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


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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    • "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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    • "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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    • "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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