The Modern "Deck-Slap" Injury-Calcaneal Blast Fractures From Vehicle Explosions

Imperial Blast Biomechanics and Biophysics Group, Imperial College London, United Kingdom.
The Journal of trauma (Impact Factor: 2.96). 07/2011; 71(6):1694-8. DOI: 10.1097/TA.0b013e318227a999
Source: PubMed

ABSTRACT Anti-vehicle mines and improvised explosive devices remain the most prevalent threat to coalition troops operating in Iraq and Afghanistan. Detonation of these devices causes rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a "deck-slap" injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore, the aim of this study is to determine the pattern of injury, medical management, and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions.
From January 2006 to December 2008, using a prospectively collected trauma registry (Joint Theater Trauma Registry), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in-depth review. For each patient, demographic data, New Injury Severity Score, and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilization, local complications, and the need for amputation were noted. Functional recovery was related to the ability of the casualty to return to military duties.
Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median New Injury Severity Score was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the United Kingdom. Four (10%) casualties required a delayed amputation for chronic pain (mean, 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit for any military duty.
Calcaneal injuries following under-vehicle explosions are commonly associated with significant multiple injuries including severe lower limb injury. The frequency of associated spinal injuries mandates radiologic evaluation of the spine in all such patients. The severity of the hindfoot injury is reflected by the high infection rate and amputation rate. Only a small proportion of casualties were able to return to preinjury military duties.

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Available from: Arul Ramasamy, Sep 29, 2015
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    • "In this way, the sequential failure of bones that are likely necessary for the fracture complex may be a variation on the theme previously described in ships and vehicles struck from underneath by explosive detonations which has been termed " deck-slap injury " . These injuries have characteristically been described as fractures of the calcaneus, tibia and knees (Keating, 1944; Barr et al, 1946; Bluman et al, 2010; Ramasamy et al, 2011a; Commandeur et al, 2012; O'Connor, 1968) but images depicting injuries consistent with the fracture complex as a result of explosions during the Global War on Terror have been presented at a forensic radiology conference. (Harcke, 2013) The key difference between explosive and impact induced fractures may be nothing more than the direction of the force. "
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    ABSTRACT: Previously, a pair of aircraft crash fatalities was reported by Byard and Tsokos involving extreme trauma to the lower legs with avulsion of the musculature and extrusion of the distal tibial shaft through the inferior aspect of the feet and shoes. This report was important to both the forensics and the injury prevention fields because it demonstrates a finding that may help to indicate not only the severity and nature/direction of an impact but also the position of the extremities at the time of collision with the terrain. Thus, here are reported an additional nine cases out of a larger series of 1182 aircraft fatalities (0.7%) with similar findings and discuss the biomechanical origins of such injuries.
    09/2015; DOI:10.1515/sjfs-2015-0002
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    • "Interestingly, advanced age was not associated with either of these complications. Previous studies with combat-related injuries to the hindfoot and ankle have shown amputation rates as high as 45% [15] [16] [22]. In contrast to these previous findings, in our study a lower-leg amputation was required in only three patients (2%), reflecting the different nature of this open injury compared to other open injuries of the lower extremity. "
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    ABSTRACT: Open ankle fractures are rare injuries with a high likelihood of wound complications and subsequent infections. There is limited information about the complications and outcomes of these injuries in different age groups. The aim of this study was to assess the contemporary demographics and complications related to this injury. We performed a chart review of all the 3030 patients treated for ankle fractures at a Level 1 trauma centre from 2006 to 2011. 137 (4.5%) patients had an open ankle fracture. The demographic data, injury mechanism, comorbidities, and fracture type were collected. Treatment, complications, length of stay and number of outpatient visits were also recorded. The mean age of the patients was 60 years and 56% were women. Most fractures were Weber type B with a medial sided wound (93%). Only 20% of the fractures were the result of high-energy trauma, and 31% were Gustilo grade III injuries. Immediate internal fixation was performed in 82% of patients, and the wound was primarily closed in most cases (80%). The incidence of postoperative wound necrosis and deep infection was 18% and 17%, respectively. There were more deep infections if pulsatile lavage was used during the wound debridement (p=0.029). About 14 (10%) patients required a flap reconstruction to cover the soft-tissue defect. Every other patient (54%) had a complication, and 21 patients (15%) suffered a long-term disability related to the injury. The number complications did not differ for nighttime and daytime operations (p=0.083). High-energy injuries were more common in younger patients (p<0.001) and these patients also had more lateral sided open wounds than older patients (p=0.002). Interestingly, younger patients also had significantly more complications (p=0.024), suffered more often from chronic pain (p=0.003), and required more flap reconstructions (p=0.026), reoperations (p=0.026), and outpatient clinic visits (p=0.006). Open ankle fractures have a high complication rate and often require multiple surgical procedures. In young patients these injuries are more likely to be the consequence of high-energy trauma leading to more complications and subsequently increased healthcare resource utilisation. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Injury 04/2015; 83(8). DOI:10.1016/j.injury.2015.04.015 · 2.14 Impact Factor
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    • "Blast exposure has been linked to a variety of clinical and cognitive outcomes in SM, including headaches (Eskridge et al. 2013), nausea, tinnitus (Fausti et al. 2009), chronic pain (Ramasamy et al. 2011), gait and balance difficulties (Akin and Murnane 2011; Sylvia et al. 2001), and sleep disturbances (Ruff et al. 2009). Cognitive/behavioral symptoms are commonly reported in blast-exposed SMs and include forgetfulness , inattention, and generally slowed cognitive processing (Cooper et al. 2011, 2012). "
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    ABSTRACT: Though cortical abnormalities have been demonstrated in moderate and severe traumatic brain injured (TBI) patients, there have been no studies examining cortical changes following blast related mild TBI (mTBI). The purpose of this study was to determine the effects and functional relevance of blast mTBI on cortical thickness in a small cohort of carefully screened blast injured US Service Members (SM). Twelve SM with mTBI acquired through blast injury were compared to 11 demographically matched control SM without TBI. Both mTBI and control participants were active duty and had completed a combat deployment. Subjects underwent MRI examination and the T1 weighted anatomic images were processed using the FreeSurfer suite of tools. Cortical thickness maps were compared between groups and examined for relationships with time since injury (TSI). Utilizing a large database of functional imaging results (BrainMap), significant regions of interest (ROI) were used to determine the behavioral profiles most consistently associated with the specific ROI. In addition, clinical variables were examined as part of post-hoc analysis of functional relevance. Group comparisons controlling for age demonstrated several significant clusters of cortical thinning for the blast injured SM. After multiple comparisons correction (False Discovery Rate (FDR)), two left hemisphere clusters remained significant (left superior temporal (STG) and frontal (SFG) gyri). No clusters were significantly correlated with TSI after FDR correction. Behavioral analysis for the STG and SFG clusters demonstrated three significant behavioral/cognitive sub-domains, each associated with audition and language. Blast injured SMs demonstrated distinct areas of cortical thinning in the STG and SFG. These areas have been previously shown to be associated with audition and language. Post-hoc analyses of clinical records demonstrated significant abnormal audiology reports for the blast injured SM suggesting that the thinning in these ROIs might be related to injury to the external auditory system rather than direct injury to the brain from the blast. It is clear that additional replication is needed in much larger cohorts. Importantly, the combination of imaging tools and methods in this study successfully demonstrated the potential to define unique ROIs and functional correlates that can be used to design future studies.
    Brain Imaging and Behavior 10/2013; 8(1). DOI:10.1007/s11682-013-9257-9 · 4.60 Impact Factor
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