Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation.

BACKGROUND: Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation. PATIENTS AND METHODS: The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for. RESULTS: Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management. CONCLUSIONS: The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.

Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan.

INTRODUCTION: International humanitarian law requires emergency medical support for both military personnel and civilians, including children. Here we present a detailed review of paediatric admissions with the pattern of injury and the resources they consume. METHODS: All paediatric admissions to the hospital at Camp Bastion between 1 January and 29 April 2011 were analysed prospectively. Data collected included time and date of admission, patient age and weight, mechanism of injury, extent of wounding, treatment, length of hospital stay and discharge destination. RESULTS: Eighty-five children (65 boys and 17 girls, median age: 8 years, median weight: 20 kg) were admitted. In 63% of cases the indication for admission was battle related trauma and in 31% non-battle trauma. Of the blast injuries, 51% were due to improvised explosive devices. Non-battle emergencies were mainly due to domestic burns (46%) and road traffic accidents (29%). The most affected anatomical area was the extremities (44% of injuries). Over 30% of patients had critical injuries. Operative intervention was required in 74% of cases. The median time to theatre for all patients was 52 minutes; 3 patients with critical injuries went straight to theatre in a median of 7 minutes. A blood transfusion was required in 27 patients; 6 patients needed a massive transfusion. Computed tomography was performed on 62% of all trauma admissions and 40% of patients went to the intensive care unit. The mean length of stay was 2 days (range: 1-26 days) and there were 7 deaths. CONCLUSIONS: Paediatric admissions make up a small but significant part of admissions to the hospital at Camp Bastion. The proportion of serious injuries is very high in comparison with admissions to a UK paediatric emergency department. The concentration of major injuries means that lessons learnt in terms of teamwork, the speed of transfer to theatre and massive transfusion protocols could be applied to UK paediatric practice.

Paediatric trauma management on deployment.

There remains a significant paediatric workload through the military hospital in Camp Bastion. In this paper the authors review and discuss particular problems with resuscitation, investigation, anaesthetic and surgical issues in dealing with children suffering from ballistic injuries. Personal experience and recent papers are used for a qualitative analysis of difficult decisions in the management of paediatric ballistic trauma. Key questions are answered in separate paragraphs for each specialty. The information described in this paper should assist any deployed physician deal with paediatric casualties particularly if they are unaccustomed to paediatric patients in their normal practice.

Femoral fractures in children, is early interventional treatment beneficial?

A protocol of early intervention (flexible intramedullary nails, early hip spica, and external fixation) was started in 1999 and during a 3-year period there were 25 children who sustained a femoral shaft fracture (early intervention group). These were prospectively reviewed with a minimum follow up of 24 months (Range 24-35 months). A historical control group of 41 children was used. These children were injured between February 1996 and February 1999 and were retrospectively reviewed. They had traditional in patient treatments with either Gallows or Thomas splint traction (traditional treatment group). Over the 6-year period from 1996 to 2002 there were a total of 66 femoral shaft fractures in the study that presented to our hospital. The mean length of hospital stay was 29 nights in the traditional group and 10 nights in the early intervention group. This difference is significant (p<0.001). The malunion rate was slightly higher in the early active group at radiological union but most of these remodelled over the 2 years of follow up. The protocol of early intervention used in our institution, of flexible nails, early hip spica or external fixation depended on the age of the child, and has resulted in a shorter hospital stay for the children. This has benefits for the child, the family and the hospital.

Management of unstable cervical spine injuries in southern Iraq during OP TELIC.

INTRODUCTION: Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3. METHODOLOGY: The MND(SE) Hospital databases were used to identify all casualties admitted with either a "Cervical" or "Neck" injury. The databases covered the period from 24 March 2003 until 15 April 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries. RESULTS: Forty seven casualties were admitted and all were British except three, two Iraqi civilians and one US soldier. Thirty three casualties were returned to their unit for duty, or discharged at the airhead on return to the UK. Fourteen casualties required hospital treatment. There were five serious cervical spine injuries over the study period which included one Hangman's fracture of C2, one flexion compression injury of C5, one flexion compression injury of C7, one unifacetal dislocation and one bifacetal dislocation. CONCLUSIONS: Five casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a Halo was flown out from the UK. RECOMMENDATIONS: All unstable cervical spine fractures should be stabilised with a Halo Vest prior to transfer from Role 3. Halo Rings and Vests should be available at Role 3 facilities.

"Failure" of forearm intramedullary elastic nails.

Elastic nails are an established modality for treating forearm fractures in children. These nails are usually removed 6-9 months after surgery as refracture may occur in 10% of cases if the nails removed earlier. We report a case of refracture of the forearm bones with elastic nails in situ, 5 months after the original fractures. The fracture was angulated approximately 80 degrees with the apex pointing anteriorly. Closed reduction was difficult and resulted in breakage of the ulnar nail. The authors describe the details and outline the management of this unreported complication.

Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections.

We have examined whether topical perioperative prophylaxis can reduce the incidence of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs). Using a controlled before and after approach on patients from four orthopaedic wards, undergoing orthopaedic surgery involving insertion of metal prostheses and/or fixation, received perioperative prophylaxis with nasal mupirocin for five days, and a shower or bath with 2% (v/v) triclosan before surgery (PPNMT). After introduction of PPNMT there was a marked decrease in incidence of MRSA SSIs (per 1000 operations) from 23 in the six months beforehand (period A) to 3.3 (P<0.001) and 4 (P<0.001) in subsequent consecutive six-month periods (B and C, respectively). Of 11 MRSA SSI cases that occurred during periods B and C, only one had actually received PPNMT, and 10 occurred after acute, as opposed to elective, surgery (P<0.001). Point prevalence nasal MRSA carriage decreased from 38% before PPNMT to 23% immediately after, and 20%, 7%, 10% and 8% (P<0.001) at six-monthly intervals post-intervention. Conversely, the prevalence of nasal MRSA carriage in a control elderly medicine ward did not change significantly. Vancomycin usage, in terms of defined daily doses, declined by 23%. Low-level mupirocin resistance was found in 2.3% of S. aureus isolates from orthopaedic patients before PPNMT, and in 3.9%, 6.1%, 10% and 0% in subsequent six month periods. No S. aureus isolates with high-level mupirocin resistance were found. PPNMT can reduce the incidence of MRSA SSls after orthopaedic surgery, probably by reducing nasal MRSA carriage in the endemic setting, without selecting for mupirocin resistance.

Early pin failure following external femoral fracture fixation in a head-injured child.

External fixation facilitates nursing care and early rehabilitation of head-injured children with femoral shaft fractures. We report an unusual complication of early fatigue failure of the external fixator pins without the patient ever bearing weight.

Complications of tibial shaft soccer fractures.

A retrospective study of AO type 42 tibial diaphyseal fractures that presented to a teaching hospital over a 54 month period was made to identify the proportion sustained whilst playing soccer, determine their characteristics and report treatment and outcome. Sport accounts for 73/329 (22.1%) of these fractures and soccer 58/73 (79. 5%) of these. All patients were male with mean age of 24.3 years (range 8-48). Fifty-four fractures were closed and 93.1% (54/58) were situated in the middle third or at the junction of the middle and distal thirds of the diaphysis. Fifty-six (96.6%) had simple or wedge patterns and 45 (77.6%) were right sided. Forty-four (76.2%) were treated non-operatively in plaster, 12 (20.3%) by intramedullary nails and two (3.4%) with external fixators. Two patients were lost to follow-up and the remaining 56 fractures united at a mean of 6.5 months. There were 21 complications in 19/56 (33.9%) patients which included 8/56 (14.3%) delayed/non-unions requiring surgery. There was a significantly higher complication rate for operated fractures (p<0.005) but no significant link to AO fracture type. Thus we cannot assume that treatment of these common fractures is without risk, especially if they are treated operatively.

CT fluoroscopy for thoracic interventional procedures.

In the past several years, CT fluoroscopy has proved a valuable new technique in guiding the performance of intrathoracic procedures. Several approaches to using CT fluoroscopy are discussed. We have found an interrupted, real-time technique optimal to facilitate biopsy of percutaneous lung nodules, particularly small lesions. The technique is also valuable in assisting thoracic drainage procedures. This article also discusses the use of CT fluoroscopy to guide transbronchial needle aspiration, which is another potentially important application.

Lung cancer: value of various imaging modalities.

Bronchogenic carcinoma is the leading cause of cancer death, and the overall prognosis remains poor. Imaging plays a critical role in the initial staging and follow-up of the disease. Bronchogenic carcinoma is typically detected first on chest radiography but computed tomography (CT) scan is the most important imaging technique, providing both staging information and assessment of recurrence. Magnetic resonance imaging (MRI) is most useful as a problem-solving tool. The increasing role of positron emission tomography (PET) scan in the evaluation is reviewed, and imaging guidelines of two national organizations are presented.

Evaluation of biopsy needles and prototypic needle guide devices for percutaneous biopsy with CT fluoroscopic guidance in simulated organ tissue.

The authors evaluated accuracy and success rates for placement of fine-aspiration, core, and coaxial biopsy needles in pork meat with three needle guide devices and computed tomographic fluoroscopic guidance. Accuracy and reliability with a metallic sponge-forceps needle holder was equal to or greater than those with other devices, and it was preferred by operators due to its lighter weight and single-handed manipulation. All needle holders functioned poorly with thin-walled needles.

Castleman disease of the thorax: radiologic features with clinical and histopathologic correlation.

