Ballistic trauma caused by military rifles: experimental study based on synthetic skull proxies

Rifles are often involved in violent deaths such as homicide and suicide. Consequently, expert knowledge and experimental forensic investigations are important to clarify the nature of ballistic trauma when applied to the human head and neurocranium. This study investigated differences in entrance wound morphology with Synbone® spheres which are described as being comparable to human flat bones. A series of ballistic experiments were conducted using two different rifle calibers (5.56 × 45 mm and 7.62 × 39 mm Full Metal Jacket (FMJ)). Synbone® spheres were used for close-range 0.3 m simulated executions as well as at 25 m and 35 m to simulate urban and military engagements. Results were compared with previously published experimental studies using similar military ammunition. In our study, entry wound morphology closely resembles real forensic cases compared to exit wound and overall shape morphology independently of the distance and the caliber. Circumferential delamination was clearly visible with full metal jacket (FMJ) rounds, yielding similar damage pattern morphology to the human crania. This study documented the presence of hydraulic burst or shock in all ten rounds from all three distances. Krönlein shots were also observed in some cases. Synbone® spheres constitute an acceptable synthetic surrogate for ballistic experiments. The present study offers new initial data on the behavior of Synbone® proxies in ballistic testing of military ammunitions; FMJ gunshot injuries to the human head, for distances that have not previously been published, suggesting that efficient tests can take place under these conditions. Further research on experimental ballistics with a larger number of controlled factors and multiple repetitions is recommended to verify the results of this pilot study before applied in forensic simulations.

Burn lessons learned from the Whakaari White Island volcanic eruption

New Zealand's most active volcano, Whakaari White Island was a common tourist attraction prior to its eruption on 9 th December 2019. At the time of the eruption, there were 47 people on the island from three tour groups. 39 people survived the initial eruption and were extracted. 31 entered into the New Zealand National Burn Service across four hospitals. The median age of the patients treated at the National Burn Centre was 45.5 years (range: 14 − 67 years) and median total body surface area burn was 49.5% (range: 9% - 90%). The three month survival of this eruptive event was 55%, which subsequently fell to an overall rate of 53% following one late death of an early survivor after repatriation home. Of the patients who survived the initial eruption for long enough to be admitted to the National Burn Service, the overall survival rate was 71% at three months. We describe 12 lessons we have learnt from our management of the survivors. The key surgical lessons among these are: The injuring mechanism combined ballistic trauma, thermal and acidic burn components, with the acid component being the most problematic and urgent for management. Volcanic ash burns result in on-going burn depth progression, deep underlying tissue damage and significant metabolic instability. Early skin grafting was not successful in many cases. Reconstructive strategy needed adjusting to cope with the high operative demand and limited donor sites in all patients. Protect yourself from potential dangers with additional personal protective equipment (PPE) in an unfamiliar setting.

Reviewing the needs of forward deployed critical care: South Sudan and the future

The UK military medical treatment facility (MTF) that deployed to the United Nations Mission in South Sudan in 2017 was based on a facility that can provide damage control surgery and resuscitation for soldiers with ballistic trauma injuries. It had to be supplemented with additional medical equipment and drugs that could support a peacekeeping mission in Africa. The clinicians used this experience and opportunity to review the critical care capability of UK Army Medical Services forward MTFs and recommend changes to reflect the increasing contemporaneous need on recent deployments to support more casualties with medical, infectious diseases and other non-battle injuries and illnesses. A concurrent review of the facility’s critical care transfer equipment was also undertaken and allowed it to be adapted for use as either transfer equipment or as a critical care surge capability, to increase the facility’s critical care capacity.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design: Retrospective case series; systematic review. Objective: It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion. Methods: A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis. Results: Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline. Conclusions: Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Firearms-related skeletal muscle trauma: pathophysiology and novel approaches for regeneration

One major cause of traumatic injury is firearm-related wounds (i.e., ballistic trauma), common in both civilian and military populations, which is increasing in prevalence and has serious long-term health and socioeconomic consequences worldwide. Common primary injuries of ballistic trauma include soft-tissue damage and loss, haemorrhage, bone fracture, and pain. The majority of injuries are of musculoskeletal origin and located in the extremities, such that skeletal muscle offers a major therapeutic target to aid recovery and return to normal daily activities. However, the underlying pathophysiology of skeletal muscle ballistic trauma remains poorly understood, with limited evidence-based treatment options. As such, this review will address the topic of firearm-related skeletal muscle injury and regeneration. We first introduce trauma ballistics and the immediate injury of skeletal muscle, followed by detailed coverage of the underlying biological mechanisms involved in regulating skeletal muscle dysfunction following injury, with a specific focus on the processes of muscle regeneration, muscle wasting and vascular impairments. Finally, we evaluate novel approaches for minimising muscle damage and enhancing muscle regeneration after ballistic trauma, which may have important relevance for primary care in victims of violence.

