The nature of head injuries depending on the specifics of the military conflict

全文:

Introduction:

Military conflicts are one way of resolving conflicts between two, and often between a group of states. Regardless of the type of military conflict, whether it is a local, regional or large-scale war a large number of injured people are observed. In virtually all conflicts since 1990, the predominant group of casualties has been civilians. This is primarily due to the tactics of combat operations, a vivid example is the war in Syria, where 70.45% of victims were civilians. In the future, it can be assumed that the special military operation of Russia will be the first major modern military conflict, where irrecoverable and sanitary losses among military personnel will be greater than among civilians. The study and analysis of the nature of injuries sustained during combat operations is an important task of modern forensic medical examination, allowing the development of more effective PPE (personal armour protection equipment) in the future.

Methods and Materials:

In this study we adhered to general scientific and special methods, in particular: system-structural analysis, observation, description, method of formal logic, comparison, analogy, generalisation, hypothesis, used in forensic medical examination, including explosive injuries.

The material of the study was scientific and special literature.

The object of this study is the practice of expert assessment of blast injury reflected in the scientific medical literature and theoretical provisions of forensic examination.

Results:

The mechanism of injury (gunshot or explosive) directly correlates with the specificity of combat operations. However, the most frequently affected areas of the head, regardless of the mechanism of injury, are the lower and upper jaws, the eye socket and the nose area.

Discussion:

The Syrian Arab Republic Civil War:

The civil war in the Syrian Arab Republic has lasted from 15 March 2011 to the present day. As of 2024, this military conflict involves not only countries in the region, but also military and political groupings with world powers. The Minister of Defence of the Russian Federation, Army General S.K. Shoigu, at the operational and mobilisation gathering of the senior staff of the Armed Forces of the Russian Federation (AFRF) noted: "We see that the confrontation in Syria is a completely different type of armed struggle, fundamentally different from classical wars, in which the enemy were regular armies" [1]. [1]. To understand the nature of the fighting, it is necessary to consider the factors due to which the PMF (Illegal Armed Forces) were able to provide a fire advantage over the government forces of the SAR. Initially, it should be noted that the APF's offensive operations were conducted by pairs (triplets) of riflemen in assault groups armed with short-barreled assault rifles with collimator sights and silent firing devices. These three groups had fire support from sniper teams, PTRKs (anti-tank missile systems), automatic and stationary grenade launchers, and mortars. Secondly, the NPF provided the forward units with high-quality operational intelligence information, which enabled the junior commanders to successfully and competently lead the units entrusted to them. Despite the absence of regular military factories, the NPFs were able to produce not only artillery, mortar systems and multiple rocket launchers (MLRS), but also ammunition for them

 

 

 

Figure 1. ISIL (a group banned in Russia) ammunition production workshops [2]

 

Fig. 2. Samples of rocket-artillery weapons of "artisanal" production [2]

 

The mobility of PMF artillery units was achieved by mounting artillery units (recoilless guns, MLRS, PTRKs, D-30, M-46 guns, etc.) on pickup trucks and lorries.

 

Fig. 3. Placement of M-46 and D-30 artillery guns on the cargo base chassis [2]

 

In a sample of 1333 individuals, a clear predominance of gunshot type of injury (71.95%; n=959) over blast injury (27.54%; n=367) can be seen. The remaining 7 injuries (0.51%) were caused by road traffic accidents. These statistics are indicative of the multiple street battles in the ATS that resulted in firearm injuries. Due to the fact that the fighting took place in urban areas, 70.45% of the patients were civilians (n=939), military personnel were almost 2.4 times less, only 29.55% (n=394). As for the sex ratio of wounded people, men were the prevailing group of injured people (90.52%; n=1207), women made up only 9.48% of the sample (n=126). The mean age of the patients was 26.73 years, range 1-66 years. Despite the overloaded ATS health care system, the survival rate of the injured was quite high and was 92.7% (n=1236). Russian military medics played an important role in helping the wounded by deploying several multidisciplinary field hospitals.

The authors decided to classify the injuries into three groups for better clarity: bone injuries, soft tissue injuries, blood vessel injuries, and nerve injuries.

 

 

 

 

 

Localisation and type of injury	Percentage of the total sample affected	Number of injured people
facial bone fractures	13,23%	176/1333
fractures of the maxilla and zygomatic arch	12,53%	167/1333
ractures in the eye socket	21,16%	282/1333
maxillary injuries	15,98%	213/1333
dental fractures	7,65 %	102/1333
mandibular fracture	28,58%	381/1333
mandible- maxilla	0,9%	12/1333

Table 1. Distribution of injuries to bone structures by their localisation during the Syrian Civil War

 

 

 

Localisation of haemorrhages in traumatic brain injury (craniocerebral trauma)	Percentage of the total sample affected	Number of injured people
Intracerebral hemorrhage	34,4% случаев	202/586
subarachnoid haemorrhage	16,4% случаев	96/586
subdural haemorrhage	13,8% случаев	81/586
intraventricular haemorrhage	8,2% случаев	48/586
epidural haemorrhage	1% случаев	6/586
other	26,2% случаев	153/533

