Blast Lung Injury in Children: Injury Patterns and Associated Organ Injuries.

BACKGROUND: Bombings are the most common cause of civilian deaths in wars, and unfortunately, a large proportion of civilian victims are children. OBJECTIVE: This study aimed to evaluate the frequency of blast lung injury (BLI), to evaluate lung injury patterns on tomographic images, and to document the relationship between blast lung and mortality in children exposed to the blast effect. METHODS: Thirty-six children (25.3% of pediatric patients brought to our hospital with blast injury) with BLI were included in the study. The pediatric trauma score evaluations made in the emergency department in the first admission were recorded. Lung injury findings in the computed tomography images of the patients were examined, and injuries detected in other systems were recorded. RESULTS: The most common lung injury pattern was contusion (right: 69.4%, left: 80.6%). The incidence of brain damage (52.4%) and intra-abdominal injury (76.2%) in children with low pediatric trauma score value was statistically significantly higher ( P = 0.049, P = 0.017, respectively). There was no statistically significant correlation between the presence of lung injury, injury patterns, and mortality. The incidence of brain damage in deceased patients (61.5%) was statistically significantly higher than the incidence of brain damage in surviving patients (26.1%) ( P = 0.036). Low pediatric trauma score was observed in 11 (84.6%) of the deceased children and in 10 (43.5%) of the survivors ( P = 0.016). The mean age of children with hemothorax in the right lung was statistically significantly lower than those without ( P = 0.014). CONCLUSION: Our findings revealed that pediatric BLI is common after a blast, that it is associated with other system injuries, and that a multimodal radiological approach is required in child victims.

Thoracoabdominal injuries after a bomb explosion: blast injuries and their clinical effects.

PURPOSE: To report the types and effects of injuries to the thoracoabdominal region caused by blast and emphasize the importance of the early detection of primary blast injuries. METHODS: Of the 98 patients injured as a result of a bomb explosion, 31 with thoracoabdominal injuries were included in the study. The demographic and laboratory data, operations performed, and radiological findings were obtained from the electronic records of the patients. The injuries caused by the explosion were divided into four categories as primary, secondary, tertiary, and quaternary. The patients with a new injury severity score (NISS) of ≥ 16 were considered to have critical injuries. RESULTS: While mortality developed in 16 (51.6%) of 31 patients included in the study, 15 (48.4%) were discharged after treatment. The mean ages of the patients in the mortality and survivor groups were 29.6 ± 4.5 and 31.1 ± 10.7 years, respectively (p > 0.005). When the two groups were examined, the rate of hypovolemic shock and NISS score were significantly higher in the mortality group (p = 0.001 and p < 0.001, respectively) and the pH of the patients in the mortality group was more acidic (7.18 ± 0.13 vs. 7.34 ± 0.13, p = 0.002). One patient in the survivor group required surgery after the explosion due to missed primary blast injuries. CONCLUSIONS: To make the best use of resources in terrorist attacks and mass casualties that place a huge burden on health systems, it is important to evaluate patients with the highest index of suspicion for concealed blast injuries in terms of hospitalization and observation. In addition, health systems need to develop a cost-effective strategy considering the possibility of delayed-onset blast injuries.

A rare case of iliopsoas abscess caused by a retained shrapnel from a blast injury.

Iliopsoas abscesses (IPA) are uncommon, with an associated mortality rate of up to 20%. We describe the case of a 55-year-old man war veteran who presented with an unusual cause of IPA secondary to retained foreign body (FB). His initial trauma 30 years before was a result of a blast injury with shrapnel penetration suffered after inadvertently driving over a landmine as an ambulance driver in a conflict region. A CT scan was performed, revealing a 13 mmx8 mm radio-opaque FB within the right psoas at the level of the fifth lumbar vertebra with a surrounding collection. Subsequent open surgical exploration removed two gravel fragments. Given the knowledge of a traumatic blast injury with retained FB and repeated episodes of sepsis, surgical exploration is warranted. To our knowledge, this is the first case of recurrent IPA secondary to a retained FB from a historical trauma.

Point-of-care ultrasound for treatment and triage in austere military environments.

BACKGROUND: Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery. METHODS: This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds. RESULTS: Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty. CONCLUSION: Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols. LEVEL OF EVIDENCE: Case series (no criterion standard), level V.