PURPOSE: To correlate the radiologic manifestations of thoracic Castleman disease with the clinical and histopathologic features. MATERIALS AND METHODS: The clinical, surgical, and histopathologic records; chest radiographs; and computed tomographic (CT) and magnetic resonance (MR) images in 30 pathologically proved cases of thoracic Castleman disease were reviewed. RESULTS: Patients with localized Castleman disease (n = 24) typically had the hyaline-vascular type (n = 23), were asymptomatic (n = 14), and had solitary, well-circumscribed mediastinal masses (n = 24). All lesions at contrast material-enhanced CT (n = 13) enhanced. All lesions at MR imaging (n = 5) were heterogeneous and had increased signal intensity on T1- and T2-weighted images. Three patterns were observed on CT or MR images in 20 patients: a solitary, noninvasive mass (n = 10); a dominant infiltrative mass with associated lymphadenopathy (n = 8); or matted lymphadenopathy without a dominant mass (n = 2). Patients with disseminated Castleman disease (n = 6) typically had the plasma cell type (n = 4), were symptomatic at presentation (n = 5), and had bilateral mediastinal masses on chest radiographs (n = 4). At CT, all lesions manifested with diffuse mediastinal lymphadenopathy. All lesions at contrast-enhanced CT (n = 5) enhanced. CONCLUSION: Localized Castleman disease manifests as either a solitary, well-circumscribed mediastinal mass or an infiltrative mass with associated lymphadenopathy on CT or MR images. Disseminated Castleman disease manifests with diffuse mediastinal lymphadenopathy.

Real-time CT fluoroscopy: usefulness in thoracic drainage.

OBJECTIVE: The purpose of our study was to review the application of real-time CT fluoroscopy in the drainage of localized pleural and mediastinal collections. SUBJECTS AND METHODS: Between July 1996 and August 1997, 20 patients with 10 loculated pleural effusions, two mediastinal fluid collections, and 12 focal pneumothoraces were treated using CT fluoroscopy. The patient population was 25-77 years old and included 14 men and six women. Methods of drainage included using a modified Seldinger technique with a guidewire and serial dilators in 10 patients and a single-stick trocar technique in the remaining 14. Total room time, procedure time, and CT fluoroscopy time were recorded. RESULTS: All 24 collections were successfully evacuated using either real-time or interrupted real-time CT fluoroscopy. The real-time capability of CT fluoroscopy proved particularly useful for rapid placement of drainage tubes in patients who were unable to cooperate with breathing instructions and in patients who had a narrow window of access. Average total room time was 65 min. Average procedure time was 32 min, and average CT fluoroscopy time was 143 sec. CONCLUSION: CT fluoroscopy permits rapid drainage of intrathoracic collections. CT fluoroscopy is a particularly useful treatment for patients who are unable to perform breath-holding or in whom access to the drainage site is difficult.

Irreducible Galeazzi injury.

We present a case of a Galeazzi-type of fracture dislocation with an irreducible distal radioulnar joint. This is illustrated by intraoperative pictures which may assist others who find themselves faced with this injury.

Mediastinal mature teratoma: imaging features.

OBJECTIVE: The purpose of this study was to characterize the cross-sectional imaging features of mediastinal mature teratomas. MATERIALS AND METHODS: Sixty-six cases of mediastinal mature teratoma were retrospectively reviewed, noting clinical, radiologic, surgical, and pathologic findings. The patient population consisted of 38 females and 28 males who were 1 week to 67 years old (mean age, 23 years 10 months). RESULTS: Forty-six patients presented with symptoms, predominantly chest pain, dyspnea, and cough. Twenty patients were asymptomatic. Fifty-four tumors were found in the anterior mediastinum, two in the posterior mediastinum, one in the middle mediastinum, and nine in multiple compartments. CT studies (n = 66) showed masses of heterogeneous attenuation with varying combinations of soft tissue, fluid, fat, and calcium. Soft-tissue attenuation was observed in 66 tumors (100%), fluid in 58 tumors (88%), fat in 50 tumors (76%), and calcification in 35 tumors (53%). The most frequent combination of attenuations was soft tissue, fluid, fat, and calcium, which was noted in 26 masses (39%). The combination of soft tissue, fluid, and fat was seen in 16 tumors (24%); and the combination of soft tissue and fluid was seen in 10 tumors (15%). Fat-fluid levels were seen in seven masses (11%). CONCLUSION: Mediastinal mature teratoma typically manifests on CT as a heterogeneous anterior mediastinal mass containing soft-tissue, fluid, fat, or calcium attenuation, or any combination of the four. Fluid-containing cystic areas, fat, and calcification occur frequently. Cystic lesions without fat or calcium were seen in 15% of tumors. Fat-fluid levels, considered highly specific for the diagnosis of mediastinal mature teratoma, are uncommon. CT is the imaging technique of choice in the evaluation of these lesions.