Table 2. Distribution of haemorrhages by localisation during the Syrian Civil War

 

Localisation and type of injury	Percentage of the total sample affected
Damage to the soft tissues of the head	57%
Damage to soft tissues of the orbital-facial region	31%

 

 

 

 

Table 3. Distribution of soft tissue injuries by their localisation during the Syrian Civil War

 

 

 

Localisation and type of injury	Percentage of the total sample affected	Number of injured people
mandible-facial nerve injury	5%	66/1333
mandible-mandibular-maxilla-facial nerve injury	5%	66/1333
maxilla-mandibular bone-facial nerve injury	5%	66/1333
mandible-facial nerve trauma-parotid gland trauma.	5%	66/1333
injury mandible- maxilla-maxilla-mandibular bone-facial nerve	5%	66/1333

 

Table 4. Distribution of nerve injuries by their localisation during the Syrian Civil War

 

 

Localisation and type of injury	Percentage of the total sample affected	Number of injured people
loss of brain matter of the brain	22,1%	129/586
contusion of the GM (brain)	11,8%	69/586
Left parietal lobe injury	28,7%	168/586
Right parietal lobe injury	24,6%	144/586
Left frontal lobe injury	21,5%	126/586
right frontal lobe injury	24,6%	144/586
Left temporal lobe injury	13,8%	80/586
right temporal lobe injury	21,0%	123/586
Left occipital lobe injury	12,8%	75/586
right occipital lobe injury	15,9%	93/586
left lobe injury	54,9%	321/586
right lobe injury	57,4%	336/586
GM trunk damage	1,5%	8/586
cerebrospinal fluid (liquor) leakage	7,7%	45/586
cranial nerve damage	6,2%	36/586
pneumocephaly	5,1%	29/586

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

Table 4. Distribution of traumatic brain injuries by their localisation during the Syrian Civil War

 

Based on the above statistics, it can be concluded that the most frequently affected area of the head is the lower jaw and the eye socket. This is primarily due to the fact that standard PPE does not protect these areas of the head. In Fig. 4. and Fig. 5. show injuries to the mandible characteristic of combat trauma.

 

А)                                        Б)

 

Fig. 4. (a) Foreign body and ultrafragmentary fracture with displacement of the left mandible (preoperatively). (b) Restoration with screw implants and miniplates (postoperative period) [3]

 

А)                                               Б)

 

Fig. 5. (a) Multiple displaced fragmentary fractures in the right mandibular branch (preoperatively). (b) Miniplate and screw implant in the right mandibular branch (postoperative period) [3]

 

Operation Iraqi Freedom (Iraq War) and Operation Enduring Freedom (Afghanistan War):

Operations Iraqi Freedom and Operation Enduring Freedom are among the largest military operations conducted by the US Army in recent decades.

Speaking about the specifics of combat operations in Iraq, it is worth noting, the US Army massively used "smart" munitions. Thus, in 2003 about 66 per cent of all munitions used by the US Air Force in Iraq and 85 per cent by the UK were guided munitions.  In total, the US spent 23 thousand guided munitions and 750 cruise missiles. Such tactics minimised the losses of the US military contingent, because after massive air strikes, many of which were carried out with cluster munitions, the Iraqi army was unable to organise defence. The Americans were able to fully exploit their technical advantage. After the air strikes, tanks shot the remaining Iraqi armoured vehicles from a distance of 1,500-2,000 metres. Having successfully destroyed it, the tanks moved forward 2 kilometres and repeated the procedure [9].

Combat operations in Afghanistan did not differ much in character from Iraq. The Taliban, as well as the Iraqi armed forces, were unable to fight back the invasion of the U.S. Army and NATO forces. The US Air Force carried out massive strikes on the caves of the Taliban armed formations.   They used thermobaric munitions with concrete-piercing warheads (BLU-118/B , BLU-109 , BLU-113). During the 2001-2002 campaign, some 18,000 aerial munitions were used, 5,000 of which were guided bombs equipped with JDAM (Joint Direct Attack Munition) kits. The Taliban had no systematic air and missile defences as such, so 75% of all munitions hit their targets accurately. However, the Taliban were able to draw the NATO and U.S. contingents into a guerrilla war, methodically destroying their armed forces with IEDs and standard munitions buried under the asphalt.

 

Figure 6. Example of an IED (improvised explosive device) [11].

 

Study sample:

Number of patients who sustained head injuries: 2850 patients

Sex ratio: males 98% (n=2793); females 2% (n=57)

Ratio of civilian/military injured: civilian 60.62% (n=1728); military 39.38% (n=1122).

Ratio of wounded military personnel by branch of service:

72.37% wounded-infantry soldiers (812 out of 1122)

24.24% of the wounded were Marines (272 out of 1122).

2.14% of the wounded were naval personnel (24 out of 1122)

1.25 per cent of the wounded were Air Force (14 out of 1,122).