Oesophageal rupture from a pneumatic blast injury: an unusual mechanism of blunt oesophageal trauma.

Oesophageal perforation is a serious condition associated with significant morbidity and mortality. Clinical suspicion of oesophageal injury in patients sustaining neck or torso trauma is essential as early diagnosis and management are associated with better outcomes. Oesophageal perforation resulting from blunt trauma is uncommon, and traumatic oesophageal perforation following blast injury is exceedingly rare. We present two cases of patients developing oesophageal perforation from this rare mechanism, review basic principles of management, and key learning points.

Bomb blast: imaging findings, treatment and clinical course of extremity traumas.

BACKGROUND: To describe the severity and types of blast-related extremity injuries and the presence of accompanying vascular injuries (VI) and amputation, and to identify the associated factors affecting the treatment management and clinical course. METHODS: The study included 101 patients with extremity injuries caused by a bomb explosion. The radiographs and computed tomography angiographies of the patients were evaluated in terms of injury patterns, presence of penetrating fragments and fractures, and localization (upper or lower extremity) and type (open or closed) of injury. The Gustilo-Anderson classification was used for open fractures. According to their severity, open fractures classified as types 1 and 2 were included in Group 1 and those classified as type 3A, 3B and 3C in Group 2. RESULTS: As a result of blast exposure, 101 (57.7%) patients had extremity injuries, of which 76 (75.2%) presented with at least one fracture. Of the total of 103 fractures, nine (8.8%) were closed and 94 (91.2%) were open. Thirty-eight (40.4%) of the open fractures were located in the upper extremities, and 56 (59.6%) in the lower extremities and pelvis. Open fractures were most frequently localized in the femur (n = 20; 21.2%), followed by the tibia (n = 18; 19.1%). The majority of patients with open fractures were in Group 1 (71.4%). The duration of hospital stay was longer in Group 2 (12.1 ± 5.8 vs. 6.3 ± 6.7 days, p <  0.0001, respectively). Mortality among patients in Group 2 (45.0%) was significantly higher than in Group 1 (8.0%) (p <  0.0001). Similarly, the injury severity score (ISS) was higher in Group 2 (median 20 vs. 9, p <  0.0001). VI was present in 13 (12.9%) of all patients, and amputation in seven (7.9%). CONCLUSION: The presence of severe open fractures, VI, and high ISS score can be considered as important factors that increase morbidity and mortality. In extremity traumas, through the secondary blast mechanism, contaminated-fragmented tissue injuries occur. Therefore, we believe that it will be beneficial to apply damage control surgery in places with low socioeconomic level and poor hygienic conditions.

Chronic elevation of plasma vascular endothelial growth factor-A (VEGF-A) is associated with a history of blast exposure.

Mounting evidence points to the significance of neurovascular-related dysfunction in veterans with blast-related mTBI, which is also associated with reduced [18F]-fluorodeoxyglucose (FDG) uptake. The goal of this study was to determine whether plasma VEGF-A is altered in veterans with blast-related mTBI and address whether VEGF-A levels correlate with FDG uptake in the cerebellum, a brain region that is vulnerable to blast-related injury 72 veterans with blast-related mTBI (mTBI) and 24 deployed control (DC) veterans with no lifetime history of TBI were studied. Plasma VEGF-A was significantly elevated in mTBIs compared to DCs. Plasma VEGF-A levels in mTBIs were significantly negatively correlated with FDG uptake in cerebellum. In addition, performance on a Stroop color/word interference task was inversely correlated with plasma VEGF-A levels in blast mTBI veterans. Finally, we observed aberrant perivascular VEGF-A immunoreactivity in postmortem cerebellar tissue and not cortical or hippocampal tissues from blast mTBI veterans. These findings add to the limited number of plasma proteins that are chronically elevated in veterans with a history of blast exposure associated with mTBI. It is likely the elevated VEGF-A levels are from peripheral sources. Nonetheless, increasing plasma VEGF-A concentrations correlated with chronically decreased cerebellar glucose metabolism and poorer performance on tasks involving cognitive inhibition and set shifting. These results strengthen an emerging view that cognitive complaints and functional brain deficits caused by blast exposure are associated with chronic blood-brain barrier injury and prolonged recovery in affected regions.

Head and neck injuries after a bomb explosion: Diagnostic findings and treatment approaches.

