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Introduction: The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan., Methods: The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold, p < 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and the independent variables were ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon., Results: A total of 3,357 (4.9%) of 67,586 patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2,186 (83%) were PNIs and the remainder were blunt injuries. When service members killed in action were included, the incidence of neck injury rose from 4.9% to 10%. Seven hundred nine (32%) of 2,186 patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230 (41%) of 555 underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64 (28%) of 228 of patients. Fatality status was positively associated with ISS on arrival (odds ratio, 1.05; 95% confidence interval, 1.04-1.06; p < 0.001) and the casualty being a local national (odds ratio, 1.74; 95% confidence interval, 1.28-2.38; p < 0.001)., Conclusion: Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study; this may reflect differing cervical protection, management protocols, and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF., Level of Evidence: Retrospective cohort study, level III.

Objectives: To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan., Setting: The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011., Participants: US and UK military personnel, local police, local military and civilians., Primary and Secondary Outcome Measures: An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables., Results: Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ 2 : 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066)., Conclusions: The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.

Background: We have previously reported a higher than expected rate of upper-extremity amputation (UEA) in victims of an antipersonnel improvised explosive device (AP-IED) compared with a similar cohort injured by antipersonnel mines (APM). The goal of this study was to describe the rate, severity and impact of UAE caused by an AP-IED., Methods: We analyzed a prospective database of 100 consecutive dismounted AP-IED victims with pattern 1 injuries to compare the outcomes of the cohort with UEA to that without., Results: We found that UEA (8 above elbow, 19 below elbow, 1 through elbow, 3 hand, 15 digit(s)) was much more prevalent with AP-IED than with APM (40% v. 6%, p < 0.001). In addition, UEA was associated with a higher rate of multiple amputations (39 [98%] v. 32 [53%], p < 0.001), bilateral lower-extremity amputation (LEA; 33 [82.5%] v. 30 [53.3%], p = 0.003) and facial injury (8 [20%] v. 4 [6.4%], p = 0.044), but not with pelvic disruption (10 [25%]), genitoperineal mutilation (19 [48%]), eye injury (6 [15%]), or skull fracture (6 [15%]). The fatality rate was higher in patients with UEA than in those without (12 [30%] v. 7 [12%], p = 0.022)., Conclusion: Upper-extremity amputation is more prevalent with AP-IED than APM. Presence of UEA is associated with more severe injury and increased risk of death in AP-IED victims. Upper-limb injury has significant consequences for rehabilitation from LEA, which universally accompanies UEA in AP-IED victims. Upper-extremity injury should be amenable to prevention by innovative personal protective equipment designed to protect the flexed elbow., Competing Interests: None declared., (© 2018 Joule Inc. or its licensors)

Maxillofacial trauma affects sensitive and essential functions for the human being such as smell, breathing, talking, and the most importantly the sight. Trauma to the orbit may cause a vision loss especially if this trauma yields a high kinetic energy like that encountered during wars. The purpose of the study was to evaluate the surgical outcomes of the orbital war trauma, enriching the literature with the experience of the authors in this field. A total of 16 patients were injured, evacuated, and managed, between June 2014 and June 2017, from the fight between the Iraqi army and the Islamic State of Iraq and Syria (ISIS) in different areas of Iraq. Two-stage protocol was adopted, that is debridement and reconstruction. There were 14 military patients and 2 civilians. The cause of trauma was either bullet or shrapnel from an explosion. In the battlefield, delayed evacuation of the casualties led to increase the morbidity and mortality. Wearing a protective shield over the eye during the war along with fast evacuation highly improved the survival rates.

Major amputations of the lower and upper limbs are among the most life-altering and debilitating combat injuries. From 1 January 2001 through 31 October 2017, a total of 1,705 service members sustained major deployment-related lower and upper limb amputations. Lower limb amputations were far more common than upper limb amputations, with a total of 1,914 lower limb amputations, compared to 302 upper limb amputations. The greatest single-year number of amputations occurred in 2011, with a reported total of 273 service members who sustained 403 major limb amputations. The injured cohort mostly comprised non-Hispanic white male service members aged 21-29 years. Furthermore, the majority of the injured cohort included active component, mid-level or junior enlisted members of the Army or Marine Corps in combat-specific occupations. These findings reiterate and extend previous reports of the annual numbers, types, and anatomic locations of deployment-related limb amputations, along with the demographics and military characteristics of the injured cohort from the Iraq and Afghanistan conflicts.

