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Original Article
One year of treating patients with open fractures of the lower extremity in a new military trauma center in Korea: a case series
Ji Wool Ko, MD1orcid, Giho Moon, MD2orcid, Jin Geun Kwon, MD3orcid, Kyoung Eun Kim, MD4orcid, Hankaram Jeon, MD5orcid, Kyungwon Lee, MD1orcid
Journal of Trauma and Injury 2023;36(4):376-384.
DOI: https://doi.org/10.20408/jti.2023.0041
Published online: December 19, 2023
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1Department of Surgery, Korea University Guro Hospital, Seoul, Korea

2Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, Korea

3Department of Plastic Surgery, Armed Forces Capital Hospital, Seongnam, Korea

4Department of Rehabilitation, Armed Forces Capital Hospital, Seongnam, Korea

5Department of Psychiatry, Armed Forces Capital Hospital, Seongnam, Korea

Correspondence to Kyungwon Lee, MD Department of Surgery, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea Tel: +82-31-789-2814 Email: enmma23@gmail.com
• Received: June 14, 2023   • Revised: August 20, 2023   • Accepted: September 11, 2023

Copyright © 2023 The Korean Society of Traumatology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • Purpose
    The Armed Forces Trauma Center of Korea was established in April 2022. This study was conducted to report our 1-year experience of treating soldiers with open fractures of the lower extremity.
  • Methods
    In this case series, we reviewed the medical records of 51 Korean soldiers with open fractures of the lower extremity between April 2022 and March 2023 at a trauma center. We analyzed patients with Gustilo-Anderson type II and III fractures and reported the duration of transportation, injury mechanisms, injured sites, and associated injuries. We also presented laboratory findings, surgery types, intensive care unit stays, hospital stays, rehabilitation results, and reasons for psychiatric consultation. Additionally, we described patients’ mode of transport.
  • Results
    This study enrolled nine male patients who were between 21 and 26 years old. Six patients had type II and three had type III fractures. Transport from the accident scene to the emergency room ranged from 75 to 455 minutes, and from the emergency room to the operating room ranged from 35 to 200 minutes. Injury mechanisms included gunshot wounds, landmine explosions, grenade explosions, and entrapment by ship mooring ropes. One case had serious associated injuries (inhalation burn, open facial bone fractures, and hemopneumothorax). No cases with serious blood loss or coagulopathies were found, but most cases had a significant elevation of creatinine kinase. Two patients underwent vascular reconstruction, whereas four patients received flap surgery. After rehabilitation, six patients could walk, one patient could move their joints actively, and two patients performed active assistive movement. Eight patients were referred to the psychiatry department due to suicidal attempts and posttraumatic stress disorder.
  • Conclusions
    This study provides insights into how to improve treatment for patients with military trauma, as well as medical services such as the transport system, by revising treatment protocols and systematizing treatment.
Background
Korea has been in a state of ceasefire for 70 years since the end of the Korean War in 1953. The Korean military maintains 500,000 soldiers, accounting for about 1% of the Korean population in the present day [1]. Accidents such as landmine explosions, gunshots, and falls during training can occur in the military. Lower extremity injuries are especially common in the military due to soldiers’ training and exercise to maintain their physical condition. Patients with lower extremity injuries are usually hospitalized for a long time because their activity level is limited [2]. In addition, severe lower extremity injuries occasionally occur. Those with multiple severe injuries often show unstable vital signs and undergo repeated operations with considerable complications and psychological problems [3].
Objectives
The Armed Forces Trauma Center (AFTC; Seongnam, Korea) was established in April 2022. This study was conducted to report our 1-year experience of treating patients (soldiers) with open fractures of the lower extremity. In addition, the clinical processes of treating these patients were described in detail.
Ethics statement
This study was approved by the Institutional Review Board of Armed Forces Capital Hospital (No. AFCH 2023-04-001). The requirement for informed consent was waived due to the retrospective nature of the study.
Study design

Data collection

In this observational study (case series), we reviewed the medical records of 51 Korean soldiers with open fractures of the lower extremity between April 2022 and March 2023 at a single trauma center.

