Friday, January 09, 2009

journal articles published about iraq and afghanistan amputees

Title: Provider perspectives on rehabilitation of patients with polytrauma
Author(s): Friedemann-Sanchez, G; Sayer, NA; Pickett, T
Times Cited: 3
Abstract: Objectives: To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation. Design: Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison. Setting: The 4 VA polytrauma rehabilitation centers (PRCs). Participants: Fifty-six purposefully selected PRC providers and providers from consulting services. Interventions: Not applicable. Main Outcomes Measures: Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves. Results: According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding. Conclusions: The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.

Title: Patterns of injury in a combat environment
Author(s): Willy, C; Voelker, HU; Steinmann, R; Engelhardt, M
Source: CHIRURG 79 (1):66-76 2008
Times Cited: 0
Abstract:Epidemiological analysis of injury patterns and mechanisms help in identifying the expertise that military surgeons need in a combat setting and also in adjusting training requirements accordingly. This paper attempts to assess the surgical specialties and skills of particular importance in the management of casualties in crisis areas. MEDLINE (1949-2007) and Google search were used. Causes of death among casualties in Afghanistan and the Iraq war were analyzed. The leading causes of injury were explosive devices, gunshot wounds, aircraft crashes, and terrorist attacks. Of the casualties, 55% died in hostile action and 45% in nonhostile incidents. Chest or abdominal injuries (40%) and brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq was approximately half as high as in the Vietnam War. In contrast, the amputation rate was twice as high. Approximately 8-15% of the deaths appeared to be preventable. Military surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. It also is of vital importance to ensure the availability of sufficient medical evacuation capabilities. Furthermore, there is a need for a standardized registration system for all injuries similar to the German Trauma Registry.

Title: Amputations in US military personnel in the current conflicts in Afghanistan and Iraq
Author(s): Stansbury, LG; Lalliss, SJ; Branstetter, JG; Bagg, MR; Holcomb, JB
Source: JOURNAL OF ORTHOPAEDIC TRAUMA 22 (1):43-46 2008
Times Cited: 2
Abstract:Objectives: To determine rates of major limb amputation in U.S. military casualties in the current conflicts in Afghanistan and Iraq, to correlate these with mechanism of injury, and compare the rate with that seen in U.S. casualties from the Vietnam War. Design: Retrospective study of all US. casualties recorded for the current conflicts from the start in October 1, 2001 to June 1, 2006. Setting: Records from U.S. military forward surgical teams (Level IIb) and combat support hospitals (Level III) in theater, evacuation (Level IV, Germany), and major military medical centers (Level V, United States). Patients/Participants: All recorded U.S. military casualties from the Afghanistan and Iraq theaters with injuries requiring evacuation out of theater or prohibiting the individual from returning to duty for more than 72 hours. Intervention: None. Main Outcome Measurements: Major limb injury, level of amputation, principal mechanism of injury. Results: Over the past 56 months, of the 8058 military casualties meeting the listed criteria, 5684 (70.5%) were recorded as having major limb injuries. Of these, 423 (5.2% of all serious injuries; 7.4% of major limb injuries) under-went major limb amputation or amputation at or proximal to the wrist or ankle joint. The mechanism of injury for 87.9% was some form of explosive device. The major amputation rate during Vietnam was 8.3% of major limb injuries. Conclusions: overall, major limb amputation rates for the current U.S. engagement in Afghanistan and Iraq are similar to those of previous conflicts.

Title: Practical use of emergency tourniquets to stop bleeding in major limb trauma
Author(s): Kragh, JF; Walters, TJ; Baer, DG; Fox, CJ; Wade, CE; Salinas, J; Holcomb, JB
Times Cited: 1
Abstract:Background: Previously we showed that tourniquets were lifesaving devices in the current war. Few studies, however, describe their actual morbidity in combat casualties. The purpose of this study was to measure tourniquet use and complications. Methods: A prospective survey of casualties who required tourniquets was performed at a combat support hospital in Baghdad during 7 months in 2006. Patients were evaluated for tourniquet use, limb outcome, and morbidity. We identified potential morbidities from the literature and looked for them prospectively. The protocol was approved by the institutional review board. Results: The 232 patients had 428 tourniquets applied on 309 injured limbs. The most effective tourniquets were the Emergency Medical Tourniquet (92%) and the Combat Application Tourniquet (79%). Four patients (1.7%) sustained transient nerve palsy at the level of the tourniquet, whereas six had palsies at the wound level. No association was seen between tourniquet time and morbidity. There was no apparent association of total tourniquet time and morbidity (clots, myonecrosis, rigor, pain, palsies, renal failure, amputation, and fasciotomy). No amputations resulted solely from tourniquet use. However, six (2.6%) casualties with eight preexisting traumatic amputation injuries then had completion surgical amputations and also had tourniquets on for >2 hours. The rate of limbs with fasciotomies with tourniquet time <= 2 hours was 28% (75 of 272) and >2 hours was 36% (9 of 25, p = 0.4). Conclusions: Morbidity risk was low, and there was a positive risk benefit ratio in light of the survival benefit. No limbs were lost because of tourniquet use, and tourniquet duration was not associated with increased morbidity. Education for early military tourniquet use should continue.

Title: Complications after fasciotomy revision and delayed compartment release in combat patients
Author(s): Ritenour, AE; Dorlac, WC; Fang, R; Woods, T; Jenkins, DH; Flaherty, SF; Wade, CE; Holcomb, JB
Times Cited: 0
Abstract:Background: Incomplete or delayed fasciotomies are associated with muscle necrosis and death in civilian trauma. Combat explosions severely damage tissue and distort normal anatomy making fasciotomies challenging. Rapid air evacuation may delay treatment of patients with evolving extremity compartment syndrome. We investigated the impact of fasciotomy revision and delayed compartment release on combat casualties after air evacuation. Methods: A retrospective review was performed of combat casualties who underwent fasciotomies in Iraq, Afghanistan, or at Landstuhl Regional Medical Center between January 1, 2005 and August 31, 2006. Outcomes were rates of muscle excision, major amputation, and mortality. Results: A total of 336 patients underwent 643 fasciotomies. Most were to the lower leg (49%) and forearm (23%). Patients who underwent a fasciotomy revision had higher rates of muscle excision (35% vs. 9%, p < 0.01) and mortality (20 % vs. 6 %, p < 0.01) than those who did not receive a revision. The anterior and deep compartments of the-lower leg were the most commonly unopened. Patients who underwent fasciotomy after evacuation had higher rates of muscle excision (25% vs. 11%), amputation (31 vs. 15%), and mortality (19% vs. 5%) than patients who received their fasciotomies in the combat theater (p < 0.01). Patients who underwent revisions or delayed fasciotomies had higher Injury Severity Score and larger burns as well as lower systolic blood pressure, acidosis, and more pressor use during air evacuation. These patients also received more blood products at Landstuhl Regional Medical Center. Conclusion: Fasciotomy revision was associated with a fourfold increase in mortality. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopened compartment was the anterior compartment of the lower leg. Patients who underwent delayed fasciotomies had twice the rate of major amputation and a threefold higher mortality.

