Daniel R. Possley

Microbiology and injury characteristics in severe open tibia fractures from combat.

BACKGROUND: Type III open tibia fractures are common combat injuries. The purpose of the study was to evaluate the effect of injury characteristics and surveillance cultures on outcomes in combat-related severe open tibia fractures. METHODS: We conducted a retrospective study of all combat-related open Gustilo and Anderson (G/A) type III diaphyseal tibia fractures treated at our centers between March 2003 and September 2007. RESULTS: One hundred ninety-two Operation Iraqi Freedom/Operation Enduring Freedom military personnel with 213 type III open tibial shaft fractures were identified. Fifty-seven extremities (27%) developed a deep infection and 47 extremities (22%) ultimately underwent amputation at an average follow-up of 24 months. Orthopedic Trauma Association type C fractures took significantly longer to achieve osseous union (p = 0.02). G/A type III B and III C fractures were more likely to undergo an amputation and took longer to achieve fracture union. Deep infection and osteomyelitis were significantly associated with amputation, revision operation, and prolonged time to union. Surveillance cultures were positive in 64% of extremities and 93% of these cultures isolated gram-negative species. In contrast, infecting organisms were predominantly gram-positive. CONCLUSIONS: Type III open tibia fractures from combat unite in 80.3% of cases at an average of 9.2 months. We recorded a 27% deep infection rate and a 22% amputation rate. The G/A type is associated with development of deep infection, need for amputation, and time to union. Positive surveillance cultures are associated with development of deep infection, osteomyelitis, and ultimate need for amputation. Surveillance cultures were not predictive of the infecting organism if a deep infection subsequently develops. LEVEL OF EVIDENCE: III.

Military penetrating spine injuries compared with blunt

BACKGROUND CONTEXT The nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers. PURPOSE The purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE All American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR). METHODS The JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury. RESULTS A total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups. CONCLUSIONS Blunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.

Does the Zone of Injury in Combat-Related Type III Open Tibia Fractures Preclude the Use of Local Soft Tissue Coverage?

Objectives: Does the large zone of injury in high-energy, combat-related open tibia fractures limit the effectiveness of rotational flap coverage? Design: Retrospective consecutive series. Setting: This study was conducted at Brooke Army Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center between March 2003 and September 2007. Patients/Participants: We identified 67 extremities requiring a coverage procedure out of 213 consecutive combat-related Type III open diaphyseal tibia fractures. Intervention: The 67 Type III B tibia fractures were treated with rotational or free flap coverage. Main Outcome Measures: Flap failure, reoperation, infection, amputation, time to union, and visual pain scale. Results: There were no differences between the free and rotational flap cohorts with respect to demographic information, injury characteristics, or treatment before coverage. The reoperation and amputation rates were significantly lower for the rotational coverage group (30% and 9%) compared with the free flap group (64% and 36%; P = 0.05 and P = 0.03, respectively). The coverage failure rate was also lower for the rotational flap cohort (7% versus 27%, P = 0.08). The average time to fracture union for the free flap group was 9.5 months (range, 5-15.8 months) and 10.5 months (range, 3-41 months) for the rotational flap group (P = 0.99). Conclusions: There was a significantly lower amputation and reoperation rate for patients treated with rotational coverage. Contrary to our hypothesis and previous reports, the zone of injury in combat-related open tibia fractures does not preclude the use of local rotational coverage when practicable.

The effect of vehicle protection on spine injuries in military conflict.

BACKGROUND CONTEXT To evaluate the effect of critical time periods in vehicle protection on spine injuries in the Global War on Terror. PURPOSE To characterize the effect of method of movement on and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009 in terms of its impact on the incidence and severity of spinal fractures sustained in combat. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE Mounted and dismounted American servicemembers who were injured during combat. METHODS Extracted medical records of servicemembers identified in the Joint Theater Trauma Registry from October 2001 to December 2009. Methods of movement were defined as mounted or dismounted. Two time periods were compared. Cohorts were created for 2×2 analysis based on method of movement and the time period in which the injury occurred. Time period 1 and 2 were separated by April 1, 2007, which correlates with the initial fielding of the modern class of uparmored fighting vehicles with thickened underbelly armor and a V-shaped hull. Our four comparison groups were Dismounted in Time Period 1 (D1), Dismounted in Time Period 2 (D2), Mounted in Time Period 1 (M1), and Mounted in Time Period 2 (M2). RESULTS In total, 1,819 spine fractures occurred over the entire study period. Four hundred seventy-two fractures (26%) were sustained in 145 servicemembers who were mounted at the time of injury, and 1,347 (74%) were sustained by 404 servicemembers who were dismounted (p<.0005). The incidence of fractures in the dismounted cohort (D1+D2) was significantly higher than in the mounted cohort (M1+M2) in both time periods (D1 vs. M1, 13.75 vs. 3.95/10,000 warrior-years [p<.001] and D2 vs. M2, 11.15 vs. 4.89/10,000 warrior-years [p<.0001]). In both the mounted and dismounted groups, the thoracolumbar (TL) junction was the most common site of injury (36.1%). Fractures to the TL junction (T10-L3) increased significantly from Time Period 1 to 2 (34% vs. 40% of all fractures, respectively, p=.03). Thoracolumbar fractures were significantly more severe in that there were more Arbeitsgemeinschaft fur Osteosynthesefragen/Magerl Type A injuries versus all TL fractures, 1.75 versus 2.68/10,000 or 27% of all spine fractures in Time Period 1 versus 40% in Time Period 2 (p=.007). Furthermore, there were significantly fewer minor fractures (spinous process and transverse process fractures) (p<.0001). In Time Period 2, significantly more TL spine fractures were classified as major fractures, according to the Denis classification system, in both the mounted and dismounted groups; M1 group, 61 of 226 (27%) versus the M2 group, 86 of 246 (34%) (p<.0005) and 173 of 786 (22%) in the D1 group versus 193 of 561 (34%) in the D2 group. The spinal cord injury (SCI) incidence did not change in the mounted groups in Time Period 1 (7 of 71, 9.9%) versus Time Period 2 (7 of 74, 9.5%) (p=.935). In the dismounted groups, SCI actually decreased from D1 (55 of 228, 24%) to D2 (28 of 176, 16%) (p=.0428). CONCLUSIONS The incidence of spine fractures and SCI is significantly higher in dismounted operations. The data suggest that current uparmored vehicles convey greater protection against spinal fracture compared with dismounted operations in which servicemembers are engaged on foot, outside their vehicles. The TL junction is at greatest risk for spine fractures sustained in mounted and dismounted combat operations. Recently, the incidence of TL fractures, especially severe fractures, has significantly increased in mounted operations. Although there has been an increased incidence of TL spine fractures, in context of the number of servicemembers deployed in support of Operation Enduring Freedom/Operation Iraqi Freedom, these severe fractures still represent a relatively rare event.

