Blast and fragment injuries of the musculoskeletal system

Blast and fragment injuries of the musculoskeletal system are the most frequently encountered wounds in modern warfare. Most injuries to the musculoskeletal system involve so-called secondary blast injuries in which casing fragments and other debris become flying projectiles. Nonoperative treatment of selected wounds caused by small-fragment debris has been successful but remains controversial. Successful surgical treatment depends on meticulous wound débridement, with excision of nonviable tissue and foreign material likely to cause infection; adequate drainage; and delayed closure. Advanced internal fixation techniques used in modern trauma centers to treat predominantly blunt trauma may not be appropriate for care of orthopaedic war wounds in a field setting.     

Physical demands and injuries to the upper extremity associated with the space program

Hand and upper-extremity overuse and repetitive injuries in astronauts have been and continue to be a common problem in the space program. The demands on upper-extremity use in the astronaut training program, the zero-gravity environment, the extreme temperature conditions of space, the effects of space travel on human physiology/anatomy, and the constraints and pressures of space suits and gloves all can negatively impact upper-extremity function in ways that can result in overuse/repetitive injuries. Future plans for space exploration include endeavors that will continue and even increase the demands on the hand and upper extremity.     

Management of acute and chronic vascular injuries to the arm and forearm. Indications and technique.

Acute arterial injuries of the upper extremity account for half of civilian arterial injuries in the United States. The great majority of these injuries are due to penetrating trauma, with stab wounds and gunshot wounds being the most common cause. The history of the injury and a careful physical examination will identify most injuries. Arteriography should be performed when a vascular injury is suspected but not confirmed by physical examination. Reconstruction of critical vascular lesions is essential for restoration of flow distally. Noncritical lesions may be repaired in most cases, with long-term patency rates averaging 50% to 68%. Although amputation is uncommon after upper-extremity vascular injury, long-term disability can be significant in those patients with concomitant nerve injury. Chronic upper-extremity ischemia may be secondary to atherosclerotic occlusive disease, aneurysms, or arteriovenous fistulas. Angiography will delineate the diseased or occluded arterial segment, allowing bypass to be successful in more than 90% of cases. With careful attention to proper diagnosis and treatment, good to excellent long-term relief of symptoms can be obtained.     

Contemporary management of wartime vascular trauma

OBJECTIVE: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. METHODS: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. RESULTS: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%). CONCLUSIONS: This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.     

Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan

INTRODUCTION

International humanitarian law requires emergency medical support for both military personnel and civilians, including children. Here we present a detailed review of paediatric admissions with the pattern of injury and the resources they consume.

METHODS

All paediatric admissions to the hospital at Camp Bastion between 1 January and 29 April 2011 were analysed prospectively. Data collected included time and date of admission, patient age and weight, mechanism of injury, extent of wounding, treatment, length of hospital stay and discharge destination.

RESULTS

Eighty-five children (65 boys and 17 girls, median age: 8 years, median weight: 20kg) were admitted. In 63% of cases the indication for admission was battle related trauma and in 31% non-battle trauma. Of the blast injuries, 51% were due to improvised explosive devices. Non-battle emergencies were mainly due to domestic burns (46%) and road traffic accidents (29%). The most affected anatomical area was the extremities (44% of injuries). Over 30% of patients had critical injuries. Operative intervention was required in 74% of cases. The median time to theatre for all patients was 52 minutes; 3 patients with critical injuries went straight to theatre in a median of 7 minutes. A blood transfusion was required in 27 patients; 6 patients needed a massive transfusion. Computed tomography was performed on 62% of all trauma admissions and 40% of patients went to the intensive care unit. The mean length of stay was 2 days (range: 1–26 days) and there were 7 deaths.

CONCLUSIONS

Paediatric admissions make up a small but significant part of admissions to the hospital at Camp Bastion. The proportion of serious injuries is very high in comparison with admissions to a UK paediatric emergency department. The concentration of major injuries means that lessons learnt in terms of teamwork, the speed of transfer to theatre and massive transfusion protocols could be applied to UK paediatric practice.     

