Shrapnel Wounds Research Articles

Analysis of Early Surgical Treatment of Incorrectly Consolidated Gunshot Fractures of the Scapula

Objective. The objective of our study was to analyze the structure of incorrectly consolidated gunshot fractures of the scapula and early outcomes of surgical treatment. Material and Methods. We analyzed 10 cases of incorrectly consolidated gunshot fractures of the scapula in Ukrainian Armed Forces servicemen, received as a result of combat operations, and early outcomes of surgical treatment. The main indications for surgical treatment were as follows: severe impairment of function of the upper limb due to pain, fractures of the articular surface of the scapula with displacement of fragments over 2 mm, fractures of the acromion with displacement of more than 8 mm, and damages to muscles and skin. In addition to radiography in standard projections, preoperative examination included computed tomography (CT). Evaluation of functional outcomes was carried out within 1 to 4 months according to the Oxford Shoulder Score (OSS) scale. The average period of postoperative survey was 2.6 months. Results. Incorrect consolidation of fractures was caused by a long period of preoperative preparation and conservative treatment of wounds in patients due to openness and infection of bullet wounds in 2 patients and shrapnel wounds because of mortar, artillery, tank and rocket attacks in 8 patients. Staged treatment until wound healing was carried out in hospitals and military hospitals of Ukraine using VAC (Vacuum-Assisted Closure) devices. Four cases were right-sided and six were left-sided; 7 of 10 cases were intra-articular fractures with displacement of fragments of the articular surface by 2 mm or more. The average duration of injury at the time of surgery was 4.2 months (range from 2 to 8 months). In addition to eliminating displacements and deformities of incorrectly consolidated fractures and osteosynthesis of fragments, the treatment included replacing the soft tissue defect of the shoulder and shoulder girdle with a non-free thoracodorsal musculocutaneous flap on a neurovascular pedicle in 3 of 10 patients. Seven patients had an isolated wound to the scapula area. Three of 10 patients had a combined wound to the scapula with a defect of the humeral head, upper third of the humerus, and acromial end of the clavicle. These patients underwent implantation of an articulating spacer, restoration of the configuration of the proximal end of the humerus, and reconstruction of the rotator muscles to make possible the shoulder joint arthroplasty. The average value according to the results of a survey of patients on the OSS scale was 20.2 (±4.39) points before surgery and 34.1 (±7.56) points after surgery, which can be considered a good result according to the OSS scoring system. Conclusions. The analysis of the early outcomes showed that reconstructive treatment of gunshot old fractures of the scapula creates biomechanical prerequisites for restoring the function of the upper limb, reduces pain syndrome, and allows for active postoperative rehabilitation.

The effectiveness of intraoperative ultrasound control in removing foreign bodies of soft tissues in military personnel with fragmentation wounds at the stage of specialized surgical care

BACKGROUND: The involvement of civilian medical institutions in medical care in military conflicts and counter-terrorism operations has become an important area of the medical support system. Modern methods of surgical navigation make possible minimal invasive, effective and safe removing foreign bodies from soft tissues. Clear understanding of injuries’ character allows better planning of procedures. AIM: Improving the results of treatment of military personnel with fragment wounds by taking into account the character of injury and the use of ultrasound control during removing soft tissue foreign bodies at the stage of specialized surgical care. MATERIAL AND METHODS: Data from 253 case histories who were treated at the State Budgetary Institution RO “Central City Hospital named Semashko”. Indications for the removal of fragments included the size of the fragment over 7 mm, localization near to large vessels and nerve trunks, and an acute purulent process. The patients were been randomized to two groups. Group I (control) included 118 patients in whom surgery was been performed in the traditional way. Group II (main) included 135 patients in whom procedures were performed with ultrasound navigation. The research methods are ultrasound, X-ray, clinical, and statistical. RESULTS: In 164 patients (64.8%), the wounds were of an isolated nature, where fragments were localized in various anatomical areas. 89 patients (35.2%) had combined shrapnel wounds. Of the 118 patients in group I, in whom surgery was performed in the traditional way, 65 patients (55.1%) underwent surgery under local anesthesia, 53 (44.9%) — under general anesthesia (anesthesia is always general). In 135 patients of group II, operations were performed by only one surgeon under local anesthesia. The duration of surgery, surgery invasion and wound infections rate were significantly lower in group II. CONCLUSION: The part of isolated fragment wounds is 64.8%, combined — 35.2%. The use of ultrasound navigation during surgery can significantly improve the effectiveness of surgical treatment of patients with fragmentation wounds: reduce the invasiveness and duration of surgery, blood loss, and the rate of wound infectious complications.