Criteria and variables

After categorizing the severity using the Gustilo-Anderson classification, we analyzed patients with type II and III fractures (Fig. 1) [4]. The process of transporting patients was described as time elapsed from the accident scene to the emergency room (ER) and from the ER to the operating room (OR). We analyzed the patients’ injury mechanisms, injured sites, types of surgery performed, associated injuries, and clinical processes. The injury mechanisms included gunshot wounds, landmine explosions, grenade explosions, being crushed under a vehicle wheel, being trapped by mooring ropes, and falls. We classified the injured sites as pelvis, thigh (femur), knee, calf (tibiofibular), ankle, and foot. The surgeries performed were bony fixation, vascular reconstruction, and performing flap. We also reported the associated injuries of these patients and calculated the Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS) for each case. We presented the initial laboratory findings upon arrival at the ER and clinical processes such as intensive care unit (ICU) stays, hospital stays, rehabilitation results, and reasons for referral to the psychiatry department for consultation.
Processes for responding to military trauma patients

Transportation system for trauma patients in the Korean military

Almost all military servicepersons who require transportation to a hospital are immediately reported to the Medical Emergency Operation Center (MEOC) under the Korean Armed Forces Medical Command (Fig. 2). The MEOC offers on-site counseling and treatment, determines the appropriate hospital (military or civilian) for patients, and prepares a transport strategy using military or civilian vehicles or helicopters. Among them, patients with traumatic injuries requiring surgical or intensive management are usually transported to the AFTC after discussion with the MEOC.
Fig. 3. shows the field triage protocol for trauma patients. Patients with minor injuries are transported to military hospitals under corps. Ultra-emergency patients who have an unstable airway, severe shock, and traumatic arrest (Fig. 4) are transported to the nearest military hospital for initial resuscitation. The helicopters depart at the same time, and then patients are re-transported to the AFTC after resuscitation. Exceptionally, by the MEOC decision, patients are sometimes transported to the nearest civilian trauma center. Patients with major injuries (Fig. 5) are also transported to the AFTC.

AFTC workforce and building structure

A total of 11 trauma surgeons work in the AFTC. Four are military officers, six are civilians who were dispatched from a cooperative hospital, and one is a civilian surgeon employed by the military. This center is part of the biggest military hospital in Korea, with 666 beds and 130 doctors (excluding residents). Physicians affiliated with this military hospital support the AFTC, including surgeons (thoracic, orthopedic, plastic, vascular, hepatobiliary, and neurosurgeons), interventionists, anesthesiologists, cardiologists, pulmonologists, neurologists, physiatrists, psychiatrists, and so on.
The AFTC is a three-story building with a helipad on the roof, which is designated as the shortest distance by foot (Fig. 6A). The ground floor includes a trauma ER with two resuscitation rooms (Fig. 6B), a computed tomography (CT) room, a magnetic resonance room, and an intervention room. The first floor includes offices and educational rooms. The second floor includes a trauma OR (Fig. 6C), a general ward for trauma patients with 60 beds, and a trauma ICU (TICU) with 20 beds (Fig. 6D).