Injuries in road and traffic accidents: improvement of the system of prevention, rendering of medical aid and treatment of the victims

Traumatism in road-and-transport accidents at present is characterized by an increase in the number and the severity of the injuries with multiple and associated ones being predominant. The most frequent types of the combinations were as follows: head - extremities (35.9%); abdomen - pelvis - extremities (15.1%); head - abdomen - extremities (13.8%); head - breast - extremities and breast - extremities (14.7%), etc. The predominant focus of the injuries which causes a direct danger to the life of the victims at the period immediately after the trauma are craniocerebral injuries and injuries of the inner organs because of their severe complications such as asphyxia and acute massive blood loss. Diagnostic and therapeutic tactics oriented towards the immediate revealing of the injuries dangerous to life and of their complications is proposed. The method of compression-and-distraction osteosynthesis occupies a more and more prominent place in the treatment of the injuries of the locomotor system.     

Epidemiology of war injuries, about two conflicts: Iraq and Afghanistan

Since March 2003, military operations in Iraq "Operation Iraqi Freedom" (OIF) and in Afghanistan "Operation Enduring Freedom" (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.     

Special lessons learned from Iraq

Operation Iraqi Freedom is the largest casualty-producing conflict this nation's military has faced since Vietnam. Medical departments from the three services have done an extraordinary job reacting to the ever-changing landscape of modern warfare and the devastating injuries produced. From the revamping of prehospital care to new applications of damage-control surgery, challenges have erupted, lessons have been learned, and lives are being saved.     

Infizierte Tierbissverletzungen an den Extremitäten

The appearance of animal bite injuries varies in regard to location and extent. Injuries with puncture wounds involving the extremities carry great risk of infection. Managing the complications often requires substantial medical treatment and increased costs. The aim of this study is the evaluation of the course of disease, medical care, and treatment costs in patients with infected bite injuries. In the year 2000, 16 patients were treated for infection after bite injuries of the extremities. Fourteen patients received substandard therapy because of incorrect assessment of the extent of the bite wound. Because of infection, the average time needed for treatment before returning to work was 3 months, including 12 days of hospitalization and 16 days of out-patient treatment. The average treatment costs exceeded 6,100 Euro for the health insurance companies. Because of its increasing prevalence and inadequate treatment, this type of injury has become a serious public health problem.     

Upper-extremity vascular injuries

Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.     

Amputation for antipersonnel mine injuries of the leg: preservation of the tibial stump using a medial gastrocnemius myoplasty

Antipersonnel mines are very commonly used in modern warfare. They produce a recognisable pattern of injury to the leg, which frequently spares the gastrocnemius muscle. Surgical amputation is often indicated. Medial gastrocnemius myoplastic below-knee amputation is suitable for these injuries. The technique permits cover and preservation of an acceptable tibial stump.     

A musician-centered approach to management of performance-related upper musculoskeletal injuries

Study DesignInvited Clinical CommentaryBackgroundPerformance related musculoskeletal disorders (PRMD) are common in instrumental musicians and often affect the upper extremities. These overuse injuries typically result from inadequate attention to the musculoskeletal demands required for the high-level performance of musician-students and experienced instrumentalists.¹ PRMDs often interfere with career trajectory, and in extreme cases, can be career ending. Many clinicians and healthcare practitioners treating upper extremity injuries are not familiar with the specific demands faced by instrumental musicians and how to tailor treatment and prevention strategies to the specific risks and occupational needs of each instrumental group.Purpose of the studyThis paper describes an evidenced-based framework for the assessment, prevention, and treatment of musculoskeletal musician injuries to provide clinicians with an instrument-specific, and musician-centered guide for practice. We synthesized available literature on instrumental ergonomics, biomechanical demands, and upper extremity injuries to highlight the risks and common upper-extremity pathologies, focusing on the specific demands of instrumental groups: piano, high strings (violin and viola), low strings (cello and bass), percussion, woodwinds, and brass. Targeted assessment, prevention, and treatment strategies are reviewed in this context to provide healthcare providers with an evidence-based framework to approach the treatment of PRMD to mitigate incidence of injury during practice and performance.MethodsA comprehensive search of electronic databases was conducted including all study designs.ResultsThis review describes risk factors for PRMD in instrumental musicians, strategies to prevent misuse and performance injury, and musician-centered interventions to allow playing while reducing risk of misuse.ConclusionThe suggested assessment and treatment framework can assist clinicians with a customized patient-centered approach to prevention and treatment by addressing the gap in clinical knowledge with the goal of ultimately reducing the incidence and severity of PRMD in musicians.     