Title: Treatment for the service member: A description of innovative interventions
Author(s): Yancosek, K; Daugherty, SE; Cancio, L
Source: JOURNAL OF HAND THERAPY 21 (2):189-194 2008
Conference Title: Conference on the Contributions of the Military Hand Therapist in Combat and Postdeployment Rehabilitation
Conference Date: 2005
Conference Location: San Antonio, TX
Times Cited: 0
Abstract:This article describes advances to the rehabilitation programs at major military medical centers since the onset of operations in Iraq and Afghanistan. The demands on military health care in times of war produce advances in the various rehabilitation professions. This article describes two programs that use new technologies for the care of military patients with devastating injuries to the upper extremity. One project relates to the application of voice-sensitive technology. The other project describes the utilization of virtual reality technology through a Firearm Training System. The article also explains an adaptive sports program and how recreation is part of a robust community reintegration program. Lastly, this article discusses the Center for the Intrepid, which is one of two new amputee care centers built to support the advanced rehabilitation of war-wounded amputees.

Title: Recombinant human bone morphogenetic protein-2 for grade III open segmental tibial fractures from combat injuries in Iraq
Author(s): Kuklo, TR; Groth, AT; Anderson, RC; Frisch, HM; Islinger, RB
Times Cited: 0
Abstract:This is a retrospective consecutive case series of 138 Gustillo-Anderson type IIIB and IIIC segmental tibial fractures treated at Walter Reed Army Medical Center in soldiers injured in Iraq between March 2003 and March 2005. Five patients with a head injury and four who were lost to follow-up were excluded. The patients were treated definitively with either a ringed external fixator or a reamed intramedullary nail, evaluated in terms of supplementary bone grafting with either autogenous bone (group 1, 67 patients) or recombinant human bone morphogenetic protein-2 at 1.50 mg/ml applied to an absorbable collagen sponge (group 2, 62 patients). The mechanism of injury, defect size and classification, associated injuries, presence of infection, preliminary treatment/fixation, number of procedures before definitive management, time to and details of definitive management, subsequent infection, re-operation, smoking history and other complications were noted. Radiographs were assessed for union, delayed union or nonunion by an independent investigator. All the patients were male. Their mean age was 26.6 years (20 to 42) and the mean follow-up was for 15.6 months (12 to 32). Group 2 had a slightly higher profile of concomitant injuries and a slightly worse fracture classification, but these were not significant. The rate of union was 76% (51 of 67) for group 1 and 92% for group 2 (57 of 62; p = 0.015). There was also a higher rate of subsequent infection in group 1 (14.9%) compared with group 2 (3.2%; p = 0.001) and a higher rate of re-operation (28%) in group 1 (p = 0.003). There were no observed hypersensitivity reactions to the recombinant human bone morphogenetic protein-2 implant.

Title: Developing a polytrauma rehabilitation center: A pioneer experience in building, staffing, and training
Author(s): MacLennan, D; Clausen, S; Pagel, N; Avery, JD; Sigford, B; MacLennan, D; Mahowald, R
Source: REHABILITATION NURSING 33 (5):198-+ 2008
Times Cited: 0
Abstract:The military operations in Iraq and Afghanistan have resulted in patterns of injury not commonly seen in previous conflicts. Improvised explosive devices are the primary weapon, and exposure to blast is the most common mechanism of injury. Blasts can result in polytrauma injury, in which multiple body systems, including the head and brain, are injured. Nursing and rehabilitation care can be further challenged by other blast sequelae such as pain, amputation, blindness or low vision, hearing impairment, and aphasia. This article describes the process by which one Veterans Affairs Medical Center developed its inpatient rehabilitation service into a polytrauma rehabilitation center to meet the medical and rehabilitation needs of these patients. Special attention is given to the education and training program developed to solidify the membership of the center's nursing staf in the interdisciplinary treatment team.

Title: Orthopedic Injuries in US Casualties Treated on a Hospital Ship during Operation Iraqi Freedom
Author(s): Enad, JG; Headrick, JD
Source: MILITARY MEDICINE 173 (10):1008-1013 2008
Times Cited: 0
Abstract:From March to May 2003. the USNS Comfort was deployed to the Persian Gulf in Support of combat operations for Operation Iraqi Freedom. The onboard orthopedic service treated 58 U.S. casualties during that period. Eighty-seven percent of the injuries were to the appendicular skeleton. Twenty-four percent were battle injuries, and 72% were nonbattle injuries. Patients with battle injuries tended to be younger and required more orthopedic operations than did patients with nonbattle injuries. Moreover, all patients with battle injuries were evacuated to higher echelons for further care, whereas 19% of patients with nonbattle injuries returned to duty in the short term. Complications were few, with no infections, amputations, or deaths. A descriptive review of the types of injuries, orthopedic care, and eventual disposition is presented.