OBJECTIVE: To identify the types and severity of head, face and neck (HFN) injuries, which occurred as a result of a bomb explosion and reached serious life-threatening levels, using radiological imaging methods, and to discuss the options of treatment at the time of presentation. METHODS: Of the 16 patients brought to the emergency department, 14 with HFN injuries were included in the study. Computed tomography (CT) and radiography scans were performed at the time of presentation in all patients, except for one. The injuries were divided into three groups according to their localization as head, face, and neck. RESULTS: A subgaleal hematoma was seen in 10 of 11 (78.5%) patients with head injuries. Eight (57.1%) of nine patients with facial injury had fractures and/or ocular injury in the orbital wall, and seven (50%) patients had maxillofacial bone fractures. Among ocular trauma cases, open-globe injuries were detected in three patients (21.4%), closed-globe in two (14.2%), and both types in three (21.4%). Of the five (35.7%) patients with secondary blast injuries in the neck, three (21.4%) had laryngeal trauma (Zone 2) due to shrapnel, localized in the false vocal cord, epiglottis, and thyrohyoid membrane, respectively. Emergency surgery was performed on a patient with a specific laryngeal injury. CONCLUSION: We consider that in patients presenting to the emergency department with blast HFN injuries, after providing airway patency and hemodynamic stability, CT and CT angiography should be performed because these modalities guide the treatment accurately and promptly.

The role of various imaging techniques in identifying and locating intraocular foreign bodies related to open-globe injury: three case reports and literature review. / Papel de distintas técnicas de imagen para identificar y localizar cuerpos extraños intraoculares relacionados con trauma ocular abierto: reporte de tres casos y revisión de la literatura.

BACKGROUND: Determining the precise location of intraocular foreign bodies is crucial for the management of patients with open-globe injury. Computed tomography is the most common method for detecting intraocular foreign bodies in the posterior segment. In this article, we describe three cases of open-globe injury with different types of intraocular foreign bodies in the posterior segment that were accurately located using computed tomography scans and B-scan ultrasonography. CASE PRESENTATION: Each of the three cases of open-globe injury described in this report had different types of ocular trauma, clinical symptoms, and intraocular foreign bodies. Computed tomography scans showed the exact location of the intraocular foreign bodies in the posterior segment in two of the three cases. A B-scan ultrasound was used to determine the location of a non-metallic intraocular foreign body in the third case. All three patients had intraocular foreign bodies, and one of them had an additional orbital foreign body. Case 1 had a perforating eye injury with the additional intraorbital foreign body; Cases 2 and Case 3 had different types of intraocular foreign bodies and prognoses. Various treatment approaches were used, ranging from observation to surgery, depending on the location of the intraocular foreign bodies, and all cases were successfully managed. These three cases show that proper use of various types of imaging tests is indispensable in the context of an intraocular foreign body related to open-globe injury. CONCLUSION: Imaging techniques are crucial for the detection of an intraocular foreign body, and computed tomography is one of the simplest and most useful, especially in cases of open-globe injury.

ANTECEDENTES: La ubicación precisa de un cuerpo extraño intraocular es crucial para el manejo de pacientes con trauma ocular abierto. La tomografía computarizada se usa habitualmente para detectar su ubicación en el segmento posterior. Reportamos tres casos con diferentes cuerpos extraños intraoculares en el segmento posterior, que fueron localizados con precisión mediante la tomografía computarizada y ecografía modo B. PRESENTACIÓN DEL CASO: Presentamos tres casos con diferentes mecanismos de trauma, tipos de cuerpo extraño intraocular, síntomas clínicos y pronóstico visual. La tomografía computarizada determinó la ubicación exacta de todos los cuerpos extraños intraoculares en el segmento posterior. El ultrasonido modo B se realizó en un paciente con un cuerpo extraño intraocular no metálico. El primer caso tuvo una lesión ocular perforante con un cuerpo extraño intraorbitario; el caso dos y el caso tres presentaron diferentes tipos de cuerpos extraños intraoculares con pronóstico diferente. El manejo y el pronóstico fue distinto en todos los casos; todos se manejaron con éxito. La ubicación exacta de los cuerpos extraños intraoculares utilizando las diferentes modalidades de diagnóstico es importante en estos pacientes. Estos casos sirven como recordatorio de que el uso adecuado de las pruebas de imagen es indispensable en el contexto de un cuerpo extraño intraocular relacionado con trauma ocular abierto. CONCLUSIÓN: Las diferentes técnicas de imágenes son muy importantes para la detección de un cuerpo extraño intraocular. La tomografía computarizada es una de las modalidades de imagen más simple y efectiva para la localización de cuerpos extraños intraoculares relacionadas con trauma ocular abierto.

