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Analysis of the Frequency and Mechanism of Injury to Warfighters in the Under-body Blast Environment
Published November 12, 2018 by The Stapp Association in United States
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During Operation Iraqi Freedom and Operation Enduring Freedom, improvised explosive devices were used strategically and with increasing frequency. To effectively design countermeasures for this environment, the Department of Defense identified the need for an under-body blast-specific Warrior Injury Assessment Manikin (WIAMan). To help with this design, information on Warfighter injuries in mounted under-body blast attacks was obtained from the Joint Trauma Analysis and Prevention of Injury in Combat program through their Request for Information interface. The events selected were evaluated by Department of the Army personnel to confirm they were representative of the loading environment expected for the WIAMan. A military case review was conducted for all AIS 2+ fractures with supporting radiology. In Warfighters whose injuries were reviewed, 79% had a foot, ankle or leg AIS 2+ fracture. Distal tibia, distal fibula, and calcaneus fractures were the most prevalent. The most common injury mechanisms were bending with probable vehicle contact (leg) and compression (foot). The most severe injuries sustained by Warfighters were to the pelvis, lumbar spine, and thoracic spine. These injuries were attributed to a compressive load from the seat pan that directly loaded the pelvis or created flexion in the lumbar spine. Rare types of injuries included severe abdominal organ injury, severe brain injury, and cervical spine injury. These typically occurred in conjunction with other fractures. Mitigating the frequently observed skeletal injuries using the WIAMan would have substantial long-term benefits for Warfighters.
- Kerry Danelson - Wake Forest Department of Orthopaedic Surgery
- Laura Watkins - Wake Forest Department of Orthopaedic Surgery
- Jonathan Hendricks - Wake Forest Department of Orthopaedic Surgery
- Patricia Frounfelker - WIAMan Case Review Team
- Karen Pizzolato-Heine - WIAMan Case Review Team
- Ray Valentine - Survivability/Lethality Analysis Directorate (SLAD)
- Kathryn Loftis - Survivability/Lethality Analysis Directorate (SLAD)
CitationDanelson, K., Watkins, L., Hendricks, J., Frounfelker, P. et al., "Analysis of the Frequency and Mechanism of Injury to Warfighters in the Under-body Blast Environment," SAE Technical Paper 2018-22-0014, 2018, https://doi.org/10.4271/2018-22-0014.
Data Sets - Support Documents
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- AAAM (2008) The Abbreviated Injury Scale 2008 revision. Des Plaines, IL: 1981-2000.
- Assal, M., Huber, P., Tencer, A., Rohr, E., Mock, C. and Kaufman, R. (2002). Are drivers more likely to injure their right or left foot in a frontal crash: A crash and biomechanical investigation. 46th AAAM Conference: 273-288.
- Bailey, A.M., Christopher, J.J., Brozoski, F. and Salzar, R.S. (2015a) Post Mortem Human Surrogate Injury Response of the Pelvis and Lower Extremities to Simulated Underbody Blast. Ann Biomed Eng 43(8): 1907-1917.
- Bailey, A.M., Christopher, J.J., Salzar, R.S. and Brozoski, F. (2015b) Comparison of Hybrid- III and postmortem human surrogate response to simulated underbody blast loading. J Biomech Eng 137(5): 051009.
- Bailey, A.M., Mcmurry, T.L., Poplin, G.S., Salzar, R.S. and Crandall, R. (2015c) Survival Model for Foot and Leg High Rate Axial Impact Injury Data. Traffic Injury Prevention 16: 96-102.
- Bass, C.R., Rafaels, K.A., Salzar, R.S., Carboni, M., Kent, R.W., Lloyd, M.D., Lucas, S., Meyerhoff, K., Planchak, C., Damon, A. and Bass, G.T. (2008) Thoracic and lumbar spinal impact tolerance. Accid Anal Prev 40(2): 487-495.
- Begeman P., B.P., Levine R., King A (1993). Dynamic human ankle response to inversion and eversion. SAE 933115. Stapp Car Crash Conference: 83-93.
- Belmont, P.J., Schoenfeld, A.J. and Goodman, G. (2010) Epidemiology of Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom: Orthopaedic Burden of Disease. Journal of Surgical Orthopaedic Advances 19: 2-7.