Mean age: 25.86 years; range 18-57 years

Survival rate: 96.2% (n=2741)

 

Localisation and type of injury	Percentage of the total sample affected	Number of injured people
cranial vault injury	3,06%	52/1700
Parenchymal brain injury	4,12%	70/1700
Basal skull fracture	2,53%	43/1700
Cervical spine fracture	1%	17/1700
facial fractures	1,76%	30/1700
Lower jaw fracture	25,65%	436/1700
nasal region	12,53%	213/1700
Upper jaw	2,47%	42/1700
maxilla/maxillary bone	14,53%	247/1700
Ocular cavity	12,3%	209/1700
Frontal sinus	2,06%	35/1700
Temporal bone fracture	2,65%	45/1700
Dental injuries	12%	204/1700
open trauma	3,35%	57/1700
fracture frequency	27%	459/1700
open fractures	76%	1292/1700
Total	100%	1700

Table 5. Distribution of injuries of bone structures by their localisation during Operation Iraqi Freedom and Operation Enduring Freedom

 

 

Localisation and type of injury	Percentage of the total sample affected	Number of injured people
zygomaticus muscle	12,38%	26
tympanic membrane injury	30%	63
facial lacerations	43,33%	91
Airway injury	14,29%	30
Abrasions	5%	10
Contusions	2%	4

 

Table 6. Distribution of soft tissue injuries by their localisation during Operation Iraqi Freedom and Operation Enduring Freedom

 

 

 

 

 

 

26% of the entire military population sustained CMF (Craniomaxillofacial) injuries. The mandible was predictably the most frequently injured area, followed by the nasal region and the eye socket. As noted above, this high percentage of injuries is due to the lack of PPE for these head regions. Fig. 7. illustrates the accessibility of the facial bones of the skull to the impact elements of an explosive device.

 

Figure 7. Vectors of possible projectile and shrapnel hits to the head in a helmet [11].

 

The war in Afghanistan and Iraq had a striking difference from the fighting in Syria. This difference lies in the mechanism of injury. 90.28% (n=4616) of all injuries were caused by explosion. Only 8.21% (n=420) of the injuries were caused by firearms. Because the Taliban were not provided with regular ammunition, 65.7% of all blast injuries were caused by IEDs (improvised explosive devices).

To understand the nature of the gunshot wounds, here are photos and X-rays of the P8 pistol wounds as well as the rifle wounds.

 

 

Figure 8. Effect of a low-velocity gunshot wound from a P8 pistol on tissue at close range (firing distance about 4 m).

(a) Entrance wound about 9 × 9 mm medially.

(b) Exit wound about 10 × 10 mm.

(c) Forceps in the bullet canal, which is also detectable on radiograph due to the location of many small bone fragments.

Palpation with a sharp spoon revealed a wound channel with a through hole measuring about 4-5 cm in soft tissue. Afghanistan,

rescue centre in Kunduz, July 2010 [11].

 

 

 

 

 

Figure 9. Bullet and shrapnel wounds to the head and neck in comparison.

(a) Secondary wound from a rifle shot.

(b) Indirect shrapnel wound to the face after a projectile ("rocket-propelled grenade", RPG). Afghanistan, rescue centre in Kunduz, April 2010. [11].

 

In the example in Figure 9, the rifle bullet travelled in a tangential trajectory, so the wound is not critical for the person. If the ammunition, in our case a bullet of 7.62 mm AK-47 calibre, touches bone structures, the damage is much more serious. These can be seen in Fig. 10 and Fig. 11.

 

Figure 10. Soft tissue and bone defect from an AK-47 assault rifle [12].

 

Figure 11. Preoperative (a) and postoperative (b) computed tomography [12].

 

Conclusions:

Based on our analysis of publications applying forensic knowledge to analyse battlefield injuries, we have identified that regardless of the specifics of combat, the weaponry used and the conflict landscape, the most commonly damaged structures of the head are the lower and upper jaw, eye socket and nasal region. This study may initiate the development and mass introduction of PPE that protects the facial structures of the skull.

 

Ethical Standards:

The study was conducted in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association "Ethical Principles for Scientific Medical Research Involving Human Subjects" as amended in 2013. The study was approved by the local ethical committee of I.M. Sechenov First Moscow State Medical University (Sechenov University), excerpt from the protocol (No. 18-21 dated 26.10.2021).

 

Availability of data and materials:

All data and materials were in the public domain and were available.

 

Conflict of interest:

The authors declare no apparent and potential conflicts of interest related to the publication of this article.

 

Funding:

The authors declare that there is no funding.

作者简介

Dmitriy Zotkin

Federal State Autonomous Educational Institution of Higher Education First Moscow State Medical University named after I.M. Sechenov of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation

编辑信件的主要联系方式.
Email: zotkin.dmitriy.83@mail.ru
ORCID iD: 0000-0002-2419-5952
Scopus 作者 ID: 56769360200

Senior Lecturer at the Department of Human Anatomy and Histology, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University).

俄罗斯联邦, 119991, Moscow, GSP-1, Trubetskaya str., 8, p. 2

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