Modulation of Post-Traumatic Immune Response Using the IL-1 Receptor Antagonist Anakinra for Improved Visual Outcomes.

The purpose of this study was to characterize acute changes in inflammatory pathways in the mouse eye after blast-mediated traumatic brain injury (bTBI) and to determine whether modulation of these pathways could protect the structure and function of retinal ganglion cells (RGC). The bTBI was induced in C57BL/6J male mice by exposure to three 20 psi blast waves directed toward the head with the body shielded, with an inter-blast interval of one hour. Acute cytokine expression in retinal tissue was measured through reverse transcription-quantitative polymerase chain reaction (RT-qPCR) four hours post-blast. Increased retinal expression of interleukin (lL)-1ß, IL-1α, IL-6, and tumor necrosis factor (TNF)α was observed in bTBI mice exposed to blast when compared with shams, which was associated with activation of microglia and macroglia reactivity, assessed via immunohistochemistry with ionized calcium binding adaptor molecule 1 and glial fibrillary acidic protein, respectively, one week post-blast. Blockade of the IL-1 pathway was accomplished using anakinra, an IL-1RI antagonist, administered intra-peritoneally for one week before injury and continuing for three weeks post-injury. Retinal function and RGC layer thickness were evaluated four weeks post-injury using pattern electroretinogram (PERG) and optical coherence tomography (OCT), respectively. After bTBI, anakinra treatment resulted in a preservation of RGC function and RGC structure when compared with saline treated bTBI mice. Optic nerve integrity analysis demonstrated a trend of decreased damage suggesting that IL-1 blockade also prevents axonal damage after blast. Blast exposure results in increased retinal inflammation including upregulation of pro-inflammatory cytokines and activation of resident microglia and macroglia. This may explain partially the RGC loss we observed in this model, as blockade of the acute inflammatory response after injury with the IL-1R1 antagonist anakinra resulted in preservation of RGC function and RGC layer thickness.

Value of lung ultrasound score for evaluation of blast lung injury in goats.

PURPOSE: To establish a severe blast lung injury model of goats and investigate the feasibility of lung ultrasonic score in the evaluation of blast lung injury. METHODS: Twenty female healthy goats were randomly divided into three groups by different driving pressures: 4.0 MPa group (n = 4), 4.5 MPa group (n = 12) and 5.0 MPa group (n = 4). The severe blast lung injury model of goats was established using a BST-I bio-shock tube. Vital signs (respiration, heart rate and blood pressure), lung ultrasound score (LUS), PO2/FiO2 and extravascular lung water (EVLW) were measured before injury (0 h) and at 0.5 h, 3 h, 6 h, 9 h, 12 h after injury. Computed tomography scan was performed before injury (0 h) and at 12 h after injury for dynamic monitoring of blast lung injury and measurement of lung volume. The correlation of LUS with PaO2/FiO2, EVLW, and lung injury ratio (lesion volume/total lung volume*100%) was analyzed. All animals were sacrificed at 12 h after injury for gross observation of lung injury and histopathological examination. Statistical analysis was performed by the SPSS 22.0 software. The measurement data were expressed as mean ± standard deviation. The means of two samples were compared using independent-sample t-test. Pearson correlation analysis was conducted. RESULTS: (1) At 12 h after injury, the mortality of goats was 0, 41.67% and 100% in the 4.0 Mpa, 4.5 MPa and 5.0 MPa groups, respectively; the area of pulmonary hemorrhage was 20.00% ± 13.14% in the 4.0 Mpa group and 42.14% ± 15.33% in the 4.5 MPa group. A severe lung shock injury model was established under the driving pressure of 4.5 MPa. (2) The respiratory rate, heart rate, LUS and EVLW were significantly increased, while PaO2/FiO2 was significantly reduced immediately after injury, and then they gradually recovered and became stabilized at 3 h after injury. (3) LUS was positively correlated with EVLW (3 h: r = 0.597, 6 h: r = 0.698, 9 h: r = 0.729; p < 0.05) and lung injury ratio (12 h: r = 0.884, p < 0.05), negatively correlated with PaO2/FiO2 (3 h: r = -0.871, 6 h: r = -0.637, 9 h: r = -0.658; p < 0.05). CONCLUSION: We established a severe blast lung injury model of goats using the BST-I bio-shock tube under the driving pressure of 4.5 MPa and confirmed that ultrasound can be used for quick evaluation and dynamic monitoring of blast lung injury.