- Bir, C., Barbir, A., Dosquet, F., Wilhelm, M., van der Horst, M. and Wolfe, G. (2008) Validation of lower limb surrogates as injury assessment tools in floor impacts due to anti-vehicular land mines. Military Medicine 173: 1180-1184.
- Bird, S.M. and Fairweather, C.B. (2007) Military fatality rates (by cause) in Afghanistan and Iraq: A measure of hostilities. International Journal of Epidemiology 36: 841-846.
- Brito, L.M., Chein, M.B., Marinho, S.C. and Duarte, T.B. (2011) Epidemiological evaluation of victims of spinal cord injury. Rev Col Bras Cir 38(5): 304-309.
- Cesari, D., Ramet, M. and Clair, P. (1980). Evaluation of pelvic fracture tolerance in side impact. 24th Stapp Car Crash Conference.
- Chirvi, S., Pintar, F., Yoganandan, N., Banerjee, A., Schlick, M., Curry, W. and Voo, L. (2017) Human Foot-Ankle Injuries and Associated Risk Curves from Under Body Blast Loading Conditions. Stapp Car Crash J 61: 157-173.
- Danelson, K., Frounfelker, P., Pizzolato, K., Valentine, R., Watkins, L., Tegtmeyer, M., Hardy, W., Bolte, J. and Loftis, K. (2017). A Case Review Method to Determine Injury Mechanisms from In-Theater Attacks. Military Health System Research Symposium, Kissimmee, FL.
- Danelson, K.A., Kemper, A.R., Mason, M.J., Tegtmeyer, M., Swiatkowski, S.A., Bolte, J.H.t. and Hardy, W.N. (2015) Comparison of ATD to PMHS Response in the Under-Body Blast Environment. Stapp Car Crash J 59: 445-520.
- Dooley, C.J., Wester, B.A., Wing, I.D., Voo, L.M., Armiger, R.S. and Merkle, A.C. (2013) Response of thoracolumbar vertebral bodies to high rate compressive loading - biomed 2013. Biomed Sci Instrum 49: 172-179.
- Dougherty, A.L., Mohrle, C.R., Galarneau, M.R., Woodruff, S.I., Dye, J.L. and Quinn, K.H. (2009) Battlefield extremity injuries in Operation Iraqi Freedom. Injury 40: 772-777.
- Eskridge, S.L., Macera, C.A., Galarneau, M.R., Holbrook, T.L., Woodruff, S.I., Macgregor, A.J., Morton, D.J. and Shaffer, R.A. (2012) Injuries from combat explosions in Iraq: Injury type, location, and severity. Injury 43: 1678-1682.
- Ficke, J. and Pollak, A. (2007) Extremity War Injuries: Development of Clinical Treatment Principles. Journal of the American Academy of Orthopaedic Surgeons 15: 590-595.
- Funk, J., Srinivasan, S., Crandall, J., Khaewpong, N., Eppinger, R., Jaffredo, A., Potier, P. and Petit, P. (2002a) The effects of axial preload and dorsiflexion on the tolerance of the ankle/subtalar joint to dynamic inversion and eversion. Stapp Car Crash J 46: 245-265.
- Funk, J., Tourret, L., George, S. and Crandall, J. (2000). The role of axial loading in malleolar fractures. SAE 2000-01-0155. SAE World Congress.
- Funk, J.R., Crandall, J.R., Tourret, L.J., MacMahon, C.B., Bass, C.R., Patrie, J.T., Khaewpong, N. and Eppinger, R.H. (2002b) The axial injury tolerance of the human foot/ankle complex and the effect of Achilles tension. J Biomech Eng 124(6): 750-757.
- Funk, J.R., Rudd, R.W., King, R.J., Srinivasan, S.C., Bailey, A.M. and Crandall, J.R. (2012) Injuries caused by brake pedal loading of the midfoot. Biomed Sci Instrum 48: 134-140.
- Gondusky, J. and Reiter, M.P. (2005) Protecting Military Convoys in Iraq: An Examination of Battle Injuries Sustained by a Mechanized Battalian during Operation Iraqi Freedom II. Military Medicine 170: 546-549.
