuation time increased survival. However, casualties still incur severe injuries especially to the extremities. We present wound patterns, anatomical distribution and severity of injuries in a Role 2 hospital.

MATERIALS AND METHODS

Two years data have been retrospectively reviewed. Only explosives and firearms injuries were included in the study. Patient profile, admission details, mechanism of injury, AIS anatomical locations, ISS, surgical and medical treatments have been analyzed.

RESULTS

Data revealed 170 male casualties. IEDs and GSW accounted for 133 (78%) and 37 (22%) casualties, respectively. An average of 1.8 IED and 1.2 GSW anatomical locations were exposed to injuries. Regardless of the mechanism, injuries were most commonly located in the extremities. IEDs caused significantly higher soft tissue injuries.

DISCUSSION

Explosives do not necessarily cause more severe injuries than firearms. However, fragments create multiple, complicated soft tissue injuries which constitute more than half of the injuries. Timely wound debridement and excision of contaminated tissue are crucial to manage extremity soft tissue injuries.

CONCLUSION

Casualty care should be assessed within the context of the capabilities present at a hospital and the cause, type and severity of the wounds. The NATO description of Role 2 care only requires an integrated surgical team for damage control surgery with limited diagnostic and infrastructural capabilities.

Systematic review of the prevalence and characteristics of battle casualties from NATO coalition forces in Iraq and Afghanistan

BACKGROUND

The North Atlantic Treaty Organization (NATO) coalition forces remain heavily committed on combat operations overseas. Understanding the prevalence and characteristics of battlefield injury of coalition partners is vital to combat casualty care performance improvement. The aim of this systematic review was to evaluate the prevalence and characteristics of battle casualties from NATO coalition partners in Iraq and Afghanistan. The primary outcome was mechanism of injury and the secondary outcome anatomical distribution of wounds.

METHODS

This systematic review was performed based on all cohort studies concerning prevalence and characteristics of battlefield injury of coalition forces from Iraq and Afghanistan up to December 20th 2013. Studies were rated on the level of evidence provided according to criteria by the Centre for Evidence Based Medicine in Oxford. The methodological quality of observational comparative studies was assessed by the modified Newcastle-Ottawa Scale.

RESULTS

Eight published articles, encompassing a total of n=19,750 battle casualties, were systematically analyzed to achieve a summated outcome. There was heterogeneity among the included studies and there were major differences in inclusion and exclusion criteria regarding the target population among the included trials, introducing bias. The overall distribution in mechanism of injury was 18% gunshot wounds, 72% explosions and other 10%. The overall anatomical distribution of wounds was head and neck 31%, truncal 27%, extremity 39% and other 3%.

CONCLUSIONS

The mechanism of injury and anatomical distribution of wounds observed in the published articles by NATO coalition partners regarding Iraq and Afghanistan differ from previous campaigns. There was a significant increase in the use of explosive mechanisms and a significant increase in the head and neck region compared with previous wars.

In vivo assessment of the Combat Ready Clamp to control junctional hemorrhage in swine

BACKGROUND

Junctional wounds and associated hemorrhage have become more common and more lethal in the current war. The Combat Ready Clamp (CRoC) has been developed and deployed for treating junctional hemorrhage on the battlefield. This study examined the efficacy of CRoC and its acute effects in an animal model.

METHODS

Anesthetized pigs (n = 6) were subjected to laparotomy, splenectomy, and abdominal closure. Next, coagulopathy was induced in animals by hemodilution and hypothermia. The left femoral artery was isolated, punctured (6-mm hole), and allowed to bleed for 15 seconds. The groin wound was packed with gauze, and a CRoC applied and tightened until hemorrhage stopped. It was kept in place for 1 hour (treatment period) and then released for another hour or less (control-period) if animal exsanguinated. Fluid resuscitation was administered, and vascular blood flow was examined by Doppler and CT scans. After death, local tissues were collected for histology.