Epidemiology of Upper Extremity Vascular Injury in Contemporary Combat.

BACKGROUND: The incidence of wartime upper-extremity vascular injury (UEVI) has been stable for the past century. The objective of this study is to provide a contemporary review of wartime UEVI, including epidemiologic characterization and description of early limb loss. METHODS: The Department of Defense Trauma Registry (DoDTR) was queried to identify US service members who sustained a battle-related UEVI in Afghanistan between January 2009 and December 2015. Anatomic distribution of injury, mechanism of injury (MOI), associated injuries, early management, and early limb loss were analyzed. RESULTS: Analysis identified 247 casualties who sustained 308 UEVIs. The most common injury was to the vessels distal to the brachial bifurcation (63.3%, n = 195), followed by the brachial vessels (27.3%, n = 84) and the axillary vessels (9.4%, n = 29). The predominant MOIs were penetrating explosive fragments (74.1%, n = 183) and gunshot wounds (25.9%, n = 64). Associated fractures were identified in 151 (61.1%) casualties and nerve injuries in 133 (53.8%). Angiography was performed in 91 (36.8%) casualties, and endovascular treatment was performed 10 (4%) times. Temporary vascular shunts were placed in 39 (15.8%) casualties. Data on surgical management were available for 171 injuries and included repair (48%, n = 82) and ligation (52%, n = 89). The early limb loss rate was 12.1% (n = 30). For all casualties sustaining early limb loss, the MOI was penetrating fragments from an explosion; the average injury severity score (ISS) was 32.3, and the mortality was 6.7% (n = 2). In those without amputation, the ISS and mortality were low at 20 and 4.6% (n = 10), respectively. Overall mortality was 4.9% (n = 12). CONCLUSIONS: The early limb loss rate was increased compared with initial descriptions from Operation Iraqi Freedom. Amputations are associated with a higher ISS. Improved data capture and fidelity, or differing MOIs, may account for this trend. Proficiency with open and endovascular therapy remains a critical focus for combat casualty care.

Papel de distintas técnicas de imagen para identificar y localizar cuerpos extraños intraoculares relacionados con trauma ocular abierto: reporte de tres casos y revisión de la literatura / The role of various imaging techniques in identifying and locating intraocular foreign bodies related to open-globe injury: three case reports and literature review

ANTECEDENTES La ubicación precisa de un cuerpo extraño intraocular es crucial para el manejo de pacientes con trauma ocular abierto. La tomografía computarizada se usa habitualmente para detectar su ubicación en el segmento posterior. Reportamos tres casos con diferentes cuerpos extraños intraoculares en el segmento posterior, que fueron localizados con precisión mediante la tomografía computarizada y ecografía modo B. PRESENTACIÖN DEL CASO Presentamos tres casos con diferentes mecanismos de trauma, tipos de cuerpo extraño intraocular, síntomas clínicos y pronóstico visual. La tomografía computarizada determinó la ubicación exacta de todos los cuerpos extraños intraoculares en el segmento posterior. El ultrasonido modo B se realizó en un paciente con un cuerpo extraño intraocular no metálico. El primer caso tuvo una lesión ocular perforante con un cuerpo extraño intraorbitario; el caso dos y el caso tres presentaron diferentes tipos de cuerpos extraños intraoculares con pronóstico diferente. El manejo y el pronóstico fue distinto en todos los casos; todos se manejaron con éxito. La ubicación exacta de los cuerpos extraños intraoculares utilizando las diferentes modalidades de diagnóstico es importante en estos pacientes. Estos casos sirven como recordatorio de que el uso adecuado de las pruebas de imagen es indispensable en el contexto de un cuerpo extraño intraocular relacionado con trauma ocular abierto. CONCLUSIÓN Las diferentes técnicas de imágenes son muy importantes para la detección de un cuerpo extraño intraocular. La tomografía computarizada es una de las modalidades de imagen más simple y efectiva para la localización de cuerpos extraños intraoculares relacionadas con trauma ocular abierto.

