Case report of thoracic spine fractures from ied blast in armoured vehicle Young


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Case report of thoracic spine fractures from ied blast in armoured vehicle Young

  1. 1. JOINT HEALTH COMMAND Thoracic Spine Compression Fractures from Vehicle IED Strike CMDR Ian Young, BSc, MD, CCFP, FRACGP, FRACS, RAN Orthopaedic Surgeon AUSMTF5 CAPT Glen Mulhall, MBBS, RAAMC Regimental Medical Officer 6RAR CASE REPORT:
  2. 2. JOINT HEALTH COMMAND Outline • Deployment • Case report • Literature review • Discussion • Future research
  3. 3. JOINT HEALTH COMMAND The Mission • Australia’s military commitment to Afghanistan as part of the NATO-led International Security Assistance Force (ISAF) – as a peace-enforcement mission under Chapter VII of the UN Charter – at the invitation of the Government of the Islamic Republic of Afghanistan (GIRoA) – under the United Nations Security Council resolution (UNSCR) 1833
  4. 4. JOINT HEALTH COMMAND My Deployment • Requirement to replace injured Orthopaedic Surgeon in RAAF-led Surgical Team within a Netherlands Army Role 2E Hospital in Tarin Kowt, Uruzgan, Afghanistan • Joined team for final 3.5 weeks of their 10 week deployment
  5. 5. JOINT HEALTH COMMAND Map of Afghanistan
  6. 6. JOINT HEALTH COMMAND Role 2E Hospital • Netherlands Army Hospital – Command & Control, Health Ops – Emergency Room, Resuscitation, Ward, Outpatients, Theatre Tech, ICU Medic, Dental, Radiography, Physio, Laboratory, Blood, Pharmacy, Medical Supply, Sterilisation, Biomedical Techs, Mortuary • Australian Surgical and ICU Team • Singaporean Team
  7. 7. JOINT HEALTH COMMAND Situation • Australian Bushmaster armoured vehicle carrying soldiers from MTF-1 sustained an Improvised Explosive Device (IED) attack in the Chora Valley area of Uruzgan province • 5 of the 9 occupants were wounded in action and transferred by AME to the ISAF Role 2E Hospital in Tarin Kowt • Above details from and are UNCLASSIFIED • Specific further details of the incident are SECRET and will not be discussed in this presentation
  8. 8. JOINT HEALTH COMMAND Casualty Reception • AME conducted as per evacuation priority • Transferred from the airfield by ambulance • Search of casualties at the entrance • Brought into the Emergency Department / Resuscitation Area
  9. 9. JOINT HEALTH COMMAND Casualty Assessment • Assessment by Resus Teams in accordance with standard EMST principles • 4 teams working simultaneously • Primary Survey and resuscitation with concurrent digital imaging, FAST and pathology • Surgeon involvement with surgical triage and secondary survey
  10. 10. JOINT HEALTH COMMAND Resuscitation
  11. 11. Secondary Survey
  12. 12. Log Roll
  13. 13. Summary of Injuries /  er Position Spine Fractures Other Fractures Other Injuries Seatbelt Seated/  Standing MCBAS  Worn Helmet  Worn M Driver ‐ ‐ Neck strain Yes Seated Yes Yes M Front passenger ‐ ‐ Neck strain Yes Seated Yes Yes M Crew Commander ‐ ‐ Periscapular contusion No Standing Yes Yes M Rear passenger ‐ ‐ Lumbar strain Yes Seated Yes Yes M Rear passenger T12 burst fracture, minor  retropulsion ‐ ‐ No Seated Yes Yes M Rear passenger T5,T6,T7 compression fractures ‐ Ankle soft tissue injury No Seated Yes Yes M Rear passenger T12 compression fracture ‐ Chin laceration No Seated Yes Yes M Rear passenger ‐ ‐ Lumbar strain, scalp  laceration No Seated Yes No M Rear gunner ‐ Tibial plafond fracture Hand soft tissue injury No Standing Yes Yes
  14. 14. Case 1 (Soldier E) Primary survey stable C-collar GCS 15 Secondary survey - tender L4/5 region Trauma series negative X-rays difficult to interpret
  15. 15. Case 1 X-rays
  16. 16. Case 1 Progress Concern of possible lumbar fracture Neurologically intact Transferred to Role 3 Hospital by helicopter for CT spine CT revealed unexpected burst fracture of T12 with small amount of retropulsion
  17. 17. Case 1 CT Scans
  18. 18. Case 1 Management Neurosurgeon opinion that fracture did not require operative management Sent to the US Forces Landstuhl Regional Medical Center (LRMC) in Germany for spinal brace then Return to Australia (RTA)
