Most wounds sustained by service members serving in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) are extremity injuries.1,2 These injuries account for approximately two thirds of initial hospitalization costs and estimated disability payments.3 However, characterization of specific disabling conditions resulting from combat injuries has never been studied. Combat casualty care has improved with better understanding of wounding patterns, and long-term care of combat casualties would benefit from enhanced understanding of the long-term disability caused by these wounds. This is especially critical as the US Department of Veterans' Affairs (VA) prepares to care for the current generation of combat veterans. This information will also be helpful in prioritizing future research funding.
The US Army Physical Evaluation Board (PEB) is a convening body of army officers and medical personnel who are responsible for determining whether an ill or injured service member is able to continue serving on active duty. Those who are wounded during combat operations receive medical care until a state of maximum medical benefit has been reached. Those who are capable are returned to active duty. However, if the medical provider feels that return to active duty is not possible, the service member is referred to the PEB to determine whether permanent disability exists that would preclude active duty service. The PEB relies on the full medical evaluation information to determine whether a service member is fit for duty, may return to active duty in a limited capacity or under a different occupational requirement, or is unfit and must be disqualified from continued service. The service member with an unfitting condition is medically retired, and a percent disability rating is determined based on the impairment of each unfitting condition. This percentage determines eligibility for disability benefits.
To further understand the disabling impact of battlefield orthopaedic injuries, we identify the unfitting conditions that prevent return to active duty, and we characterize the frequency and severity of these conditions at the time of medical discharge. The wounds that necessitate evacuation from combat operations are not necessarily the wounds that ultimately result in long-term disability. The disabling conditions resulting from battlefield orthopaedic injuries lead to most unfitting conditions and have a greater impact on permanent disability than previously thought.
The patient cohort for this study is adopted from a previously published cohort of combat-wounded US service members evacuated from OEF and OIF and entered into a military casualty database.1 A query in the Joint Theater Trauma Registry identified 3,102 casualties entered consecutively between October 2001 and January 2005. Of these, 1,566 were wounded in action and did not return to duty within 72 hours. Complete records were available for resource utilization analysis for 1,333 persons in that group.3 Four hundred sixty-four of the 1,333 service members were formally evaluated for permanent physical disability by the PEB. PEB disability information was available for 450 of these 464 patients. Five were found to be fit for duty, and nine had died while on the temporary disabled retirement list. These 450 service members make up the present cohort (Figure 1).
The PEB database was searched for board results on each person; codes of unfitting conditions and the percent disability determined for each condition were captured. The PEB results listed included fit for duty, continuation on active duty in a limited capacity, placement on a temporary disabled retirement list, separation from the service with severance pay, or permanent medical retirement. The codes used by the PEB are those used in the published Veterans Affairs Schedule for Rating Disabilities (VASRD).4–7 A VASRD formula was used to calculate the overall percent disability from the disability assigned to each code. Once the PEB results and VASRD codes were identified for each service member, the VASRD codes were linked to clinical diagnoses that contributed to the unfitting condition. Each unfitting condition was sorted into a category consistent with the VASRD groups (Tables 1 and 2).
Each narrative summary in the service member's PEB record was reviewed. The narrative summary includes thorough documentation of patient history and physical examination performed by the medical care provider during the impairment evaluation. For battlefield-injured service members, the documentation includes details on the injuries, the recovery process, and residual impairments from the wounds. Other demographic data collected from the PEB record include mechanism of injury, theater of operation, age, and rank at the time of injury.
The frequency of unfitting conditions and the average percent disability for each category were calculated. The cohort impact for each unfitting condition was determined by multiplying the average percent disability by the frequency for each group. For orthopaedic-related unfitting conditions, data were further classified by the affected anatomic region.
The typical medically retired service member is a young enlisted man injured in an explosion, a demographic similar to previous descriptions of battlefield-injured personnel (Tables 3 and 4). Degenerative arthritis was the most common unfitting condition (Table 5). Upper limb amputation was associated with the greatest average percent disability (Table 6). Lower extremity amputation, given its incidence and relatively high corresponding average percent disability, had the highest impact (Table 7). Of all unfitting conditions, 70% were orthopaedic (Figure 2).
