Elsevier

Injury

Volume 40, Issue 7, July 2009, Pages 772-777
Injury

Battlefield extremity injuries in Operation Iraqi Freedom

https://doi.org/10.1016/j.injury.2009.02.014Get rights and content

Abstract

Objective

Extremity injuries account for the majority of wounds incurred during US armed conflicts. Information regarding the severity and short-term outcomes of patients with extremity wounds, however, is limited. The aim of the present study was to describe patients with battlefield extremity injuries in Operation Iraqi Freedom (OIF) and to compare characteristics of extremity injury patients with other combat wounded.

Patients and methods

Data were obtained from the United States Navy-Marine Corps Combat Trauma Registry (CTR) for patients who received treatment for combat wounds at Navy-Marine Corps facilities in Iraq between September 2004 and February 2005. Battlefield extremity injuries were classified according to type, location, and severity; patient demographic, injury-specific, and short-term outcome data were analysed. Upper and lower extremity injuries were also compared.

Results

A total of 935 combat wounded patients were identified; 665 (71%) sustained extremity injury. Overall, multiple wounding was common (an average of 3 wounds per patient), though more prevalent amongst patients with extremity injury than those with other injury (75% vs. 56%, P < .001). Amongst the 665 extremity injury patients, 261 (39%) sustained injury to the upper extremities, 223 (34%) to the lower extremities, and 181 (27%) to both the upper and lower extremities. Though the total number of patients with upper extremity injury was higher than lower extremity injury, the total number of extremity wounds (n = 1654) was evenly distributed amongst the upper and lower extremities (827 and 827 wounds, respectively). Further, lower extremity injuries were more likely than the upper extremity injuries to be coded as serious to fatal (AIS > 2, P < .001).

Conclusions

Extremity injuries continue to account for the majority of combat wounds. Compared with other conflicts, OIF has seen increased prevalence of patients with upper extremity injuries. Wounds to the lower extremities, however, are more serious. Further research on the risks and outcomes associated with extremity injury is necessary to enhance the planning and delivery of combat casualty medical care.

Introduction

Battlefield extremity injuries account for the majority of combat wounds sustained by United States armed forces during military conflicts of the twentieth century.10, 12, 13, 18, 19 Extremity wounds, however, account for a relatively small proportion of battlefield and hospital deaths compared with head, chest, and abdominal wounds.5, 18, 19 Overall, more than 65% of the wounded survivors from World War II and the Korean War sustained extremity injuries.18, 19 Despite the changing nature of warfare, the prevalence of extremity injuries during Operation Enduring Freedom and Operation Iraqi Freedom (OIF) is comparable to previous US military conflicts.11, 15, 16, 22

The emerging and widespread use of improvised explosive devices (IEDs) has resulted in new injury patterns amongst combat casualties during OIF compared with previous conflicts.9, 20 In combat, lower extremity injuries (LEIs) are generally more common than upper extremity injuries (UEIs: 37–42% vs. 27–29%).18, 19 Recent studies from OIF, however, demonstrate equivalent and, in some cases, higher proportion of UEIs to LEIs.9, 16, 17, 22 The difference in severity of upper and lower extremity injuries has not been examined.

The objectives of this descriptive study were to characterise the prevalence, types, and severities of battlefield extremity injuries amongst US service members who received treatment for their injuries at Navy-Marine Corps facilities during OIF, and to compare injury-specific and short-term outcomes of (a) patients with extremity injury versus those with other injuries and (b) patients with UEI versus those with LEI. This research was conducted in compliance with all applicable United States federal regulations governing the protection of human subjects in research and was approved by the Institutional Review Board of the Naval Health Research Center, San Diego, CA, United States (Protocol NHRC.2003.0025).

Section snippets

Patients and methods

A retrospective review of clinical encounter data in the United States Navy-Marine Corps Combat Trauma Registry (CTR) was performed. The study population consisted of US service members injured in hostile action who presented to forward-deployed US Navy-Marine Corps medical treatment facilities (MTFs) (i.e., medical units that provide immediate triage and stabilisation of patients before sending them on to a higher level of care within the medical chain of evacuation) during a 6-month period of

Results

A total of 935 combat casualties were identified in the Navy-Marine Corps CTR between September 2004 and February 2005 and sustained a total of 3218 injuries (an average of 3 injuries per patient). Nine patients incurred two separate combat injury events during the study period; each event was counted as one casualty. The mean age was 24 ± 5.2 years (range 18–54 years). All but 8 patients were male. The majority of patients were junior enlisted (67.4%) and were marines (75.9%).

Overall, 665

Discussion

During the 6-month OIF study period, more than 70% of combat casualties included in the Navy-Marine Corps CTR sustained one or more injuries to the extremities. The majority were due to blasts, such as IEDs. Although the prevalence of extremity injury is comparable to previous studies of OIF11, 15, 16, 22 and other major US military conflicts,10, 12, 13, 18, 19 a new pattern of extremity injuries has emerged during OIF. During World War II, the Korean War, and Vietnam War, US combatants were

Conclusions

Although extremity wounds are less likely to be fatal than head, chest, or abdominal wounds,10, 18, 19 these injuries can be severely disabling. The high prevalence and severity of extremity injuries from the current conflict in Iraq stresses the significance of proper and immediate orthopaedic care for combatants in theatre. Protection for the extremities has been developed and is currently in use, but improvements may help mitigate these injuries. Further research on the risks and outcomes

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Acknowledgements

The work was supported by the United States Office of Naval Research, Casualty Care Management, Arlington, Virginia under Work Unit No. 60802 and the United States Office of the Secretary of Defense Business Transformation Agency (BTA), Warfighter Support Office, Arlington, Virginia under Work Unit No. 60829. The views and opinions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the United States Navy, Department of Defense, nor the US

References (22)

  • B.A. Johnson et al.

    Operation Iraqi Freedom: the Landstuhl Regional Medical Center experience

    J Foot Ankle Surg

    (2005)
  • M.S. Xydakis et al.

    Analysis of battlefield head and neck injuries in Iraq and Afghanistan

    Otolaryngol Head Neck

    (2005)
  • S.P. Baker et al.

    The injury severity score: an update

    J Trauma

    (1976)
  • S.P. Baker et al.

    The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care

    J Trauma

    (1974)
  • V. Barell et al.

    An introduction to the Barell body region by nature of injury diagnosis matrix

    Inj Prev

    (2002)
  • R.F. Bellamy

    Combat trauma overview

  • H.F. Champion et al.

    A profile of combat injury

    J Trauma

    (2003)
  • Commission on Professional Hospital Activities

    International classification of diseases, 9th Revision, clinical modification

    (1977)
  • M.R. Galarneau et al.

    The Navy-Marine Corps Combat Trauma Registry

    Mil Med

    (2006)
  • T. Gennarelli et al.

    The abbreviated injury scale—2005

    (2005)
  • J.S. Gondusky et al.

    Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II

    Mil Med

    (2005)
  • Cited by (0)

    View full text