Title: In-theater management of vascular injury: 2 years of the balad vascular registry
Author(s): Clouse, WD; Rasmussen, TE; Peck, MA; Eliason, JL; Cox, MW; Bowser, AN; Jenkins, DH; Smith, DL; Rich, NM
Conference Title: 92nd Annual Clinical Congress of the American-College-of-Surgeons
Conference Date: OCT, 2006
Conference Location: Chicago, IL
Times Cited: 10
Abstract:BACKGROUND: Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts. STUDY DESIGN: Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed. RESULTS: During this 24-month period, 6,801 battle-related casualties were assessed. Three hundred twenty-four (4.8%) were diagnosed with 347 vascular injuries. Extremity injuries accounted for 260 (74.9%). Vascular injuries in the neck (n = 56; 16.1%) and thoracoabdominal domain (n = 3 1; 8.9%) were less common. US forces accounted for 149 casualties (46%), 97 (30%) were local civilian, and 78 (24%) were Iraqi forces. One hundred seven (33%) patients with vascular injury were evacuated from forward locations after treatment initiation. Fifty-four (50%) of these had temporary shunts placed. Of 43 proximal shunts placed in-field, 37 (86%) were patent at the time of our assessment. Early amputation rate was 6.6% for those extremity injuries treated for limb salvage. Perioperative mortality was 4.3%. CONCLUSIONS: This evaluation represents the first in-theater report of wartime vascular injury since Vietnam. Extremity injuries continue to predominate, although the incidence of vascular injury appears to be somewhat increased. Local forces and civilians now represent a substantial proportion of those injured. The principles of rapid evacuation, temporary shunting, and early reconstruction are effective, with satisfactory early in-theater limb salvage. (J Am Coll Surg 2007;204: 625-632. (C) 2007 by the American College of Surgeons).

Title: Infectious complications of open type III tibial fractures among combat casualties
Author(s): Johnson, EN; Burns, TC; Hayda, RA; Hospenthal, DR; Murray, CK
Source: CLINICAL INFECTIOUS DISEASES 45 (4):409-415 2007
Times Cited: 14
Abstract:Background. Combat is associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection. We characterize the infections seen in conjunction with combat-associated type III tibial fractures. Methods. We performed a retrospective medical records review to identify US military service members wounded in Iraq or Afghanistan with open diaphyseal tibial fractures who were admitted to our facility (Brooke Army Medical Center, Fort Sam Houston, Texas) between March 2003 and September 2006. Results. Of the 62 patients with open tibial fractures who were identified in our initial search, 40 had fractures that met our inclusion criteria as type III diaphyseal tibial fractures. Three patients were excluded because their fractures were managed with early limb amputation, and 2 were excluded because of incomplete follow-up records. Twenty-seven of these 35 patients had at least 1 organism present in initial deep-wound cultures that were performed at admission to the hospital. The pathogens that were identified most frequently were Acinetobacter, Enterobacter species, and Pseudomonas aeruginosa. Thirteen of the 35 patients had union times of 19 months that appeared to be associated with infection. None of the gram-negative bacteria identified in the initial wound cultures were recovered again at the time of a second operation; however, all patients had at least 1 staphylococcal organism. One patient had an organism present during initial culture and in the nonunion wound; this organisim was a methicillin-resistant Staphylococcus aureus strain that was inadvertently not treated. Five of 35 patients ultimately required limb amputation, with infectious complications cited as the reason for amputation in 4 of these cases. Conclusions. Combat-associated type III tibial fractures are predominantly associated with infections due to gram-negative organisms, and these infections are generally successfully treated. Recurrent infections are predominantly due to staphylococci.

Title: Hearing regeneration in a dog after deafness due to unprofessional excision of the external ear during puppyhood
Author(s): Konig, F
Source: KLEINTIERPRAXIS 52 (5):291-+ 2007
Times Cited: 0
Abstract:In some areas of Asia, the unprofessional excision of the external ear and tail of male puppies is often practiced. By this treatment, dog owners from Turkey, over Russia to Afghanistan try to evoke aggressive and guarding behaviour in their dogs. Due to increasing intercontinental travel, more and more dogs mistreated in this way have been imported to Germany. The diagnosis of hearing loss and treatment options in the dog are discussed on the basis of a case report concerning a male dog deafened as a puppy. We could resolve his conductive deafness by opening the remnants of his ear canals. Postoperatively, he showed disturbances in sound interpretation and possibly somatosensory pain phenomena. The observed postoperative phenomena are compared with the literature and reports about experiences with prelingually deafened children after prosthetic implant surgery.

Title:The complete management of extremity vascular injury in a local population: A wartime report from the 332nd expeditionary medical Group/Air Force Theater Hospital, Balad Air Base, Iraq
Author(s): Peck, MA; Clouse, WD; Cox, MW; Bowser, AN; Eliason, JL; Jenkins, DH; Smith, DL; Rasmussen, TE
Source: JOURNAL OF VASCULAR SURGERY 45 (6):1197-1204 2007
Conference Title: 20th Annual Meeting of the Eastern-Vascular-Society
Conference Date: SEP 28-30, 2006
Conference Location: Washington, DC
Times Cited: 5
Abstract: Background: Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. Methods: From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. Results: During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n = 134), neck and great vessel 17% (n = 33), and thoracoabdominal 13% (n = 25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strictwound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n = 21). Surgical wound infection occurred in 3.7% (n = 5), and acute anastomotic disruption in 3% (n = 4). Graft thrombosis occurred in 4.5% (n = 6), and early amputation and mortality rates during the study period were 3.0% (n = 4) and 1.5% (n = 2), respectively. Conclusions: To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.
ISSN: 0741-5214
DOI: 10.1016/j.jvs.2007.02.003
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Title: Key factors for civilian injuries and deaths from exploding landmines and ordnance
Author(s): Surrency, AB; Graitcer, PL; Henderson, AK
Source: INJURY PREVENTION 13 (3):197-201 2007
Times Cited: 0
Abstract:Objective: To identify risk factors for death or injury from landmines and ordnance in Kabul City, Afghanistan, so programs can target preventive actions. Methods: Active surveillance in hospitals and communities for injuries and deaths from landmine and ordnance explosions in Kabul City. Results: Of the 571 people the authors identified during the 25-month period, 161 suffered a traumatic amputation and 94 were killed from a landmine or ordnance explosion. Of those asked, 19% of victims had received mine awareness education before the incident, and of those, the majority was injured while handling or playing with an explosive device. Most victims were young males with a few years of education. The occupation types most at risk were students and laborers, and unemployment was common among the victims. Collecting wood or paper and playing with or handling an explosive were the most frequent activities associated with injuries and deaths. Conclusions: From May 1996 to July 1998, explosions from landmines and ordnance claimed 571 victims and were an important preventable cause of injury and death among people in Kabul City. Prevention strategies should focus on high-risk groups and changing risky behaviors, such as tampering with explosive devices.