RESULTS

CRoC generated 800 to 900 mm Hg pressure on the wounds, which stopped the hemorrhage and prevented rebleeding during the first hour in all animals. Blood loss was minimal (≤137 mL), and mean arterial pressure remained at or higher than the target level (65 mm Hg) during this period. Removal of the clamp promptly led to rebleeding and exsanguination of five of six pigs during the second hour despite fluid resuscitation. Blood loss, survival, shock indices, and other measures were significantly (p < 0.01) different between the two periods. Doppler tests and CT scans showed no blood flow in the proximal, distal, and collateral arteries of the clamped leg. Minor inflammation was seen on blood vessels (endothelium) and nerves.

CONCLUSION

CRoC functioned as an effective hemostatic adjunct for compression and control of groin hemorrhage. Although no acute histological damages were seen in compressed tissues, the short- and long-term effects of CRoC application (e.g., total ischemia) on limb function remain unknown and warrant investigation.

Injuries from combat explosions in Iraq: injury type, location, and severity

INTRODUCTION

Explosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel.

MATERIALS AND METHODS

A descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion.

RESULTS

A total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%).

CONCLUSION

The results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries.

Wartime spine injuries: understanding the improvised explosive device and biophysics of blast trauma

The improvised explosive device (IED) has been the most significant threat by terrorists worldwide. Blast trauma has produced a wide pattern of combat spinal column injuries not commonly experienced in the civilian community. Unfortunately, explosion-related injuries have also become a widespread reality of civilian life throughout the world, and civilian medical providers who are involved in emergency trauma care must be prepared to manage casualties from terrorist attacks using high-energy explosive devices. Treatment decisions for complex spine injuries after blast trauma require special planning, taking into consideration many different factors and the complicated multiple organ system injuries not normally experienced at most civilian trauma centers. Therefore, an understanding about the effects of blast trauma by spine surgeons in the community has become imperative, as the battlefield has been brought closer to home in many countries through domestic terrorism and mass casualty situations, with the lines blurred between military and civilian trauma. We set out to provide the spine surgeon with a brief overview on the use of IEDs for terrorism and the current conflicts in Iraq and Afghanistan and also a perspective on the biophysics of blast trauma.

Assessment of the effects of acute and repeated exposure to blast overpressure in rodents: toward a greater understanding of blast and the potential ramifications for injury in humans exposed to blast

Mild traumatic brain injury (mTBI) resulting from exposure to improvised explosive devices (IEDs) has fueled a requirement to develop animals models that mirror this condition using exposure to blast overpressure (BOP). En route to developing a model of repeated exposure to BOP we sought to initially characterize the effects of acute BOP exposure in rodents, focusing specifically on the levels of BOP exposure that produced clinical mTBI symptoms. We first measured BOP effects on gross motor function on a balance beam. Separate groups of unanesthetized rats were exposed (in different orientations) to 36.6, 74.5, and 116.7 kPa BOP exposure inside a pneumatically driven shock tube. Results demonstrated that rats exposed to 116.7 kPa demonstrated transient alterations or loss of consciousness indicated by a transient loss of righting and by increased latencies on the balance beam. The 116.7 kPa exposure was the threshold for overt pathology for acute BOP exposure with approximately 30% of rats presenting with evidence of subdural hemorrhage and cortical contusions. All animals exposed to 116.7 kPa BOP manifested evidence of significant pulmonary hemorrhage. Anterograde memory deficits were observed in rats exposed to 74.5 kPa facing the BOP wave and rats exposed to 116.7 kPa in the lateral (side) orientation. We next assessed repeated exposure to either lateral or frontal 36.6 kPa BOP in anesthetized rats, once per day for 12 days. Results showed that repeated exposure in the frontal, but not side, orientation to the BOP wave produced a transitory learning deficit on a Morris water maze task as shown by significantly longer latencies to reach the submerged platform in the second and third blocks of a four block session. Implications of these data are discussed in relation to the manifestation of mTBI in military personnel exposed to IEDs. Finally, we suggest that there are multiple types of long-term brain injury from blast exposure.

Combat-related gunshot wounds in the United States military: 2000-2009 (cohort study)

INTRODUCTION

The armed forces of the United States are engaged in the longest conflict in their history. No prior works have described the incidence or epidemiology of gunshot wounds in the U.S. military.

