Iraq and Afghanistan Producing New Pattern of Extremity War Injuries

Richard Hyer

March 27, 2006

March 27, 2006 (Chicago) — The survival rate of casualties from Iraq and Afghanistan is more than 90% due to advances in forward medical care made possible in part by the miniaturization of medical equipment, and also due to a highly efficient system of evacuation, according to a presentation here at the American Academy of Orthopedic Surgeons (AAOS) 2006 annual meeting.

The volume of casualties from Iraq and Afghanistan is now the highest since the Vietnam War, with nearly 17,000 injuries to date, and, as of March 27, 2325 deaths. Many of the casualties result from use of high-energy explosives with shrapnel, which cause ultra–high velocity fragmentation injuries, often to the extremities. The average wound from one of these improvised explosive devices requires 5 surgeries, and it is estimated that these conflicts have been responsible for an estimated total of 28,000 to 30,000 surgeries, including 367 amputations.

During the Vietnam conflict it took an average of 45 days for an injured soldier to be transported from the theater of operations to the continental United States (CONUS, in military parlance). A soldier wounded today in Iraq could arrive at the level 4 trauma center in Landstuhl, Germany, in as few as 12 hours, and be back in the United States for complete care within 3 days of the original event.

The state of the art in treating injuries from the current conflicts was subject of a trauma symposium here at the AAOS annual meeting.

This symposium reviewed information from an earlier symposium on extremity war injuries that took place January 25 to 27 in Washington, DC, as a joint venture of the AAOS and the Orthopedic Trauma Association.

The primary cause of injury in Iraq is the relatively common 155-mm artillery shell (howitzer round) which is buried under asphalt and triggered by a cell phone. The round may be combined with improvised shrapnel such as steel nuts and nails covered with human feces to increase the likelihood of secondary infection.

The conflict has also seen the use of vehicle-borne improvised explosive devices or "V-BIDs," in which the round may be accompanied by tanks of propane or other chemical to enhance the burning effect. The conventional rocket-propelled grenade and 122-mm rocket are also popular weapons in these conflicts, as are .50-caliber rifles.

Captain D. C. Covey, MD, chair of the Department of Orthopaedic Surgery at Naval Medical Center, San Diego, California, and orthopaedic consultant to the Surgeon General of the Navy, credits sophisticated body armor and helmets for much of the improved survival rate.

"In the past, when body armor was less developed, people would be killed outright by wounds to the thorax," Dr. Covey said during a press conference.

Civilian emergency medicine physicians often talk of the "golden hour" after admission when they have the relative leisure to make the correct choices. "In this conflict, there's no such thing as the golden hour; maybe a golden 15 minutes," Dr. Covey said.

Survival rates in previous wars show a relatively flat line: World War II, 69.7%; Korea, 75.4%; Vietnam, 76.4%. With the 2 current conflicts, the survival rate jumps to 90.5%, according to the symposium's first speaker, Colonel James R. Ficke, MD, from Brooke Army Medical Center at Fort Sam Houston outside San Antonio, Texas, who spent the last year in Iraq.

According to Dr. Ficke, 60% to 75% of the wounds from current battles are to the limbs.

"Most of the work that we're doing right now in terms of outcomes has to do with far forward surgery," D. Ficke explained to Medscape. "We've seen a kind of a revision of thinking at this mature theater, where there's less need for the very small forward surgical teams, and there's more of the need for large multicapable facilities such as the combat support hospital."

Dr. Ficke added that he credited aggressive debridement in particular.

"We're still seeing significant casualty rates for the intensity of this conflict," Dr. Ficke continued. "The differences, I think, are multiple aggressive debridements, or washouts, and essentially taking away the devitalized tissue. That's occurring at every level from the forward surgical teams to the combat support hospitals. We're seeing 4 to 5 washouts within the first week of the injury, so that by the time they get back to the United States in 4 or 5 days, the surgeons in the US really can start a reconstructive effort. That's made the biggest difference," he told Medscape.

According to the next speaker, Mark R. Bagg, MD, also from from Brooke Army Medical Center at Fort Sam Houston, there is disagreement in the medical community on whether the time from injury to debridement prevents infection. He praised vacuum-assisted closure in his presentation on wound management, and he described current practices on the battlefield and during evacuation, including standards for closure and soft tissue reconstruction.