Title: Traumatic transfemoral amputation with concomitant ipsilateral proximal femoral fracture - A report of two cases
Author(s): Pickard-Gabriel, CJ; Ledford, CL; Gajewski, DA; Granville, RR; Andersen, RC
Times Cited: 0
Abstract:In contrast to civilian amputations, military amputations today are almost entirely due to trauma(1-6). The current conflicts in Afghanistan and Iraq have resulted in more than 700 major limb amputations(7). We present the cases of two patients who sustained traumatic transfemoral amputations with concomitant ipsilateral femoral fractures. The injuries in these two patients represent particularly complex injuries that are rarely, if ever, seen in the civilian trauma setting. These patients represent a different segment of the population than do traditional civilian amputees because of their young age, excellent physical conditioning prior to injury, high capacity for healing, and long life expectancy following amputation(8-11). When a traumatic lower-limb amputation occurs in a young healthy adult, the best outcome is attained with use of a prosthetic limb to restore as much function and mobility as possible(12). More distal levels of amputation (e.g., trans-tibial compared with transfemoral) allow more efficient walking(8,10,11,13-16) and better overall function(14.17). It is therefore important to maintain as much skeletal length as possible to optimize outcome. The current standard suggests that a minimum length of 5 to 10 cm distal to the lesser trochanter (approximately one-third of the original femoral length) is necessary to fit a patient with a transfemoral total-contact ischial-containment narrow-medial-lateral socket prosthesis rather than a hip-disarticulation total-contact ischial-containment prosthesis. Ideally, the residual length should be approximately 20 cm distal to the lesser trochanter (approximately two-thirds of the original femoral length).

Title: Developing a trauma registry in a forward deployed military hospital: Preliminary report
Author(s): Acosta, JA; Hatzigeorgiou, C; Smith, LS
Times Cited: 1
Abstract:Background. The 325th Field Surgical Team (FST), a US Army trauma surgical group, was deployed to Afghanistan during Operation Enduring Freedom. Unlike civilian trauma centers, complete trauma registries are lacking from the FST care model. Methods. A trauma registry was created using a commercially available relational database. Data entry was done using a handheld personal data organizer (PDA). Results. In 82 days, 125 trauma patients were evaluated and treated. The mean age was 23 +/- 11.69 and 85 (68%) were local Afghan nationals. Most patients were transported by helicopter (83; 66%); the remaining arrived by ground transportation (42; 34%). The average US military casualty arrival time from injury was 1 hour 38 minutes +/- 46. The most common injury was gunshot wounds 47(38%) and the mean Injury Severity Score was 9, with 29 (23%) patients scoring >= 15. Initial mean vitals were systolic blood pressure (SBP); 119 +/- 23.7, heart rate; 103 +/- 7.35, respiratory rate; 20 +/- 7.35, and temperature (degrees C); 36.6 +/- 1.6. The median Glasgow Coma Scale was 15, and presenting mean hematocrit and base deficit were 35 +/- 9.56 and -5.02 +/- 5.03, respectively. Operative procedures were performed in 54 (43.2%) patients, and the mean time to surgery from admission was 80 +/- 11.5 minutes. The most common operative procedure was debridement or completion of amputation of lost limb debridement and completion of amputations (13). The average length of stay was 4.37 +/- 2.88 days. The mortality rate was 8%. Conclusion. The collection of comprehensive prospective data using a PDA can be an efficient and effective method in expanding trauma base registries in forward deployed surgical units.

Title:Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraq Feedom: One unit's experience
Author(s): Chambers, LW; Green, DJ; Sample, K; Gillingham, BL; Rhee, P; Brown, C; Narine, N; Uecker, JM; Bohman, HR
Times Cited: 7
Abstract: 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.

Title: Upper extremity vascular injury: A current in-theater wartime report from Operation Iraqi Freedom
Author(s): Clouse, WD; Rasmussen, TE; Perlstein, J; Sutherland, MJ; Peck, MA; Eliason, JL; Jazerevic, S; Jenkins, DH
Source: ANNALS OF VASCULAR SURGERY 20 (4):429-434 2006
Conference Title: 16th Annual Winter Meeting of the Peripheral-Vascular-Surgery-Society
Conference Date: JAN 27-29, 2006
Conference Location: Pk City, UT
Times Cited: 6
Abstract:Past wartime experience and recent civilian reports indicate upper extremity (UE) vascular injury occurs less often and with less limb loss than lower extremity (LE) injury. Given advances in critical care, damage control techniques, and military armor technology, the objective of this evaluation was to define contemporary patterns of UE injury and effectiveness of vascular surgical management in UE vascular injury during Operation Iraqi Freedom (OIF). From 1 September 2004 through 31 August 2005, 2,473 combat-related injuries were treated at the central echelon III surgical facility in Iraq. Patients with UE vascular injuries upon arrival were reviewed. Vessels injured were delineated. Therapeutic interventions, early limb viability, and complication rates following vascular repair were recorded. Of casualties treated during the study period, 43 (1.7%) UE and 83 (3.3%) LE vascular injuries were identified. Of the UE injuries, 11 (26%) had been operated on at forward locations and six (14%) had temporary shunts in place upon arrival at our facility. Injury levels included 10 (23%) subclavian-axillary, 25 (58%) brachial, and 10 (23%) distal to the brachial bifurcation. Two patients had multilevel injury. Twenty-eight grafts were placed, and 10 vessel repairs and eight ligations were performed. Two (4.7%) brachial interposition grafts required removal due to infection. Four (9.3%) subacute brachial graft thromboses occurred. Four (9.3%) patients underwent early UE amputation. In this most recent U.S. military evaluation of wartime UE vascular injury, UE injury appears rare, with LE injury twice as frequent. Yet, UE limb loss appears more substantial than noted previously. These findings are likely related to significant tissue destruction occurring with the combined mechanisms of injury sustained in OIF.

