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Injury, Int. J. Care Injured 33 (2002) 167–171 Hindfoot injuries due to landmine blast accidents M. Tahir Khan *, Faisal N. Husain, Aftab Ahmed Department of Orthopaedic Surgery, King Edward Medical College /Mayo Hospital, Lahore, Pakistan Accepted 15 June 2001 Abstract Landmines were initially developed as anti-tank weapons. They are still used indiscriminately and in a disorganised fashion, violating the United Nations Treaty on their use [United Nations (1980)]. The injury produced by these devices is variable depending upon the construction and strength of the landmine and body parts coming in contact with the landmine at the time of detonation. The purpose of the present study was to report the type of landmine-blast injuries of the lower limbs and the surgical options available to treat them. Twenty-eight patients, all with lower limb injuries were included in the present study. They had received injuries on the control line of the troubled Jammu and Kashmir regions in the north of Pakistan. All were male patients between the age of 13 and 55 years. A salvage procedure for the forefoot was possible on four patients only and all the rest had a below-knee amputation. Time lapsed between the injury and receiving medical help was the crucial determining factor as to the final outcome of the limb. We believe that the pattern of injury, amount of energy dissipation and part of body in contact with the landmine at the time of explosion are the main determining factors for the final outcome. If skin along with the underlying soft tissue and the neuro-vascular structures on the dorsum of the foot are spared then an attempt can be made at limb salvage. © 2002 Elsevier Science Ltd. All rights reserved. www.elsevier.com/locate/injury 1. Introduction Landmines were developed as anti-tank weapons. The basic device consists of artillery shells with exposed fuses, buried in the path of advancing troops. Advances in the warfare have led to the development of more sophisticated antipersonnel mines and booby traps in all shapes and sizes. The demoralising effect of these mines is obvious on the enemy troops since they cause devastating damage to the advancing warfare and the personnel. The proclamations of the Geneva Conven- tion of 1949 imposed constraints on the conduct of war. Landmines though, are still used indiscriminately and in a disorganised fashion in contravention to the United Nations Treaty on their use (United Nations, 1980). The injury produced by these devices is variable depending upon the type of the device and body parts coming in contact with the landmine at the time of detonation. It involves the lower limbs, perineum and upper half of the body in that order [1–5]. The earth, mud and projectiles penetrating deep into the tissue spaces contaminate the wound. The nations worst affected by this plague of land- mines are Afghanistan, Iraq, African countries and now Kashmir. Pakistan due to its geographical location provides refuge to many of the unfortunate landmine victims from across the border and many of them are therefore referred for treatment to the referral hospitals in larger cities. The purpose of the present study was to report the type of landmine-blast injuries of the lower limbs and the surgical options available to treat them. We have reviewed the available literature and a brief re ´sume ´ is presented here. Treatment protocols were reviewed and follow-up arranged for the affected victims prospec- tively where possible. * Corresponding author. Present address: Bone Tumor Service, Royal Orthopaedic Hospital, Northfield, Birmingham B31 2AQ, UK. 0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII:S0020-1383(01)00092-4

Hindfoot injuries due to landmine blast accidents

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Page 1: Hindfoot injuries due to landmine blast accidents

Injury, Int. J. Care Injured 33 (2002) 167–171

Hindfoot injuries due to landmine blast accidents

M. Tahir Khan *, Faisal N. Husain, Aftab AhmedDepartment of Orthopaedic Surgery, King Edward Medical College/Mayo Hospital, Lahore, Pakistan

Accepted 15 June 2001

Abstract

Landmines were initially developed as anti-tank weapons. They are still used indiscriminately and in a disorganised fashion,violating the United Nations Treaty on their use [United Nations (1980)].

The injury produced by these devices is variable depending upon the construction and strength of the landmine and body partscoming in contact with the landmine at the time of detonation.

The purpose of the present study was to report the type of landmine-blast injuries of the lower limbs and the surgical optionsavailable to treat them.

Twenty-eight patients, all with lower limb injuries were included in the present study. They had received injuries on the controlline of the troubled Jammu and Kashmir regions in the north of Pakistan. All were male patients between the age of 13 and 55years. A salvage procedure for the forefoot was possible on four patients only and all the rest had a below-knee amputation. Timelapsed between the injury and receiving medical help was the crucial determining factor as to the final outcome of the limb.

