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
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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
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8. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation after legthreatening injuries. N Engl J Med
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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
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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
© 2011 by American Academy of Orthopaedic Surgeons
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
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