Complex orthopedic injury patterns found in US combat team

A study of U.S. combat musculoskeletal wounds in Iraq found a high incidence of major amputation and fractures.

“Over the past 9 years, there have been over 4,200 deaths and over 31,000 casualties that have been medically evacuated during Operation Iraqi Freedom,” said lead author Philip J. Belmont Jr., MD, an orthopedic surgeon at William Beaumont Army Medical Center in El Paso, Tex.

Belmont noted that previous reports indicate more than 50% of all combat casualties during the first phases of the Iraq War involved sustained injuries to the extremities.

“It is important that we examine the current status of combat casualties and their treatment,” he said.

Extremity wounds

The few published reports about extremity wounds from Iraq and Afghanistan have originated from hospital and surgical treatment facilities.

“These casualty statistics, though, frequently underestimate the magnitude of the problem,” Belmont said.

Following study approval from the Institutional Review Board, the investigators performed a longitudinal cohort study of a U.S. Army Brigade Combat Team that was deployed to Iraq for 15 months. A centralized casualty roster, the military electronic medical record system and the Joint Theater Trauma Registry were employed to capture all medical visits during the deployment.

To be consistent with previous reports, the investigators followed a strict definition of a combat casualty (ICD-9 codes 800-960). Of the 4,122 soldiers deployed, there were 242 musculoskeletal combat wounds among 176 combat casualties. Overall, 35% of these casualties were medically evacuated from theatre and 112 of the 176 casualties returned to duty within 72 hours.

The study, which was presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons, found that the musculoskeletal combat casualty rate for the brigade combat team was 32.2/1,000 soldier combat-years.

“There were no significant differences between rank group, medical evacuation and return to duty,” Belmont said. “This may be due to the increasing reliance on the enemy using explosive devices.”

Explosions were responsible for 81% of all musculoskeletal combat casualties, followed by gunshot wounds at 14%. There was also a trend for soldiers injured by gunshots to be more likely medically evacuated compared to explosion injuries.

Orthopedic surgical procedures

The majority of musculoskeletal injuries (65%) were classified as soft tissue injuries. In addition, there were 11 major amputations and 59 fractures, with nearly half of the fractures being open.

A total of 92 different orthopedic surgical procedures were performed on 66 of the combat casualties, with fracture fixation, debridement and irrigation and various soft tissue procedures being the most prevalent.

“More often, the most commonly used weapon by the enemy is an improvised explosive device (IED),” Belmont said. “The use of these IEDs, coupled with the uniform use of individual body armor and vehicular body armor, has certainly decreased mortality rates, but has resulted in more complex orthopedic injuries. As a result, amputation rates have increased.”

At the same time, improvements in the time of care and quality of care have allowed many soldiers to return to duty.

“Analysis of data will help guide appropriate research and resource allocations toward examining the prevention and treatment and subsequent outcomes of most of these combat injuries, allowing the military medical system to effectively treat deployed soldiers,” Belmont said. – by Bob Kronemyer

Reference:

• Belmont Jr. PJ, Schoenfeld A, Thomas DM, et al. Combat musculoskeletal wounds in a U.S. Army Brigade Combat Team during Operation Iraqi Freedom. Paper #728. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19. San Diego.

• Philip J. Belmont Jr., MD, can be reached at William Beaumont Army Medical Center, 5005 N. Piedras St., El Paso, TX 79920; 915-569-2288; email: philip.belmont@us.army.mil.
• Disclosure: Belmont has no relevant financial disclosures.