- Guillemot, H., Got, C., Besnault, B., Le Coz, J., Robin, S. and Lavaste, J. (1997). Pelvis injuries in side impact collisions: Dynamic tests on isolated pelvic bones. 41st Stapp Car Crash Conference.
- Hoencamp, R., Idenburg, F.J., Hamming, J.F. and Tan, E.C.T.H. (2014) Incidence and Epidemiology of Casualties Treated at the Dutch Role 2 Enhanced Medical Treatment Facility at Multi National Base Tarin Kowt, Afghanistan in the period 2006-2010. World Journal of Surgery 38: 1713-1718.
- Joaquim, A.F., Fernandes, Y.B., Cavalcante, R.A., Fragoso, R.M., Honorato, D.C. and Patel, A.A. (2011) Evaluation of the thoracolumbar injury classification system in thoracic and lumbar spinal trauma. Spine (Phila Pa 1976) 36(1): 33-36.
- Johnson, B.A., Carmack, D., Neary, M., Tenuta, J. and Chen, J. (2005) Operation Iraqi Freedom: The Landstuhl Regional Medical Center Experience. The Journal of Foot & Ankle Surgery 44: 177-183.
- JTAPIC. (2018). "http://jtapic.amedd.army.mil/." 2018.
- Kallieris, D., Riedl, H. and Mattern, R. (2001). Response and vulnerability of the ankle joint in simulated footwell intrusion experiments – A study with cadavers and dummies. ESV Conference.
- Kitagawa, Y., Ichikawa, H., King, A. and Levine, R. (1998). A severe ankle and foot injury in frontal crashes and its mechanism. SAE 983145. Stapp Car Crash Conference.
- Klopp, G., Crandall, J., Hall, G., Pilkey, W., Hurwitz, S. and Kuppa, S. (1997). Mechanisms of injury and injury criteria for the human foot and ankle in dynamic axial impacts to the foot. IRCOBI Conference: 73-86.
- Kress, T., Porta, D., Snider, J., Fuller, P., Psihogios, J., Heck, W., Frick, S. and Wasserman, J. (1995). Fracture patterns of human cadaver long bones. IRCOBI Conference: 155-169.
- Lin, D.L., Kirk, K.L., Murphy, K.P., Mchale, K.A. and Doukas, W.C. (2004) Evaluation of Orthopaedic Injuries in Operation Enduring Freedom. Journal of Orthopaedic Trauma 18: 300-305.
- Loftis, K., Mazuchowski, E., Clouser, M. and Gillich, P. (2017). Prominent Injury Types in Vehicle Underbody Blast. Military Health System Research Symposium. Kissimmee, FL.
- Loftis, K.L. and Gillich, P.J. (2014) Trauma Comparison of Civilian Automotive with Military Combat Injuries. Short Communications from AAAM’s 58th Annual Scientific Conference. Traffic Injury Prevention 15(sup 1): 4.
- MacKenzie, E.J., Bosse, M.J., Kellam, J.F., Burgess, A. R., Webb, L.X., Swiontkowski, M.F., Sanders, R., Jones, A.L., McAndrew, M.P., Patterson, B., McCarthy, M.L., Rohde, C.A. and Group, L.S. (2002) Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 52(4): 641-649.
- MacKenzie, E.J., Bosse, M.J., Pollak, A.N., Webb, L.X., Swiontkowski, M.F., Kellam, J.F., Smith, D.G., Sanders, R.W., Jones, A.L., Starr, A.J., McAndrew, M.P., Patterson, B. M., Burgess, A.R. and Castillo, R.C. (2005) Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 87(8): 1801-1809.
- Mazurek, M.T. and Ficke, J.R. (2006) The Scope of Wounds Encountered in Casualties From the Global War on Terrorism: From the Battlefield to the Tertiary Treatment Facility. Journal of the American Academy of Orthopaedic Surgeons 14:S18-S23-S18-S23.
- Mckay, B.J. and Bir, C.A. (2009) Lower Extremity Injury Criteria for Evaluating Military Vehicle Occupant Injury in Underbelly Blast Events. Stapp Car Crash Journal 53: 229-249.