COMPUTER PRODUCTION OF FACIAL EPITHETS

BACKGROUND: The issue of rehabilitation of patients with facial defects is extremely acute. In addition to the annual increase in the number of patients with cancer of the maxillofacial region, in recent years the number of people with shrapnel and gunshot wounds to the face has increased as a result of local wars and conflicts. Traditional methods of orthopedic rehabilitation of patients and the manufacture of facial epitheses are quite a complex and lengthy process. In the postoperative period, there is a sharp decrease in the quality of life of this category of patients, a violation of the basic body functions necessary for vital activity and poor social adaptation. Direct prosthetics of the face in the postoperative period was impossible due to the lack of necessary digital modeling technologies and structural materials for additive or subtractive production methods. The production of temporary or permanent facial epitheses using digital technologies is an urgent task that can improve the social and functional living conditions of patients. AIMS: Development of 3D modeling technology for additive manufacturing of facial epithets. METHODS: To achieve this goal, the first task was to develop specialized three-dimensional software for modeling defects in the facial area. The functionality of the program should allow you to virtually simulate the missing parts of the face (ear, eye, nose, orbit). To create a digital platform together with IT specialists, it was decided to use the following programming languages: C++ - Writing the software core, writing UI/UX interaction modules, interacting with the Windows operating system; C# - Complex assembly of the entire project; Python is an automated assembly of virtual library modules; OpenGL HSLS is a shader language for graphical visualization of objects; C is the creation of functions for interacting with shaders that require high speed. RESULTS: A specialized computer program has been developed for 3D modeling of prostheses in patients with defects in the middle zone of the face using combined facial scanning and computed tomography data (Computer program. Apresyan S.V., Stepanov A.G. "A program for 3D modeling of facial epitheses. Registration number (certificate) 2023663490, Registration date: 07/04/2023). Instead of obtaining analog impressions with plaster or silicone material, the developed technology uses a special 3D facial scanner, which greatly eases the suffering of patients. A virtual three-dimensional database of ears, noses, orbits, and zygomatic bones of patients of various ages and gender is integrated into the developed program. This allows the specialist to select the most adaptive part of the face to make up for the defect. Built-in modeling tools allow you to personalize a 3D model of a part of the face, based on the structural features of the maxillofacial region of a person. The finished three-dimensional model of a part of the face can be exported in various formats CONCLUSIONS: The developed 3D program for modeling defects allows to avoid invasive prosthetics approaches, to coordinate the shape of future structures with the patient. The built-in library of structures with a database provides remote manufacturing of the prosthesis without the presence of the patient, in case of a need to replace it. Among the undeniable advantages of the technology, it is important to include the fact that prostheses can be made directly on the day of surgery to remove part of the face, completely restoring lost functions and providing rapid social adaptation.

The Role of Computed Tomography in Ophthalmic Surgeon Tactics in Shrapnel Wounds to the Eyeball. Clinical Case

There is a clinical case of eyeball metallosis in the background of a foreign body of the posterior segment of the eye in the article. Patient N, 41, complained of a gradual decrease in vision of the right eye. A duration of open injury to the right eye about eight years ago. At the primary ophthalmic examination, the most corrected visual acuity of the right eye was 0.3. The visual acuity of the left eye was 1.0. Intraocular pressure according to pneumotonometry: OD — 13 mm Hg, OS — 14 mm Hg. According to biomicroscopy of the right eye, it was found: the skin of the eyelids is unchanged, the conjunctiva is hyperemic, the mixed reaction of the vessels, the cornea is transparent, spherical, shiny, the anterior chamber is transparent, uneven, the iris is changed in color, foci of stroma hyperpigmentation are observed, the pupil is deformed, narrowed, displaced along the meridian for 1 hour, artificial. Examination of the central and peripheral parts of the fundus is difficult due to deformation and narrowing of the pupil diameter. Due to difficulty performing ophthalmoscopy, the patient underwent the following studies: static perimetry, ultrasound biomicroscopy (UBM) of the anterior segment of the eyeball, electrophysiological examination, B-­scan, computed tomography of the eyeball and orbit. The static perimetry revealed a concentric narrowing of the OD field of view. According to the ultrasound biomicroscopy, the IOL dislocation was revealed anteriorly. В­-Scanning visualizes the blistering cystic edema of the retina, inside which the induration is determined, giving an acoustic shadow. The electrophysiological examination showed changes in the electrical sensitivity and lability of the retina. According to the results of CT in the vitreous cavity, a foreign body was detected in the lower segment along the meridian 6 hours. In accordance with this, the diagnosis was made: OD — metallosis of the eye. Foreign body of the eye.

