WAR WOUNDS: SOME HISTORY, MECHANISMS AND PATHOLOGY MR JOHN BEAVIS FRCS DMCC CONSULTANT TRAUMA SURGEON PAST SENIOR LECTURER UNIVERSITY COLLEGE LONDON PAST.

WAR WOUNDS:WAR WOUNDS:SOME HISTORY, MECHANISMS AND SOME HISTORY, MECHANISMS AND

PATHOLOGYPATHOLOGY

MR JOHN BEAVIS FRCS DMCC

CONSULTANT TRAUMA SURGEONPAST SENIOR LECTURER UNIVERSITY COLLEGE LONDON

PAST HUNTERIAN PROFESSOR ROYAL COLLEGE OF SURGEONS OF ENGLAND

Cave Dweller Painting In FranceCave Dweller Painting In FranceAt Least 25,000 At Least 25,000 YearsYears Old Old

HIGH ENERGY WOUNDS

LOW ENERGY WOUNDSLOW ENERGY WOUNDS

History of war injuriesLOW AND HIGH ENERGY

WOUNDS

• Sharp/blunt weapons personally delivered by hand and contact

• Projectiles -- stones, arrows

• Explosive Discharge Projectiles -- bullets, shell fragments, mines

• Explosive --- blast injuries

LOW ENERGY MISSILES

• Sharp/blunt weapons personally delivered• Projectiles -- stones, arrows

STUDY OF TROJANSTUDY OF TROJANWARS IN HOMER’S WARS IN HOMER’S ILIAD BY FROLICHILIAD BY FROLICH

LOW ENERGY LOW ENERGY PENETRATINGPENETRATING

WOUNDSWOUNDS

DESPITE VITAL SITE OF DESPITE VITAL SITE OF INJURY THEY CAN BE INJURY THEY CAN BE

TREATED ------TREATED ------

------ IFTHE VITAL ORGANS ------ IFTHE VITAL ORGANS ARE ARE

NOT DAMAGEDNOT DAMAGEDTOO MUCH BECAUSE TOO MUCH BECAUSE

THE DAMAGE IS THE DAMAGE IS LOCALISED TO THELOCALISED TO THE

TRACK OF THE INJURY TRACK OF THE INJURY !!

LOW ENERGY WOUNDS ARE MUCH DIFFERENT TO HIGH ENERGY WOUNDS

1.A 1.A SINGLESINGLE LOW ENERGY LOW ENERGY knife knife wound of wound of the heart which was sutured and the heart which was sutured and patient survived. patient survived. 6 in days in 6 in days in hospitalhospital

2. A 2. A SINGLE SINGLE HIGH ENERGY HIGH ENERGY bullet bullet wound of the arm -- massive blood wound of the arm -- massive blood loss and infection. Patient nearly loss and infection. Patient nearly died of complications. died of complications. 8 weeks in 8 weeks in hospitalhospital

BUT WHAT MAKES A MISSILEBUT WHAT MAKES A MISSILE HIGH ENERGY?HIGH ENERGY?

ANSWER: SIZE AND VELOCITYANSWER: SIZE AND VELOCITY

WHEN THE WHEN THE OBJECT STOPSOBJECT STOPS

THE ENERGY HAS THE ENERGY HAS TO GO TO GO

SOMEWHERE!!SOMEWHERE!!

MODERN RIFLE VELOCITY OF HIGH ENERGY BULLET 2009

VERSUS MUSKET BALL 1805

RANGE IN METRESRANGE IN METRES

VELOCITY /SECONDVELOCITY /SECOND

SUPERSONICSUPERSONIC

OVER THE CENTURIESMAN’S ABILITY TO MAKE GUNS MORE POWERFUL

HAS BEEN MUCH GREATER THAN HIS ABILITY TO MAKE PEACE

SOME CAUSES OFHIGH ENERGY

MISSILE WOUNDS

HIGH ENERGY WOUNDS 1THE DAMAGE GOES WELL OUTSIDE THE INITIAL TRACK OF THE MISSILE

• Projectiles -- explosive discharge, bullets shell fragments.

• Explosive --mines,

HIGH ENERGY GUN SHOT DIAGRAM OF MINE INJURYHIGH ENERGY GUN SHOT DIAGRAM OF MINE INJURY

High EnergyHigh Energy

Low Energy Low Energy

Small entrance woundSmall entrance woundFrom high energy From high energy

Bullet woundBullet wound

Large exit wound.Large exit wound.What has What has

happened internally?happened internally?

