Background: Limb amputation has been a common injury occurring in the conflicts in Iraq and Afghanistan. Compared to other injuries, less attention has been given to this serious, disabling wound.
Purpose: The article describes the Allied military experience of traumatic limb amputation in Iraq and Afghanistan. It intends to inform health care personnel involved in the care of serving military personnel and veterans about the scale of these casualties.
Methods: A literature search of both civilian and military academic databases was conducted.
Results: Both the US and UK have incurred very significant numbers of casualties involving traumatic limb amputation, many of whom have suffered multiple limb loss. The rate of blast injuries causing traumatic limb amputation among US forces has increased since the surge of troops in Afghanistan. Dismounted Complex Blast Injury (DCBI) consisting of multiple limb amputations with pelvic, abdominal or genito-urinary injuries has been reported as increasing in frequency among US troops in Afghanistan since 2010. Australian Defence Force casualties suffering traumatic limb amputation remain low.
Conclusions: Significant casualties involving traumatic limb amputation are likely to continue among Allied troops while current counter-insurgency tactics are continued. Planned troop withdrawals should eventually result in fewer casualties, including reduced numbers of traumatic limb amputation.
Traumatic limb amputation is a highly visible wound that causes enormous personal distress and disability as well as incurring considerable national cost in physical and vocational rehabilitation. Recently, this injury appears to be increasing in frequency in the war in Afghanistan1. A pattern of multiple lower limb amputations, with associated severe abdominal, pelvic or genito-urinary injuries, has been dubbed the ‘new signature wound of the war’1, a term previously often used in relation to mild traumatic brain injury2.
The purpose of this article is to describe the Allied military experience of traumatic limb amputation in the conflicts in Iraq and Afghanistan, and inform health care personnel involved in the care of serving military personnel and veterans about the scale of these particular casualties. Based on a review of the literature, it examines the numbers and causes of traumatic limb amputations in Allied military personnel in the current conflicts.
In doing so, it should be noted that military casualty statistics can be complex3,) and politically sensitive, with reports on traumatic limb amputations being especially so. Some countries (e.g. Canada and The Netherlands) have chosen not to disclose figures on these injuries. Furthermore, official figures casualties 13. Explosive devices were the mechanism of injury associated with most (87.9%) amputations14.
A prospective longitudinal study of wound patterns on a large US Army unit during ‘The Surge’ in Iraq in 2007 found the distribution of wounds was approximately 50% to the extremities13. A British study of injuries requiring surgery found a similar distribution of injuries to extremities (50%)15. This burden of extremity injuries is similar to the US experience in previous conflicts from World War II to the First Gulf War 1990-9116.
The parts of a soldier’s body that may be injured in combat are strongly affected by the personal protective equipment (PPE) – with PPE also significantly increasing the chances of survival in the current conflicts in Iraq and Afghanistan8,17. Body armour has been improved with blast resistant ballistic goggles or glasses worn with improved Kevlar Advanced Combat Helmets. However, this equipment still leaves a soldier’s face, hemicranium and extremities vulnerable18,19, particularly when blast forces are directed upward through the floor of a vehicle(20). For dismounted troops, the lower extremities are particularly vulnerable to blast injury, as most IEDs are detonated from ground level. Commercially available ‘Ballistic Boxers’ or Kevlar underpants, are being studied to assess their ability to provide some protection from genito-urinary and femoral artery injury 21.
Counterinsurgency doctrine implemented through the Surge of US Forces in Iraq from 200722 and in Afghanistan from 2009, calls for securing the local population by building a local presence within threatened communities23. Such local engagement requires troops to live in small outposts and to conduct frequent foot patrols24, exposing them to greater risk from IEDs than if they were in armoured vehicles.
Allied military personnel are issued tourniquets capable of being applied with one hand, as individual first-aid for wounds sustained under fire. Notwithstanding some controversy over their benefit 25,26, several studies have found tourniquets to be effective in controlling severe haemorrhage, especially in upper limbs27-29. Numerous confronting accounts exist of US and UK military personnel routinely wearing their tourniquets on their legs, ready to be tightened in preparation for IED strikes30-33.
