title: Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation.
abstract: BACKGROUND
  Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation.
  
  
  METHODS
  The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for.
  
  
  RESULTS
  Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management.
  
  
  CONCLUSIONS
  The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.
authors.affiliation: Royal Air Force,United Kingdom. Electronic address: nealjacobs@doctors.org.uk.
authors.forename: N
authors.initials: N
authors.lastname: Jacobs
authors.affiliation: Royal Naval Reserve,United Kingdom.
authors.forename: K
authors.initials: K
authors.lastname: Rourke
authors.affiliation: Royal Army Medical Corps,United Kingdom.
authors.forename: J
authors.initials: J
authors.lastname: Rutherford
authors.affiliation: US Navy Medical Corps,United States.
authors.forename: A
authors.initials: A
authors.lastname: Hicks
authors.affiliation: Royal Navy,United Kingdom.
authors.forename: S R C
authors.initials: SR
authors.lastname: Smith
authors.affiliation: Royal Army Medical Corps,United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Templeton
authors.affiliation: 16 Air Assault Medical Regiment, Royal Army Medical Corps,United Kingdom.
authors.forename: S A
authors.initials: SA
authors.lastname: Adams
authors.affiliation: 16 Air Assault Medical Regiment, Royal Army Medical Corps,United Kingdom.
authors.forename: J O
authors.initials: JO
authors.lastname: Jansen
mesh_terms: D055826:Afghan Campaign 2001-; D000673:Amputation, Traumatic / Q000145:classification / Q000601:surgery*; D001753:Blast Injuries / Q000145:classification / Q000503:physiopathology / Q000601:surgery*; D004635:Emergency Medicine / Q000193:education / Q000379:methods; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000145:classification / Q000503:physiopathology / Q000601:surgery*; D008887:Military Medicine / Q000193:education / Q000379:methods; D008889:Military Personnel / Q000706:statistics & numerical data; D009104:Multiple Trauma / Q000601:surgery*; D010388:Pelvis / Q000293:injuries; D010502:Perineum / Q000293:injuries; D011446:Prospective Studies; D014111:Tourniquets