Endophthalmitis in war and peace penetrating eye injuries

BACKGROUND/AIM: Nowadays, eye injuries are a leading cause of one-eye disease or blindness worldwide. The aim of this study was to comparatively analyze the frequency of endophthalmitis following war and peace eye injuries. METHODS: All the patients went throught the detailed ophthalmologic examinations, prophylactic antibiotic treatment, and pars plana vitrectomies (VPP), or other required surgical interventions. RESULTS: Inside the period from 1991 to 1998, 647 patients with eye injuries were hospitalized, out of which 500 with penetrating eye injuries. In the period 1999-2004, 611 patients with eye injuries, were treated, out of which 297 had penetrating eye injuries. Out of 500 patients with war penetrating eye injuries, in 286 of the cases intrabulbar foreign bodies (IFB) were detected. The signs of endophthalmitis were observed in 26 eyes (5.2%) at admission. Out of totally 297 peace penetrating eye injuries, 196 (66%) were IBF. In 25 eyes (8.4%) endophthalmitis was observed. CONCLUSION: In our study, the frequency of posttraumatic endophthalmitis following penetrating war eye injuries was relatively low, even lower than the frequency of endophthalmitis following peace eye injuries.     

现代高技术局部战争中眼战伤救治策略初探

目的：初步探讨高技术局部战争中我军实施眼战伤救治的策略。方法：调研二十世纪以来我军和外军重大战争中眼战伤卫勤资料，对“两山”作战和海湾战争中卫勤保障和眼战伤救治情况进行对比分析。结果：认识到现代战争眼战伤具有高发性、严重性、多样性的特点；高技术局部战争卫勤保障强调战区救治机构机动、灵活、靠前配置；与美军相比，我军“两山”作战中眼战伤救治力量配置相对靠后，救治水平不高。结论：我军眼战伤卫勤保障在救治机构优化配置、专科技术力量建设方面尚待提高；眼战伤救治也应倡导“时效救治”，在我军大规模快速后送运力不足的情况下，其实施的核心是眼战伤救治技术力量的前伸。     

Colorectal war injuries

During the war in Croatia (1991-1995), 851 war casualties were treated by the surgical teams of Rijeka Clinical Hospital. Among them, 66 patients (7.8%) had colon and/or rectum injuries, usually combined with trauma of other abdominal organs, most often jejunum and ileum (24.2%). Regarding the site of injury, right and sigmoid colon were the most frequently traumatized areas (30.3% and 31.8%, respectively). All patients received surgical treatment within 3 hours from wounding. In 89% of patients, relieving colostomy was formed after the resection of the damaged part of the intestine; 11% of patients were treated with primary resection or sutures without colostomy. The mortality rate of 3% (2 patients) was caused by mutilating multiple organ abdominal trauma combined with massive brain injury.     

Penetrating eye injury in war

The percentage of penetrating eye injuries in war has increased significantly in this century compared with the total number of combat injuries. With the increasing use of fragmentation weapons and possibly laser weapons on the battle-field in the future, the rate of eye injuries may exceed the 13% of the total military injuries found in Operations Desert Storm/Shield. During the Iran-Iraq War (1980-1988), eye injuries revealed that retained foreign bodies and posterior segment injuries have an improved prognosis in future military ophthalmic surgery as a result of modern diagnostic and treatment modalities. Compared with the increasing penetrating eye injuries on the battlefield, advances in ophthalmic surgery are insignificant. Eye armor, such as visors that flip up and down and protect the eyes from laser injury, needs to be developed. Similar eye protection is being developed in civilian sportswear. Penetrating eye injury in the civilian sector is becoming much closer to the military model and is now comparable for several reasons.     

Peripheral nerve war injuries.

OBJECTIVE: The purpose of this study is to evaluate peripheral nerve war injuries sustained during the war in southern Croatia and Bosnia and Herzegovina. PATIENTS AND METHODS: During the war in Croatia, 713 patients (99% male and 1% female) with wounds inflicted by firearms were examined at the Laboratory of Neurophysiology, University Hospital, Split. The patients, soldiers and civilians alike, ranged in age from 6 to 73 years (average, 28 years). All patients with firearm nerve war injuries underwent detection by electromyography and plurisegmental examination of the damaged peripheral nerve (neurography). The patients were examined and controlled on three occasions: within 2 months after wounding; up to 6 months after wounding; and more than 6 months after wounding. RESULTS: Single peripheral nerve lesions were present in 80% of the patients, and multiple peripheral nerve or plexus lesions were present in 20% of the patients. Peroneal and ulnar nerves were most often involved (20.9% and 19.8%, respectively). Associated massive injuries to the muscles, large blood vessels, or vital organs were present in 45% of the patients. Wounds were inflicted by shell fragments in 80% of the patients and by projectiles in 20% of the patients. CONCLUSION: According to our results, better recovery was achieved with conservative treatment and when physical therapy was initiated early with maximal patient cooperation. Electromyoneurographic findings were the most valid in the prognostic classification of war-inflicted peripheral nerve injuries.     

Elbow arthrodesis after war injuries

Arthrodesis is a surgical procedure that results in fusion of the joint and bony ankylosis. With this operation, we can achieve satisfactory function of the limb in cases in which options for different treatments no longer exist. Severe joint destruction, joint infections, and nonunions, as well as complex war injuries (with large bone and soft tissue defects), are indications for arthrodesis. The elbow is the most susceptible joint of the upper limb to war injury. Between 1992 and 1995, we performed elbow arthrodesis for nine patients in our department after war injuries. As analysis of our results shows, elbow arthrodesis, although a rarely performed surgical procedure, is the best treatment for patients with complex war injuries of the elbow. For arthrodesis, we used external fixation in combination with internal fixation (cancellous bone screw) and additional autologous cancellous bone grafts.     