- Morrison, J.J., Hunt, N., Midwinter, M. and Jansen, J. (2012) Associated injuries in casualties with traumatic lower extremity amputations caused by improvised explosive devices. British Journal of Surgery 99: 362-366.
- Nusholtz, G., Alem, N. and Melvin, J. (1982). Impact response and injury of the pelvis. 26th Stapp Car Crash Conference.
- Owens, B.D., Kragh, J.F., Jr., Macaitis, J., Svoboda, S. J. and Wenke, J.C. (2007) Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 21(4): 254-257.
- Owens, B.D., Kragh, J.F., Jr., Wenke, J.C., Macaitis, J., Wade, C.E. and Holcomb, J.B. (2008) Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 64(2): 295-299.
- Parenteau, C., Viano, D. and Petit, Y. (1998) Biomechanical properties of human cadaveric ankle-subtalar joints in quasistatic loading. Journal of Biomechanical Engineering 120: 105-111.
- Perry, B.J., Gabler, L., Bailey, A., Henderson, K., Brozoski, F. and Salzar, R.S. (2014) Lower Extremity Characterization and Injury Mitigation. IRCOBI Conference: 186-197.
- Petaros, A., Slaus, M., Coklo, M., Sosa, I., Cengija, M. and Bosnar, A. (2013) Retrospective analysis of free-fall fractures with regard to height and cause of fall. Forensic Sci Int 226(1-3): 290-295.
- Pietsch, H.A., Bosch, K.E., Weyland, D.R., Spratley, E.M., Henderson, K.A., Salzar, R.S., Smith, T. A., Sagara, B.M., Demetropoulos, C.K., Dooley, C.J. and Merkle, A.C. (2016) Evaluation of WIAMan Technology Demonstrator Biofidelity Relative to Sub-Injurious PMHS Response in Simulated Under-body Blast Events. Stapp Car Crash J 60: 199-246.
- Pintar, F.A., Schlick, M.B., Yoganandan, N., Voo, L., Merkle, A.C. and Kleinberger, M. (2016) Biomechanical Response of Military Booted and Unbooted Foot-Ankle-Tibia from Vertical Loading. Stapp Car Crash J 60: 247-285.
- Ramasamy, A., Harrisson, S.E., Clasper, J.C. and Stewart, M.P. (2008) Injuries from roadside improvised explosive devices. J Trauma 65(4): 910-914.
- Ramasamy, A., Hill, A.M., Masouros, S., Eng, D., Gibb, I., Phillip, R., Bull, A. and Clasper, J. (2013) Outcomes of IED Foot and Ankle Blast Injuries. The Journal of Bone and Joint Surgery 95: 1-7.
- Ramasamy, A., Hill, A.M., Masouros, S., Gibb, I., Bull, A.M.J. and Clasper, J.C. (2011a) Blast-related fracture patterns: a forensic biomechanical approach. Journal of the Royal Society, Interface / the Royal Society 8: 689-698.
- Ramasamy, A., Hill, A.M., Masouros, S.D., Gordon, F., Clasper, J.C. and Bull, A.M. (2011b) Evaluating the effect of vehicle modification in reducing injuries from landmine blasts. An analysis of 2212 incidents and its application for humanitarian purposes. Accid Anal Prev 43(5): 1878-1886.
- Ramasamy, A., Hill, A.M., Phillip, R., Gibb, I., Bull, A.M.J. and Clasper, J.C. (2011c) The modern “deck-slap” injury—calcaneal blast fractures from vehicle explosions. The Journal of Trauma: Injury, Infection, and Critical Care 71: 1694-1698.
- Ramasamy, A., Masouros, S.D., Newell, N., Hill, A.M., Proud, W.G., Brown, K.A., Bull, A.M. and Clasper, J.C. (2011d) In-vehicle extremity injuries from improvised explosive devices: current and future foci. Philos Trans R Soc Lond B Biol Sci 366(1562): 160-170.
- Rao, R.D., Berry, C.A., Yoganandan, N. and Agarwal, A. (2014) Occupant and crash characteristics in thoracic and lumbar spine injuries resulting from motor vehicle collisions. Spine J 14(10): 2355-2365.
