Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study.

OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement.

OBJECTIVE: To investigate the reliability and diagnostic accuracy of individual tests and combination of tests for subacromial impingement syndrome (SAIS). DESIGN: A prospective, blinded study design. SETTING: Orthopedic surgeon shoulder clinic. PARTICIPANTS: Patients with shoulder pain (n=55, mean age=40.6y). INTERVENTIONS: Patients were evaluated with 5 physical examination tests for SAIS: Neer, Hawkins-Kennedy, painful arc, empty can (Jobe), and external rotation resistance tests. Surgical diagnosis was the reference standard. MAIN OUTCOME MEASURES: Diagnostic accuracy calculated with a receiver operating characteristic (ROC) curve and sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). A forward stepwise binary logistic regression analysis was used to determine the best test combination for SAIS. An ROC curve analysis was also used to determine the cut point of the number of tests discriminating between the presence and absence of SAIS. Kappa coefficients and percent agreement assessed interrater reliability. RESULTS: The ROC analyses revealed a significant area under the curve (AUC) (AUC=.67-.72, P<.05) for all tests, except for the Hawkins-Kennedy. The tests with a +LR greater than or equal to 2.0 were the painful arc (+LR=2.25; 95% CI, 1.33-3.81), empty can (+LR=3.90; 95% CI, 1.5-10.12), and the external rotation resistance tests (+LR=4.39; 95% CI, 1.74-11.07). Tests with -LR less than or equal to 0.50 were the painful arc (-LR=.38; 95% CI, .16-.90), external rotation resistance (-LR=.50; 95% CI, .28-.89), and Neer tests (-LR=.35; 95% CI, .12-.97). The regression analysis had no specific test combinations for confirming or ruling out SAIS. The ROC analysis was significant (AUC=.79, P=.001), with a cut point of 3 positive tests out of 5 tests. Reliability was moderate to substantial agreement (kappa=.45-.67) for the painful arc, empty can, and external rotation resistance tests and fair strength of agreement (kappa=.39-.40) for the Neer and Hawkins-Kennedy tests. CONCLUSIONS: The single tests of painful arc, external rotation resistance, and Neer are useful screening tests to rule out SAIS. The single tests of painful arc, external rotation resistance, and empty can are helpful to confirm SAIS. The reliability of all tests was acceptable for clinical use. Based on reliability and diagnostic accuracy, the single tests of the painful arc, external rotation resistance, and empty can have the best overall clinical utility. The cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS, while less than 3 positive of 5 rules out SAIS.

Descriptive analysis of patients undergoing shoulder surgery at a tertiary care military medical center.

Shoulder pain is a common musculoskeletal complaint. Patients with shoulder pain who are seeking care in a military tertiary setting in the United States have not been previously described. This study describes the clinical features of 55 patients (47 men, 8 women) undergoing shoulder surgery at a tertiary care military medical center. Patients presenting to a military medical center are different than other previously described samples in the literature. Specifically, the patients in this study had a known mechanism of injury (n = 42; 76%), multiple structures involved (n = 46; 84%) and a high prevalence of glenoid labral involvement (n = 44; 80%). Further research is needed to determine if these patient characteristics identified in this study warrant different management strategies and resource utilization in both the tertiary care center, and in the primary care center where these patients are typically seen before referral to a tertiary care center.

Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial.

The purpose of this report is to compare outcomes after arthroscopic versus open distal clavicle excision in the treatment of refractory acromioclavicular joint pain. A randomized, prospective clinical trial comparing the 6-month and 1-year outcomes of patients undergoing open distal clavicle excision (group 1) with those undergoing arthroscopic distal clavicle excision (group 2) was carried out. The Modified American Shoulder and Elbow Surgeons form, visual analog scale pain score, Short Form 36, and satisfaction questions were assessed preoperatively and at 6 months and 1 year postoperatively. Seventeen patients were enrolled. There was a trend across all measures for earlier or better outcomes (or both) after arthroscopic over open treatment. The improvement in visual analog scale pain score from preoperatively to 1 year postoperatively was significant for group 2 but not group 1 (P = .006 vs P = .13). Occult intra-articular pathology was detected and treated in 50% of group 2 patients. Arthroscopic and open distal clavicle excisions both provide significant pain reduction at 1 year. Both are effective surgeries for the treatment of refractory acromioclavicular joint pain. The ability to diagnosis and treat subtle concomitant shoulder pathology is a unique advantage of the arthroscopic approach.

