Battlefield extremity injuries in Operation Iraqi Freedom

Objective

Extremity injuries account for the majority of wounds incurred during US armed conflicts. Information regarding the severity and short-term outcomes of patients with extremity wounds, however, is limited. The aim of the present study was to describe patients with battlefield extremity injuries in Operation Iraqi Freedom (OIF) and to compare characteristics of extremity injury patients with other combat wounded.

Patients and methods

Data were obtained from the United States Navy-Marine Corps Combat Trauma Registry (CTR) for patients who received treatment for combat wounds at Navy-Marine Corps facilities in Iraq between September 2004 and February 2005. Battlefield extremity injuries were classified according to type, location, and severity; patient demographic, injury-specific, and short-term outcome data were analysed. Upper and lower extremity injuries were also compared.

Results

A total of 935 combat wounded patients were identified; 665 (71%) sustained extremity injury. Overall, multiple wounding was common (an average of 3 wounds per patient), though more prevalent amongst patients with extremity injury than those with other injury (75% vs. 56%, P < .001). Amongst the 665 extremity injury patients, 261 (39%) sustained injury to the upper extremities, 223 (34%) to the lower extremities, and 181 (27%) to both the upper and lower extremities. Though the total number of patients with upper extremity injury was higher than lower extremity injury, the total number of extremity wounds (n = 1654) was evenly distributed amongst the upper and lower extremities (827 and 827 wounds, respectively). Further, lower extremity injuries were more likely than the upper extremity injuries to be coded as serious to fatal (AIS > 2, P < .001).

Conclusions

Extremity injuries continue to account for the majority of combat wounds. Compared with other conflicts, OIF has seen increased prevalence of patients with upper extremity injuries. Wounds to the lower extremities, however, are more serious. Further research on the risks and outcomes associated with extremity injury is necessary to enhance the planning and delivery of combat casualty medical care.     

Burns in motor vehicle accidents

Burns received as a result of motor vehicle accidents (MVA's) create special problems in their care, as they are frequently severe and are often associated with other injuries. One hundred seventy-eight consecutive patients with burns sustained in an MVA were studied. The mean TBSA burn was 33.9%. The mortality was 24.7%, but the mean burn size in this fatal group was almost doubled at 63.9%. The injury most commonly associated with death was inhalation injury (in 36.3%). Thirty-six per cent of the patients sustained other injuries in addition to their burn, the most frequent of which was to the musculoskeletal system (67 injuries). Multiple trauma had little effect on mortality unless severe, but fractures especially complicated burn wound care unless surgically stabilized. Current methods of management are presented along with our approach to multiply injured burn patients.     

Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit's experience

BACKGROUND: Rapidly restoring perfusion to injured extremities is one of the primary missions of forward military surgical teams. The austere setting, limited resources, and grossly contaminated nature of wounds encountered complicates early definitive repair of complex combat vascular injuries. Temporary vascular shunting of these injuries in the forward area facilitates rapid restoration of perfusion while allowing for deferment of definitive repair until after transport to units with greater resources and expertise. METHODS: Standard Javid or Sundt shunts were placed to temporarily bypass complex peripheral vascular injuries encountered by a forward US Navy surgical unit during a six month interval of Operation Iraqi Freedom. Data from the time of injury through transfer out of Iraq were prospectively recorded. Each patient's subsequent course at Continental US medical centers was retrospectively reviewed once the operating surgeons had returned from deployment. RESULTS: Twenty-seven vascular shunts were used to bypass complex vascular injuries in twenty combat casualties with a mean injury severity score of 18 (range 9-34) and mean mangled extremity severity score of 9 (range 6-11). All patients survived although three (15%) ultimately required amputation for nonvascular complications. Six (22%) shunts clotted during transport but an effective perfusion window was provided even in these cases. CONCLUSION: Temporary vascular shunting appears to provide simple and effective means of restoring limb perfusion to combat casualties at the forward level.     

Predictors of mortality in close proximity blast injuries during Operation Iraqi Freedom

BACKGROUND: Blast injury is an increasingly common problem faced by military surgeons in the field. Because of urban terrorism worldwide, blast injury is becoming more common in the civilian sector as well. Blast injuries are often devastating and can overwhelm medical resources. We sought to determine whether simple factors easily obtained from the clinical history and primary survey could be used to triage patients more effectively. STUDY DESIGN: A retrospective review of 18 consecutive close-proximity blast injury patients presenting to a forward deployed surgical unit in Iraq was performed. Patients' injuries and outcomes were recorded. We compared the presence of sustained hypotension, penetrating head injury, multiple (three or more) long-bone fractures, and associated fatalities (whether another patient involved in the same explosion died) between nonsurvivors and survivors using Fisher's exact test. RESULTS: All patients who presented alive but exhibited sustained hypotension (n = 5) died, versus 0% who did not exhibit sustained hypotension (n = 9, p < 0.01). There was no marked increase in mortality with presence of multiple long-bone fractures, penetrating head injury, or associated fatalities individually. Having two or more of these factors was associated with a mortality of 86% (6 of 7) versus 20% (2 of 10, p = 0.015) in those who had less than two factors. CONCLUSIONS: Blast injury can overwhelm military and civilian trauma systems alike. Sustained hypotension and presence of two or more easily determined factors, including three or more long-bone fractures, penetrating head injury, and associated fatalities, are associated with increased mortality and can potentially help triage patients and allocate scarce resources more efficiently.     