Effectiveness of the use of early secondary sutures and injections of platelet-rich autoplasma in isolated gunshot shrapnel wounds of soft tissues

Effectiveness of the use of early secondary sutures and injections of platelet-rich autoplasma in isolated gunshot shrapnel wounds of soft tissues

Ultrasound-Guided Removal of Deep-Lying Foreign Bodies of the Soft Neck Tissue in a Patient with a Shrapnel Wound

The paper describes a clinical case of intraoperative constant ultrasound-guided removal of deep-lying foreign bodies of the soft left neck tissue in a patient with a shrapnel wound resulted from mortaring. When deciding on a surgical option, the potential C-arm-guided foreign body removal was also considered; however, due to the topical localization of the foreign body between the internal jugular vein and the bifurcation area of the common carotid artery, the use of this technique was associated with a high risk of vascular trauma. The surgery was performed under local anesthesia using constant “free hand” US method in duplex mode. The foreign body was successfully removed. The wound completely healed by secondary intention, and a series of control ultrasound examinations revealed no signs of postoperative complications.

Profile of bomb blast injuries

Bomb blast injuries in India have unfortunately been a recurring and tragic reality, stemming from acts of terrorism and insurgency that have targeted various regions of the country. These incidents have resulted in significant loss of life, severe injuries, and lasting trauma for those affected. The impact of bomb blast injuries in India is not only physical but also psychological, affecting individuals, families, and communities at large.The injuries sustained in bomb blasts can vary in severity and type, depending on factors such as the type of explosive device used, the location of the blast, and the proximity of individuals to the explosion. Common injuries include shrapnel wounds, burns, fractures, traumatic amputations, and head injuries. The force of the blast can cause extensive damage to internal organs, leading to conditions such as blast lung injury, abdominal trauma, and hearing loss. The pattern of injuries due to bomb blast on the victims. Identification of the dead body of the deceased victims. To ascertain the distance of the victim from the blast from nature of injuries. Eardrum injuries sustained and mental trauma to live victims. To ascertain the presence of foreign bodies, primary and secondary missiles and there by assisting in investigations. The present study “The Profile of Bomb Blast Injuries’’ has been carried out in the one of the Major Medical College and Hospital in Maharashtra State. The present study has been carried out during the period of January 2003 to July 2004, During this study total cases studied were sixty nine (69), they are grouped as A & B. A : - 32 cases died due to bomb blast has been meticulously studied. B: - 37 injured persons ( clinical cases) due to bomb blast has been studied in the different wardsof hospital. In the present work total 69 cases were studied by group A & B i.e group A: 32 cases brought dead in the hospital, while group B:37 cases admitted in the hospital and following conclusion are derived :-1. Maximum affected persons from group A: deaths as well as from group B : clinical cases injured in bomb blast, were in the age group of 11 to 40 years. 2. Maximum cases from group A (brought dead to the hospital) as well as clinical cases from group B admitted in the hospital are much higher in males as compared to females. 3. The persons died, group A and injured cases (clinical) group B, during bomb blast in present study was mainly belong to Hindu religion as compared to other religions. 4. It was found in the present study that the persons died in bomb blast were mostly the residents of Mumbai city in comparison with those who are residing outside of Mumbai.