BACKGROUND: Determining the precise location of intraocular foreign bodies is crucial for the management of patients with open-globe injury. Computed tomography is the most common method for detecting intraocular foreign bodies in the posterior segment. In this article, we describe three cases of open-globe injury with different types of intraocular foreign bodies in the posterior segment that were accurately located using computed tomography scans and B-scan ultrasonography. CASE PRESENTATION: Each of the three cases of open-globe injury described in this report had different types of ocular trauma, clinical symptoms, and intraocular foreign bodies. Computed tomography scans showed the exact location of the intraocular foreign bodies in the posterior segment in two of the three cases. A B-scan ultrasound was used to determine the location of a non-metallic intraocular foreign body in the third case. All three patients had intraocular foreign bodies, and one of them had an additional orbital foreign body. Case 1 had a perforating eye injury with the additional intraorbital foreign body; Cases 2 and Case 3 had different types of intraocular foreign bodies and prognoses. Various treatment approaches were used, ranging from observation to surgery, depending on the location of the intraocular foreign bodies, and all cases were successfully managed. These three cases show that proper use of various types of imaging tests is indispensable in the context of an intraocular foreign body related to open-globe injury. CONCLUSION: Imaging techniques are crucial for the detection of an intraocular foreign body, and computed tomography is one of the simplest and most useful, especially in cases of open-globe injury.

Bone Grafting in Total Wrist Arthrodesis With Large Bone Defects Using the Reamer-Irrigator-Aspirator: A Case Study of 2 Patients.

Total wrist arthrodesis, fusion of the carpus to the radius, is a well-established and commonly performed procedure for the management of pancarpal degenerative arthritis, trauma, and other severe diseases of the wrist. A well-known complication of this is radiocarpal nonunion, with a rate of 4.4%. Commonly, bone grafting is done at the time of the surgery using local bone, iliac crest bone graft, or cancellous allograft bone. The Synthes Reamer-Irrigator-Aspirator (RIA) is a flexible reamer originally designed as a single-pass intramedullary reamer that can be used in reaming of long bone fractures prior to insertion of an intramedullary nail. Recently, its use has been expanding to the harvesting of bone graft. We present a case study of 2 patients who had total wrist arthrodesis after severe trauma to the wrist resulting in severe bone loss, in whom we used an RIA to obtain bone graft, and both patients went on to union. The first patient is a 17-year-old male who sustained a blast injury from a firework resulting in a mangling injury to the wrist with soft tissue and severe bone loss of his carpus. After being treated with multiple debridements with an external fixator, he was definitively treated with a wrist fusion with RIA bone graft. He went on to osseous union by his 4-month follow-up. Our second patient is a 53-year-old woman who sustained a gunshot wound to the wrist resulting in massive bone loss of the distal radius. After being initially treated with multiple debridements and external fixation, she was treated with a wrist fusion with RIA bone graft and went on to osseous fusion by her 3-month follow-up. Neither patient had complications from the RIA procedure.

Union Rates and Reported Range of Motion Are Acceptable After Open Forearm Fractures in Military Combatants.