We believe that the pattern of injury, amount of energy dissipation and part of body in contact with the landmine at the timeof explosion are the main determining factors for the final outcome. If skin along with the underlying soft tissue and theneuro-vascular structures on the dorsum of the foot are spared then an attempt can be made at limb salvage. © 2002 ElsevierScience Ltd. All rights reserved.

www.elsevier.com/locate/injury

1. Introduction

Landmines were developed as anti-tank weapons.The basic device consists of artillery shells with exposedfuses, buried in the path of advancing troops. Advancesin the warfare have led to the development of moresophisticated antipersonnel mines and booby traps inall shapes and sizes. The demoralising effect of thesemines is obvious on the enemy troops since they causedevastating damage to the advancing warfare and thepersonnel. The proclamations of the Geneva Conven-tion of 1949 imposed constraints on the conduct of war.Landmines though, are still used indiscriminately andin a disorganised fashion in contravention to theUnited Nations Treaty on their use (United Nations,1980).

The injury produced by these devices is variabledepending upon the type of the device and body partscoming in contact with the landmine at the time ofdetonation. It involves the lower limbs, perineum andupper half of the body in that order [1–5]. The earth,mud and projectiles penetrating deep into the tissuespaces contaminate the wound.

The nations worst affected by this plague of land-mines are Afghanistan, Iraq, African countries and nowKashmir. Pakistan due to its geographical locationprovides refuge to many of the unfortunate landminevictims from across the border and many of them aretherefore referred for treatment to the referral hospitalsin larger cities.

The purpose of the present study was to report thetype of landmine-blast injuries of the lower limbs andthe surgical options available to treat them. We havereviewed the available literature and a brief resume ispresented here. Treatment protocols were reviewed andfollow-up arranged for the affected victims prospec-tively where possible.

* Corresponding author. Present address: Bone Tumor Service,Royal Orthopaedic Hospital, Northfield, Birmingham B31 2AQ, UK.

0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved.PII: S 0 0 2 0 -1383 (01 )00092 -4

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2. Patients and methods

Data were collected prospectively on all the landminevictims (with lower limb involvement) reporting to thisunit. Twenty-eight patients, all with lower limb injurieswere included in the present study. They had receivedinjuries on the control line of the troubled Jammu andKashmir regions in the north of Pakistan. All weremale patients between the ages of 13 and 55 years.Twenty-one of them were peasants and seven Mu-jahidine (freedom fighters) also came for treatment.

Only six reported within 24 h after injury. Four ofthem were actively involved in the conflict. The other22 were treated locally and referred to our rehabilita-tion and surgical unit for definitive treatment (usuallyamputation).

The most common injury pattern encountered was aType III-C open fracture (Gustillo) [6] or Grade 3 (IRCwar wounds classification [2]) of the foot and ankle.

The average age of the patients was 17.75 years(ranging from 13 to 55 years). The average time takenfor complete recovery was 11 months (8–14 months).

3. Limb salvage

A salvage procedure for the forefoot was possible infour of the patients. They had all presented within 24 hof injury, the neuro-vascular structures (dorsalis paedisartery) for the dorsal skin of the ankle and forefootwere spared but hindfoot (talus and calcaneus) werebadly mutilated (Table 1 and Fig. 1).

Good capillary return was confirmed before embark-ing on limb salvage. The presence of fractures in theankle and/or foot bones was not considered as a con-traindication to limb salvage but the status of the limbwas always re-evaluated after thorough debridementand stabilization of fractures. The mode of stabilizationin all four cases was external fixation initially but it wassupplemented with internal fixation with intramedullaryrush rods or crossed K-wires once the status of thewound was satisfactory.

Arthodesis of the inter-tarsal and ankle joints wasperformed in all cases and local skin flaps in associationwith the split thickness skin grafts were used to achieveskin cover over the heel. Weight bearing was allowed

only after the heel wounds were epithelialised but oth-erwise patients remained mobile on crutches during thetreatment period.

