Prevalence and Risk Factors for Musculoskeletal Back Injury Among U.S. Army Personnel.

INTRODUCTION: Physical and medical readiness have emerged as a top priority in the army over the last decade. With this emphasis on deployment readiness, it is important to understand key risk factors attributed to common medical problems that arise in our soldiers, including low back pain. The purpose of this study is to elucidate demographic and lifestyle risk factors which would result in seeking medical care for musculoskeletal low back pain among active duty army personnel. MATERIALS AND METHODS: A cross-sectional retrospective study investigating all active duty soldiers between October 1, 2016 and September 30, 2018 was performed using the existing Military Health System Data Repository to retrospectively review administrative claims data. Our study queried 39 unique International Classification of Disease codes, 10th Revision codes for low back pain to determine a positive case. We compared those with and without back pain across all variables using a chi-square analysis in SAS. Multivariate logistic analysis was performed to adjust for confounding within any single proposed risk factor and the six other proposed risk factors. RESULTS: Six hundred fifty seven thousand and six thirty soldiers met inclusion criteria; 228,184 of whom had a medical encounter for low back pain (34.7%). All of the proposed risk factors included statistically significant unadjusted and adjusted odds ratios (ORs) with age conferring the greatest risk in soldiers aged 50-59 with an OR of 2.89 (2.73-3.05) compared to those aged 20-29. Obesity-adjusted OR was 1.77 (1.74-1.80) compared to those who were normal weight. Senior Enlisted status-adjusted OR was 1.34 (1.32-1.36). Females were 66% more likely to have low back pain compared to males with an OR of 1.66 (1.63-1.68). CONCLUSION: Disease burden for low back pain tends to be high in the U.S. Army with 34.7% of service members experiencing low back pain. Older age, obesity, and being an enlisted, female service member are risk factors for these musculoskeletal injuries, which is in agreement with previously reported literature on the topic. To mitigate the burden of low back pain, policies and incentives to encourage healthy body mass index and lifestyle are needed. The results of this work inform future studies aimed at further delineating the risk factors found in this study.

Non-modifiable Risk Factors Associated with Avascular Necrosis in the US Military.

INTRODUCTION: Often referred to as aseptic or osteonecrosis, avascular necrosis (AVN) typically affects people between 30 and 50 years of age. Given the substantial morbidity associated with AVN as well as overlapping age groups of both the military and average age at diagnosis for AVN, the military represents an ideal cohort for a large database study to elicit the incidence and epidemiology of AVN. The purpose of this study was to identify demographic risk factors in the United States military. MATERIALS AND METHODS: First-time occurrences for ICD-9-CM codes for all types of AVN (head of humerus, head and neck of femur, medial femoral condyle, talus, and other bone) between 2004 and 2014 were queried in the Defense Medical Epidemiology Database. Multivariate data analysis was performed to obtain adjusted rate (adjusted for age, sex, race, rank, and branch of service). RESULTS: Between 2005 and 2014, 2,671 cases of AVN occurred among an at-risk population of 13,820,906 servicemembers for an unadjusted IR of 0.19 per 1,000 person-years. The most common location was located at the proximal femur, responsible for 41.7% of all cases. With an adjusted rate ratio of 18.7, the over 40 age-group accounted for 53.3% of cases. Servicemembers of black race, Senior rank, and the Army branch of service were more at risk for AVN. CONCLUSIONS: The overall incidence of AVN was 0.19 per 1,000 person-years. Whilte increasing age had the greatest influence on the development of symptomatic AVN, other statistically significant risk factors were found to be increasing age, black race, senior enlisted rank, and Army branch of service.

Reliability and validity of the Turkish version of the WHO-5, in adults and older adults for its use in primary care settings.