METHODS

All combat-related gunshot wounds sustained by uniformed servicemembers in the years 2000-2009 were identified using the Defense Medical Epidemiology Database. Demographic information for all individuals identified as having sustained gunshot injuries was obtained and like data was captured for the entire military population serving in the same time-period. Raw unadjusted incidence rates were calculated for gunshot wounds within the entire demographic, as well as for the subcategories of sex, military rank, branch of service, and age. Adjusted incidence rate ratios were also calculated via multivariate Poisson regression analysis, using subcategories with the lowest unadjusted incidence rates as referents.

RESULTS

We identified 4693 gunshot wounds within a population of 13,813,333 person-years for an overall incidence of 0.34 per 1000 person-years. Marine Corps service demonstrated the highest unadjusted incidence rate at 0.68 per 1000 person-years. Male sex, Junior Enlisted rank, Army and Marine Corps service, and ages 20-29 demonstrated significant adjusted incidence rate ratios and maintained unadjusted incidence rates above the population mean.

CONCLUSIONS

Male sex, Junior Enlisted rank, Army and Marine Corps service, and ages 20-29 were identified as significant independent risk factors for war-related gunshot injuries. This investigation is the first to report on the incidence and epidemiology of gunshot wounds and includes the largest cohort of individuals to sustain such injuries in the literature.

The evaluation and treatment of comorbid pain and PTSD in a military setting: an overview

The present article reviews the growing prevalence of comorbid pain and post-traumatic stress disorder (PTSD) in the military. This has been caused by the ongoing military conflicts in Iraq and Afghanistan, where new combat conditions/strategies are causing these comorbid conditions. Fortunately, comprehensive interdisciplinary treatment programs, originally developed for a civilian population and in academic settings, are being successfully "translated" or utilized in the military environment. Recent data demonstrating this translational clinical intervention are presented. Finally, challenges encountered when translating these interventions in a military environment are also discussed.

Prevention of infections associated with combat-related eye, maxillofacial, and neck injuries

The percentage of combat wounds involving the eyes, maxillofacial, and neck regions reported in the literature is increasing, representing 36% of all combat-related injuries at the start of the Iraq War. Recent meta-analysis of 21st century eye, maxillofacial, and neck injuries described combat injury incidences of 8% to 20% for the face, 2% to 11% for the neck, and 0.5% to 13% for the eye and periocular structures. This article reviews recent data from military and civilian studies to support evidence-based recommendations for the prevention of infections associated with combat-related eye, maxillofacial, and neck injuries. The major emphasis of this review is on recent developments in surgical practice as new antimicrobial studies were not performed. Further studies of bacterial infection epidemiology and postinjury antimicrobial use in combat-related injuries to the eyes, maxillofacial, and neck region are needed to improve evidence-based medicine recommendations. This evidence-based medicine review was produced to support the Guidelines for the Prevention of Infections associated with Combat-related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Combat-related craniofacial and cervical injuries: a 5-year review from the British military

BACKGROUND

Recent international publications have noted a sustained increase in the incidence of head, face, and neck (HFN) wounds in comparison with total battle injuries from the 20th to the 21st century. The aim of this review was therefore to perform an analysis of the epidemiology of all HFN injuries sustained by British forces in Iraq and Afghanistan from March 1, 2003, to December 31, 2008.

METHODS

Descriptive injury data for this research were obtained from the Joint Theater Trauma Registry and overall battle injury and evacuation figures from the Defense Analytical and Statistical Agency.

RESULTS

During this period, 448 servicemen sustained injuries to their HFN. A total of 71% of HFN injuries were sustained in battle. Of all service personnel sustaining HFN injuries, 32% died before the field hospital and a further 6% died subsequently. A total of 73% of injuries required evacuation back to the United Kingdom, whereas 27% of injuries were managed definitively in the theater of operations. HFN injuries altogether were found in 29% of battle injuries between 2006 and 2008.

CONCLUSIONS

The individual incidences of head (15%) and face (19%) injuries in relation to total battle injuries, although greater than seen in previous United Kingdom conflicts, were only slightly higher than that seen by US forces. The incidence of neck injury alone in relation to total battle injuries of 11% in United Kingdom forces in comparison with 3% to 5% found in US forces warrants further investigation. This article also provides further evidence to support the existing published opinion of multiple international authors in the requirement to develop innovative methods of protecting the vulnerable HFN regions.

