While terrorism was a problem of only underdeveloped and developing countries in the past, it now presents as a global problem affecting innocent civilians worldwide and results in widespread fear, injury, chaos, and death(7). In recent years, the world has been subjected to the devastating effects of many terrorist attacks, such as the bombings of 2001 New York, 2004 Madrid train, 2005 London metro, 2013 Boston marathon, 2015 Ankara, and 2003–2014 Iraq and Afghanistan conflicts (4, 5, 8).
This study described blast extremity injuries in people exposed to terrorist attacks. The effects of open fracture types and the presence of VI accompanying extremity injuries were shown in terms of the types of surgery performed and LHS. Our data reveal that most of the victims that survived terrorist attacks in recent years present with extremity injuries (Table 5). The data obtained also show that open fractures were significantly higher in blast injuries than closed fractures (91.2% vs. 8.8%). Similarly, in the literature, the rate of open fractures (61.5%-83%) is reported to be higher than that of closed fractures(4, 9, 10).
Table 5
Incidence of extremity injuries observed in the current study and reported in other sources
Anatomic localization (n, %) | 2003–2014 Iraq and Afghanistan conflicts (3) | OIF and OEF 2007 (16) | Current study |
Open fracture n (%) | 941/1530 (61.5) | 758/915, (82) | 94/103, (91.2) |
Upper extremities | 344 /941 (36.5) | 392/758, (51.7) | 38/94, (40.4) |
Lower extremities and pelvis | 597/941 (63.5) | 366/758, (48.3) | 56/94, (59.6) |
Extremity injuries n (%) | 1813/2348, (77) | 3575/6609, (54) | 101/176, (57.7) |
Total injuries (n) | 2348 | 6609 | 176 |
OIF Operation Iraqi Freedom, OEF Operation Enduring Freedom. |
In this study, although 71.4% of open fractures were types 1 and 2 according to GAC, the cases that resulted in amputation and VI were associated with type 3B and 3C fractures. In addition, LHS, ISS, and mortality rate were higher in type 3B and 3C fractures. This can be explained by blast injuries often occurring through more than one mechanism and affecting multiple systems. The destructive power of bombs depends on the combined effect of the blast wave (primary), shrapnel penetration (secondary), and blunt trauma (tertiary) caused by the explosion(7, 8). Similarly, although the majority of injuries to the extremities consisted of shrapnel fragments detected on imaging, the coexistence of extensive tissue loss, severe VI, and 6.9% amputation suggest that blast mechanisms other than secondary may have also been involved. In addition, unpredictable types of injuries may occur due to the effects of nails, screws and metal balls filled in IEDs used in the explosion. Accordingly, multiple shrapnel fragments hit different parts of the body, resulting in multiple organ damage and injuries that are difficult to treat. In this study, high ISS and accompanying thoracoabdominal and cranial injuries were found to be factors associated with mortality.
Although open fractures of the extremities can lead to disability, mortality can be significantly reduced without surgery through minimum first aid, fluid supplements, and antibiotic use. With the application of these treatments, blast injuries to the extremities rarely cause death. However, other accompanying systemic injuries, such as thoracoabdominal and cranial injuries have been shown to significantly increase mortality(11). This is also supported by the presence of accompanying injuries to non-extremity organs and high ISS values in the current study. In such cases, mortality will inevitably develop. In addition, although isolated bone and soft tissue injuries in the extremities are not an important cause of mortality today, they constitute the most important part of surgical load due to their high frequency. Even if mortality does not develop in these patients, they appear as the most common cause of permanent disability in low-income countries, such as Somalia, in which services related to physical rehabilitation and socioeconomic reintegration are not easily accessible at the end of the recovery period.
One of the important factors affecting mortality and healing process in extremity injuries is VI, a condition that requires urgent surgical intervention because it can lead to hemodynamic instability and severe ischemia. In a comprehensive study examining all traumas in Israel between 2000 and 2005, it was reported that 243 (9.85%) of 2,466 people injured in terrorist acts had VI, and mortality occurred in 22.2% of these cases(8). Therefore, it can be stated that the presence of VI in extremity injuries directly affects mortality and the clinical course of the patient(7, 8). In the current study, all patients requiring amputation had VI and accompanying type 3C open fractures. In addition, the patients with VI presented to the hospital with hypovolemic shock and low hemoglobin values compared to NVIs (p = 0.033), supporting the idea that VI is a factor associated with mortality. On the other hand, in the presence of multiple fractures, in addition to arterial injuries, bleeding resulting from the bone itself has also been shown to easily lead to a clinical presentation of hypovolemic shock(11).
In this study, fasciotomy was performed in three patients with severe VI due to the development of compartment syndrome in the lower extremities. The rapid increase in the serum creatinine levels of these patients, who were followed up in the intensive care unit, was explained by the occurrence of acute tubular necrosis due to traumatic rhabdomyolysis and hypovolemia. Although hemodialysis was performed on these patients, mortality developed due to multiple organ failure. The creatinine values in the patients with VI in the study cohort being higher than the NVI group even at early stages may be indicative of severe muscle destruction (rhabdomyolysis) and the consequent development of acute renal tubular necrosis. It should not be forgotten that crush injuries and rhabdomyolysis may also occur as a result of blasts, and patients with this hypovolemic condition should receive urgent volume resuscitation(12).
In the treatment of extremities injuries, the most important point to consider is the necessity of performing damage control surgery (DCS) in certain patients. This treatment involves early, marginal and meticulous wound debridement, temporary stabilization of fractures (usually with an external fixator), ensuring physiological recovery, and then performing definitive therapy after the acute phase is completed. Treatment with DCS is primarily aimed at correcting impaired physiology, not anatomy(2, 13, 14). However, as was the case in this study, the application of DCS treatment in stages is challenging in areas facing frequent terrorist attacks, having insufficient resources, and poor hygienic and socio-economic conditions. Thus, debridement and late primary closure form the basis of surgical treatment. In the treatment of fractures, due to high tissue loss in blast injuries and risk of infection, after the fixation procedure using bone immobilization methods, it is recommended to leave the wound open to provide drainage. In addition, primary closure is not recommended in these patients(2, 7, 13). It has been suggested that it would be more appropriate to use an external fixator for the first bone immobilization in open fractures (especially types 3B and 3C) and that internal fixation should not be routinely preferred for this type of injury because it can cause a high rate of infection. This was supported by the presence of infection in 50–80% of soldiers in the United States Army during the Vietnam war and the Soviet Army during the Afghanistan war(7).
An important limitation of this study is that the patients who were discharged after the first treatment could not be fully followed up due to their low socioeconomic level and lack of health insurance. Despite this, our study presents as a comprehensive work describing blast-related extremity injuries in Somalia.