Process of care for battle casualties at Walter Reed Army Medical Center: Part I. Orthopedic surgery service.

Walter Reed Army Medical Center has been a primary hub in the United States for receiving Army battle casualties from Operation Enduring Freedom and Operation Iraqi Freedom. We detail the process of care that was developed to effect the timely effective management of these casualties.

Process of care for battle casualties at Walter Reed Army Medical Center: Part II. Physical therapy service.

Physical therapists, physical therapy assistants, and physical therapy technicians provide care to soldiers, sailors, Marines, and airmen returning from Operation Enduring Freedom and Operation Iraqi Freedom. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned at the beginning of the war.

Process of care for battle casualties at Walter Reed Army Medical Center: Part IV. Occupational therapy service.

Occupational therapy addresses deficits in activities of daily living, upper-extremity motor performance deficits secondary to injury or disease, and occupational or role performance deficits attributable to mental and behavioral health conditions. We describe the inpatient and outpatient services provided, the problems and solutions encountered, and the lessons learned.

Process of care for battle casualties at the Walter Reed Army Medical Center: Part III. Physical medicine and rehabilitation service.

The Physical Medicine and Rehabilitation Service provides a critical role in the assessment, management, and disposition of the newly injured combatant. This role has been well demonstrated during Operation Enduring Freedom and Operation Iraqi Freedom. Military physiatrists are uniquely suited to support military service members as they maximize their function and either return to duty or transition to civilian life.

Pectoralis major ruptures.

Although previously considered rare, ruptures of the pectoralis major muscle and tendon have become more common over the past 20 years with increasing participation in competitive sports and weight lifting. These injuries result from maximal eccentric contraction of the muscle with the arm held in an abducted, extended position. Most often, they occur near the tendon insertion. Complete ruptures are more common than partial tears, though many mild strains and partial tears likely go unreported or undiagnosed. Magnetic resonance imaging is the diagnostic study of choice when the diagnosis or extent of the injury is unclear. Partial tears and neglected complete tears with near complete restoration muscle strength after rehabilitation may be treated nonoperatively, with good results. Excellent results can be obtained with early anatomic repair for complete ruptures, though good results have also been reported with delayed repair of complete injuries. Early diagnosis and, when appropriate, anatomic surgical repair are the factors critical to optimizing patient outcomes after pectoralis major rupture.

Effect of drain use in the early postoperative period after arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.

BACKGROUND: Little data exist on the effect of routine use of postoperative drainage after arthroscopic anterior cruciate ligament reconstruction, although clinical studies of other procedures have not shown benefit to this practice. HYPOTHESIS: Use of a postoperative drain will not result in decreased suprapatellar girth, increased range of motion, and decreased pain compared with nonuse. STUDY DESIGN: Prospective randomized clinical trial. METHODS: Twenty-one patients undergoing arthroscopically assisted bone-patellar tendon-bone anterior cruciate ligament reconstruction were randomly assigned to receive a drain for 24 hours (12 patients) or no drain (9 patients). Data for comparison of groups were collected daily through postoperative day 7. RESULTS: Pain scores on a visual analog scale demonstrated the same improving trend over time for both treatment and control groups; however, the treatment group had significantly higher average pain scores, except on day 7. Differences in suprapatellar girth, flexion, and extension were not found to be statistically significant between groups. CONCLUSION: Use of a drain after arthroscopically assisted anterior cruciate ligament reconstruction provided no benefit in terms of range of motion, effusion, or pain in the early postoperative period.

Evaluation of orthopaedic injuries in Operation Enduring Freedom.

Orthopaedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts. Orthopaedic injuries sustained in Operation Enduring Freedom from December 2001 to January 2003 that were treated in forward-deployed military medial facilities and evacuated to a U.S. army medical center were reviewed. The spectrum of injuries included open fractures, amputations, neurovascular, and soft-tissue injuries. Forty-four patients (85%) received treatment beyond local wound care prior to arrival at a military medical center. Debridement and irrigation was the most commonly performed procedure due to the contaminated nature of these combat injuries. There were no infections among patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days. Two amputations were infected and were treated with revision and delayed wound closure. There were no primary amputations done at our institution due to infection or ischemia. All arterial injuries underwent urgent revascularization in a field hospital. None of the arterial repairs required revision after evacuation to a medical center. Operation Enduring Freedom has been an excellent example of how early and aggressive intervention in a forward-deployed area has a significant effect on rehabilitative and reconstructive efforts at a rear echelon tertiary care center.

Evaluation of orthopaedic injuries in Operation Enduring Freedom.

Orthopaedic injuries constitute a majority of the combat casualties in recent U.S. military conflicts. Orthopaedic injuries sustained in Operation Enduring Freedom from December 2001 to January 2003 that were treated in forward-deployed military medical facilities and evacuated to a U.S. army medical center were reviewed. The spectrum of injuries included open fractures, amputations, neurovascular, and soft-tissue injuries. Forty-four patients (85%) received treatment beyond local wound care prior to arrival at a military medical center. Debridement and irrigation was the most commonly performed procedure due to the contaminated nature of these combat injuries. There were no infections among patients with open fractures, and no patients with external fixators had pin tract infections. None of the open fracture patients underwent primary internal fixation or primary wound closure. The average time from injury to wound coverage of the open fracture wounds was 12 days. Two amputations were infected and were treated with revision and delayed wound closure. There were no primary amputations done at our institution due to infection or ischemia. All arterial injuries underwent urgent revascularization in a field hospital. None of the arterial repairs required revision after evacuation to a medical center. Operation Enduring Freedom has been an excellent example of how early and aggressive intervention in a forward-deployed area has a significant effect on rehabilitative and reconstructive efforts at a rear echelon tertiary care center.

Orthopedic injuries during Operation Enduring Freedom.

Orthopedic injuries comprise a majority of combat injuries seen in recent U.S. military conflicts. Interventions in the forward deployed area have played an important role in improving mortality rates of soldiers as well as outcome at a medical center level. A retrospective review was conducted on orthopedic injuries from Operation Enduring Freedom evaluated at Walter Reed Army Medical Center (WRAMC). Patients were grouped into one of five injury categories (open fracture, amputation, arterial injuries, neurological injuries, and soft tissue injury) with evacuation time (days from time of injury to arrival at WRAMC) and procedures performed before arrival at WRAMC evaluated. The average evacuation time for all orthopedic casualties was 7.9 days. There was an average of 2.6 procedures performed per patient before arrival at WRAMC. There was no difference in evacuation time among the injury groups. Those with only soft tissue injuries underwent fewer procedures than the other injury groups; however, there was no difference among the injury groups in terms of procedures performed. The number of procedures performed did not affect the evacuation time. Fifty-six percent of casualties required operative intervention after arrival at WRAMC. With the unavoidable evacuation time that all casualties must endure regardless of severity of the injury, early operative intervention in forward deployed medical assets, such as the forward surgical team and combat support hospital, remains a necessity for rehabilitative and reconstructive efforts of the soldiers at the medical center level.

Primary coracoid impingement syndrome.

We measured treatment responses for patients with primary coracoid impingement syndrome to determine whether coracoplasty provided pain relief and improved function. Eleven patients (12 shoulders) were included in the primary group, and secondary cases were excluded. Symptoms included burning pain occurring at the site of the coracoid process aggravated by exercise (push-ups). Magnetic resonance imaging and computed tomography showed a narrow coracohumeral interval. Surgical findings confirmed the diagnosis. Follow-up averaged 2.7 years. After follow-up, coracoplasty responses showed significant relief of pain (P < 0.0001) and improved function (P = 0.006). Treatment responses were good in primary cases, as indicated by pain and function scores.