Review of 88 nail gun injuries to the extremities

BACKGROUND: Nail guns have been employed since 1959 to speed construction work, but with the increased productivity came an increasing number of injuries associated with the device. The majority of reported cases occur to the extremities. METHODS: Our study retrospectively examines 88 cases of nail gun injuries to the extremities collected from a 4-year period. Radiographs and charts were used to collect data on anatomic site, type of treatment, type and duration of antibiotic treatment, and outcomes. RESULTS: We found that infections associated with nail gun injuries were relatively rare (n=3) and in our study were limited to those patients who presented later than the day of injury. The majority of injuries were to the hand and knee (38.6% and 28.1%, respectively). No significant vascular or neurological injuries were encountered. CONCLUSIONS: It appears that simple emergency room removal of the nail with local debridement and a short course of antibiotics is appropriate in most cases. The exception to this is where there is intra-articular or neurovascular involvement, then operative debridement is recommended.     

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.Type of study/level of evidenceTherapeutic III.     

四肢主干动脉损伤诊治106例分析

目的 探讨四肢主干动脉损伤诊断、手术方法及并发症处理。方法 回顾性分析新疆维吾尔自治区人民医院血管外科2004年1月-2013年10月手术治疗的106例共110条四肢主干动脉损伤患者的病例情况,分别行动脉端端吻合33例,自体静脉移植53例,动脉裂口缝合13例;假性动脉瘤切除5例,结扎术6例。结果 110条动脉重建血运,患者无1例死亡,9例行截肢术。结论 早期诊断,有效控制出血和抗休克治疗,早期重建血流、防治并发症是降低截肢率和病死率的有效方法。     

Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries

PURPOSE: Nonoperative treatment of serious renal injuries has been advocated and yet to our knowledge the optimum level of operative treatment has not been established to date. We report a unique data set, in which patients with severe renal injuries were treated with an ultraconservative nonoperative approach during a period when urological consultation was not available at a major urban trauma center. MATERIALS AND METHODS: We retrospectively reviewed the charts of 51 patients identified with renal trauma in the Detroit Receiving Hospital trauma data base from 1997 to 2001. RESULTS: Injuries were grades I to V in 15, 7, 11, 14 and 4 cases, respectively, and had a tendency toward serious injury. Renorrhaphy was never performed. Nephrectomy was done sparingly, only for grade V renal injuries and only in patients who were exsanguinating from the kidney. Two of the 4 patients with grade V injury died of multiple injuries, including massive head injuries. Only 2 of the patients treated nonoperatively (4%) had complications, including fever and hematuria in 1 each. CONCLUSIONS: This data set seems to support an ultraconservative approach of limiting renal surgery to only patients with active exsanguination. The nephrectomy rate for 14 grade IV injuries, including some gunshot wounds to the kidney, was 0%. When comparing this rate with that in the literature, we would expect it to be 1 patient to as high as 10. This approach was safe and resulted in a low complication rate of 4%. Series in which more aggressive therapy for renal injuries is advocated should compare favorably to ultraconservative therapy if aggressive therapy is to continue to be widely advocated.     

Using an external fixation "kickstand" to prevent soft-tissue complications and facilitate wound management in traumatized extremities

External fixation represents an extremely effective and versatile means of treating severe musculoskeletal injuries of both upper and lower extremities, particularly in austere environments. A relatively simple modification of standard external fixation techniques can facilitate the care of complex soft-tissue wounds and prevent unnecessary wound complications. Additional carbon bars can be attached to the primary construct to create a "kickstand" that can effectively support the extremity and eliminate the risk for pressure ulcers. This kickstand modification, which also allows improved access for wound care and dressing changes, has proved to be an effective adjunct in the treatment of high-energy extremity trauma.     

Refrigeration anesthesia: With special reference to treatment of a severely damaged extremity complicated by visceral injury

In the care of the usual types of severe injuries to the extremities one is able to proceed with definitive therapy following the treatment of shock which is frequently present. There are, however, some cases of injuries to the extremity complicated by visceral damage. Before the advent of refrigeration anesthesia, the surgeon was left in a quandary trying to decide what should be done first.It is generally agreed that visceral damage must receive immediate treatment and when an attempt is made to carry out major amputations at the same time, the outcome is usually fatal. In the opinion of the author, the use of refrigeration anesthesia seems to make it possible to delay the treatment of the extremity without harmful effect to the patient.When the decision is reached regarding the necessity of sacrificing the extremity a tourniquet must be applied and amputation must be done above this level, thus several inches more of the extremity must be lost. The tourniquet appears necessary due to the rather considerable oozing that one sees in severely macerated extremities with comminuted fractures even after the major vessels have been ligated. It is rather difficult to reach a definite decision to amputate and then continue to wait. However, in the case presented, packing the injured leg in ice and waiting thirty-nine hours appears to have been of definite aid to the patient. Dissection of the amputated specimens have shown some soft clot formation. One naturally wonders if this type of anesthesia might not be used also for short reconstructive surgeries of the extremities when other anesthesias are contraindicated.     