BACKGROUND: High-energy open forearm fractures are unique injuries frequently complicated by neurovascular and soft tissue injuries. Few studies have evaluated the factors associated with nonunion and loss of motion after these injuries, particularly in the setting of blast injuries. QUESTIONS/PURPOSES: (1) In military service members with high-energy open forearm fractures, what proportion achieved primary or secondary union? (2) What is the pronation-supination arc of motion as stratified by the presence or absence of heterotopic ossification (HO) and synostosis? (3) What are the risks of heterotopic ossification and synostosis? (4) What factors may be associated with forearm fracture nonunion? METHODS: A retrospective study of all open forearm fractures treated at a tertiary military referral center from January 2004 to December 2014 was performed. In all, 76 patients were identified and three were excluded, leaving 73 patients for inclusion. All 73 patients had serial radiographs to assess for HO and union. Only 64 patients had rotational range of motion (ROM) data. All patients returned to the operating room at least once after initial irrigation and débridement to ensure the soft tissue envelope was stable before definitive fixation. The indication for repeat irrigation and débridement was determined by clinical appearance. Patient demographics, fracture and soft tissue injury patterns, surgical treatments, neurovascular status at the time of injury, incidence of infection, heterotopic ossification (defined as the presence of heterotopic bone visible on serial radiographs), radioulnar synostosis, bony status after initial definitive treatment (union, nonunion, or amputation), and forearm rotation at final followup were retrospectively obtained from chart review by someone other than the operating surgeon. Seventy-six open forearm fractures in 76 patients were reviewed; 73 patients were examined for osseous union as three went on to early amputation, and 64 patients had forearm ROM data available for analysis. Union was determined by earliest radiology or orthopaedic staff official dictation stating the fracture was healed. Nonunion was defined as the clinical determination by the orthopaedist for a repeat procedure to achieve bony union. Secondary union was defined as union after reoperation to achieve bony union, and final union was defined as overall percentage of patients who were healed at final followup. Of the patients analyzed for union, 20 had less than 1 year of followup, and of these, none had nonunion. Of the patients analyzed for ROM, eight patients had less than 6 months of followup (range, 84-176 days). Of these, one patient had decreased ROM, none had a synostosis, and the remaining had > 140° of motion. RESULTS: Initial treatment resulted in primary union in 62 of 73 patients (85%); secondary union was achieved in eight of 11 patients (73%); and final union was achieved in 70 of 73 patients (96%). Although pronation-supination arc in patients without HO was 140° ± 35°, a limited pronation-supination arc was primarily associated with synostosis (arc: 40° ± 40°; mean difference from patients without HO: 103° [95% confidence interval {CI}, 77°-129°], p < 0.001); patients with HO but without synostosis had fewer limitations to ROM than those with synostosis (arc: 110° ± 80°, mean difference: 77° [35°-119°], p < 0.001). Heterotopic ossification developed in 40 of 73 patients (55%), including a radioulnar synostosis in 14 patients (19%). Bone loss at the fracture site (relative risk (RR) 6.2; 95% CI, 1.8-21) and healing complicated by infection (RR, 9.9; 95% CI, 4.9-20) were associated with the development of nonunion after initial treatment. Other potential factors such as smoking status, vascular injury, both-bone involvement, need for free flap coverage and blast mechanism were not associated. CONCLUSIONS: Despite a high-energy mechanism of injury and high rate of soft tissue defects, the ultimate probability of fracture union in our series was high with a low infection risk. Nonunions were associated with bone loss and deep infection. Functional motion was achieved in most patients despite increased burden of HO and synostosis compared with civilian populations. However, if synostosis did not develop, HO itself did not appear to interfere with functional ROM. Future investigations may provide improved decision-making tools for timing of fixation and prophylactic means against HO synostosis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bomb blast shrapnel trauma to the main pulmonary artery: learning points to achieve a safe outcome.

A 47-year-old patient was injured in a bomb blast and sustained trauma due to multiple fragments of shrapnel from a terrorist explosive device. We report on the surgery required to safely remove a piece of shrapnel from the anterior wall of the main pulmonary artery (PA). A chest X-ray revealed a left-sided haemothorax. A computed tomography scan confirmed the trajectory and position of a metal bolt that had lodged between the main PA and the aortic arch. At surgery, a limited left anterior thoracotomy was performed initially. A significant quantity of blood was observed in the pericardium, and the incision was extended to perform a hemi-clamshell incision with a transverse division of the sternum. Cardiopulmonary bypass (CPB) was initiated before prizing the shrapnel from a haematoma involving the front wall of the main PA. The use of the CPB prevented uncontrolled haemorrhage, and the injury to the wall was successfully repaired. The patient subsequently developed acute respiratory distress syndrome and required a prolonged period of ventilation but made a full recovery after multiple further surgeries to remove the shrapnel from his neck and legs, having been injured by 11 pieces of the shrapnel in total.

A comparison of CT lung voxel density analysis in a blast and non blast injured casualty.