- Schneider, L.W., Rupp, J.D., Scarboro, M., Pintar, F., Arbogast, K.B., Rudd, R.W., Sochor, M.R., Stitzel, J., Sherwood, C., Macwilliams, J.B., Halloway, D., Ridella, S. and Eppinger, R. (2011) BioTab–a new method for analyzing and documenting injury causation in motor-vehicle crashes. Traffic injury prevention 12: 256-265.
- Schreiber, P., Crandall, J., Micek, T., Hurwitz, S. and Nusholtz, G. (1998) Static and dynamic bending strength of the leg. International Journal of Crashworthiness 3(3).
- Singleton, J.A.G., Gibb, I.E., Hunt, N.C.A., Bull, A.M.J. and Clasper, J.C. (2013) Identifying future ‘unexpected ' survivors: a retrospective cohort study of fatal injury patterns in victims of improvised explosive devices. BMJ Open 3: 1-8.
- Smith, B.R., Begeman, P.C., Leland, R., Meehan, R., Levine, R.S., Yang, K.H. and King, A.I. (2005) A mechanism of injury to the forefoot in car crashes. Traffic Inj Prev 6(2): 156-169.
- Smith, D.C. (2015) Extremity Injury and War: A Historical Reflection. Clinical Orthopaedics and Related Research 473: 2771-2776.
- Teh, J., Firth, M., Sharma, A., Wilson, A., Reznek, R. and Chan, O. (2003) Jumpers and fallers: a comparison of the distribution of skeletal injury. Clin Radiol 58(6): 482-486.
- Vasquez, K.B., Brozoski, F.T., Logsdon, K.P. and Chancey, V.C. (2018) Retrospective Analysis of Injuries in Underbody Blast Events: 2007-2010. Mil Med 183(suppl_1): 347-352.
- Veltman, E.S., Doornberg, J.N., Stufkens, S.A.S., Luitse, J.S.K. and Van Den Bekerom, M.P.J. (2013) Long-term Outcomes of 1,730 Calcaneal Fractures: Systematic Review of the Literature. The Journal of Foot & Ankle Surgery 52: 486-490.
- Viano, D., Culver, C., Haut, R., Melvin, J., Bender, M., Culver, R. and Levine, R. (1978). Bolster impacts to the knee and tibia of human cadavers and an anthropomorphic dummy. SAE 780896 Stapp Car Crash Conference: 403-428.
- Yoganandan, N., Chirvi, S., Pintar, F.A., Uppal, H., Schlick, M., Banerjee, A., Voo, L., Merkle, A. and Kleinberger, M. (2016) Foot-Ankle Fractures and Injury Probability Curves from Post-mortem Human Surrogate Tests. Ann Biomed Eng 44(10): 2937-2947.
- Yoganandan, N., Chirvi, S., Voo, L., DeVogel, N., Pintar, F.A. and Banerjee, A. (2017) Foot-ankle complex injury risk curves using calcaneus bone mineral density data. J Mech Behav Biomed Mater 72: 246-251.
- Yoganandan, N., Moore, J., Arun, M.W. and Pintar, F.A. (2014) Dynamic Responses of Intact Post Mortem Human Surrogates from Inferior-to-Superior Loading at the Pelvis. Stapp Car Crash J 58: 123-143.
- Yoganandan, N., Pintar, F., Gennarelli, T., Seipel, R. and Marks, R. (1999). Biomechanical tolerance of calcaneal fractures. 43rd AAAM Conference: 345-356.
- Yoganandan, N., Pintar, F.A., Kumaresan, S. and Boynton, M. (1997) Axial impact biomechanics of the human foot-ankle complex. J Biomech Eng 119(4): 433-437.
- Yoganandan, N., Pintar, F.A., Schlick, M., Humm, J.R., Voo, L., Merkle, A. and Kleinberger, M. (2015) Vertical accelerator device to apply loads simulating blast environments in the military to human surrogates. J Biomech 48(12): 3534-3538.
- Zhu, J., Cavanaugh, J. and King, A. (1993) Pelvic biomechanical response and padding benefits in side impact based on a cadaver test series. 37th Stapp Car Crash Conference.