Of the 450 persons studied, 377 (84%) had at least one orthopaedic-related unfitting condition. Two hundred fifty-nine were found to be unfit for duty solely because of orthopaedic conditions. Injuries to the leg and thigh were the most numerous (83 and 66, respectively) and caused the greatest number of unfitting conditions (89 and 78, respectively). Unfitting conditions related to the arm were associated with the highest percent disability (Table 8). The elbow had the most unfitting conditions per injury. Soft-tissue injury, fracture, and nerve injury were the most common types of injury, and pain, loss of nerve function/sensation, and loss of joint motion were the most common outcomes (Table 9). Of the 359 service members with complete records, 112 were evacuated from theater primarily due to injury sustained in the abdomen, thorax, or head. Of these 112, 85 were unfit primarily because of an orthopaedic condition at the time of the PEB (Table 10). In this subgroup, 72% of total-percent disability was related to an orthopaedic unfitting condition.
Long-term care of combat casualties would benefit from enhanced understanding of how combat injuries lead to permanent disability. Current applications of combat casualty care and planning for longer-term demands on the VA system depend on knowing which conditions persist following successful management of acute injury. We have provided a descriptive analysis of the unfitting conditions resulting from battle injuries that disqualify persons from continued service in a representative cohort of wounded service members and demonstrated that orthopaedicspecific conditions contribute heavily to permanent disability. Our findings are consistent with those of studies performed in civilian multitrauma populations. These studies have demonstrated that extremity injuries are among the most, if not the most, important influence on long-term outcome and return to work.8–10 The predominant influence of extremity injury on long-term disability persisted in wounded services members who were admitted with a primary diagnosis in other anatomic regions.
The cohort we studied, based on demographic information and injury mechanism, represents long-term disability outcomes of the group previously studied by Owens et al.1 The Owens cohort adequately represented the total combat-wounded population for the period studied. Our study may likewise be extended to the overall impact of disability resulting from the current conflicts. Masini et al3 demonstrated that 35% of battle-injured and evacuated service members were placed before the medical board. Of these, only 1% were able to return to duty. These percentages show that battle injuries are permanently decreasing US fighting strength.
Masini et al3 were the first to document the high cost of hospitalization and disability resulting from combat injuries. Their study demonstrated the tremendous resources required to manage extremity injuries. Although extremity injury accounted for 54% of all wounds, these injuries required 64% of resource utilization. However, this study relied on several assumptions that suggested that the impact of extremity injury was still being underestimated. At the time of the study by Masini et al,3 the PEB data for each injury were not accessible; thus, disability calculations were assigned to the anatomic region associated with the primary diagnosis for each respective hospital admission, which generally correlated with the primary diagnosis that necessitated evacuation from theater. Although the primary reason for evacuation from theater may be related to a primary injury to the abdomen, thorax, or head for some service members, the majority ultimately have a primary orthopaedic disqualifying condition (92%, 92%, and 56%, respectively). Thus, the cost of disability noted in the study by Masini et al3 that was attributed to extremity injury was slightly underestimated (69% versus 64%). A 5% difference may seem small, but that difference represents an underestimation in financial impact of orthopaedic disability benefits of $95 million.
The final disability attributed to head, thorax, and abdominal injuries is also inflated by eliminating psychiatric conditions. To our knowledge, ours is the first study to delineate specific conditions found at the final evaluation of physical disability. We demonstrated that psychiatric conditions make up 16% of permanent disability. We also demonstrated that the residual conditions from abdominal and chest injuries are far less frequent than previously thought. This finding suggests that those who survive abdominal and chest injuries are likely to make a complete or near complete recovery from these injuries. Head-injured patients account for approximately 29% of overall injury frequency and 20% of resource utilization. However, the effect of head injury remains high; 44% of the patients evacuated for a head injury have a head-related unfitting condition as the primary contributor to overall percent disability. The overall impact of extremity injuries is not as proportionally great in the head-injured patient, but extremity injuries account for most disabilities in head-injured patients (Table 10).
The breakdown of injuries by anatomic region has not previously been published in such detail. It is notable that some injury sites, such as the elbow, tend to be related to more than one unfitting condition per injury. This is not unanticipated, however. For example, elbow injury is commonly associated with nerve disability, elbow stiffness, and pain, each of which can cause disability. Lower extremity injuries make up the largest percentage of injury numbers (249 of 438) and unfitting conditions (275 of 502). Most injuries in these conflicts are caused by explosive projectiles; the lower extremities are usually most exposed to the shrapnel, and they account for the greatest body surface area.
This retrospective study offers a longitudinal account of an original large cohort, with high correlation of records as well as subject identification. Ours is the first effort to classify the unfitting conditions resulting from the current conflicts. The same group of combat casualties has been followed longitudinally from injury characterization to primary diagnosis at time of evacuation; we know the hospital costs associated with initial treatment and, now, the unfitting conditions that persisted after adequate treatment. Despite the general completeness of the PEB records, this study was subject to the limitations inherent in any record review. The narrative summary on which much of the clinical diagnoses for each unfitting condition were determined was often supplemented by an orthopaedic surgeon's addendum, but this was lacking in some cases, which limited our ability to classify the injury specifics any further.
