Musculoskeletal injuries in terrorist attacks—A comparison between the injuries sustained and those related to motor vehicle accidents, based on a national registry database
Introduction
High-energy injuries caused by terror attacks are becoming more frequent in the civilian setting, and may result in severe polytrauma injuries which differ in nature from non-terror-related trauma. In general, victims have a higher Injury Severity Score (ISS), multiple organ systems involvement and an increased mortality rate.11 The predominant mechanism of action in terror injuries is related to blast effects. Primary blast injuries are characterised by the acceleration–deceleration mechanism caused by the blast wave, inflicting damage mainly to air- and fluid-filled cavities such as the lungs and hollow viscera.7 Secondary blast injuries are defined as penetrating injuries caused by metal shrapnel such as bolts, screws, nails and other metal particles. These are deliberately placed in the explosives in order to increase the damage to victims. This mechanism of injury is the main cause of morbidity in Middle Eastern terror attacks and has been responsible for the majority of open and penetrating limb injuries.1, 3, 16, 17 Tertiary blast effect is blunt trauma caused by falls of victims, the impacts of objects or structural collapse7 but, in general, this does not include crush syndrome effects. Severity of injuries depends on the setting of the attack; in confined spaces the higher pressure of the blast wave inflicts more damage.1, 12, 16 Most published data concerning blast extremity injuries derive from military conflicts. These differ considerably from trauma in the civilian setting because of the explosive used, the environment of the explosions and the differing treating personnel and facilities.5, 6, 9, 10, 12, 13, 16
During the period from November 2002 to December 2003, almost 100 suicide bombings and numerous gunman attacks took place in Israel.15 The purpose of this study was to compare the nature of terror-related injuries (TRIs) of the extremities, spine and pelvis with conventional trauma caused by motor vehicle accidents (MVAs), which is the type of injury more commonly encountered in civilian levels I and II trauma centres and can serve as a standard reference for the characterisation of severe trauma for study purposes.11 Although a general comparison between these two mechanisms of injury was previously described,11 specifically musculoskeletal comparisons are still lacking. Our hypothesis is that knowledge and recognition of the unique characteristics of TRIs will assist the orthopaedic trauma surgeon with triage and will eventually optimise diagnostic and therapeutic efforts in the mass casualty scenario. This is a retrospective cohort comparative study based on a national trauma registry.
Section snippets
Methods
The Israeli National Trauma Registry emanates from ten trauma centres and includes all six level I centres and four large regional level II centres. The study period was from October 2000 to December 2003, representing the peak of the violent Palestinian upsurge (intifada) characterised by numerous terror attacks on civilian targets.15 The Registry recorded all casualty admissions to these hospitals, in-hospital deaths and inter-hospital transfers. Victims treated and discharged from the
Results
The TRI group differed in distribution of gender and age from the control group (Table 1), with significantly lower proportions of children (age 0–14 years) and of higher age groups (45–59, 60–74 and >75 years old). The commonest age to be involved in a TRI was 15–29 years, forming 57.8% of the total TRI group versus 35.9% of the MVA group (p < 0.01). Although in both groups the predominant gender was male, there was a slight but statistically significant higher proportion of males in the
Discussion
This is a report of musculoskeletal injuries caused by terrorist attack, based on the records of a national registry. The analysis of the results demonstrates that these injuries are altogether different from the more usual musculoskeletal trauma caused by MVAs, which is commonly encountered by most orthopaedic surgeons in the civilian setting. MVA injuries were chosen to represent severe conventional trauma, since they comprise 42% of the severe trauma (ISS ≥ 16) recorded in the registry. The
Conclusions
TRIs are unique in nature and are characterised by a higher morbidity, increased rate of associated injuries and increased prevalence of open injuries compared with conventional trauma. Assessment and treatment of these devastating injuries require alertness and preparedness on the part of healthcare facilities.
Conflict of interests
All authors have nothing to disclose and had not received any funding or grants from a third party in preparing this manuscript.
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Anthropogenic Disasters
2019, Critical Care ClinicsCitation Excerpt :The records of Israeli children injured from terrorist activities over a 2 year period were reviewed and showed a higher incidence of penetrating trauma (54% vs 9%), internal injury to the torso (11% vs 4%), and severe trauma, defined as an increased Injury Severity Score (ISS) greater than 25 (25% vs 3%), but, interestingly, a lower instance of traumatic brain injury compared with non–terror-related injuries (22% vs 44%).4 Weil and colleagues5 noted similar findings when comparing terror-related musculoskeletal injuries with motor vehicle accidents in adults. They found a higher ISS and higher rates of polytrauma, amputations, open fractures, and abdominal injuries.
Terrorist Stabbings—Distinctive Characteristics and How to Prepare for Them
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Israeli Trauma Group (ITG): J. Jeroukhimov, B. Kessel, Y. Klein, M. Michaelson, Y. Mintz, A. Rivkind, D. Soffer, D. Simon, G. Shaked, M. Stein, I. Waksman.