Secondary neurosurgical management of craniocerebral war injuries

In Belgrade Military Medical Academy 88 males and 1 female (aged 13-55, average 28.6 years) with war craniocerebral injuries (CCI) were secondarily neurosurgically treated from October 1991 trough December 1992. Primary neurosurgical management of these patients was performed in war hospitals in former Yugoslavia. Out of 89 patients, 78 had penetrating, and 11 closed CCI. Out of 55 patients with penetrating CCI who underwent surgery, intracranial debridement was performed in 34 patients. All patients with severe CCI (GCS = 3-8) were severely by disabled or died, and in the majority of patients with minor CCI (GCS = 13-15) the outcome was good (p < 0.01). Statistical analysis showed no significant correlation between the extent of cerebral lesion and the outcome of penetrating CCI (p > 0.05). Eight (10.3%) patients with penetrating CCI died. The outcome of war CCI mostly depended on the severity of injury.     

Early failure of external fixation in the management of war injuries

OBJECTIVE: To review external fixation in the management of war injuries. METHOD: We prospectively followed up 15 external fixators (14 patients) applied in the management of war injuries. All these patients were treated at 202 Field Hospital during the 2003 Gulf Conflict. RESULTS: Of the 15 fixators, 13 (86.7%) required early revision or removal due to complications of the injury or the fixator. Instability was a problem with 10 fixators (67%), pin loosening was noted with 5 fixators (33%) involving twelve pins, and a significant pin track infection developed at 14 pin sites (3 fixators - 20%), which failed to resolve despite intravenous antibiotics. CONCLUSIONS: This study demonstrates a very high early complication rate of external fixation in the management of military injuries and cautions against its universal acceptance. If used, consideration must be given to the optimum time of frame application, whether at the time of initial debridement or at a later operation, and the optimal frame design, which will depend on the specific bone and fracture pattern. Pin site care must also be considered, particularly with the restrictions imposed by the military environment.     

Laser eye injuries in military occupations

INTRODUCTION: Lasers (light amplification by stimulated emission of radiation) play an important role in our world and their use is increasing. They are powerful tools for good, but can also cause tragedy, especially in an aviation environment. Information about injuries associated with lasers is limited. This study highlights several laser eye injuries in the U.S. military and discusses issues pertaining to them. METHODS: We gathered data from the U.S. Army Safety Center, the U.S. Army Center for Health Promotion and Preventive Medicine, and the Walter Reed Army Institute of Research. This paper describes ten representative cases of laser eye injury that occurred in the U.S. military between 1984 and 2000. RESULTS: Patients suffered retinal damage, though no corneal injury occurred. Most were caused by accidental exposure to a Q-switched, Neodynium:YAG (Nd:YAG) laser at 1064 nm wavelength. The incidents occurred both on and off duty, indoors and outdoors, and from close and long ranges. None of the victims were wearing eye protection. Inadequate training and poor equipment design were major factors in at least six of the nine unintentional cases. The tenth occurred during military operations in the Persian Gulf. All of the victims needed several months medical care and follow up. Two received medical discharges as a result of their injuries. DISCUSSION: As illustrated by these cases, human and societal costs from unintentional laser eye injuries can be reduced by improving operator training, safety procedure compliance, and equipment design. In addition, intentional laser eye injuries are a growing concern and further research is needed to design appropriate protection, treatment and countermeasures.     

Severe eye injuries in cricket.

We report five cases of severe eye injury sustained in cricket, including retinal detachment and rupture of the globe. The eye is at particular risk from a rising ball. We comment on the need for appropriate facial protection for batsmen and close fielders.     

Treatment of war injuries of the shoulder with external fixators

In this retrospective study, 18 patients with war injuries of the shoulder were reviewed to evaluate the technical problems associated with external fixation and to analyze the incidence of infection and late functional results. The average patient age was 28.5 years. All patients were male. Thirteen patients had explosive wounds, whereas five wounds were caused by gunshot missiles. All injuries were extensive in terms of bone and soft tissue defects. Six patients presented with complex injuries involving neurovascular structures. Sixteen patients were treated with external fixation. Application of the proximal pins of the external fixator through the humeral head was possible in eight patients, the scapula served as the site of proximal fixation in four patients, only the clavicle was available for placement of pins in two patients, and both the scapula and the clavicle had to be pinned to achieve proximal stabilization in two patients. In two patients, fixation was not possible and early amputation was performed. Infection was eventually eradicated in all patients, allowing for adequate soft tissue coverage of the wounds. Analysis of functional results at an average of 6 years after the injury showed a considerable degree of functional deficit in most patients.     

Management of war injuries of blood vessels in prolonged ischemia

We present a successful management of a gunshot wound of major blood vessels of the leg, in condition of prolonged ischemia. The patient has been sent to our hospital for the complete vascular management of the complete interruption of the major blood vessels of the left leg that were primarily ligated and marked. Because of the difficulties in evacuation, the patient arrived 20 hours after the wounding. There was no indication for the arteriography. The interruptions of the continuity of the superficial femoral artery in length of approximately 10 cm and of deep femoral vein in length of 8 cm were managed by interposition of autovenous grafts taken from the large subcutaneous vein of the other leg. Standard fasciotomy and partial exclusion of muscles of the left lower leg with relaxing fasciotomy of the left upper leg muscles were performed in the operative procedure. A successful rehabilitation has been completed and five years after the wounding, completely correct vascular and functional condition of the wounded leg was observed.