  19. 19. Case 2 (Soldier F) Primary survey stable Complaining of mid-thoracic back pain Neurologically intact Tender lower C-spine and at T6 region X-rays difficult to interpret Abnormal C4/5 but no obvious fracture Sent to Role 3 Hospital for CT scan
  20. 20. Case 2 X-rays
  21. 21. Case 2 CT Scan
  22. 22. Case 2 Management CT scan revealed compression fractures at T5, T6 and T7 – The abnormality of the C-spine felt to be from previous injury or congenital Non-operative management Analgesia RTA
  23. 23. Case 3 (Soldier G) Stable, C-collar, chin laceration Complaining of lower back pain Tender lower lumbar spine on palpation Neurologically intact Possible small L5 compression fracture on plain X-ray Sent to Role 3 Hospital for CT scan
  24. 24. Case 3 X-rays
  25. 25. Case 3 CT Scan
  26. 26. Case 3 Management CT scan showed compression fracture of T12 with minimal loss of height Neurosurgeon opinion stable fracture No operation or bracing required RTA
  27. 27. Injury Pattern All 3 casualties were seated at the time of ED strike in an armoured vehicle All were wearing body armour system that prevented flexion in thoracolumbar region Axial compressive force of blast resulted in compression /burst fractures of the horacic spine
  28. 28. Main Clinical Issue n 2 of 3 cases T12 fractures were not clinically suspected on secondary survey – CT scans done for other potential spinal pathology
  29. 29. Other Casualties 1 casualty with tibial plafond fracture – Treated operatively 1 casualty with flank pain but no midline enderness – X-ray showed possible fracture of pedicle at L3
  30. 30. Other Occupants The 4 remaining occupants were reviewed n subsequent days – 1 occupant with thoracolumbar pain • Normal X-ray • CT scan did not reveal a fracture – 2 occupants complained of neck pain – 1 occupant with periscapular contusion
  31. 31. Literature Review US Forces paper Retrospective bjective: analysis of spine fractures sustained by NATO soldiers when vehicles are attacked by IEDs ethods: review of all soldiers admitted with spine fractures following vehicle IED rom 1 Jan – 15 May 2008 (OEF)
  32. 32. Literature Review esults: 12 male patients with 16 thoracolumbar ractures – 6 flexion-distraction fractures (Chance fractures) = 38% – 7 compression fractures – 3 burst fractures 3 patients had neurologic deficits
  33. 33. Literature Review Possible mechanism for Chance fracture
  34. 34. Literature Review onclusion: Reported incidence of flexion-distraction ractures 1-2.5% in world literature n this study the incidence was 38% The blast pattern from IED explosion may be responsible for the high rate of these njuries in vehicle occupants
  35. 35. Discussion Our case series did not have any flexion- distraction injuries, only compression and burst fractures – postulated that the spine support provided by the body armour prevented the flexion- distraction injuries – still allowed axial transmission of the blast to cause compression and burst fractures
  36. 36. Discussion No cases with neurological injury in our series – May be related to magnitude of blast or protection from armoured vehicle Physical examination unreliable – Only 1 casualty had thoracic tenderness – Need high index of suspicion based on blast mechanism of injury
  37. 37. Discussion None of the casualties were wearing seat restraints at the time – Was it protective to be unrestrained? Majority of seated personnel complained of lumbar pain – Possibly related to edge of body armour – Superficial trauma
  38. 38. Conclusion Personnel involved in IED strikes while in armoured vehicles must be closely scrutinised for spinal injuries afterwards
  39. 39. Conclusion Medical staff treating casualties following an IED vehicle attack should have a low ndex of suspicion for spinal fractures – Physical exam alone may be unreliable especially when other injuries are present CT scans are recommended for all IED casualties with back pain or tenderness
  40. 40. Future Research Seat design to absorb blast Types of restraints that reduce injury Possible protection from flexion-distraction njuries at thoracolumbar junction from body armour?
  41. 41. Role 2 Hospital Staff
  42. 42. AUSMTF5
  43. 43. The Authors
  44. 44. Thank You