title: Blast-mediated traumatic amputation: evidence for a revised, multiple injury mechanism theory.
abstract: BACKGROUND
  The accepted mechanism of blast-mediated traumatic amputation (TA) is blast wave induced fracture followed by limb avulsion from the blast wind, generating a transosseous amputation. Blast-mediated through-joint TAs were considered extremely rare with published prevalence <2%. Previous studies have also suggested that TA is frequently associated with fatal primary blast lung injury (PBLI). However, recent evidence suggests that the mechanism of TA and the link with fatal primary blast exposure merit review.
  
  
  METHODS
  A trauma registry (UK Joint Theatre Trauma Registry) and postmortem CT (PM-CT) database were used to identify casualties (survivors and deaths) sustaining a blast-mediated TA in the 2 years from August 2008. TA metrics and associated significant injuries were recorded. Detailed anatomical data on extremity predebridement osseous and soft tissue injuries were only consistently available for deaths through comprehensive PM-CT imaging.
  
  
  RESULTS
  146 cases (75 survivors and 71 deaths) sustaining 271 TAs (130 in survivors and 141 in deaths) were identified. The lower limb was most commonly affected (117/130 in survivors, 123/141 in deaths). The overall through-joint TA rate was 47/271 (17.3%) and 34/47 through-joint injuries (72.3%) were through knee. More detailed anatomical analysis facilitated by PM-CT imaging revealed only 9/34 through-joint TAs had a contiguous fracture (ie, intra-articular involving the joint through which TA occurred), 18/34 had no fracture and 7/34 had a non-contiguous (ie, remote from the level of TA) fracture. No relationship between PBLI and TA was evident.
  
  
  CONCLUSIONS
  The previously reported link between TA and PBLI was not present, calling into question the significance of primary blast injury in causation of blast mediated TAs. Furthermore, the accepted mechanism of injury can't account for the significant number of through-joint TAs. The high rate of through-joint TAs with either no associated fracture or a non-contiguous fracture (74%) is supportive of pure flail as a mechanism for blast-mediated TA.
authors.affiliation: Department of Bioengineering, Imperial College London, London, UK.
authors.forename: James A G
authors.initials: JA
authors.lastname: Singleton
authors.affiliation: Royal Centre for Defence Medicine, Defence Centre for Imaging, Birmingham, UK.
authors.forename: I E
authors.initials: IE
authors.lastname: Gibb
authors.affiliation: Department of Bioengineering, Imperial College London, London, UK.
authors.forename: A M J
authors.initials: AM
authors.lastname: Bull
authors.affiliation: Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
authors.forename: J C
authors.initials: JC
authors.lastname: Clasper
mesh_terms: D000673:Amputation, Traumatic / Q000145:classification / Q000453:epidemiology* / Q000401:mortality; D001753:Blast Injuries / Q000145:classification / Q000453:epidemiology* / Q000401:mortality; D005107:Explosions; D006801:Humans; D008889:Military Personnel; D012042:Registries; D016019:Survival Analysis; D014857:Warfare
keywords: Forensic Medicine; Morbid Anatomy; Orthopaedic & Trauma Surgery