The correlation between stabbing-related upper extremity wounds and survival of stabbing victims with abdominal and thoracic injuries

BackgroundWhen treating patients with stab injuries of the torso, clinicians often lack timely information about the degree and nature of internal organ damage. An externally observable sign significantly associated with characteristics of torso injuries may therefore be useful for practitioners. One such potential sign is the presence of wounds to the hands, sometimes sustained during victims' attempt to defend themselves during the violent altercation. Thus, the primary aim of this study was to evaluate the association between presence of upper extremity wounds and the severity of the thoracic and intra-abdominal injuries due to stabbing.MethodsThis study was carried out retrospectively using data on 8714 patients with stabbing-related injuries from 19 trauma centers that participated in the Israeli National Trauma Registry (INTR) between January 1st1997 and December 31st 2013. Patients with wounds of upper extremities in addition to torso injuries (UE group) were compared to other patients with torso injuries (TO group) in terms of demographics, injury characteristics and clinical outcome.ResultsThe compared groups were found to be homogeneous in terms of age and systolic blood pressure; the number of sustained torso injuries was also identical. The UE group comprised a slightly greater percentage of females, however both groups were predominantly male. Patients with upper extremity injuries had a lower proportion of internal organ damage (36% vs. 38.5%) and lower mortality (0.9% vs. 2%). The higher mortality of patients without upper extremity wounds remained significantly different even when adjusted by other epidemiological parameters (OR 2.46, 95% CI 1.33–5.08).The number of sustained upper extremity injuries was positively associated with deeper penetration of the torso by the stabbing instrument.ConclusionsPatients with stabbing-related upper extremity wounds had a significant survival advantage over patients without such injuries. However, a greater number of sustained upper extremity wounds may be an external sign of greater severity of thoracic and intraabdominal stabbing injuries.     

Penetrating femoropopliteal injury during modern warfare: experience of the Balad Vascular Registry

OBJECTIVE: Wounding patterns, methods of repair, and outcomes from femoropopliteal injury have been documented in recent civilian literature. In Operation Iraqi Freedom, as in past conflicts, these injuries continue to be a therapeutic challenge. Therefore, the objective of the current study is to document the pattern of femoropopliteal injuries, methods of repair, and early outcomes during the current military campaign in Iraq. METHODS: From September 1, 2004, to April 30, 2007, all vascular injuries arriving at the Air Force Theater Hospital (the central echelon III medical facility in Iraq; equivalent to a civilian level I trauma center), Balad Air Base, Iraq were prospectively entered into a registry. From this, injuries involving the lower extremities were reviewed. RESULTS: During the 32-month study period, 9289 battle-related casualties were assessed. Of these, 488 (5.3%) were diagnosed with 513 vascular injuries, and 142 casualties sustained 145 injuries in the femoropopliteal domain. Femoral level injury was present in 100, and popliteal level injury occurred in 45. Injuries consisted of 59 isolated arterial, 11 isolated venous, and 75 combined. Fifty-eight casualties were evacuated from forward locations. Temporary arterial shunts were placed in 43, of which 40 (93%) were patent on arrival at our facility. Our group used shunts for early reperfusion before orthopedic fixation, during mass casualty care, or autogenous vein harvest in 11 cases. Arterial repair was accomplished with autogenous vein in 118 (88%), primary means in nine (7%), or ligation in seven (5%). Venous injury was repaired in 62 (72%). Associated fracture was present in 55 (38%), and nerve injury was noted in 19 (13%). Early limb loss due to femoropopliteal penetrating injury occurred in 10 (6.9%). Early mortality was 3.5% (n = 5). CONCLUSIONS: Femoropopliteal vascular injury remains a significant reality in modern warfare. Femoral injuries appear more prevalent than those in the popliteal region. Early results of in-theater repair are comparable with contemporary civilian reports and are improved from the Vietnam era. Rapid evacuation and damage control maneuvers such as temporary shunting and early fasciotomy assist timely definitive repair and appear effective.