Features of the impact of combat-related traumatic brain injury in the long-term period, depending on the severity and course of the injury on the cognitive sphere of patients

Background. The number of consequences of mine-explosive injuries, multiple gunshot and shrapnel wounds has increased significantly in the world of current events related to the conduct of full-scale military operations on the territory of Ukraine. In particular, cases of combat traumatic brain injury (TBI) have increased, which is becoming one of the most important problems. Purpose The purpose of the research was to study the characteristics of cognitive functions in patients with the consequences of a combat craniocerebral injury (bTBI) depending on the severity and catamnesis of the received injury. Materials and Methods. 350 patients Cognitive functions of 350 patients who suffered a combat traumatic brain injury (cTBI),was carried out using the Montreal scale of cognitive deficits (MoCA test). The assessment of neurological status was carried out by a routine method and NOS-TBI (Neurological Outcome Scale for Traumatic Brain Injury), the level of anxiety and depression was determined using the HADS scale. In addition, the state of cognitive functions was evaluated using a number of modern neuropsychological tests: the method of learning 10 words, which allowed to investigate memory processes (memorization, preservation and reproduction of information). Schulte’s tables were used to assess the pace of sensorimotor reactions, mental capacity, and the volume of active attention. Results. The results of the MoCA scale in patients with consequences of combat TBI of varying degrees of severity corresponded to mild cognitive decline: Mild cTBI 22.21 ± 0.29 points, cTBI (ST) 21.36 ± 0.33 points, Severe cTBI 21.32 ± 0.28 points. There was no statistically significant difference between MoCA values at different severity of combat TBI. A longer injury history had a negative effect on cognitive function in patients with Mild effects combat TBI and Severe combat TBI. Conclusions. As a result of the investigation, officials who contributed to the formation of cognitive deficits were identified: anxiety disorder (with mild effects combat TBI and severe combat TBI), anxiety-depressive state (with mild effects combat TBI with a follow-up period of up to 3 years and combat TBI (moderate) with follow-up). period more than 5 years), age (combat TBI (moderate) up to 7 years), neurological deficit (severe combat TBI, follow-up period in case of injury more than 5 years).

Use of magnets in minimally invasive surgery of shrapnel wounds

Use of magnets in minimally invasive surgery of shrapnel wounds

ATP-dependent ion-transport systems functioning in immunocompetent cells of men with erectile dysfunction due to combat trauma

Background. The study of the problem of physical and mental health of people who have survived combat trauma is a component of a wide field of research on the problem of stress, which manifests itself at all levels of the organization of the body. Combat injuries, in particular those of the areas of pelvis and genitourinary system, stressful events, lead to the development of erectile dysfunction (ED). In recent decades, a sufficient number of scientific facts have been accumulated, which confirm the significant influence of stress factors on the reduction of sexual desire and sexual activity. Therefore, determination of Ca2+,Mg2+- and Na+,K+-ATPase activity on a convenient model like peripheral blood lymphocytes add complexity to the understanding of the development of the pathophysiological and pathobiochemical mechanisms of the body, the result of which is the development of ED. Materials and methods. The research was conducted on peripheral blood lymphocytes of men injured as a result of combat operations (shrapnel and bullet wounds) in the Russian-Ukrainian war and treated at the Military Medical Clinical Center of the Western Region. The research group of men with combat injuries was divided into two subgroups: men aged 20–39 years (subgroup 1) and men aged 40–53 years (subgroup 2). The control group consisted of 48 practically healthy men without complaints of sexual dysfunction or cardiac, neurological or endocrinological pathology. Among the men of the control group were 30 men aged 20–39 years (subgroup 3) and 18 men aged 40–53 years (subgroup 4). Results. It has been shown that in the peripheral blood lymphocytes of men injured as a result of hostilities, there is a decrease in Na+,K+-ATPase activity and Ca2+,Mg2+-ATPase activity of the plasma membrane and endoplasmic reticulum, which leads to overloading of the cytosol with Na+ and Ca2+ ions, respectively, which is characteristic of pathological processes. Conclusion. Erectile dysfunction due to combat trauma is accompanied by a decrease in both Ca2+,Mg2+-ATPase activity of the plasma membrane and Ca2+,Mg2+-ATPase activity of endoplasmic reticulum of blood lymphocytes. As the age of patients with disorders of sexual function increases, the decrease in Ca2+,Mg2+-ATPase activities becomes more expressed. In men with erectile dysfunction due to combat trauma, the activity of Na+,K+-ATPase is also inhibited. According to the ROC curve, Ca2+,Mg2+-ATPase activity of the endoplasmic reticulum in blood lymphocytes is a potential biomarker of erectile dysfunction.