By theatre of operations to September 2010, 1,158 US military personnel suffered major or partial limb amputations as a result of the conflict in Iraq, 249 in Afghanistan, and 214 in ‘unaffiliated conflicts’34 in Yemen, Pakistan and Uzbekistan.
From mid-2008, the rate of blast injuries resulting in traumatic limb amputation in US Forces in Afghanistan began to consistently exceed those occurring in Iraq. By 2010, blast injuries to US Forces in Iraq declined to near zero (from a peak prevalence of 3.3 per 10,000); whereas by mid to late 2010, a significant increase in blast injuries to US personnel in Afghanistan emerged (with a prevalence of 5.2 per 10,000)35. For the whole of 2010, a total of 196 US military personnel suffered the loss of at least one limb, increasing to 240 in 201136. Even though amputations increased, US combat deaths actually declined for the same period, from 437 to 368, further confirming improvements in wound survivability 37.
Most were attributed to ground-placed IEDs or land-mines, with 88% of survivors being on foot. An emerging pattern of high, multiple extremity amputations with pelvic, abdominal or genito-urinary injuries was described as Dismounted Complex Blast Injury35. Rates of genito-urinary injury among all casualty admissions from Afghanistan in 2010 were two to three times higher than historical averages. Furthermore, in 2010-11, nearly half a sample of US combat fatalities suffered bilateral lower limb extremity amputations, with almost a third losing three limbs35.
Prior to April 2006, the United Kingdom Ministry of Defence (MOD) resisted calls to publish data on British military personnel who had undergone traumatic or surgical limb amputation in Iraq (Operation Telic) and Afghanistan (Operation Herrick)38. Since then, quarterly amputation statistics have been released. However, the MOD ‘suppresses’ results when fewer than five persons experiencing amputations have been recorded in a particular reporting period for reasons of operational security and patient confidentiality39. This meant that a recent decision to publish historical figures from both conflicts between 2001-2006 failed to shed light on the exact number of these particular casualties40.
Between April 2006 and December 2011, at least 20 British military personnel suffered traumatic limb amputations in Iraq, and 237 in Afghanistan. UK limb amputation casualties in Afghanistan have significantly increased since 2009 with 55 sustained in 2009, 79 in 2010, and 53 in 201139, 40. Multiple amputee casualties were also the worst to date with 32 in FY2009/10 and 36 in 2010/1139, 40.
At least three Australian soldiers have suffered traumatic limb amputations41, among the 32 killed and 218 wounded in Afghanistan from 2002 to 14 January 201242. The Australian Department of Veterans’ Affairs reported one veteran of the Iraq War in 2003 and one veteran of the conflict in Afghanistan with accepted disabilities for limb amputation43.
Both the US and UK have incurred very significant numbers of casualties involving traumatic limb amputation, many of whom have suffered multiple limb loss. Numbers of US limb amputation casualties peaked following the surges in troop numbers in Iraq in 2007 and Afghanistan in 2009. During counter-insurgency operations in Afghanistan since late 2010, the use of dismounted troops as foot patrols has been associated with the emergence of what has been termed Dismounted Complex Blast Injury, involving multiple limb amputations. Australian casualties involving limb amputations in Afghanistan to date have fortunately remained low.
Significant rates of traumatic limb amputation among allied military personnel in Afghanistan are likely to persist while current counter-insurgency tactics continue. The withdrawal of US forces, which commenced in July 2011 and which will increase in 2012, should be accompanied by a fall in overall casualties, including traumatic limb amputation, particularly as their role is anticipated to change from combat to more mentoring of Afghan security forces.
Even when all allied troops are eventually withdrawn from Iraq and Afghanistan, it must be recognized that a major, enduring burden has been imposed on personnel who have suffered traumatic limb amputations, and on their families. US and UK veterans’ health care and rehabilitation services face an expensive commitment of years of work ahead to assist veterans in their adjustment to these disfiguring and life-changing wounds of war.