AFTC treatment protocols

One or more trauma surgeons are on duty all the times in the AFTC. Trauma surgeons respond to patients’ arrival at the trauma ER, apply critical care in the TICU, participate in surgery, and operate the trauma general ward. When the MEOC contacts the AFTC trauma team leader (a trauma surgeon) for patient transportation, the team leader decides whether to accept the patient, and then whether to activate the trauma team following standard criteria (Fig. 7). The trauma team consists of trauma surgeons (including the trauma team leader), trauma ER nurses, emergency medical technicians, radiology technicians, and security guards. The trauma team leader can also call for additional staff affiliated with the supporting military hospital, such as surgeons from other departments, anesthesiologists, and interventionists. When trauma patients arrive at the AFTC, trauma surgeons assess and resuscitate them if needed, together with trained nurses assigned to the trauma ER. They then discuss the treatment plan with supporting staff members. In the trauma ER, protocols are in place for CT scans, transfusion, laboratory studies, and performing necessary procedures.
Table 1 shows the transportation processes of patients from the accident site to the AFTC ER, along with their demographics. This study included nine male patients aged between 21 and 26 years old. Five patients were transported directly to the AFTC (cases 1, 2, 4, 5, 7), and four patients (cases 3, 6, 8, 9) were transferred to the center through another hospital. Military trauma patients can be transported in four ways: military helicopter, military ambulance, public helicopter, public ambulance. In this study, four patients were transported by military helicopter, four patients by military ambulance, and one patient by public helicopter. The time it took to transport patients from the accident scene to the AFTC ER ranged from 75 minutes (case 4) to 455 minutes (case 9), and from the ER to the OR ranged from 35 minutes (case 4) to 200 minutes (case 6). Cases that went through another hospital (cases 4, 6, 8, 9) took more time to transport. Among them, military-specific injuries included gunshot wounds (cases 1, 3), landmine explosions (cases 2, 5) (Fig. 8AC), a grenade explosion (case 4), and entrapment by a warship’s mooring ropes (case 7) (Fig. 8DF). The foot was the most common site of injury, and only one patient (case 4) had serious associated injuries (namely, an inhalation burn, open facial bone fractures, and hemopneumothorax with multiple rib fractures). Systolic blood pressure, ISS, Revised Trauma Score, and TRISS were not unusually low except in one case (case 4).
Table 2 displays the initial laboratory findings upon arrival at the ER. No cases with serious blood loss (hemoglobin, <7.0 g/dL) or coagulopathies were found. Most cases showed a significant elevation of creatinine kinase (316–2,876 IU/L), except for cases 3 and 5, which were within normal range.
Table 3 shows the operative methods used. The patients in cases 4 and 7 underwent vascular reconstruction, and the patients in cases 2, 4, 5, and 7 received external fixation during their initial surgery. The patients in cases 4, 5, 7, and 8 underwent flap surgery.
Table 4 shows hospitalization-related variables. Case 4, a patient with multiple injuries, remained in the ICU for 169 days due to requiring long-term ventilator care and management of serious infections. Patients who required rehabilitation for an extended period were hospitalized for more than 16 weeks (cases 1, 2, 4, 5, 7, 8, 9). The results of rehabilitation were as follows: the patients in cases 1, 2, 3, 6, 8, and 9 were able to walk; the patient in case 5 was able to perform active joint movements; and the patients in cases 4 and 7 were able to perform active assistive joint movements. Eight patients in this study required referral to the psychiatry department. Four of these patients had suicidal ideation; those patients had injuriess caused by suicide attempts (cases 3, 4, 8, and 9). Their suicidal ideation were addressed following the accidents. All eight patients had posttraumatic stress disorder (PTSD).
Transportation processes
When a patient with traumatic injuries (or other serious illness) occurs, the military tries to choose the fastest transportation method. Helicopters are very useful for the military because military camps are scattered throughout the country. However, helicopter operations are limited by inclement weather, including rainy, snowy, severely windy, and foggy conditions. Additionally, military helicopters are not able to operate near the ceasefire line, since it could cause military tension. When it is difficult for the MEOC to operate a helicopter and when they suspect that a patient’s injury is serious, they arrange transportation to a nearby military or civilian hospital. After evaluation and (if needed) resuscitation, MEOC discusses the situation with AFTC medical staff and decides whether to transfer the patient to the AFTC.
Characteristics of military trauma
Several cases in this study included military-specific injuries unusual in civilian society, such as gunshot wounds, landmine explosions, grenade explosions, and entrapment by a warship’s mooring ropes. Additionally, there were cases of military-specific injuries caused by pinching a foot between a cannon and a cannonball, crashing a parachute, and falling from a military helicopter. These cases occurred during the study period but were excluded since they involved closed fractures of the lower extremity. Crashing injuries caused by heavy military equipment, such as moving tanks, cannons, helicopters, and warships, should be taken seriously. In addition, the medical staff of a military trauma center should understand the characteristics of various weapons. For example, even blank cartridge shot can cause severe injury due to the gunpowder blast and projectile gas [5,6]. Grenade explosions can cause whole-body injury by countless fragments with burns, including to the airway [7].