Parameters of oxidative, nitrasive and anti-oxidative status in men with erectile dys-function due to combat trauma

The development of oxidative and nitrative stress and the processes of free radical oxidation are associated with many pathological processes. Damage of any origin leads to the activation of free radical processes not only in the place of damage, but also in the whole organism. The aim of the study is to assess the state of lipid peroxidation, content of GSH and GSSG and the activity of NO-synthase and arginase in lymphocytes and peripheral blood serum in men with erectile dysfunction due to combat trauma. The research was conducted on peripheral blood lymphocytes of men injured as a result of combat operations (shrapnel and bullet wounds) in the Russian-Ukrainian war, and who were treated at the Military Medical Clinical Center of the Western Region (Lviv, Ukraine). The research group of men with combat injuries was divided into two age groups: men aged 20–39 years and men aged 40–53 years. The MDA content in the blood serum of patients of both age groups was 1.35 times higher than in the control group. In peripheral blood lymphocytes, the MDA content in patients of the young age group was 1.27, and in patients of the middle age group in 1.39 times higher than in the control group. Simultaneously, no significant changes in the concentration of oxidized glutathione in blood serum and blood lymphocytes were found between men with erectile dysfunction due to combat trauma and healthy men. GSH content in blood serum in patients of both age groups was significantly lower than in the control group. The arginase/NOS ratio in blood serum was 9.75 times lower in the young age group and in 20.45 times lower in the middle age group compared to healthy men. It was established that in the blood serum and blood lymphocytes of men with erectile dysfunction due to combat trauma, processes of lipid peroxidation were intensified and the GSH level was reduced. The GSH/GSSG ratio was reduced only in blood serum. It was found that the oxidative stress is associated with development of nitrative stress. The arginase/NOS ratio was shifted towards increased NOS activity. Activation of iNOS was accompanied by significant inhibition of cNOS. Further study of biochemical mechanisms is important to understand the triggers of erectile dysfunction due to combat trauma.

Erectile dysfunction and quality of life of men affected by hostilities in the Russian-Ukrainian war

Erectile dysfunction and the associated quality of life are a pressing social and medical problem for millions of people. The basis of the work was the results of a survey of 298 men injured as a result of combat operations (shrapnel and bullet wounds) using the questionnaires of the International Index of Erectile Function-5 (IIEF-5) and the SF-36 Health Status Survey (SF-36) questionnaire to characterize the quality of life. The research group was divided into two: men aged 20-39 years (group 1) and men aged 40-53 years (group 2). The control group consisted of 48 clinically healthy men without complaints of sexual dysfunction or cardiac, neurological or endocrinological pathology. It is shown that men aged 20-39 years have a mild form of ED where the total score is 19.57 ± 0.44. Men of the 2nd group aged 40-53 years also have a mild form of ED, but the total score is much lower and is 17.74 ± 0.41. Patients of both age groups affected by hostilities suffer from both mental and physical health components. Indicators such as general health, role functioning due to physical condition, and pain intensity have probably lower values compared to the contol group. Lower indicators of role functioning due to physical condition indicate limitations in everyday life due to unsatisfactory physical condition. The decrease in the physical functioning index has statistically significant differences only in patients of the 2nd observed group. Thus, a mild form of erectile dysfunction is observed in men injured as a result of hostilities. No significant differences in the severity of erectile dysfunction were found between male war victims of two age groups. All IIEF-5 domains were significantly reduced in men affected by combat operations. It has been proven that the physical and mental components of health suffer in victims of hostilities. Against the background of a decrease in all indicators on the scales of the physical component of health, general health and role functioning caused by physical condition lag behind the most. In the psychological domain, the most pronounced changes are recorded in such components as mental health, vital activity and social functioning. Сorrelation analysis revealed the significant correlation between physical functioning and role functioning caused by emotional state (r = +0.64; P < 0.05).