Injuries of the thoracolumbar spine associated with restraint use in head-on motor vehicle accidents

Many authors have described spinal and bodily injuries associated with seat belt use. However, most reports have focused primarily on lap seat belts and resultant flexion-distraction injuries. This retrospective chart review studies the relation between the specific type of restraint or air bag and the resultant thoracolumbar spinal injury subtype and associated bodily injuries. The charts of 221 patients who had sustained thoracolumbar fractures in motor vehicle accidents during a 10-year period were reviewed, and 37 patients were identified whose accidents were clearly described as a frontal collision and whose specific form of restraint was recorded. Among the 15 patients who used a shoulder strap and lap belt device (three-point restraint), 12 patients sustained burst fractures (80%) compared with 4 of the 14 patients (28.6%) restrained with lap seat belts alone. Life-threatening intraabdominal injuries occurred in 57.1% of lap-belted victims and in 26.7% of patients who used three-point restraints, and the character of these injuries also differed. No patients in an automobile in which an air bag deployed sustained major associated bodily injuries. Among restrained occupants of head-on motor vehicle accidents who have sustained a thoracolumbar fracture, patients using lap belts are more likely to sustain the classic flexion-distraction injury patterns, whereas patients using three-point restraints may sustain a higher incidence of burst fractures. In addition, three-point restraints are associated with a decreased risk of intraabdominal injury compared with lap seat belts.     

Injuries associated with fracture of the femur secondary to motor vehicle accidents in children

A retrospective review of the medical records of 149 children < 18 years old who sustained femur fractures secondary to a motor vehicle accident found 159 fractured femurs; 89.3% were closed. One hundred seventy-nine associated injuries occurred in 87 patients (58.4%). Associated fractures were common (50.3%), followed by soft-tissue injuries (18.5%) and head injuries (14%; 3 deaths). The lower limbs were most commonly involved with associated fractures (37.8%), 9 had a "floating knee." The incidence of intra-abdominal injury was 5%, with the liver most commonly lacerated followed by the spleen and intestine. Forty-seven children (43.1%) developed 1 or more complications. The Pediatric Trauma Score ranged from -3 to 11 (73.8% scored > or = 8, while 26.2% scored < 8). Fractures of the femur in children are commonly associated with other injuries, particularly other fractures.     

Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom

OBJECTIVE: To assess outcome differences between locally burned civilians and military personnel burned in a distant combat zone treated in the same facility. SUMMARY BACKGROUND DATA: The United States Army Institute of Surgical Research (USAISR) Burn Center serves as a referral center for civilians and is the sole center for significant burns in military personnel. We made the hypothesis that outcomes for military personnel burned in the current conflict in Iraq and Afghanistan would be poorer because of delays to definitive treatment, other associated injury, and distance of evacuation. METHODS: We reviewed the civilian and military records of patients treated at the USAISR from the outset of hostilities in Iraq in April 2003 to May 2005. Demographics, injury data, mortality, and clinical outcomes were compared. RESULTS:: We cared for 751 patients during this time period, 273 of whom were military (36%). Military injuries occurred in a younger population (41 +/- 19 vs. 26 +/- 7 years for civilian and military respectively, P < 0.0001) with a longer time from injury to burn center arrival (1 +/- 5 days vs. 6 +/- 5, P < 0.0001), a higher Injury Severity Score (ISS 5 +/- 8 vs. 9 +/- 11, P < 0.0001), and a higher incidence of inhalation injury (8% vs. 13%, P = 0.024). Total burn size did not differ. Mortality was 7.1% in the civilian and 3.8% in the military group (P = 0.076). When civilians outside the age range of the military cohort were excluded, civilian mortality was 5.0%, which did not differ from the military group (P = 0.57). Total body surface area (TBSA) burned, age > or =40 years, presence of inhalation injury, and ventilator days were found to be important predictors of mortality by stepwise regression, and were used in a final predictive model with the area under receiver operator characteristic curve of 0.97 for both populations considered together. No significant effect of either group was identified during development. CONCLUSIONS: Mortality does not differ between civilians evacuated locally and military personnel injured in distant austere environments treated at the same center.     

