case report of thoracic spine fractures from ied blast in armoured vehicle young

JOINT HEALTH COMMAND

Thoracic Spine Compression Fractures from Vehicle IED Strike

CMDR Ian Young, BSc, MD, CCFP, FRACGP, FRACS, RANOrthopaedic Surgeon AUSMTF5

CAPT Glen Mulhall, MBBS, RAAMCRegimental Medical Officer 6RAR

CASE REPORT:

JOINT HEALTH COMMAND

Outline

• Deployment• Case report• Literature review• Discussion• Future research

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

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

JOINT HEALTH COMMAND

Map of Afghanistan

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

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 www.defence.gov.au and are UNCLASSIFIED

• Specific further details of the incident are SECRET and will not be discussed in this presentation

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

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

JOINT HEALTH COMMAND

Resuscitation

Secondary Survey

Log Roll

Summary of Injuries/ er

Position Spine Fractures Other Fractures Other Injuries SeatbeltSeated/ 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

Case 1 (Soldier E)

Primary survey stableC-collar GCS 15Secondary survey - tender L4/5 regionTrauma series negativeX-rays difficult to interpret

Case 1 X-rays

Case 1 Progress

Concern of possible lumbar fractureNeurologically intactTransferred to Role 3 Hospital by helicopter for CT spineCT revealed unexpected burst fracture of T12 with small amount of retropulsion

Case 1 CT Scans

Case 1 Management

Neurosurgeon opinion that fracture did not require operative managementSent to the US Forces Landstuhl Regional Medical Center (LRMC) in Germany for spinal brace then Return to Australia (RTA)

Case 2 (Soldier F)

Primary survey stableComplaining of mid-thoracic back painNeurologically intactTender lower C-spine and at T6 regionX-rays difficult to interpretAbnormal C4/5 but no obvious fractureSent to Role 3 Hospital for CT scan

Case 2 X-rays

Case 2 CT Scan

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 congenitalNon-operative managementAnalgesiaRTA

Case 3 (Soldier G)

Stable, C-collar, chin lacerationComplaining of lower back painTender lower lumbar spine on palpation Neurologically intactPossible small L5 compression fracture on plain X-raySent to Role 3 Hospital for CT scan

Case 3 X-rays

Case 3 CT Scan

Case 3 Management

CT scan showed compression fracture of T12 with minimal loss of heightNeurosurgeon opinion stable fractureNo operation or bracing requiredRTA

Injury Pattern

All 3 casualties were seated at the time of ED strike in an armoured vehicleAll were wearing body armour system that prevented flexion in thoracolumbar regionAxial compressive force of blast resulted in compression /burst fractures of the horacic spine

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

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

– CT scan normal

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

Literature Review

US Forces paperRetrospectivebjective: analysis of spine fractures sustained by NATO soldiers when vehicles are attacked by IEDsethods: review of all soldiers admitted with spine fractures following vehicle IED from 1 Jan – 15 May 2008 (OEF)

Literature Review

esults:12 male patients with 16 thoracolumbar fractures– 6 flexion-distraction fractures (Chance

fractures) = 38%– 7 compression fractures– 3 burst fractures

3 patients had neurologic deficits

Literature Review

Possible mechanism for Chance fracture

Literature Review

onclusion:Reported incidence of flexion-distraction fractures 1-2.5% in world literaturen 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

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

Discussion

No cases with neurological injury in our series– May be related to magnitude of blast or

protection from armoured vehiclePhysical examination unreliable– Only 1 casualty had thoracic tenderness– Need high index of suspicion based on blast

mechanism of injuryL th h ld f CT

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

Conclusion

Personnel involved in IED strikes while in armoured vehicles must be closely scrutinised for spinal injuries afterwards

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 presentCT scans are recommended for all IED casualties with back pain or tenderness

Future Research

Seat design to absorb blastTypes of restraints that reduce injuryPossible protection from flexion-distraction njuries at thoracolumbar junction from body armour?

Role 2 Hospital Staff

AUSMTF5

The Authors

Thank You