Characteristics of First Aid Types for Pelvic Trauma in Women Injured During Local Military Conflicts

AIM OF STUDY. To assess the types and scope of first aid for pelvic injuries in women in conditions of local military conflict. MATERIAL AND METHODS. To achieve this goal, an analysis of injuries received during local military operations carried out in the Republic of Chechnya from 1991 to 2000 was carried out. The treatment was carried out on the basis of the surgical hospital of medical organization No. 9 in Grozny. The severity of the injury was determined retrospectively using the Field Surgery Scale, distinguishing four degrees of severity. Injured patients with combined injuries to the chest, abdomen, and head were excluded. The average age of patients was 34 [28; 40] years. The total number was 86. RESULTS. As the study shows, group A included 54 (62.8 %), and group B included 32 (37.2 %) patients. The distribution by group is presented as follows: in group A, 44 (51.2 %) shrapnel wounds, 10 (11.6 %) gunshot wounds. In group B, there were, respectively, 25 shrapnel (29.1 %) and 7 gunshot (8.1 %) wounds. Further analysis showed that penetrating wounds predominated, which were observed in 67 (77.9 %) cases, non-penetrating wounds were only revealed in 19 (22.1 %) cases (r = 0.97, p < 0.05, statistically significant). Distribution by groups: in group A there were 48 (55.8 %) and 6 (7.0 %), respectively, in group B there were 19 (22.1 %) and 13 (15.1 %) observations. Anti-shock measures, which include pain relief and infusion therapy, were carried out in 31 (36.0 %) cases in group A and in 5 (5.8 %) cases in group B (r = 0.97, p < 0 .05, statistically significant). At the same time, in the group of patients where first aid was provided by random witnesses or as self-help, the n

Endoscopic rhinosurgery in shrapnel wounds of the paranasal sinuses and adjacent areas

Endoscopic rhinosurgery in shrapnel wounds of the paranasal sinuses and adjacent areas

Влияние акубаротравмы на состояние слуха в условиях современного вооруженного конфликта

The blast shock wave is the main damaging factor in conditions of modern armed conflict. The effect on the body of a loud sound and a sharp increase in air pressure in the environment leads to the development of acubarotrauma. The value of sanitary losses of the otorhinolaryngological profile amounted to 6.5% of the total number of requests for medical care at the advanced stage of providing specialized care. Damage to the ENT organs by a blast wave with the development of acubarotrauma out of the total number of sanitary losses of the otorhinolaryngological profile was 38%. The development of protective equipment has changed the nature of damage to the head and neck area toward a significant decrease in the number of isolated damages of the auditory system. A combination of acubarotrauma with shrapnel wounds of the head was observed in 17% of cases; with closed-head injury, in 43%; with shrapnel wounds of the upper and lower extremities, in 26%; with mechanical injuries, in 13%. Depending on the location of the victim relative to the shelter, the remoteness of the damaging factor, distinctive complaints, the nature of damage to the tympanic membrane, and acumetry data, 4 types of acubarotrauma were identified that can be used to determine the medical and evacuation characteristics of the victims. Timely provision of medical care, depending on the nature of the acubarotrauma, will allow the most effective use of the rehabilitation potential of a particular victim at the following stages of treatment.

Indicators of oxidative-nitrosative stress of men injured as a result of combat actions

The article presents data on the state of lipid peroxidation and the activity of NO-synthase isoforms and arginase in lymphocytes and peripheral blood serum in men injured in combat (bullet and shrapnel wounds). 68 men injured as a result of hostilities (shrapnel and bullet wounds), who made up the main group, were examined. 48 practically healthy men were included in the control group. Patients of the main and control groups were divided into two age subgroups each: 20–39 years and 40–60 years. The MDA content in the blood serum of patients of both subgroups of the main group was 1.4 times higher than in the individuals of the corresponding subgroups of the control group (p<0.05). In peripheral blood lymphocytes, the MDA content in patients of both age subgroups of the main group was 1.3–1.4 times higher than in individuals of the corresponding subgroups of the control group (p<0.05; p<0.01). The activity of inducible (Ca2+-independent) de novo synthesis of NO significantly increases in blood serum and lymphocytes of men injured as a result of hostilities. At the same time, the activity of Ca2+-dependent NO-synthase in blood lymphocytes of men injured as a result of hostilities was 2.4 times lower compared to the values in practically healthy men (p<0.001), while it almost did not change in blood serum. It was confirmed that the inducible NOS can activate the processes of lipid peroxidation in men injured as a result of hostilities, as a direct significant correlation of high strength was recorded between the activity of Ca2+-independent iNOS and the MDA content (r=0.74; p<0.05). A significant correlation of medium strength was also established between arginase activity and MDA content (r=0.52; p<0.05). Keywords: malondialdehyde, NO-synthase, arginase.