Title: Long-term follow-up of Iranian veteran upper extremity amputees from the Iran-Iraq War (1980-1988)
Author(s): Ebrahimzadeh, MH; Fattahi, AS; Nejad, AB
Times Cited: 1
Abstract:Background: Despite their frequency, there are limited reports concerning long-term follow up of upper limb amputation among battle-injured patients, which occurred at a young age. The purpose of this study was to evaluate how well these patients function years after their injury. Methods: The study consisted of a thorough assessment and examination and review of the history and war time medical records of 25 Iranian veteran amputees from imposed Iran-Iraq war with a comprehensive survey including a detailed questionnaire. Information was analyzed and compared with limited similar reports in the literature. Results: Out of 200 war amputees there were 25 unilateral upper limb amputees; all others were lower limb amputees. The average age at the time of injury was 23.06 years, average age at follow-up was 41.55 years, and the average time between injury and follow-up was 17.5 years. The most common level of amputation was below elbow (40%), and the most common cause of war injury was artillery shells, mortar or rocket shells. The prevalence of clinical symptoms of phantom sensation, phantom pain, phantom movement and stump pain were; 64%, 32%, 20%, 24%, respectively. All patients were married (100%) and had children except one case (96%). Sixty percent of patients were employed. Thirty-six percent had a documented psychiatric history ranging from minor depression to post-traumatic stress disorders. Conclusion: The study showed-despite long period of time between war, amputation, and follow-up-there is a significant rate of amputation symptoms, but on the other hand good family and social function of the patients.

Title:A case report on the collaboration of health care professionals in fitting and training seven Iraqi clients with right wrist disarticulations 9 years postamputation
Author(s): Krenek, SM; Vasquez, M
Times Cited: 0
Abstract: In 1995, seven men from Iraq had their right hands surgically amputated under the regime of Sad dam Hussein. The men have lived with the shame, that is associated with miss in g a right hand in their culture, since that time. Recently, the media and a team of health care providers collaborated to bring these seven men to Houston, Texas, for surgical revisions, prosthetic hands, and occupational therapy services. The preprosthetic, interimprosthetic, and postprosthetic interventions are discussed, as well as the typical time frames for each. This case report outlines the time restrictions that were placed on the health care team and demonstrates the continuous collaborative approach between occupational therapists, prosthetists, and other health care professionals, which contributed to the initial successful outcomes for these men.

Title:Evaluation of quality of life in self-care of stumps skin in Janbazan: Persons who suffered an injury in imposed Iran-Iraq war leading to lower limb amputation
Author(s): Saeidolzakerin, MA
Conference Title: 7th International Symposium on Osteoporosis
Conference Date: APR 18-22, 2007
Conference Location: Washington, DC

Title: Extremity vascular injuries on the battlefield: Tips for surgeons deploying to war
Author(s): Starnes, BW; Beekley, AC; Sebesta, JA; Andersen, CA; Rush, RM
Times Cited: 13
Abstract: Background: Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that. Methods: We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone Results: The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed. Conclusions: The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.

Title: Responding to challenges in modern combat casualty care: Innovative use of advanced regional anesthesia
Author(s):Stojadinovic, A; Auton, A; Peoples, GE; McKnight, GM; Shields, C; Croll, SM; Bleckner, LL; Winkley, J; Maniscalco-Theberge, ME; Buckenmaier, CC
Source: PAIN MEDICINE 7 (4):330-338 2006
Times Cited: 8
Abstract: Background. The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge. Methods. From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected. Results. Over 900 operations (mean 4 +/- 2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2 +/- 1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1-34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7 +/- 0.2 to 2.2 +/- 0.2, P < 0.001). Conclusion. Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty.

Title: Experience of treating gunshot wounds of large vessels in Afghanistan
Author(s): Brusov, PG; Nikolenko, VK
Source: WORLD JOURNAL OF SURGERY 29S25-S29 Suppl. 1 2005
Times Cited: 1
Abstract:The problem of treating injuries of large vessels in times of peace has been sufficiently well developed both in theoretical and practical aspects. In times of war, however, due to the large numbers of the wounded, a shortage of expert angiosurgeons, and multiple gunshot wounds, many theoretical tenets lose their academic regularity. The present study is based on the experience of treating 302 patients wounded during the Afghanistan war (1981-1985). Most of the injuries were to the vessels of the extremities. The gunshot wounds were complex. They included extensive destruction of tissue in the damaged segments of the extremities with simultaneous damage of large veins (42.0% of the cases), nerves (45.5%), and bones (47.4%). Multiple-vessel injuries were encountered in 4% of the cases, with combined injuries comprising 17.5%. Most of the wounded (83.7%) were in a state of shock, with 6.4% in a terminal condition. The blood loss amounted to 15% to 65% of the total volume. Ninety percent of the wounded were admitted to hospitals in the first 6 hours. A two-stage method was used to treat 71 of the wounded. The method included temporary bypass of the injured arteries and veins while evacuating the wounded and during surgery. Two hundred ninety-five wounded underwent vessel surgery. Out of the total number of injuries of arteries and veins, vessel sutures were used in 36.9% and 35.9% of the cases, vessel plastics in 41.4% and 7.1% of the cases, and vessel ligation in 21.7% and 60.0% of the cases, respectively. Surgery was completed by fixing the bone fragments externally with the help of special devices using the Ilizarov method. Amputation was performed in 13.9% of the cases. In 7.3% of the cases amputation was performed according to primary indications (no reconstructive surgery attempted on the vessels). In 6.6% of the cases extremities were amputated during the early postoperative period as a result of vessel thrombosis and an increase of tissue ischemia. The mortality rate after vessel surgery was 5.3%. We believe that for patients with gunshot wounds involving vessel injuries, early one-time reconstruction of the destroyed anatomical structures should be performed.

Title: Contemporary management of wartime vascular trauma
Author(s): Fox, CJ; Gillespie, DL; O'Donnell, SD; Rasmussen, TE; Goff, JM; Johnson, CA; Galgon, RE; Sarac, TP; Rich, NM
Source: JOURNAL OF VASCULAR SURGERY 41 (4):638-643 2005
Conference Title: Joint Annual Meeting of the Society-for-Vascular-Surgery/American-Association-for-Vascular-Surgery
Conference Date: JUN 03-06, 2004
Conference Location: Anaheim, CA
Times Cited: 18
Abstract:Objective: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. Methods: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. Results: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 (88%)) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%). Conclusions: This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.