Complications associated with military spine injuries

BACKGROUND CONTEXT To assess the presence of complications associated with spine injuries in the Global War on Terror. PURPOSE To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009. STUDY DESIGN/SETTING Retrospective study. PATIENT SAMPLE American servicemembers sustaining spine injury during combat. METHODS Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma. RESULTS Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord-injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005). CONCLUSIONS Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

Musculoskeletal Injuries Sustained in Modern Army Combatives

INTRODUCTION Participation in martial arts has grown over the past 15 years with an estimated 8 million participants. In 2004, the Chief of Staff of the Army directed that all Initial Military Training soldiers receive Modern Army Combatives (MAC) training. The mechanical differences between the various martial arts styles incorporated into mixed martial arts/MAC pose challenges to the medical professional. We report the incidence of musculoskeletal injuries by Level 1 and 2 trained active duty soldiers participating in MAC over a 3-year period. METHODS From June 1, 2005 to January 1, 2009, the Orthopaedic Surgery service treated and tracked all injuries in MAC. Data was analyzed using the Chi(2) method of analysis. (p < 0.05). RESULTS 155 of 1,025 soldiers presenting with MAC injuries reported inability to perform their military occupation specialty duties. The knee was most frequently injured followed by shoulder. Surgical intervention was warranted 24% of the time. CONCLUSION Participants in MAC reported injuries severe enough to impact occupational duties at 15.5%. Surgical intervention was warranted only 24% of the time. The knee and shoulder are the most frequently injured body parts. Labral repair was the most frequent surgical procedure.ABSTRACTIntroduction: Participation in martial arts has grown over the past 15 years with an estimated 8 million participants. In 2004, the Chief of Staff of the Army directed that all Initial Military Training soldiers receive Modern Army Combatives (MAC) training. The mechanical differences between the various martial arts styles incorporated into mixed martial arts/MAC pose challenges to the medical professional. We report the incidence of musculoskeletal injuries by Level 1 and 2 trained active duty soldiers participating in MAC over a 3-year period. Methods: From June 1, 2005 to January 1, 2009, the Orthopaedic Surgery service treated and tracked all injuries in MAC. Data was analyzed using the χ2 method of analysis. (p < 0.05). Results: 155 of 1,025 soldiers presenting with MAC injuries reported inability to perform their military occupation specialty duties. The knee was most frequently injured followed by shoulder. Surgical intervention was warranted 24% of the time. Conclusion: Participants in MA...

Orthopedic Trauma: Extremity Fractures

Fractures continue to account for a large proportion of combat-related injuries. The basic tenets of irrigation, debridement, soft tissue care, and vigilant monitoring/fasciotomy for acute compartment syndrome persist. Closed management of fractures with splinting or casting is acceptable. If time and facility allow, external fixation of fractures offer many advantages over closed treatment but require knowledge, experience and skill in the safe placement of pins. The care of host nationals presents unique challenges and deployed surgeons must be flexible and resourceful in these situations.

Comparison of Calcaneal Exposure Through the Extensile Lateral and Sinus Tarsi Approaches

The purpose of this study was to compare the exposure of the posterior facet with the extensile lateral (EL) approach compared with the sinus tarsi (ST) approach. We hypothesized that the ST approach will provide a similar exposure of the posterior calcaneal facet. A total of 8 sequential ST then EL approaches were performed on cadavers. Calcaneal landmarks were identified by visualization or palpation. Calibrated digital photographs of the posterior facet and lateral calcaneal body were obtained from standardized positions and used to calculate the exposed surface area. No significant difference was found in the average square area of the posterior facet exposed with the 2 approaches. Significantly more of the lateral calcaneal body was seen with the EL approach. Excluding the posterior facet superomedial quadrant, all the landmarks were visualized in 100% of approaches. The superomedial corner was visualized in significantly more of the cadavers with the EL approach and was palpable in 12.5% of the remaining cadavers in both approaches. Whereas the ST approach exposes less of the lateral wall of the calcaneus, it exposes similar amounts of the posterior facet when compared with the EL approach. Levels of Evidence: Therapeutic, Level V