Background: Civilians constitute 33-51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury patterns and types of surgical treatment for females., Methods: A total of 3028 patient files (376 females) from consecutively admitted patients to the ICRC-hospital in Peshawar from February 2009 to May 2012 were included. Information regarding injury-mechanism, time since injury, vital parameters at admission, type of injury, treatment and basic outcome was extracted from the files and analyzed. Comparisons between gender and age-groups were done by cross-table analyses or nonparametric tests., Results: Females were younger than males (20 vs. 25 years), arrived sooner after injury (24 vs. 48 h) (p < 0.001 for both) and were victims of bombs and missiles more frequently (64.4 vs. 54.6%) (p < 0.001). Vital parameters such as systolic blood pressure (110 vs. 113 mmHg) and pulse rate (100 vs. 86) were more affected at admission (p < 0.001 for both). Females were subjected to surgery (83.0 vs. 77.4%) (p < 0.05) and were given blood transfusions more often (18.8 vs. 13.6%) (p < 0.01). No differences in amputations or in-hospital mortality were found., Conclusions: Females treated at the ICRC-hospital in northwestern Pakistan are markedly affected by indiscriminate weapons such as bombs and missiles. Their average consumption of surgery is greater than for males, and this might be relevant in planning for staffing and facility needs in similar contexts.

Introduction: It is known that phacoemulsification of cataracts after penetrating keratoplasty there are always some difficulties and of course a higher rate of different intraoperative complications. Phacoemulsification after PK may cause significant endothelial injury and affect long term graft survival., Aim: The aim of this report is to describe one of these cases and the possible ways to manage them., Case Report: We report a case o of a 31-year-old female patient, with a cataract on her left eye. She reported that when she was 10 years old, she was admitted to regional hospital in Bosnia and Herzegovina due perforative corneal war injury. At the age of 11 years at Germany on her left eye corneal transplantation was performed. She reported that she wasn't ever seeing quite good, due high myopia. Twenty years after war injury she was admitted to hospital. At that moment patient has been ophthalmologicaly examined (visual acuity testing, biomicroscopy, tonometry, ultrasound of both eyes with biometry and ophthalmoscopy). At the day of admission to the hospital on slit lamp we found occlusion of pupil and complicated cataract. Her only wish was to get operated due cosmetic reasons. Before surgery her visual acuity on her left eye was light perception. Thirty days after surgery her visual acuity was 0,1 without correction., Conclusion: It is concluded that cataract surgery in patients after keratoplasty is more complicated. Therefore, these patients should be managed with utmost care and operated by an experienced surgeon., Competing Interests: • Conflict of interest: All authors have none to declare.

The combined wars in Afghanistan and Iraq represent the longest ongoing conflicts in American military history, with a combined casualty estimate of >59,000 service members. The nature of combat over the last decade has led to precipitous increases in severe orthopaedic injuries, including traumatic amputations and injuries to the spine. Nearly 75% of all injuries sustained in combat now are caused by explosive mechanisms, and fractures comprise 40% of all musculoskeletal injuries. Injuries to the axial skeleton are more frequent among personnel exposed to combat, and spinal trauma is identified in nearly 40% of those killed. Musculoskeletal injuries are expensive and generate some of the highest rates of long-term disability. Noncombat musculoskeletal injuries are endemic within deployed military service members and occur at a greater than threefold rate compared with combat musculoskeletal injuries. Service members with musculoskeletal injuries or behavioral health conditions, such as posttraumatic stress disorder, depression, and psychosis, and those occupying a low socioeconomic status, have an increased risk of inferior outcomes.

Background: Accurate point-of-injury reports and casualty evacuation requests allow for optimal resource utilization. However, the accuracy of these reports has not been previously studied., Methods: All trauma patients treated at one of three forward surgical elements (FSE) in Western Afghanistan during May-August 2012 were prospectively included. North American Treaty Organization (NATO) 9-line medical evacuation request and mechanism, injuries, signs, and treatments (MIST) reports were compared to the initial findings on arrival to the FSE., Results: There were 179 casualty evacuation reports and 298 patients. NATO 9-line and/or MIST reports were available for 70% of these. Triage was accurate for 77%, but there was 17% overtriage and 6% undertriage (k = .619). The number of patients was accurate in 95% of reports, the mechanism of injury was accurate for 98%, and the body region involved was accurate for 92% (k = .850, .943, and .870, respectively). There was no difference between the mean vital signs at the point of injury or on arrival at the FSE. When analyzed individually, however, there was no correlation between each casualty's pulse, mean arterial pressure, or respiratory rate between the two time points., Discussion: There was a high degree of correlation between the triage category of casualty evacuation reports and the patient's actual medical needs. There was also a highly significant association with the number of patients, mechanism of injury, and bodily injuries. However, there was discordance between the vital signs at an individual level, which may represent regression toward the resuscitation threshold., (2016.)