INTRODUCTION: Primary blast lung injury (PBLI) is a prominent feature in casualties following exposure to blast. PBLI carries high morbidity and mortality, but remains difficult to diagnose and quantify. Radiographic diagnosis of PBLI was historically made with the aid of plain radiographs; more recently, qualitative review of CT images has assisted diagnosis. METHODS: We report a novel way of measuring post-traumatic acute lung injury using CT lung density analysis in two casualties. One casualty presented following blast exposure with confirmed blast lung injury and the other presented following extremity injury without blast exposure. Three-dimensional lung maps of each casualty were produced from their original trauma CT scan. Analysis of the lung maps allowed quantitative radiological comparison exposing areas of reduced aeration of the patient's lungs. RESULTS: 45% of the blast-exposed lungs were non-aerated compared with 10% in the non-blast-exposed lungs. DISCUSSION: In these example cases quantitative CT lung density analysis allowed blast-injured lungs to be distinguished from non-blast-exposed lungs.

Distribution characteristics of combat-related shrapnel and relationship to weapon type and conflict location: Experience of an operational field hospital.

BACKGROUND: The aim of this study was to investigate the characteristics of shrapnel distribution in the body and a possible relationship to the type of weapon and type of location of the conflict. METHODS: The records of 246 patients admitted to a level-III trauma center with any kind of firearm injury were examined retrospectively. Ninety patients who had at least 1 radiologically-proven piece of shrapnel in their body were included in the study. For the purposes of the study, the body was divided into 5 regions (head/neck, thorax/back, abdomen/pelvis/waist, upper extremities, and lower extremities) and shrapnel distribution was noted according to these divisions. Medical data and detailed information regarding the weapon type (long-barreled weapon, rocket-propelled grenade [RPG], or improvised explosive device [IED]), conflict location (residential or rural area), and all radiological examinations (radiography and/or computed tomography) were carefully reviewed. The relationship between these variables and the shrapnel distribution in the body was investigated. RESULTS: No statistically significant differences were seen between weapon type and shrapnel distribution (p<0.05), except a significantly higher percentage of head/neck region shrapnel injuries as a result of RPG and IED injuries (p=0.002). There was no statistically significant relationship between the shrapnel distribution characteristics and conflict location, classified as either residential or rural (p<0.05). CONCLUSION: Secondary blast injuries induced by penetrating shrapnel are the most common type of explosion- and combatrelated injuries. In the current study, a significantly higher rate of head/neck region shrapnel injuries was observed in RPG and IED injuries compared with long-barreled weapon-induced injuries. The prim.

A contemporary, 7-year analysis of vascular injury from the war in Afghanistan.

OBJECTIVE: Vascular injury is a leading cause of death and disability in military and civilian trauma. Although a previous interim study defined the distribution of vascular injury during the wars in Iraq and Afghanistan, a contemporary epidemiologic assessment has not been performed. The objective of this study was to provide a current analysis of vascular injury during the final 7 years of the war in Afghanistan, including characterization of anatomic injury patterns, mechanisms of injury, and methods of acute management. METHODS: The Department of Defense Trauma Registry was analyzed to identify U.S. military service members who sustained a battle-related vascular injury and survived to be treated at a surgical facility in Afghanistan between January 1, 2009, and December 31, 2015. All battle-related injuries (nonreturn to duty) were used as a denominator to establish the injury rate. Mechanism and anatomic distribution of injury as well as the acute management strategies of revascularization, ligation, and use of endovascular techniques were defined. RESULTS: Of 3900 service members who sustained a battle-related injury, 685 patients (17.6%) had 1105 vascular injuries (1.6 vascular injuries per patient). Extremity trauma accounted for 72% (n = 796) of vascular injuries, followed by the torso (17%; n = 188) and cervical (11%; n = 118) regions. Lower extremity vascular injury was the most prevalent anatomic location (45%; 501/1105). Explosion with fragment penetration accounted for 70% (477/685) of injuries, whereas gunshot wounds accounted for 30% (205/685). Open repair was performed in 559 cases (57%; 554/981), whereas ligation was the initial management strategy in 40% (395/981) of cases. In addition, 374 diagnostic endovascular procedures were completed, 27 therapeutic endovascular interventions to include stent placement and angioplasty were performed and 55 inferior vena cava filters were placed. Mortality of the vascular injury cohort was 5%. CONCLUSIONS: The rate of vascular injury in modern combat is higher than that reported in previous wars. Open reconstruction is performed in half of cases, although ligation is an important damage control option, especially for minor or distal vessel injuries. Angiographic techniques are increasingly being used and documented within wartime registries more than ever. Proficiency with open and endovascular methods of vascular injury management remains a critical need for the U.S. military and will require partnership with civilian institutions to attain and maintain.