Title:A method for determining the rate of major limb amputations in battle casualties: Experiences of a British Field Hospital in Iraq, 2003
Author(s): Ramalingam, T; Pathak, G; Barker, P
Times Cited: 1
Abstract: Introduction: The majority of battle casualties undergoing surgery at 34 Field Hospital, the sole Coalition field hospital in Iraq during the conflict, sustained injuries to the extremities. To compare our experiences with those from previous conflicts, we report data on major limb amputations and propose a method for determining the rate of major limb amputation in a conflict setting. Patients and Methods: A retrospective review of battle casualties admitted to the hospital was carried out based on casualty records and operating theatre logbooks. Data were collected for the period 26 March and 8 May 2003, focusing on casualties undergoing surgery for battle-injured extremities during the conflict. Results: 68 (55%) casualties underwent surgery for battle injuries to extremities. Six upper and eight lower limb amputations (proximal to carpals and tarsals) were carried out from a total of 87 battle-injured limbs that had surgery, giving an overall amputation rate of 16% (14/87). Conclusions: In presenting our amputation rate of 16%, we highlight the lack of uniformity in describing 'amputation rates' between conflicts. A consistent method for quantifying amputations performed in a conflict setting could prove to be a useful tool.

Title: Human rights abuses and concerns about women's health and human rights in southern Iraq
Author(s): Amowitz, LL; Kim, G; Reis, C; Asher, JL; Iacopino, V
Times Cited: 16
Abstract:Context Although human rights abuses have been reported in Iraq, the full scope of these abuses has not been well documented. Objective To assess the prevalence of human rights abuses since 1991 in southern Iraq, along with attitudes about women's health and human rights and women's rights and roles in society, to inform reconstruction and humanitarian assistance efforts in Iraq. Design Cross-sectional, randomized survey of Iraqi men and women conducted in July 2003 using structured questionnaires. Setting Three major cities in 3 of the 9 governorates in southern Iraq. Participants A total of 1991 respondents representing 16520 household members. Main Outcome Measures Respondent demographics, information on human rights abuses that occurred among household members since 1991, women's health and human rights, opinions regarding women's rights and roles in society, and conditions for community health and development. Results Respondents were a mean age of 38 years and were mostly of Arab ethnicity (99.7% [1976/1982]) and Muslim Shi'a (96.7% [1906/1971]). Overall, 47% of those interviewed reported 1 or more of the following abuses among themselves and household members since 1991: torture, killings, disappearance, forced conscription, beating, gunshot wounds, kidnappings, being held hostage, and ear amputation, among others. Seventy percent of abuses (408/586) were reputed to have occurred in homes. Baath party regime-affiliated groups were identified most often (95% [449/475]) as the perpetrators of the abuses; 53% of the abuses occurred between 1991 and 1993, following the Shi' a uprising, and another 30% between 2000 and the first 6 months of 2003. While the majority of men and women expressed support for women's equal opportunities for education, freedom of expression, access to health care, equality in deciding marriage and the number and spacing of children, and participation in community development decisions, there was less support among both men and women for women's freedom of movement, association with people of their choosing, and rights to refuse sex. Half of women and men (54% and 50%, respectively) reported agreeing that a man has the right to beat his wife if she disobeys. Fifty-three percent of respondents reported that there were reasons to restrict educational opportunities for women at the present time and 50% reported that there were reasons to restrict work opportunities for women at the present time. Conclusions Nearly half of participating households in 3 southern cities in Iraq reported human rights abuses among household members between 1991 and 2003. The households surveyed supported a government that will protect and promote human rights, including the rights of women. However, currently, neither men nor women appear to support a full range of women's human rights.

Title: Prosthetic device provision to landmine survivors in Bosnia and Herzegovina: Outcomes in 3 ethnic groups
Author(s): Burger, H; Marincek, C; Jaeger, RJ
Times Cited: 0
Abstract:Objective: To determine differences in prosthetic provision, use, and effectiveness among unilateral lower-extremity amputees from 3 ethnic groups in Bosnia and Herzegovina. Design: Case series with a consecutive sample of patients seen in field clinics. Setting: Multiple field clinics in Bosnia and Herzegovina from October 1998 to May 2002. Participants: A total of 671 patients were examined, and information about their prosthetic history was recorded from observation or verbal responses. The majority of the amputations resulted from injuries inflicted by landmines. Interventions: Not applicable. Main Outcome Measures: Self-reported walking distance per day, prosthesis functionality (functional or nonfunctional as assessed by a physician and a prothetist), prosthesis status (broken or nonbroken as assessed by a physician and a prothetist), and employment status. Results: Ethnic groups differed significantly in types of prostheses provided, functional status of the prostheses, and use of the prostheses for community ambulation. Conclusion: Prosthetic devices and delivery of rehabilitation services for unilateral lower-extremity amputees differed between ethnic groups. Despite these differences, functional prosthetic devices increased mobility. Persons in all 3 ethnic groups with functional prostheses were more mobile than persons with nonfunctional prostheses. The employment rate was higher for people with functional prostheses.

Title: Extremity injuries remain a high surgical workload in a conflict zone: experiences of a British Field Hospital in Iraq, 2003.
Author(s): Ramalingam, T
Source: J R Army Med Corps 150 (3):187-90 2004
Times Cited: 0
Abstract:Background: During this conflict 34 Field Hospital, the sole Coalition field hospital located in Iraq, received and treated casualties with a wide range of injuries. Located very close to the front line during the period of combat hostilities, it was potentially going to deal with relatively fewer battle-injured extremities. Method: A retrospective review of battle casualties admitted to the hospital was carried out based on casualty records and operating theatre logbooks. Data was collected for the period between the 26th March and the 8th May, focusing on casualties who had surgery for battle-injured extremities during the conflict. Results: Sixty eight (55%) of the 124 casualties who underwent surgery did so for battle injuries to extremities. 139 (58%) of all operating theatre episodes and 189 (53%) of all surgical procedures undertaken were for battle-injured extremities. Fourteen major limb amputations were carried out from a total of 87 battle-injured limbs that had surgery, giving an amputation rate of sixteen percent (14/87). Conclusion: The experience at 34 Field Hospital confirms that extremity injuries do confer a high surgical workload in war. Surgical resources should, therefore, be aimed at this and surgical teams deployed to such environments should be well versed in the surgical management of casualties with limb trauma.