Efficiency of the Damage Control Orthopedic Strategy in the Management of Military Ballistic Limb Trauma.

Background: In conflicting areas, orthopaedic surgeons adopted this concept of damage control orthopaedic (DCO) to face limb fracture due to ballistic trauma because of the gravity of the hurts, the limitation of equipment, and precarious conditions of asepsis. They use external fixation as an initial treatment at the nearest health centre. They delay the definitive treatment to be realized in better conditions. Our study aims to assess the outcome of the damage control orthopaedic (DCO) strategy in military ballistic limb trauma according to the experience of the Military Hospital of Tunisia.Materials and methods: This study is a retrospective study on patients who were hospitalized for a limb ballistic fracture. It includes military patients treated urgently with primary external fixation at the nearest health centre. We adapted the Gustilo classification to describe wound opening, the Winquist and Hansen classification to define fracture comminution and the grading system for bone loss to evaluate bone loss. Then, all victims were evacuated secondary to the military hospital to receive the definitive treatments. The conversion to internal osteosynthesis had taken place according to some criteria. They were the absence of local sepsis, a haemoglobin level (> 10 g/dl), a serum protein level (> 50 g/l) and negative or falling CRP kinetics. We studied the delay of conversion from external fixation to internal osteosynthesis, bone healing time and complications.Result: Our study included 32 patients, all men, with a mean age of 31 years. The average follow-up was 33.2 months. Eighty-eight percent of trauma concerned the lower limb. The average delay for conversion from external fixation to internal osteosynthesis was 7.8 days. Bone union was achieved in 26 cases, with an average delay of 4.23 months. The observed general complications were anaemia, pulmonary embolism and rhabdomyolysis. Local complications were essentially sepsis on osteosynthesis material and pseudarthrosis. These complications were significantly associated with a type III Gustilo skin opening, a type III and IV Winquist fracture comminution, a type II and III Grading system for bone loss, and a delay in conversion from external fixation to internal osteosynthesis.Conclusion: DCO is a global strategy that involves all measures participating in the acceleration of wound healing and fighting against infection. These measures shorten the delay of conversion from external fixation into internal osteosynthesis, which constitutes a key parameter in the management of limb fracture due to ballistic trauma.

Efficiency of damage control orthopaedics strategy in the management of military ballistic limb trauma

Background: In conflict areas, orthopaedic surgeon adopted this concept of damage control orthopaedic (DCO) to face limb fracture due to ballistic trauma because of the gravity of the hurts, the limitation of equipment, and precarious conditions of asepsis. They use external fixation as an initial treatment at the nearest health centre. And they delay the definitive treatment to be realized in better conditions. Our study aims to assess the outcome of damage control orthopaedic (DCO) strategy in military ballistic limb trauma according to the experience of the Military Hospital of Tunisia. Materials and methods: This study is a retrospective study on patients who were hospitalized for a limb ballistic fracture. It includes military patients treated urgently with primary external fixation at the nearest health centre. We adapted Gustilo classification to describe the wound opening, Winquist and Hansen classification to define the fracture comminution and Grading system for bone loss to evaluate the bone loss. Then all victims were evacuated secondary, to the Military hospital to receive the definitive treatments. The conversion to internal osteosynthesis had taken place according to some criteria. They were the absence of local sepsis, a haemoglobin level (> 10 g/dl), a serum protein level (> 50 g/l) and a negative or falling CRP kinetics. We studied the delay of conversion from external fixation to an internal osteosynthesis, bone healing time and complications. Result: Our study included 32 patients, all men, mean age was 31 years. The average follows up was 33,2 months. 88% of trauma concerned lower limb. The average delay for conversion from external fixation to internal osteosynthesis was 7,8 days. The bone union was achieved in 26 cases, with an average delay of 4.23 months. Observed general complications were anaemia, pulmonary embolism and rhabdomyolysis. Local complications were essentially sepsis on osteosynthesis material and pseudarthrosis. These complications were significantly associated with a type III of Gustilo skin opening, a type III and IV of the Winquist fracture comminutions, a type II and III of the Grading system for bone loss, and the delay for conversion from external fixation to internal osteosynthesis. Conclusion: DCO is a global strategy which involves all measures participating in the acceleration of the wound healing and fighting against the infection. These measures shorten the delay of conversion from external fixation into an internal osteosynthesis, which constitutes a key parameter in the management of limb fracture due to ballistic trauma.