These data are relevant to the civilian community, as well. Trauma is the second most expensive health care cost; it is responsible for nearly $300 billion per year in lost wages and productivity.11 Several studies have demonstrated that the sequelae of extremity injuries limit the ability of multiply-injured patients to return to work.12–14 Furthermore, complications related to their orthopaedic care may drive a poor overall health status outcome.15,16 The recent earthquake in Haiti highlights the burden of extremity injuries that can occur from a natural disaster. Handicap International estimates that >85% of injuries in the earthquake survivors are orthopaedic in nature (ie, fracture, amputation).17 It is difficult to predict the long-term disability and financial impact resulting from these injuries on Haiti's economy.17
It is important to know which conditions prevent the return of service members to active-duty service. The battle-related injuries serve as force subtractors that reduce combat effectiveness and result in lifelong disability. Further investigation is required to reduce disability and preserve the ability of US service members to serve the nation.
Investigations into wounding characteristics, resource utilization, and the specific injuries that ultimately disqualify service members from active duty demonstrate that musculoskeletal injuries are the most common and the most costly and that they create the greatest loss of fighting strength. Data on the civilian burden of musculoskeletal injury parallels our findings with respect to frequency of injury, resource utilization in total bed days, and disability in lost work days.18 Continued efforts are required to improve outcomes in orthopaedic care of musculoskeletal injuries.
1. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB: Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma
2. Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC: Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma
3. Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR: Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma
4. US Army Personnel Separations: Physical evaluation for retention, retirement, or separation. Army Regulations 635-40. Updated February 8, 2006. Available at: http://armypubs.army.mil/epubs/pdf/r635_40.pdf
. Accessed October 1, 2010.
5. US Army Medical Services: Standards of medical fitness. Army Regulations 40501. Updated December 14, 2007. Available at: http://www.army.mil/usapa/epubs/pdf/r40_501.pdf
. Accessed October 1, 2010.
6. US Army Medical Services: Patient administration. Army Regulations 2008. Available at: http://armypubs.army.mil/epubs/pdf/r40_400.pdf
. Accessed October 1, 2010.
7. Veterans Benefits Administration References: Book C, schedule for rating disabilities. Title 38 Code of Federal Regulations
.. Available at: http://www.warms.vba.va.gov/bookc.html
. Accessed October 1, 2010.
8. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation after legthreatening injuries. N Engl J Med
9. Czaja AS, Rivara FP, Wang J, et al: Late outcomes of trauma patients with infections during index hospitalization. J Trauma
10. Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB: Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project. J Trauma
11. Statement of the American College of Surgeons to the US House of Representatives Committee on Ways and Means: Health Care Reform in the 21st Century: Reforming the Health Care Delivery System. April 1, 2009. Available at: http://www.facs.org/ahp/testimony/testimony040109.pdf
. Accessed October 1, 2010.
12. Kivioja AH, Myllynen PJ, Rokkanen PU: Is the treatment of the most severe multiply injured patients worth the effort? A follow-up examination 5 to 20 years after severe multiple injury. J Trauma
13. MacKenzie EJ, Morris JA Jr, Jurkovich GJ, et al: Return to work following injury: The role of economic, social, and job-related factors. Am J Public Health
14. Read KM, Kufera JA, Dischinger PC, et al: Life-altering outcomes after lower extremity injury sustained in motor vehicle crashes. J Trauma
15. Stalp M, Koch C, Ruchholtz S, et al: Standardized outcome evaluation after blunt multiple injuries by scoring systems: A clinical follow-up investigation 2 years after injury. J Trauma
16. van der Sluis CK, Eisma WH, Groothoff JW, ten Duis HJ: Long-term physical, psychological and social consequences of severe injuries. Injury
17. Handicap International: Preliminary findings about person with injures: Haiti Earthquake 12 January 2010. Published January 29, 2010. Available at: http://www.operationgivingback.facs.org/stuff/contentmgr/files/f3c4e87c7ceca489d3197cab5d6de592/miscdocs/pinternational_preliminaryfindingsaboutinjuries_1feb2010.pdf
. Accessed October 1, 2010.
18. American Academy of Orthopaedic Surgeons: The Burden of Musculoskeletal Diseases in the United States:
2008. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2008. Available at: http://www.boneandjointburden.org
. Accessed October 1, 2010.