Title: Physician participation in human rights abuses in southern Iraq
Author(s): Reis, C; Ahmed, AT; Amowitz, LL; Kushner, AL; Elahi, M; Iacopino, V
Times Cited: 6
Abstract: Context Physicians are known to have participated in human rights abuses in Iraq during Saddam Hussein's Baathist regime, but the nature and extent of that participation are not well documented., Objectives To characterize the nature of physician participation inhuman rights abuses, identify structural factors that facilitated physician participation, and assess approaches for accountability and for prevention of future physician participation in abuses. Design, Setting, and Participants A self-administered survey in June and July, 2003, of a convenience sample of 98 physicians and semistructured interviews of hospital directors and physicians in 3 major hospitals with general surgical units in 2 cities in southern Iraq. Main Outcome Measure Respondent reports of peer and self-participation in. human rights abuses in Iraq since 1988. Results The majority of participants were male (88% [86/98]) and Shi'a Muslims (97% [95/98]). Respondents reported a mean of 6.8 years in practice. A total of 71% of respondents (65/91) reported that torture was a problem to an extreme extent in Iraq since 1988. The proportion of respondents indicating that, since 1988, their physician peers as a group were extremely or quite a bit involved in human rights abuses included 50% (42/83) for nontherapeutic amputation of ears as a form of punishment, 49% (39/ 79) for falsification of medical-legal reports of torture, and 32% (25/78) for falsification of death certificates. Fewer numbers of respondents (range, n=2 to 6) reported participation in abuses themselves. More than half (52% [48/92]) indicated that physicians did not willingly participate in these abuses; 93% (52/71) reported that the Iraqi paramilitary force Fedayeen Saddam was responsible for initiating physician complicity. Fear of harm to oneself or family members was a common explanation for complicity. Respondents reported that physicians who refused to participate in abuses faced consequences including loss of job, imprisonment, torture, and disappearance. Respondents reported on preventive measures that should be undertaken to prevent physician involvement in future abuses, including increasing human rights and ethics education of physicians (99% [79/80]), legal provisions to ensure effective monitoring (97% [73/75]), punitive sanctions for physicians who commit abuses (96% [77/80]), and ensuring the independence of physicians from state authorities (95% [76/80]). Conclusions Although not generalizable beyond the study participants, the findings of this study suggest that among those surveyed, physician participation in human rights abuses included falsification of medical-legal reports of alleged torture, physical mutilation as a form of punishment, and falsification of death certificates. As Iraq rebuilds, it is essential that the country address these violations and enact measures to prevent physicians from future complicity in human rights abuses.

Title: Land mine injuries: A study of 708 victims in North Iraq and Cambodia
Author(s): Husum, H; Gilbert, M; Wisborg, T; Van Heng, Y; Murad, M
Source: MILITARY MEDICINE 168 (11):934-940 2003
Times Cited: 0
Abstract:Objective: The aim of this study was to explore the effect of low-cost prehospital trauma systems on trauma outcome in land mine victims and to study prehospital risk indicators for better triage of land mine injuries. Methods: A 5-year prospective study of the effect of in-field advanced life support provided by local paramedics was conducted in mine-infested areas in North Iraq and Cambodia. Results: After implementation of a rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001 (95% confidence interval for difference, 5.1%-23.6%). The mortality rate was significantly higher in fragmentation mine victims, 25.2%, as compared with blast mine victims, 5.7% (95% confidence interval for difference, 14.4%-24.6%). The severity of associated fragment injuries in patients with traumatic amputations is a solid risk predictor (area under the curve in receiver operating characteristics plots >0.9). Conclusions: Low-cost prehospital trauma systems improve trauma outcome in land mine victims where prehospital transit times are high. The fragment wounds represent the main challenge for trauma care providers.

Title: Chronic pain in land mine accident survivors in Cambodia and Kurdistan
Author(s): Husum, H; Resell, K; Vorren, G; Van Heng, Y; Murad, M; Gilbert, M; Wisborg, T
Source: SOCIAL SCIENCE & MEDICINE 55 (10):1813-1816 PII S0277-9536(01)00315-X 2002
Times Cited: 3
Abstract:The aims of the study were to study chronic pain in land mine accident survivors, and to study the impact of trauma and trauma care parameters on chronic pain. The level of chronic pain was registered (patient-rated and by clinical examination) in 57 severely injured adult land mine accident survivors in Cambodia and Northern Iraq more than one year after the accident. As all study patients had been managed by a standardized trauma system, we could assess the impact of injury severity and primary trauma care on chronic pain. 64% of the study patients (n = 36) had chronic pain syndromes (non-significant difference between the two countries). 68% of the amputees (19 out of 28) had phantom limb pain. Pre-injury trauma exposure, the severity of the actual trauma, and the quality of trauma care had no impact on end point chronic pain. In 85% of cases (n = 48), the economic standing of the patients' family had deteriorated after the accident. Patient-rated loss of income correlated with the rate of chronic pain syndromes. (C) 2002 Elsevier Science Ltd. All rights reserved.

Title:Causes of locomotor disability and need for orthopaedic devices in a heavily mined Taliban-controlled province of Afghanistan: issues and challenges for public health managers
Author(s): Francois, I; Lambert, ML; Salort, C; Slypen, V; Bertrand, F; Tonglet, R
Times Cited: 6
Abstract: We conducted a locomotor disability survey on a heavily mined Taliban-controlled province of Afghanistan to document the problem of locomotor disability and to assess the need for orthopaedic rehabilitation devices in a study population of 12065. Global prevalence of locomotor disability was 23/1000 (95% CI: 20-26). War-related injuries were the leading cause of disability, affecting almost exclusively adult males. Leading causes of disability among women and children were medical and poliomyelitis. Devices most needed were lower limb ortheses (8.2 devices/1000 people; 95% CI: 5.9-10.4) and orthopaedic shoes (6.0/1000; 95% CI:4.3-8.0). The need for lower limb prostheses was less frequent (2.0/1000; 95% CI: 1.1-2.8). Most lower limb amputees (mainly victims of landmine injuries) were fitted with an artificial leg, while rehabilitation needs for other types of disability remained largely unmet. We estimated that it would take at least 3 years to provide enough orthopaedic shoes and 10 years for ortheses, whereas the need for lower limb prostheses could be met in less than 4 months. None of the 27 women with lower limb disability were equipped with an orthopaedic device, although this was the case for 31 of 89 men (35%). The problem of landmines should not divert attention from other causes of disability such as poliomyelitis or from other rehabilitation requirements. Immunization programmes and restoration of the public health infrastructure should be given high priority; rehabilitation services are largely insufficient and should be developed. Extreme gender difference in needs coverage is a matter of concern. Researching culturally sensitive strategies to tackle this problem should be a priority for donors and implementing agencies.