Although historically restricted from combat roles, women suffer from combat-related injuries, especially in recent conflicts where asymmetrical warfare erases distinctions between forward and rear operating areas. U.S. servicewomen who sustained combat-related injury in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) between January 2003 and May 2014 were identified from the Expeditionary Medical Encounter Database. Injuries were characterized using Abbreviated Injury Scale and International Classification of Diseases, 9th Revision codes. Of the 844 combat-related injury episodes in women, 51% (n = 433) were OIF injuries and 49% (n = 411) were OEF injuries. Blast events were responsible for 90% of injuries. The average Injury Severity Score was 3, with no statistical difference in means between OIF and OEF. Of significance were increased head injuries in OEF compared with OIF (80% vs. 48%; p < 0.001). Although the majority of combat-related injuries suffered by women were mild, some women suffered life-threatening injuries, and nearly 65% of the injury episodes resulted in more than one injury. More research is needed as the roles of women in the military continue to expand. Future studies will investigate quality of life outcomes and gender differences in combat-related injuries., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Current military operations require soldiers to carry heavy external loads that are widely acknowledged to impair the ability to move tactically on the battlefield. However, to date, the effect of load on susceptibility to enemy fire (the probability of being hit) has not been examined. Nineteen soldiers completed a break contact simulation (five 30-m sprints commencing every 44 seconds) and a fire and movement simulation (sixteen 6-m bounds commencing every 20 seconds) in each of the 5 load conditions (ranging from 9.8 to 30.1 kg). For each simulation, the impact of load on exposure time and peak movement velocity was examined. In addition, the 6 fastest and 6 slowest soldiers (determined by exposure time in the heaviest condition) were parsed into subgroups to examine interindividual differences in response to load. Susceptibility for the 2 subgroups was modeled using exposure time for the 2 simulations and the assumed reaction time, shooting cadence, and shooting accuracy of the enemy. Susceptibility increased as a function of load for both the break contact and fire and movement simulations and became more pronounced when the participant population was parsed into fast and slow groups. When the impact of personal protection systems was isolated and analyzed, it was found that not only were the slower participants more vulnerable (as a result of not wearing the personal protection system) but also more susceptible than the faster participants who carried 11.2 kg more load. Large interindividual differences in response to external load have meaningful consequences for battlefield susceptibility, and it is therefore critical that personnel are afforded tailored training such that they maximize their proficiency in the execution of tactical combat movements.

Purpose: To describe the characteristics, visual outcomes, and predictive value of the Ocular Trauma Score (OTS) in eyes with traumatic cataract from combat ocular trauma., Setting: Walter Reed Army Medical Center, Washington, DC, USA., Design: Retrospective case series., Methods: Records of service members with traumatic cataract from combat ocular trauma over a 7-year period were reviewed. Visual acuity at initial presentation and visual acuity at the final follow-up were compared in addition to outcomes in closed versus open globes, by final lens status, and in eyes receiving primary versus secondary intraocular lenses (IOLs). Visual outcomes were predicted using the OTS and compared to the achieved corrected distance visual acuity (CDVA)., Results: A total of 181 eyes of 167 patients were included in the final analysis. Twenty-six percent of all eye injuries sustained traumatic cataract. The mean final visual outcome was 0.86 logMAR ± 1.01 (SD) with 44 no light perception (NLP) eyes and 26 light perception (LP) eyes compared with an initial visual acuity of 2.41 ± 0.88 logMAR with 27 no NLP eyes and 64 LP eyes (P ≤ .001, 2-tailed Student t test). Final CDVAs in eyes receiving primary IOLs were 0.72 ± 0.84 logMAR with 1 NLP and 1 LP eye versus 0.51 ± 0.78 logMAR with 2 LP eyes in eyes receiving a secondary IOL (P = .37, Student t test)., Conclusion: Traumatic cataracts are frequently associated with ocular trauma. The OTS is a reliable means of predicting visual outcome. There was no difference in eyes receiving primary IOLs versus secondary IOLs., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Published by Elsevier Inc.)

Each year musculoskeletal injuries (MSIs) result in thousands of lost duty days and medical discharges. Women represent 15% of the Army and have higher incidence of injury than male soldiers; studies that have investigated MSIs in deployed women are lacking. Therefore, the purpose of this prospective cohort study was to investigate MSIs in women during a 9-month deployment to Afghanistan. Participants were recruited from three Brigade Combat Teams. Participants completed a demographic survey before deployment and a second survey on occupational demands and MSIs after deployment. Of the 160 women, 57 (36%) suffered 78 MSIs resulting in 1,642 days of limited duty, a median of 7 days per MSI, losing 10% of the available duty time to MSIs. Most injuries affected the knee (24%) or low back (18%). Soldiers attributed the majority of injuries (27%) to physical training and trips/falls (17%). Of the MSIs, 93% caused limitations to physical training and 76% resulted in large limitations to occupational tasks. Most MSIs (41%) resolved within 3 weeks and most (37%) occurred before the fourth month of deployment. Prevention measures should target knee and low back injuries. Physical training should be further investigated to discover modifications capable of reducing injuries., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)