Pictorial Review of Radiographic Patterns of Injury in Modern Warfare: Imaging the Conflict in Afghanistan

Initial radiographic assessment of a casualty in a trauma bay at the Role 3 Hospital, Kandahar Airfield.

Typical computed tomography protocol for assessment of improvised explosive device strike injuries.

Pulmonary barotrauma. Patchy air-space opacities in the right lung are easily seen on radiographs (A), but associated pneumatoceles (arrows) are better demonstrated on computed tomography (B).

Shrapnel wounds and pulmonary barotrauma suffered by the occupant of an armored vehicle hit by a suspected antitank weapon. (A) Despite only 1 visible shrapnel fragment in the soft tissues (circle), the orthopaedic surgeon reported innumerable carbon filaments embedded in bone and throughout the posterior compartment muscles during exploration. These could not be seen on retrospective review of the imaging. (B) A small focus of right perihilar air-space disease (arrow) is secondary to barotrauma.

Widespread pulmonary barotrauma of another individual involved in the same suspected antitank weapon strike as depicted in Figure 4. Note the absence of rib fractures or pneumatoceles, despite widespread air-space involvement. Minimal hemoptysis was reported in the intensive care unit.

Penetrating, posterior head injury by metallic fragments. Metal lies immediately adjacent to the sagittal sinus (arrow) (A), with bone fragments driven into the deep white matter of the left parietal lobe (B). The patient eventually succumbed to widespread cerebral venous infarction secondary to sagittal sinus injury.

Bolts as improvised explosive device projectiles. (A) This patient was struck by several scrap metal pieces, some still recognizable as hardware on the chest radiograph (circle and arrow). (B) The computed tomography shows 1 bolt embedded in the posterior paraspinal muscles and another to have entered the pleural space from posterior; the latter passed through both diaphragm and spleen, crossing the diaphragm again, finally coming to rest as a free body in the pleural space.

Gravel as projectiles. Because improvised explosive devices are often buried at the roadside, mineral fragments frequently are seen in large numbers. The density of these projectiles is less than that of metal on both radiographs (A) and computed tomography (B), but their effects on the body are much the same.

Shrapnel and/or fragment injury in a pediatric patient. (A) The metal fragment lying just beneath the skin (circle) had entered the abdomen from posterior. (B) Thickened loops of small bowel (arrow) and small locules of free gas (arrowhead) are indicators of intestinal perforation, confirmed on laparotomy.

Victim of an improvised explosive device blast. Traumatic bilateral lower leg amputations at the level of the knee (A, B), pubic rami fractures (C, D), sacral fracture (arrow, E), and extension teardrop fracture of C2 (arrowhead, F).

This victim of an improvised explosive device blast suffered an L2 compression fracture (A, B) and severe pelvic injuries (C). Note the widened symphysis pubis and right sacroiliac joint (arrow) (C), in addition to right pubic rami and femoral fractures.

Typical severe, bilateral lower limb injuries from an improvised explosive device strike on an unarmored vehicle (A, B, and C). (A) Note the application of 2 below-knee tourniquets (arrows). In North America, extensive injuries such as these might be treated with amputation and individually engineered prostheses. Because of cultural and religious beliefs, some Afghan patients refuse amputation, despite facing the prospect of death from gangrene.

A victim of an improvised explosive device strike on a civilian vehicle. Severely comminuted hindfoot injuries seen on radiograph (A) and coronal computed tomography reconstructions (B). (C) Patchy air-space opacities on initial chest radiograph are from associated barotrauma.

Improvised explosive device strike injuries suffered by a passenger riding in a lightly armored HUMVEE. Right supraorbital skull fracture (arrow) (A); bilateral pneumothoraces (B); thoracic spine fractures at T7 and T10 (C, D); and complex left knee injury with anterolateral tibial plateau, fibular head (arrowhead) (E), and posterior cruciate ligament avulsion fractures (open arrows) (E, F). Not shown are multiple brain contusions and superior mediastinal hematoma from venous injury.

Improvised explosive device strike injuries inflicted on a soldier who was inside an armored fighting vehicle. Ankle fracture-dislocation (A), femoral fracture (B), thoracic vertebral endplate fracture (C), typical splenic laceration (arrow) (D), and right mandibular fractures (arrowheads) (E, F). Mandibular fractures may result when the head (with the added weight of a helmet) flexes forward as the body is thrust upward by the blast; the jaw makes abrupt contact with the upper edge of the body armor's ceramic breastplate.

Nonsurvivable high-velocity projectile injury. The projectile grazed this patient's skull and carved a regular, superficial defect in the left frontal vertex (arrow) (A), with bone fragments driven deep into the brain (B, C). Note the associated right frontal skull fracture (arrowhead) (B) and intraventricular blood (open arrow) (D). Surgical exploration confirmed gross disruption of the anterior sagittal sinus.

Spine injury caused by a high-velocity bullet wound. The projectile passed through the retroperitoneal tissues and destroyed the posterior elements at L3-4 (arrows) but left no metal fragments behind. Although the injury is below the level of the conus, the patient was left with profound lower limb neurologic deficits.

Facial fractures from a high-velocity gunshot wound. The projectile passed through both maxillary sinuses (arrows) (A), between the hard palate and orbital floors (B). Although there is obvious disruption of all adjacent osseous structures, the eyes miraculously escaped injury.

Nonsurvivable high-velocity projectile injury. (A) The undeformed, partially jacketed bullet is visible in the left supraclavicular soft tissues. It had entered through the left mandible (B) and fractured the C2 vertebral body (C) after it traversed the upper airway. Widespread anoxic injury (D) resulted from soft-tissue injury and airway occlusion. Metal fragments in the neck (B, C) represent dental amalgam from fractured teeth, not bullet jacket fragments.

High-velocity bullet and “soft” adolescent bone. The bullet passed through the relatively soft infratrochanteric femur (circle) (A), from anterior to posterior; note the few cortical fragments at the bony exit site (arrow) (B). (C) A regular tunnel-defect carved through the femur (arrowhead) was confirmed at surgery.

Femoral fracture and arterial injury by high-velocity projectile. In contrast to the patient in Figure 20, the harder adult mid femur was fractured through direct injury (A), with laceration of the distal deep femoral artery by bone fragments (arrow) (B). At surgery, devitalized muscle extended for several centimetres on either side of the projectile path.

A high-velocity gunshot wound that involved the peripheral chest and abdomen. Chest radiograph and computed tomography demonstrate numerous metal fragments along the projectile's path through the right anterior ribs and thoracic cavity (arrows) (A, B). (C) The right lobe of the liver is filled with metal fragments dispersed through broad areas of nonenhancing parenchyma. (D) The large exit wound contains herniated colon, liver, and gallbladder. These images hint at the lethality of central torso injuries caused by assault weapons.

(A) Neck injury from a nearly spent rifle bullet. A computed tomography angiogram shows the bullet entered the left anterior neck (arrow) (B) and lodged against the vertebral artery (C), without injuring either the carotid or jugular vessels.

A 9-mm pistol gunshot wound. The bullet's final location is easily visible on the chest radiograph (circle) (A), as is the pneumothorax. (B) The bullet initially entered the posterior midline neck (entry point was not seen on initial clinical survey), fracturing the C3 spinous process as it travelled down and anterior (arrows). (C) The bullet then fractured the clavicle (arrowhead) before deflecting inward to break the right second and third anterior ribs (not shown) before entering the chest. (D) The radiographically intact bullet in the posterior sulcus had tunneled beneath the sternocleidomastoid fascia, yet retained enough kinetic energy to break clavicle and ribs. No major vascular injury resulted.