Title: Rehabilitation of lower limb traumatic amputees: The Sandy Gall Afghanistan Appeal's experience
Author(s): Hettiaratchy, SP; Stiles, PJ
Times Cited: 1
Abstract:Physical rehabilitation after lower limb traumatic amputation due to acts of war has not yet been investigated. It has been shown that patients suffering non-war injuries rehabilitate well. This study shows that despite the difficult circumstances and limited resources available in an area of conflict, good rehabilitation of war victims is possible. However, economic rehabilitation is worse than that seen in non-war populations. Given that this type of injury is very common in war zones worldwide, this failure of economic rehabilitation may represent a major healthcare issue. Copyright (C) 1996 Elsevier Science Ltd.
ISSN: 0020-1383
Record 35 of 42
Author(s): COURT, C
Source: BRITISH MEDICAL JOURNAL 309 (6957):760-760 1994

Source: UNFALLCHIRURG 96 (8):438-442 1993
Times Cited: 2
Abstract:High-energy missile and explosion injuries of the upper and lower extremities are complex and require treatment over a long time. Following classic strategies of surgical therapy, bone defects can be reconstructed only after the injured soft tissue has healed. The callus distraction technique now permits the beginning of bony reconstruction at the same time as the initial surgical debridement. During the period 1 July 1987 ot 30 June 1990, 25 grade III open fractures in 24 patients were primarily treated with the Ilisarow technique at Wazir Akbar Khan Hospital, Kabul, Afghanistan. Twelve months after the removal of the fixation devices the patients were examined and the following results were demonstrated: no amputations; bony, aseptic healing in 22.cases (88%); 3 non-unions, including 2 infected non-unions; 2 axial deviations > 10-degrees. The primary initiation of bony reconstruction by callus distraction offers numerous advantages in the treatment of gunshot and explosion injuries.

Author(s): NAZIR M
Source: Tidsskrift for den Norske Laegeforening 112 (8):1026-1028 1992
Times Cited: 0
ISSN: 0029-2001
Record 38 of 42
Title: Injuries from mines
Author(s): Pillgram-Larsen, Johan; Mellesmo, Sindre; Peck, Richard
Source: Tidsskrift for den Norske Laegeforening 112 (17):2183-2187 1992
Times Cited: 0
Abstract:In autumn 1991, 157 patients injured by mine explosions were taken care of by a Norwegian military medical unit attached to the United Nations mission in the demilitarized zone between Iraq and Kuwait. 146 of the patients were seen during a three week period of Iraqi mine harvesting in the desert. The detachment worked according to the principles of a second echelon surgical installation. The patients were operated upon if necessary, stabilized and evacuated to Iraqi hospitals. 20 patients in all (13%) died primarily. Four of 109 patients evacuated to the field hospital died (4%). 68 patients had major amputations, in seven of them two extremities were blown off. One patients had an open chest wound, two had tracheal puncture wounds, and one had penetrating head injury. 27 patients had eye injuries, 13 of which were penetrating, 64 major surgical procedures were performed. When evacuation times are long after mine injuries, approximately six hours, almost only patients with injuries to the extremities can be expected to reach hospital for treatment. The pattern of injury was regular, with crushed extremities, amputations and damaged eyes.

Title: Tight compression dressing without tourniquet: Experiences with 68 traumatic amputations after injuries from mines
Author(s): Pillgram-Larsen, Johan; Mellesmo, Sindre
Source: Tidsskrift for den Norske Laegeforening 112 (17):2188-2190 1992
Times Cited: 0
Abstract: In autumn 1991, 68 patients with traumatic amputations after injuries caused by mines were evacuated to the United Nation's field hospital in the demilitarized zone between Iraq and Kuwait. Most were seen during a three week period when civilians harvested mines. During the first days of this period, continuous bleeding distally to applied tourniquets was frequently observed. Orders were issued to remove any tourniquets and cover the wounds with a very tight elastic bandage. Prehospital intravenous infusions were decreased. Three out of 18 patients died prior to the change of routine compared with one out of 50 afterwards. The new directives led to visibly less hemorrhage. Hemoglobin on admission was mean 8.6 g/100 ml during the first part of the observation period compared with mean 10.5 g/100 ml with the new routine. 23 patients received blood transfusions. Fewer patients needed transfusions after the use of tourniquets was discontinued. A tourniquet should not be used in the treatment of bleeding extremity injuries. In extensive crush injuries and traumatic amputations, a compressive dressing should be used, applied from the end of the extremity in a proximal direction.

Author(s): SHERIF, AA
Source: INTERNATIONAL SURGERY 77 (2):114-117 1992
Times Cited: 6
Abstract: This is a prospective study done over an 18-month period in three base evacuation hospitals serving the Afghan refugees in Pakistan. Out of 224 patients, 78 had major and 146 had minor arterial injuries. Late presentation was a common finding. Mine explosions ranked first as a causative agent. This explains the high incidence of lower limb affections and minor vascular injuries. In the major arterial injury group, the superficial femoral artery was the commonest injured (33.4%), followed by the brachial (28.2%). Associated major venous injury occurred in 41% of cases while 25.6% had a compound fracture of the nearby bone. All subclavian and axiliary artery injury patients had concomitant brachial plexus injury. Arterial repair was done in 73 patients (93.6%) and ligation in 5. The importance of venous repair was emphasised; venous ligation was done in 6 patients only (19.4%). Repeated extensive debridement was done in 4 patients and useful limbs were left. This is believed to be a good alternative for selected cases with extensive muscle laceration. 3 patients died in the early post-operative period and 3 needed amputation (4%). Other complications were graft sloughing (1.3%) thrombosis (6%) and stenosis (9%). Only 56.9% of patients were followed up for 3-6 months.

Conference Date: SEP 05-09, 1989
Conference Location: TORONTO, CANADA
Times Cited: 1

Author(s): HAMDAN, TA
Times Cited: 12
ISSN: 0020-1383


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