4. Results

Below-knee amputation was the most commonly per-formed procedure in 22 patients presenting more than24 h after the accident. This was usually a completionof the traumatic amputation caused by the explosionitself. A distal tibial amputation (just above the ankle— leaving as long a tibial stump as possible) wasattempted, to make a load-bearing stump in 19 pa-tients. Wound healing was not a problem in any of thecases and none developed chronic infection. None re-quired revision to a more proximal amputation. All hada delayed wound closure and all required prosthesis formobilization and failed to weight bear without one. Aforefoot amputation was possible in three patients andthey continued to mobilise without any prosthetic aid.

A complete follow-up on all of them was not possiblefor logistic reasons (all the patients came from far offmountainous areas), but none of the amputees whocame for follow-up were entirely happy with the pros-thesis. They usually complained about the prosthesisfitting. The hot weather, social taboos and the geo-graphical terrain of the region prevented them fromwearing the prosthesis.

4.1. Patients presenting early

Six (22.4%) patients presented directly to us —within 24 h of injury. Four were considered suitable forsalvage of the foot and the other two had to have abelow-knee amputation. These four patients had aninjury of the hindfoot mainly, sparing the dorsum ofthe ankle and forefoot along with its blood vessels andnerve supply. All went on to have acceptable skin cover(after shortening of the foot) over the heel and remainfull weight bearing with shoe adjustments. They arecoming for follow-up regularly and remain satisfiedwith the procedure mainly because they do not have towear a bulky prosthesis.

The average number of surgical procedures per-formed on these patients was eight ranging from six to

Table 1Data for patients who had a limb salvage

Age (years)Patient Time since injury (h) at presentation No. of procedures Satisfied Further surgery

MU Yes Yes21 10 7NoYes10BA 818

6 EnthusiasticAA 19 May need leg equalisation20NoYesTR 35 913

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Fig. 1. Usual pattern of injury caused by a landmine explosion.

ten. Further surgery is planned in possibly two patients.One requires an arthodesis of the distal fibula with thetarsus and leg length equalisation. The other has anon-healing ulcer on the heel which may need a fullthickness skin cover (Table 1).

5. Discussion

In every conflict since the Second World War, an-tipersonnel mines have been used in large numbers [7].They continue to be a public hazard in war zones[8,7,1,9,10]. Once laid, the landmines become a blindweapon that cannot distinguish between friend or en-emy. Civilians not actually involved in the fighting[8,9,11,10] can constitute up to 29% of all the landmine

victims as shown in studies from Afghanistan andCambodia [8,9]. In these studies 16% were women and7% children under the age of 15 were also involved;80% of all the amputations are caused by landmines[12] and the case fatality rate [8] is 48%. Exact data arenot available from the fighting in Kashmir but webelieve that figures would not be much different.

The injuries produced by landmine explosions havebeen classified into three broad categories [7]:1. Extensive injury to the lower limb due to the victim

treading on the pressure plate and hence detonatingthe landmine (this is by far the most common typeof injury pattern).

2. Injuries caused by fragmentation devices present aswidespread low velocity missile injuries to chest,abdomen and major blood vessels.

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3. Injuries to face and/or hands because of a landmineexploding at close range usually in a landmineclearer or children.

Lower extremities are at least twice as commonlyinvolved as any other part of the body [13] producing atype 1 pattern of injury. Landmine victims are ingreater need of resuscitation compared to other victimsof war because of the extent of injury [13]. Many ofthem lose their life due to unavailability of medical helpwhile others may lose the limb(s). Peasants foraging forwood, children playing on the hills and women on theirdaily chores are the usual victims [7,14].

Recommendations for management of the landminevictims are variable [8,1–5,15–17,12,18]. Only a fewcentres (usually IRC [International Red Cross] hospi-tals) have enough experience in their treatment. Thefirst priority is clearly the patient’s life followed by limbsalvage if possible. Amputations remain unacceptableboth functionally and cosmetically in society.

All the patients in our study had a type 1 injuryusually caused by the victim treading on the landmineand thus detonating it. They were all males and mostwere not involved directly in the fighting.