Managing traumatic brain injury secondary to explosions

Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined.

Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage

BACKGROUND

This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates.

METHODS

Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality.

RESULTS

The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted.

CONCLUSION

Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

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.

Civilian and Military Trauma: Does Civilian Training Prepare Surgeons for the Battlefield?

The management of trauma patients continues to be a major focus of resident training. The purpose of this review is to compare the mechanism and distribution of injuries in civilian and military trauma and to ascertain whether we are optimally preparing surgeons for the injuries seen on the battlefield. We performed a retrospective 5-year review of all trauma admissions to our urban trauma center (TC). We then compared this data with that recently acquired from Operation Iraqi Freedom (OIF). There were 7732 trauma patients seen during that time at our TC with 9.8 per cent sustaining gunshot wounds. Of those, 26 per cent sustained a gunshot wound to the thorax, and injuries to the abdomen and pelvis were sustained in 28.5 per cent. In total, truncal trauma accounted for 55 per cent of the injuries. Extremity injuries occurred in just 31 per cent. Data from OIF show the mechanism and distribution of injuries to be quite different. Improvised explosive devices accounted for greater than 50 per cent of the injuries in OIF. Truncal injuries accounted for just 14 per cent of the injuries seen and extremity injuries accounted for, a significant, 56 per cent of all the injuries observed. The civilian experience with gunshot wounds often focuses on truncal trauma, yet the military data show a need for knowledge of devastating injuries to the extremity. This divergent experience may be even more salient in the future as the battlefield is brought closer to home through domestic terrorism and the line is blurred between military and civilian trauma.

Repair of traumatic skeletal muscle injury with bone-marrow-derived mesenchymal stem cells seeded on extracellular matrix

Skeletal muscle injury resulting in tissue loss poses unique challenges for surgical repair. Despite the regenerative potential of skeletal muscle, if a significant amount of tissue is lost, skeletal myofibers will not grow to fill the injured area completely. Prior work in our lab has shown the potential to fill the void with an extracellular matrix (ECM) scaffold, resulting in restoration of morphology, but not functional recovery. To improve the functional outcome of the injured muscle, a muscle-derived ECM was implanted into a 1 x 1 cm(2), full-thickness defect in the lateral gastrocnemius (LGAS) of Lewis rats. Seven days later, bone-marrow-derived mesenchymal stem cells (MSCs) were injected directly into the implanted ECM. Partial functional recovery occurred over the course of 42 days when the LGAS was repaired with an MSC-seeded ECM producing 85.4 +/- 3.6% of the contralateral LGAS. This was significantly higher than earlier recovery time points (p < 0.05). The specific tension returned to 94 +/- 9% of the contralateral limb. The implanted MSC-seeded ECM had more blood vessels and regenerating skeletal myofibers than the ECM without cells (p < 0.05). The data suggest that the repair of a skeletal muscle defect injury by the implantation of a muscle-derived ECM seeded with MSCs can improve functional recovery after 42 days.

Functional assessment of skeletal muscle regeneration utilizing homologous extracellular matrix as scaffolding

The loss of a portion of skeletal muscle poses a unique challenge for the normal regeneration of muscle tissue. A transection injury with tissue loss will not heal due to the gap between muscle segments. A damage model was developed by removing a portion of the lateral gastrocnemius (GAS) of Sprague-Dawley rats. Maximal isometric, tetanic tension (P(o)) was measured after the removal of either a small defect (0.5 x 1.0 cm) or a large defect (1.0 x 1.0 cm) piece of the GAS. In situ P(o) immediately after creation of the defect was 88.3 +/- 2.0% of the nonoperated contralateral GAS force for small defect and 76.9 +/- 3.2% of control for large defect. No functional recovery occurred in either group over the course of 28 days. To enhance recovery, a homologous, decellularized, muscle extracellular matrix (ECM) was implanted into the 1 x 1 cm defect of the lateral GAS of Lewis rats. After 42 days, growth of blood vessels and myofibers into the ECM was apparent, but no restoration of P(o) occurred. These data demonstrate the ability of the ECM to support muscle and blood vessel regeneration, but full recovery of function does not occur after 42 days.