BACKGROUND: This study aims to determine the psychometric properties of the World Health Organization Well-Being Index (WHO-5) Turkish version in Turkish adults and older adults. METHODS: This is a multicenter cultural adaptation study carried out with 1752 participants. Internal consistency (by Cronbach's alpha); Construct validity (by known groups and confirmatory factor analysis-CFI) and discriminant validity are evaluated stratified by adults and older adults. Cohen's Effect Size is used in known groups and discriminant validity analyses. RESULTS: Distribution properties of the WHO-5 Turkish version are in acceptable limits. Alpha values are 0.81 for adults and 0.86 for older adults. The variances of the 58.5% of the adults sample and 63.9% of the older adults sample are explained in Exploratory FA. Model fits (CFI) are satisfactory ( > 0.95) in both samples; but RMSEA is poor in the older adults sample (0.166) whereas it is acceptable (0.073) in the adults sample. Known groups validity and discriminant analyses are satisfactory in both adults and older adults. CONCLUSION: The WHO-5 Turkish version has a good measurement capacity, internal consistency and good model fits in both samples. The error values in the older adults group suggest that the results when testing older adults should be interpreted with caution.

Non-modifiable Risk Factors Associated with Sternoclavicular Joint Dislocations in the U.S. Military.

INTRODUCTION: Sternoclavicular joint (SCJ) dislocations, although uncommon, are observed in patients with ligamentous laxity as well as those who experience traumatic injuries. The incidence and epidemiology of this costly and debilitating injury to our relatively young and active military population have not previously been reported. The purpose of this study is to consider and quantify the non-modifiable risk factors associated with this injury. METHODS: Using Defense Medical Epidemiological Database, first-time occurrences, from 2006 to 2015 for the ICD-9-CM code 839.61 (closed dislocation of the SCJ), were obtained and further categorized by gender, race, age, rank, and branch of service. Race was classified based on self-reporting of patients into White, Black, or other categories. Age was divided into the categories of less than 20 yr, 20-24 yr, 25-29 yr, 30-34 yr, 35-39 yr, and greater than 40 yr. Rank was categorized as junior enlisted (E-1 to E-4), senior enlisted (E-5 to E-9), junior officer (O-1 to O-3), and senior officer (O-4 to O-10). Branch of service includes Army, Navy, Air Force, and Marines. Multivariate data analysis was performed to obtain rate per 1,000 person-years as well as adjusted rate (adjusted for age group, gender, race, rank, and service) to isolate risk factors. RESULTS: Between 2006 and 2015, 427 cases of closed SCJ dislocations occurred among an at-risk population of 13,772,342 person-years for an unadjusted incidence rate (IR) of 0.031 per 1,000 person-years. The annual unadjusted IR ranged from 0.017 in 2006 to 0.059 in 2014 with the greatest increase occurring between 2006 and 2007 representing 61% increase in the rate of injuries. Males were almost twice as likely to sustain these injuries compared with females (adjusted rate ratio 1.73; 95% confidence interval [CI] 1.23, 2.43). Age was not found to be a risk factor for the development of these injuries with IRs for each age group overlapping with 95% CI for all other age groups. Similarly, the other category for race was also not found to be a statistically significant risk factor. Junior Officers (adjusted rate 0.017; 95% CI 0.011, 0.025) were found least likely to suffer from these injuries with Junior Enlisted (0.034; 95% CI 0.030, 0.040) and Senior Enlisted (0.032; 95% CI 0.028, 0.037) most at risk. Being in the Navy (0.019; 95% CI 0.015, 0.025) was found to be most protective compared with Air Force (0.032; 95% CI 0.026, 0.039), Army (0.036; 95% CI 0.031, 0.041), and Marines (0.036; 95% CI 0.028, 0.045). DISCUSSION and CONCLUSION: Annual unadjusted IR of SCJ dislocations readily increased from 2006 to 2014. Statistically significant risk factors, for suffering a closed SCJ dislocation, identified by our study, were male sex, enlisted rank, and branch of service other than Navy. Age and race were not found to have a statistically significant risk. These results can shed light on non-modifiable risk factors for dislocations of the SCJ and can be used in other studies to aid in reducing injury burden on the U.S. Military.