It is difficult to be sure of the numbers who diebefore reaching the hospital but many lose their life dueto excessive haemorrhage of their limb due to gasgangrene and other anaerobic infections [8]. Less than20% of the patients reach a hospital within 24 h of theaccident [8,18,9]. We have had the same experience inour study where only six patients reached the hospitalon the same day. This highlights the difficult terrainand scarcity of resources at the usual place of landmineexplosion. The chances of dying from the direct effectsof the accident are reduced with the passage of time butit also becomes extremely difficult to attempt limbsalvage after 24 h. We were unable to save the limb inany of the patients presenting after 24 h. This is mainlydue to the fact the muscle necrosis and deep woundinfection (usually anaerobic) sets in after this time andmakes limb salvage extremely hazardous for the pa-tient’s life. Below-knee amputation had to be per-formed in 22 (78%) patients. This was usually acompletion of the already amputated limb. Our resultsare similar to the figures quoted by others[8,9,19,10,20].

The ultimate goal of treatment following complexfoot injuries in the multiply-injured patient is restora-tion of a painless, stable and plantigrade foot [21]. Incomplex trauma to the foot, e.g. landmine-blast, pri-mary amputation may be indicated. Limb salvage de-pends on the intraoperative assessment during thesecond look (within 24–48 h after injury). The debride-ment has to be radical, the selection of amputation levelshould be at the most distal point compatible withtissue viability and wound healing. A free tissue trans-fer should be performed early if necessary. Open frac-

tures are reduced following radical debridement andstabilised with stout K-wires and/or tibiotarsal transfix-ation with an external fixator. The use of externalfixation is widely recommended in the management ofwar injuries for the ease of use and nursing friendlynature of the equipment. We used an AO-type fixatorin all the cases because it was readily available, easy toapply and look after. It allowed easy access to thewounds for dressing and debridement if required.

Six patients who did manage to reach our hospitalwithin 24 h of their injury were all in shock. Resuscita-tion procedures were carried out. After blood transfu-sion, initial re-hydration and prophylactic antibiotics,wound debridement and fracture stabilization were per-formed using an AO-type of external fixator. Thewound was inspected after 24 h and further debride-ment carried out if required. The presence of myonecro-sis and infection deep in the intermuscular planes wasconsidered a contraindication for limb salvage. Initialstabilisation with the external fixation was maintainedfor 2 weeks, then if the wound was considered free ofinfection, internal fixation with smooth wires, screwsand/or staples was performed. Skin cover was alsoachieved at the same time through split thickness skingrafting or local flaps. All the patients required multiplesurgical procedures but they remain satisfied and happysince they did not require prosthesis. Shoe adjustmentswere required in all cases but they were usually not ahindrance to their mobility.

We believe that the pattern of injury, amount ofenergy dissipation and part of body in contact with thelandmine at the time of explosion are the main deter-mining factors for the final outcome. If the skin, alongwith the underlying soft tissue and the neuro-vascularstructures on the dorsum of the foot are spared, then anattempt can be made at limb salvage. The dorsal skinflap obtains its blood supply from the dorsalis paedisartery and vein. This skin flap if present, remains viableand can provide skin cover for the deficient areas onthe heel. The skin on the amputated parts also shouldnot be discarded as it can always be used for splitthickness skin grafting.

This study focuses on the medical aspects of land-mine injury, but it must be remembered that Kashmir isa hilly area and most of the residents depend onagriculture for a living. An amputee would be consid-ered as a burden on the family and society as a whole,and would not be welcome, especially when prostheticfacilities are neither free nor widely available. Patientsprefer to keep their own limb rather than undergoamputation, even if the function in the salvaged limb isnot good. Many of these patients discharge themselvesfrom hospital and it is difficult to be sure of theiroutcome but when interviewed directly or indirectly(through their acquaintances who did come for follow-up), few were using any prosthesis because of the social

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taboos. A belief of fate and destiny was the only drivingforce and source of motivation for these unfortunatepeople. In contrast, the four patients who managed tokeep their own feet (even though partially) remaineduseful members of society and maintained their inde-pendence, although they required multiple surgical pro-cedures and may need further intervention in future.

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