LOW ENERGY HIGH ENERGYLOW ENERGY HIGH ENERGY

SMALL ENTRY WOUND

MASSIVE TISSUE DESTRUCTION

HIGH ENERGY HIGH ENERGY GUN GUN SHOT WOUNDSHOT WOUND

HIGH ENERGY HIGH ENERGY MORTAR MORTAR SHELL FRAGMENT SHELL FRAGMENT LOWER SPEED THAN A LOWER SPEED THAN A BULLET BUT HEAVIERBULLET BUT HEAVIER CAN ONLY BE TREATED CAN ONLY BE TREATED BY WIDE EXCISION OF BY WIDE EXCISION OF DEAD TISSUE AND DEAD TISSUE AND EVENTUAL GRAFTINGEVENTUAL GRAFTING

LEAVE THE WOUND LEAVE THE WOUND OPEN UNTIL YOU ARE OPEN UNTIL YOU ARE CERTAIN THE CERTAIN THE INFECTION/DEAD INFECTION/DEAD MATERIAL ARE MATERIAL ARE REMOVED.REMOVED.

MINE INJURIES

SARAJEVO 1994 LOOKING FOR WOOD

FOR HIS FAMILY

HIGH ENERGY HIGH ENERGY PARTICLES ARE PARTICLES ARE DRIVEN UP WELL INTO THE DRIVEN UP WELL INTO THE

HEALTHY TISSUES AND HEALTHY TISSUES AND MAY BE CONCEALEDMAY BE CONCEALED

• COMMON CAUSE OF AMPUTATION AND

MANY ARE BILATERAL

• OFTEN IN WOMEN AND CHILDREN

• • MULTIPLE INJURIES

ESPECIALLY PERINEAL

• ANTI-PERSONAL ARE USUALLY UPPER LIMB

MINE INJURIES

HIGH ENERGY WOUNDS 2• Explosive -- blast injuries MULTIPLE MULTIPLE HIGH HIGH

ENERGYENERGYMISSILESMISSILES

MULTIPLE ORGANMULTIPLE ORGAN HIGH ENERGY AND HIGH ENERGY AND LOW ENERGY LOW ENERGY BLAST BLAST INJURIESINJURIES

BURNS AND BURNS AND SMOKE INHALATIONSMOKE INHALATION

EFFECTS OF BEINGEFFECTS OF BEINGPROJECTEDPROJECTED

CRUSHING INJURIESCRUSHING INJURIES

TREATMENT TREATMENT DELAY WHEN DELAY WHEN TRAPPEDTRAPPED

BLAST SHOCK WAVEBLAST SHOCK WAVEHIGH ENERGYHIGH ENERGY

Blast lung at 12 hours.Notice the areas of haemorrhage

Blast Ear drum

Blast Blast withwithleft lobeleft lobeof liver of liver destroydestroyed ed

MULTIPLE MULTIPLE HIGH AND LOW ENERGY HIGH AND LOW ENERGY TYPES OF FRAGMENTATION FROM TYPES OF FRAGMENTATION FROM

SHELL/BOMB EXPLOSIONSHELL/BOMB EXPLOSION

POSTMORTEM STUDIES ALWAYS SHOW POSTMORTEM STUDIES ALWAYS SHOW PRESENCE OF SHRAPNELPRESENCE OF SHRAPNEL

OVER PAST TEN YEARS VERY SEVERE HIGH ENERGY INJURIES HAVE BEEN NOTICED WITH

GROSS BLASTING BUT NO EVIDENCE OF FRAGMENTS IN WOUNDS

• Wounds demonstrate very severe local blast effect

• These weapons are very high energy explosives encased in metal containers which vaporise on explosion and deeply penetrate tissues and enter the blood stream

• Tissues from 2006 Gaza victims contain high concentrations of carbon aluminium copper and tungsten Dr. Carmela Vaccaio at University Parma

VERY HIGH ENERGY WEAPONSDENSE INERT METAL EXPLOSIVES D.I.M.E.

• No collateral damage and primarily anti- personal. People are damaged and not buildings so less evidence remains.

• May have long term effects of carcinogenic and second generation genetic deformities

HEAVY METAL HEAVY METAL

IONIZINGIONIZINGRADIATIONRADIATION

CHEMICAL WEAPONSCHEMICAL WEAPONS

PHOSPHORUS BURNSPHOSPHORUS BURNSOXYGEN IS BADOXYGEN IS BAD

SUMMARY OF WAR WOUNDS

• The classification HIGH AND LOW ENERGY serves us well to plan treatment

• Weapons continue to be developed and anatomical injury is now only part of the problem with carcinogenic and genetic complications likely.