Advanced medical care for soldiers injured in Iraq and Afghanistan.

War inevitably advances medical knowledge, particularly in the area of orthopedic surgery. This article presents an overview of the types of injuries emerging from the current conflicts in Iraq and Afghanistan, the majority of which are extremity injuries, and the care soldiers are receiving on the battlefield, while being evacuated, and at Walter Reed Army Medical Center. It highlights the Army's use of new therapeutic approaches such as use of methyl methacrylate antibiotic beads, vacuum-assisted closure devices, and new prosthetic technologies.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma.

BACKGROUND: The study was performed to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. METHODS: This is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, or a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of amputation and salvage were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. RESULTS: Overall response rates were modest (59.2%) and significantly different between those who underwent amputation (64.5%) and those treated with limb salvage (55.4%) (p = 0.02). In all SMFA domains except arm/hand function, the patients scored significantly worse than population norms. Also, 38.3% screened positive for depressive symptoms and 17.9%, for posttraumatic stress disorder (PTSD). One-third (34.0%) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities (pain interference), or work/school status. CONCLUSIONS: Major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.

Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions.

CONTEXT: Type I superior labrum anterior-posterior (SLAP) lesions involve degenerative fraying and probably are not the cause of shoulder pain. Type II to IV SLAP lesions are tears of the labrum. OBJECTIVE: To determine the diagnostic accuracy of patient history and the active compression, anterior slide, and crank tests for type I and type II to IV SLAP lesions. DESIGN: Cohort study. SETTING: Clinic. PATIENTS OR OTHER PARTICIPANTS: Fifty-five patients (47 men, 8 women; age = 40.6 ± 15.1 years) presenting with shoulder pain. INTERVENTION(S): For each patient, an orthopaedic surgeon conducted a clinical examination of history of trauma; sudden onset of symptoms; history of popping, clicking, or catching; age; and active compression, crank, and anterior slide tests. The reference standard was the intraoperative diagnosis. The operating surgeon was blinded to the results of the clinical examination. MAIN OUTCOME MEASURE(S): Diagnostic utility was calculated using the receiver operating characteristic curve and area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). Forward stepwise binary regression was used to determine a combination of tests for diagnosis. RESULTS: No history item or physical examination test had diagnostic accuracy for type I SLAP lesions (n = 13). The anterior slide test had utility (AUC = 0.70, +LR = 2.25, -LR = 0.44) to confirm and exclude type II to IV SLAP lesions (n = 10). The combination of a history of popping, clicking, or catching and the anterior slide test demonstrated diagnostic utility for confirming type II to IV SLAP lesions (+LR = 6.00). CONCLUSIONS: The anterior slide test had limited diagnostic utility for confirming and excluding type II to IV SLAP lesions; diagnostic values indicated only small shifts in probability. However, the combination of the anterior slide test with a history of popping, clicking, or catching had moderate diagnostic utility for confirming type II to IV SLAP lesions. No single item or combination of history items and physical examination tests had diagnostic utility for type I SLAP lesions.

Posterior remodeling of medial clavicle causing superior vena cava impingement.

Injuries involving the sternoclavicular region resulting in posterior displacement of the medial clavicle are rare, and those that occur prior to fusion of the medial epiphyseal growth plate are more often a result of physis fracture, rather than sternoclavicular joint dislocation. Medial clavicular physis fractures initially are treated by closed reduction with the expectation of normal osseous repair and remodeling. We report a case of a previously fractured medial clavicle physis that abnormally remodeled, was reinjured, and resulted in posterior displacement with superior vena cava impingement and brachioplexopathy. Our case report describes the patient's initial injury and repair, the reinjury and discovery of abnormal remodeling, and the outcome of surgical intervention. We also include a review of recent literature on sternoclavicular joint injuries and treatment options. To our knowledge, this is the first reported case of an abnormally remodeled medial clavicle resulting in superior vena cava compression.