Initial experience of US Marine Corps forward resuscitative surgical system during Operation Iraqi Freedom

HYPOTHESIS: Modern US Marine Corps (USMC) combat tactics are dynamic and nonlinear. While effective strategically, this can prolong the time it takes to transport the wounded to surgical capability, potentially worsening outcomes. To offset this, the USMC developed the Forward Resuscitative Surgical System (FRSS). By operating in close proximity to active combat units, these small, rapidly mobile trauma surgical teams can decrease the interval between wounding and arrival at surgical intervention with resultant improvement in outcomes. DESIGN: Case series. SETTING: Echelon 2 surgical units during the invasion phase of Operation Iraqi Freedom. PATIENTS: Ninety combat casualties, consisting of 30 USMC and 60 Iraqi patients, were treated in the FRSS between March 21 and April 22, 2003. INTERVENTIONS: Tactical surgical intervention consisting of selectively applied damage control or definitive trauma surgical procedures. MAIN OUTCOME MEASURES: Time to surgical intervention and outcome following treatment in the FRSS. RESULTS: Ninety combat casualties with 170 injuries required 149 procedures by 6 FRSS teams. The USMC patients were received within a median of 1 hour of wounding with the critically injured being received within a median of 30 minutes. Fifty-three USMC personnel were killed in action and 3 died of wounds for a killed in action rate of 13.5% and a died of wounds rate of 0.8% during the invasion phase of Operation Iraqi Freedom. All Marines treated in the FRSS survived. CONCLUSION: The use of the FRSS in close proximity to the point of engagement during the initial, dynamic combat phase of Operation Iraqi Freedom prevented delays in surgical intervention of USMC combat casualties with resultant beneficial effects on patient outcomes.     

Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom

BACKGROUND: Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield. METHODS: Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. Formal implementation of the system occurred in November 2004, the collaborative effort of the three Surgeons General of the U.S. military, the United States Army Institute of Surgical Research, and the American College of Surgeons Committee on Trauma. One trauma surgeon (Trauma System Director) and a team of six trauma nurse coordinators were deployed to theater to evaluate trauma system component issues. Demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data were gathered for 4,700 injured patients using the Joint Theater Trauma Registry. Interview and survey methods were utilized to evaluate logistic aspects of the system. RESULTS: System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care. Among the issues were transfer of casualties from point of injury to the most appropriate level of care, trauma clinical practice guidelines, standard forms, prophylactic antibiotic regimens, morbidity/mortality reporting, on-line medical evacuation regulation, improved data capture for the trauma registry, and implementation of a performance improvement program. CONCLUSIONS: The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield.     

Treatment of gallbladder disease during operations Iraqi Freedom and Enduring Freedom

Background  

We examined the outcome after treatment for gallbladder disease in deployed military service members and the impact of instituting a clinical pathway to expedite return to duty (RTD).     

Operation Iraqi Freedom: The Landstuhl Regional Medical Center Experience

Landstuhl Regional Medical Center, Germany, the only American medical center in Europe, received approximately 80% of American military patients evacuated out of theater during the first 4 months of Operation Iraqi Freedom. 1236 patients arrived at Landstuhl Regional Medical Center from the beginning of Operation Iraqi Freedom until May 15, 2003, consisting of 256 battle casualties (20.7%), 510 injury patients (41.3%), and 470 disease patients (38.0%). Retrospective record reviews were done on all battle casualties, as well as all disease and injury patients with a musculoskeletal diagnosis. Of the battle casualty patients, 68.4% suffered an extremity injury--a percentage that is consistent with that from prior wars. 52.8% had a lower extremity injury and 21.5% had a foot or ankle injury. Additionally, of all disease and non-battle injury patients with a musculoskeletal diagnosis, 74.7% had an extremity complaint, 44.1% had a lower extremity diagnosis, and 23.2% had foot or ankle pathology. Of all 1236 patients evacuated during this period, 39.5% had extremity pathology, 25.8% had lower extremity pathology, and 12.4% had foot and ankle pathology in isolation or combined with other complaints. Extremity injuries, and specifically lower extremity injuries, continue to be the predominant wounding pattern found in surviving troops in modern warfare. Proper staffing and positioning of medical specialties involved in musculoskeletal trauma care is vital in ensuring proper casualty care in future conflicts.     

Pelvic trauma in rapidly fatal motor vehicle accidents

OBJECTIVE: To study the incidence and nature of pelvic fractures in rapidly fatal automobile accidents. DESIGN: Retrospective. SETTING: County Medical Examiner's Office. PATIENTS: The files of 255 consecutive motor vehicle accident fatalities examined at the Jefferson County Coroner/Medical Examiner's office (study period 1996-1998) were reviewed. We correlated this information with our previous findings, derived from a review of 392 such cases (study period 1994-1996). RESULTS: Approximately 25% of decedents involved in rapidly fatal automobile accidents sustained pelvic fractures. In 93% of the cases, postmortem radiographs were available and suitable for scoring according to the Orthopaedic Trauma Association nomenclature. The distribution of pelvic fractures by type was type A, 16%; type B, 32%; and type C, 52%, with the most common pelvic fracture being type C1 (26%). Additionally, pedestrians and motorcyclists were twice as likely to sustain a pelvic fracture, and the severity of pelvic fracture type seemed to correlate with increasing speed of the automobile. No correlation between drug use or direction of impact and incidence or type of pelvic fracture was observed. Compared with published studies on survivors of automobile accidents, our data suggest that pelvic injuries may tend to be more severe in victims who do not survive to hospitalization. CONCLUSIONS: Our data indicate that current estimates about the mortality of pelvic fractures may be faulty due to exclusion of victims who fail to survive to hospitalization. This series suggests that an appreciation of the full spectrum of pelvic ring disruptions requires collaboration between orthopaedic surgeons and forensic pathologists.