Between 60% to 70% of wounds from this conflict are musculoskeletal, according to Lieutenant Commander Michael Mazurek, MC, USN, from the Naval Medical Center in San Diego, California. LCDR Mazurek discussed contemporary blast physics, including the high-speed chemical change of explosive to gas. The blast effect is complex, and includes the effects of pressure (overpressure), penetrating trauma (fragments and debris), blast wind and structural collapse, burns, and toxic inhalants. The primary blast effect mainly affects air-fluid interfaces, with orthopaedic trauma as a secondary or tertiary effect.

LCDR Mazurek described the salient differences between blast and gunshot wounds, and stabilization options when the casualty occurs far forward. He described indications for conversion of external fixation to definitive treatment.

The current gold standard for reconstruction of bone defects in extremity war injuries is autogenous bone graft, according to Michael J. Bosse, MD, from Charlotte, North Carolina, whose presentation was on segmental bone defects. Dr. Bosse said he looks forward to the use of osteogenic proteins and targeted tissue engineering in bone repair.

This war has witnessed an increasing number of resistant Acinetobacter baumannii (rAcb) infections, according to Jason Calhoun, MD, from Columbia, Missouri, who discussed antibiotics and infection. This bacteria is commonly found in Turkey, Taiwan, and Vietnam, and the infections have breathed new life into the old drug, colistin. This cyclic polypeptide antibiotic was discovered in the late 1940s, and its use declined in the early 1950s due to reports of renal toxicity. However, Dr. Calhoun noted that it may be state of the art for osteomyelitis secondary to rAcb.

Tigecycline is another option. This new semisynthetic glycylcycline has broad activity against multidrug-resistant organisms, according to Dr. Calhoun. He predicted that more rapid and early identification of bacteria will allow for the most precise targeting.

The largest US military hospital in Iraq is the Air Force Theater Hospital in Balad, and it was under the command of Colonel Elisha T. Powell IV until January of this year. Colonel Powell told Medscape that "this is the largestAir Force theater hospital since Vietnam. The Air Force also hasn't put a theater hospital this far forward in the battlefield since Vietnam."

Medscape asked his opinion of the overall efficiency of medical care in Iraq.

"I think the military has done a great job with pushing the technology, the training, and the personnel so far forward in the battlefield that we're able to save lives," Colonel Powell said. "If you made it to our hospital in Balad alive, you've got a 96% survival rate. And a lot of that is due to the Marine and Army foremen and airmen out in the field, giving lifesaving care right out in the battlefield. Credit also belongs to the aerovac crews who are able to transport these critically injured patients back to Germany, and then to the large medical centers in the United States, in rapid fashion. The whole aerovac system and air crews do an outstanding job of getting those patients back," he said.

In his remarks to the conference, Colonel Powell noted that the wounded soldier was 10 days from CONUS during Operation Desert Storm but only 3 days in the current conflicts. Most urgent/priority patients take an average of 13.2 hours to move from Iraq or Afghanistan. Colonel Powell described the path from battalion aid station to field hospital, air transportable hospital, and finally to definitive care.

Air transport of wounded has its own problems, Colonel Powell said, including decreased partial pressure of oxygen, barometric pressure, tactical takeoffs and landings, and alarms that are difficult to hear.

What do civilian orthopaedic surgeons hope to gain from this discussion? Medscape interviewed one audience member, Cathleen Murphy-Weaver, MD, a board-certified orthopaedic surgeon from Mexico, Missouri.

"My brother was in the reserves and drove trucks on the front line in the first Desert Storm," Dr. Weaver told Medscape. "You never know when you will have to be overseas. You never know what the world's status is going to be. I was raised in Beirut, so I have a real respect for how incredibly crazy the Middle East can get."

Dr. Weaver added, "And if there's something that the general orthopaedic surgeon should know about wartime training, we should make this information available. Because you never know in what circumstances or what disaster you're going to have to know this."

AAOS 2006 Annual Meeting: Symposium: Extremity war injuries: state of the art and future directions. Presented March 23, 2006.

Reviewed by Robert Chevrier

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