Epidemiology of Lower Extremity Stress Fractures in the United States Military.

PURPOSE: To comprehensively quantify established risk factors for the development of lower extremity stress fractures within a contemporary U.S. military cohort. METHODS: Using the Defense Medical Epidemiological Database, all U.S. service members diagnosed with tibia/fibula, metatarsal, other bone, femoral neck, and femoral shaft stress fractures were identified based on International Classification of Diseases, 9th Revision, Clinical Modification code from 2009 to 2012. Incidence rates (IRs) and adjusted IRs controlling for sex, race, age, rank, and branch of service were obtained with multivariate Poisson regression analysis. RESULTS: Between 2009 and 2012, 31,758 lower extremity stress fractures occurred among 5,580,875 person-years, for an unadjusted IR of 5.69 per 1,000 person-years. Tibial/fibular (40%) involvement was the most common. Bimodal age distribution revealed that service members under 20 years old (23.06; 95% confidence interval [CI] 22.52, 23.55) or ≥40 (6.86; 95% CI 6.65, 7.07) had greatest risk. Females were at higher risk for total lower extremity (3.11; 95% CI, 3.03, 3.18). White service members were also more at risk than Black service members (p < 0.0001). The majority of stress fractures (77.5%) occurred in junior enlisted service members, with the Army and Marines most at risk. CONCLUSION: This investigation elucidates several nonmodifiable risk factors for stress fractures in the military and may inform screening measures to reduce this significant source of disability.

Traumatic basal ganglia hematoma following closed head injuries in children.

PURPOSE: High-velocity trauma with acceleration/deceleration forces turns into shear stress over lenticulostriate or anterior choroidal arteries that lead to basal ganglia hemorrhage. Traumatic basal ganglia hematoma has rarely been described in pediatric population. The aim of this study was to present our clinical series of pediatric patients with traumatic basal ganglia hematoma and to analyze the prognostic indicators of traumatic basal ganglia hematoma. METHODS: In this retrospective case series, emergency admissions of pediatric patients with traumatic basal ganglia hematoma due to closed head injury were analyzed. Demographic, clinical, and radiographical data of the patients were retrieved from patients' charts and picture archiving and communication system. RESULTS: There were four children with traumatic basal ganglia hematoma (TBGH). All patients were male. Median age was 8 years (range = 7-16 years). Road accident (three) and fall (one) were the causes of the traumas. Basal ganglia hematoma was present on the right side in one patient and on the left side in three patients. Hematoma volumes ranged from 0.9 to 8.94 ml. All patients were treated conservatively. One patient recovered fully; two patients were moderately disabled at their last clinical follow-ups. The last patient with diffuse subarachnoidal hemorrhage and edema died despite all interventions. CONCLUSIONS: Traumatic basal ganglia hematomas are unique and different from other kind of intracerebral hematomas. The eloquent nature of basal ganglia makes it more vulnerable to head trauma. Mechanism of injury, energy and velocity of injury are the most important prognostic criteria. Post-traumatic phase of injury should be carefully observed in patients with TBGH, especially when mechanism and velocity of injury are severe and high.

Post-traumatic dynamic hallux varus instability.

Acquired hallux varus secondary to traumatic disruption of the lateral joint structures of the 1st MTPJ is uncommon and has only been reported in the literature once previously.(4) We present a case of traumatic hallux varus that is unique since the deformity is dynamic in nature. In our patient the hallux remained reduced on standing weight bearing films, and luxated only during fluoroscopic stress testing. We also describe our surgical correction where a soft tissue anchor alone was utilized to stabilize the joint through repair of the lateral capsule and collateral ligament. One year following the described repair the patient reports no limitations in performing activities of daily living, and complains of only mild pain with recreational activities.