Endovascular treatment of post-thrombotic syndrome of the lower extremities caused by combat trauma. Clinical case

In the course of Russia’s military invasion of Ukraine, gunshot shrapnel wounds of the lower extremities that result in damage to major blood vessels have become a common phenomenon. Their incidence is consistent with the general data on combat‑related vascular injuries. Vascular gunshot injuries can cause significant changes to the normal anatomy and hemodynamics of the extremity as a result of the bullet or shrapnel travelling through the wound channel. Combat trauma of the vascular bundle, either as a primary factor or in combination with other lesions, often causes a serious condition in the wounded that requires urgent surgical intervention]. Injury to the major blood vessels of the lower limbs carries the risk of critical ischemia, which can lead to higher mortality rates, poor limb recovery, and disability. This clinical case demonstrates the endovascular management of a disabling combat‑related vascular injury. The treatment involves the use of modern imaging techniques and minimally invasive surgical procedures. This case highlights the progression of the pathological process after a gunshot shrapnel wound to the soft tissues and major blood vessels. It also shows a change in the normal anatomy of the major blood vessels and the subsequent development of regional hemodynamic disorders of the lower limb after injury. In January 2023, a 51‑year‑old male received a gunshot wound to the soft tissues of the pelvis and right lower limb, as well as a gunshot fracture of the right femur. Immediate post‑evacuation therapy included the management of life‑threatening bleeding by ligating the deep femoral artery and providing external fixation of the gunshot femur fracture. Following the healing of the wounds and the removal of the external fixation device, the injured individual experienced a progressive and notable swelling of the lower limb over a period of 3 months. Subsequently, trophic ulcers appeared on the lower leg. In September 2023, the patient was admitted to the National Military Medical Clinical Centre in Kyiv after developing clinical signs of the post‑thrombotic syndrome. However, further examination revealed the presence of an AV fistula. Consequently, a simultaneous endovascular reconstructive intervention was performed on the arteries and veins of the patient’s lower extremity. Conclusions. A gunshot wound to the major blood vessels can contribute to pathological changes in the normal anatomical structure, resulting in arterial collateral blood circulation or narrowing of blood vessels that can lead to regional hemodynamic disorders. The clinical case exemplifies the importance of using modern imaging techniques for a comprehensive examination of the vascular system and the possibility of minimally invasive treatment for patients with gunshot injuries to the major blood vessels.

PROBLEMATIC ISSUES OF LIMB AMPUTATION IN WOUNDED WITH COMBAT TRAUMA

Among the wounded with limb injuries admitted to the Military Medical Center of the Western region during the year of Russia’s full-scale war in Ukraine, 29% had a mine-blast injury, 47% had shrapnel wounds, 8% had gunshot bullet wounds, 1.5% – thermal injuries, and14.5% – traumatic injuries. Upper limbs were injured in 22%, lower – in 32%, 15% had two limbs injured, and 31% had combined combat trauma. In all hospitalized with multi-fragment fractures, limbs were fixed with external fixation devices. 2% of patients had vascular damage. All wounded had unhealed wounds with a soft tissue defect. The average age of patients was 30 years. There were no comorbid diseases in the wounded, and concomitant diseases that did not affect the course of injury were found in 10%. Amputations of limbs were performed in 6.5%. Traumatic separation of a limb segment or its destruction with crushed bone and non-viable soft tissues, nerve damage with significant defect, soft tissue and bone defect, as well as thermal ischemia of the limb for more than 6 hours with necrosis of its soft tissues, were indications for primary limb amputation in 3% of wounded and injured, which were in the nature of primary debridement. Progressive wound infection with the development of the septic condition of the wounded despite intensive treatment, total ischemic necrosis, and recrudescent arrosive bleeding from great vessels required a secondary limb amputation in 1.5%. In 1.5% of the wounded, staged operations were performed as re-amputations. Re-amputation had to be performed in 0.6% of patients with an inappropriate limb stump level, which complicated prosthetics. To reduce the number of amputations for secondary indications, a timely diagnosis is needed of compartment syndrome and rational treatment of soft tissue wounds and gunshot fractures with surgical and medical prevention of the infectious process.

