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:
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