Analysis of isolated transverse process fractures sustained during blast related events

AbstractBackgroundA range of devastating blast injuries have been sustained by personnel during recent conflicts. Previous studies have focused on severe injuries, including to the spine, however, no study has specifically focused on the most common spinal injury; transverse process (TP) fractures. Although their treatment usually requires limited intervention, analysis of TP fractures may help determine injury mechanisms.MethodsData was collected from victims with spinal fractures injured in Improvised Explosive Device (IED) attacks, from the UK’s Joint Theatre Trauma Registry. The level and side of each TP fracture was recorded, as well as associated injuries, whether they were mounted or dismounted, and outcome (survivor or fatality).ResultsThe majority of TP fractures were lumbar (80%). More bilateral (both left and right fractures at the same level), and L5 TP fractures, were seen in fatalities than survivors. In the mounted group, lumbar TP fractures were statistically significantly associated with fatality, head injury, non-compressible torso haemorrhage, pelvic injury, and other spinal injuries. In the dismounted group, thoracic TP fractures were associated with head, chest wall, and other spinal injuries, and lumbar TP fractures were associated with pelvic, and other spinal injuries.ConclusionsDifferent injury mechanisms of the TP in the mounted and dismounted groups are likely. Inertial forces acting within the torso due to rapid loading being transferred through the seat, or high intra-abdominal pressures causing the tensile forces acting through the lumbar fascia to avulse the TPs are likely mechanisms in the mounted group. Blunt trauma, violent lateral flexion-extension forces, or rapid flail of the lower extremities causing tension of the psoas muscle, avulsing the TP are likely causes in the dismounted group. Isolated lumbar TP fractures can be used as markers for more severe injuries, and fatality, in mounted blast casualties.Level of EvidencePrognostic and Epidemiological, Level III. Background A range of devastating blast injuries have been sustained by personnel during recent conflicts. Previous studies have focused on severe injuries, including to the spine, however, no study has specifically focused on the most common spinal injury; transverse process (TP) fractures. Although their treatment usually requires limited intervention, analysis of TP fractures may help determine injury mechanisms. Methods Data was collected from victims with spinal fractures injured in Improvised Explosive Device (IED) attacks, from the UK’s Joint Theatre Trauma Registry. The level and side of each TP fracture was recorded, as well as associated injuries, whether they were mounted or dismounted, and outcome (survivor or fatality). Results The majority of TP fractures were lumbar (80%). More bilateral (both left and right fractures at the same level), and L5 TP fractures, were seen in fatalities than survivors. In the mounted group, lumbar TP fractures were statistically significantly associated with fatality, head injury, non-compressible torso haemorrhage, pelvic injury, and other spinal injuries. In the dismounted group, thoracic TP fractures were associated with head, chest wall, and other spinal injuries, and lumbar TP fractures were associated with pelvic, and other spinal injuries. Conclusions Different injury mechanisms of the TP in the mounted and dismounted groups are likely. Inertial forces acting within the torso due to rapid loading being transferred through the seat, or high intra-abdominal pressures causing the tensile forces acting through the lumbar fascia to avulse the TPs are likely mechanisms in the mounted group. Blunt trauma, violent lateral flexion-extension forces, or rapid flail of the lower extremities causing tension of the psoas muscle, avulsing the TP are likely causes in the dismounted group. Isolated lumbar TP fractures can be used as markers for more severe injuries, and fatality, in mounted blast casualties. Level of Evidence Prognostic and Epidemiological, Level III. Corresponding author: Dr Nicolas Newell, Postdoctoral Research Fellow, Department of Bioengineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, Tel: 07843895728, E-mail: n.newell09@imperial.ac.uk Conflict of Interest Statement: The authors declare no conflicts of interest. This paper is for consideration for the Military supplement. © 2018 Lippincott Williams & Wilkins, Inc.

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