MACROSCOPIC AND MICROSCOPIC FEATURES OF FIREARM PENETRATING ABDOMINAL INJURIES WITH DAMAGE TO THE APPENDIX

Introduction. In the structure of combat abdominal trauma during all periods of hostilities (according to ATO/JFO data), gunshot wounds dominated, accounting for 87.1%. An analysis of the distribution of those injured with gunshot wounds by the type of projectile causing the injury showed a prevalence of shrapnel injuries over bullet wounds – more than 80%.
 The aim of the research was to analyze the macroscopic and microscopic changes in firearm penetrating abdominal injuries with damage to the appendix.
 Materials and Methods. Eight appendectomies were performed due to firearm penetrating abdominal injuries with damage to the appendix. Complaints, medical history, examination data, ultrasound examination according to the FAST protocol, and radiological examinations were studied in all injured patients. To refine the diagnosis and determine the scope of surgical intervention, the WOLF videoendoscopic system was used.
 Histological examination of the removed appendices was performed, which were stained with hematoxylin and eosin and with the Van Gieson stain. A complex of pathomorphological studies was conducted using the Primo Star microscope (Carl Zeiss) at a magnification of ×140.
 Results. All injuries occurred while wearing a bulletproof vest and were characterized as blind, with 1 (12.5%) being gunshot wounds and 7 (87.5%) being shrapnel wounds. The entrance wound in firearm blind penetrating abdominal injuries with appendix damage was located in the right hypochondriac region – 4 (50%), right flank – 1 (12.5%), right inguinal region – 2 (25%), and mesogastric region – 1 (12.5%) cases. The average size of the entrance wound on the skin was 23.3±0.4×12.4±0.3 cm. All skin wounds were outside the bulletproof vest protection area.
 The injuries to the appendix had an average size of 15.4±1.2×9.3±0.1 cm. All removed foreign bodies were larger than 1 cm in their largest dimension.
 Conclusions. In most cases of firearm penetrating abdominal injuries, damage to the appendix is noted with an entrance wound predominantly on the right side. Macroscopically, in firearm blind penetrating abdominal injuries with appendix involvement, the wound on the skin is larger than on the appendix. All foreign metal bodies removed from the abdominal cavity after firearm shrapnel blind abdominal injuries with appendix involvement were of large size. Contusional injuries to the appendix tend to undergo destructive transformation, requiring surgical treatment - appendectomy. The increased frequency of appendix injuries can be explained by the widespread use of shrapnel ammunition in abdominal injuries when personal protective equipment does not provide protection for this area.

Медицинская помощь детям, пострадавшим в вооруженных конфликтах: систематический обзор литературы

Summary. The aim of the study is to analyze the data on mortality, structure of injuries, terms of hospitalization, routing of patients and organization of medical care for children injured in armed conflicts and terrorist acts. Materials and research methods. A systematic review was performed in accordance with the recommendations of the PRISMA protocol. A comprehensive search was conducted in PubMed, ScienceDirect, E-library, and GoogleScholar databases for the period from 1995 to 2022. The search revealed 2995 publications, of which 25 papers were included in the quantitative analysis according to the inclusion criteria. Results of the study and their analysis. We analyzed 54205 cases of medical care for children injured in 15 armed conflicts and 48 terrorist attacks between 1988 and 2020. The average age of the injured children was 9.7 years; the proportion of children in the total mass of the injured was 12.7%. The average percentage of bed days in children was 10.9%; the average duration of hospitalization was 7.4 days; 82% of patients required surgery; the pediatric mortality rate was 7.6%. The most common mechanisms of injury in children were shrapnel and explosive wounds; the most frequent cause of death was craniocerebral trauma.