No case of serious blood loss (hemoglobin, <7.0 g/dL) and coagulopathy was observed in this study because military medical officers were able to control bleeding well at the accident scenes. Additionally, the AFTC ICU, which is separated into single-occupancy rooms, could help patients maintain a comfortable state and enable monitoring of possible self-injury and abnormal behaviors. Patients with suicidal attempts or a concerning level of PTSD who require repeated surgery are admitted to the ICU until ready for a closed psychiatric ward or until their psychiatric problems become less concerning.
Treatment strategies for open fractures in lower extremities
Trauma patients should be considered in two aspects: (1) the severity of the injured site; and (2) possible life-threatening associated injuries. Aspects of the military context contribute to fractures in many patients. This is natural because soldiers undergo high-intensity training, exercise regularly, and often participate in hazardous tasks such as landmine removal. Most patients experience minor injuries, but some cases are very serious, such as limb injuries with degloving, severe associated injuries, or both [8,9]. Many cases involve injuries from which patients find it difficult to achieve a full recovery. The treatment of these patients requires a strategy consisting of several steps.
The first step is to decide whether to salvage or sacrifice the injured leg. Trying to salvage the injured limb may require repeated operations, cause serious complications (such as infection, thrombosis, and chronic pain), impose a huge financial burden, and delay rehabilitation. For many patients with severe leg injuries, amputation might be a better option [10,11]. Patients admitted to the AFTC have their medical expenses covered by the military, and most soldiers, such as military officers and sergeants who suffered disabilities from accidents on duty, can keep their jobs postinjury and are paid during the treatment period. Therefore, we tried our best to salvage the leg in each case, since we could focus on saving the leg without worrying about time or cost [12]. In this study, no cases involved amputation of a lower limb.
The second step is to manage concurrent injuries that could have adverse effects. Life-threatening injuries such as those affecting the brain, heart, lungs, liver, and large vessels are treated with priority.
The third step is to perform surgery. OR decisions were made according to the injury mechanism, injured site, general condition, and the surgeon’s experience, including their skill level [13,14]. During operations, surgeons must solve problems such as vascular reconstruction, muscle repairing, and overlapping skin defects. The most crucial point for surgeons is planning. Surgeons should plan what may be feasible, up to a certain limit of reconstruction, if the injury is too serious to permit a full recovery. In particular, landmine explosions can cause serious intimal injuries that make it difficult to reconstruct vascular structures and create flaps for covering defective tissue. We tried to salvage limbs as much as possible, since most patients in this study were young, otherwise healthy soldiers.
The fourth step is to perform rehabilitation, which may take a long time [15,16]. The timing for initiating rehabilitation depends on many factors such as how the fracture heals, the fixation method, and how related ligaments heal. The rehabilitation process typically begins with restrictive weight bearing, followed by a range of motion evaluation, continuous passive motion, and finally muscle strengthening exercises [17]. Appropriate pain control is needed across the rehabilitation period. Moreover, addressing psychological problems is the most difficult part of recovery [1820]. Many patients have PTSD, and a psychiatrist’s active involvement is required if the cause of injury is self-harm or a suicidal attempt. In conclusion, management of lower extremity injuries requires complex processes. This study has shown our experiences and management policy for lower extremity injuries in a new military trauma center, which could be useful for other trauma centers that manage lower extremity injuries.
Strengths and limitations
The strengths of this study include its analysis of data based on a specialized transporting system and treatment strategies for military trauma patients. We were able to observe the entire period of treatment from initial ER management to rehabilitation. However, this study has several limitations. First, the volume of the data was small because the AFTC was established only 1 year ago. Second, it is difficult to evaluate the relevance of intensive care, since there was only one case (case 4) with life-threatening associated injuries.
Conclusions
This study showed the experiences of treatment in patients with lower extremity injuries in the military. We hope that the study may help improve treatment in patients with military trauma, as well as improve military medical services such as the transport system, in order to revise treatment protocols and systematize treatment during hospitalization.

Author contributions

Conceptualization: KL; Data curation: all authours; Formal analysis: JWK, KL; Investigation: all authours; Methodology: KL; Project administration: KL; Visualization: JWK, KL; Writing–original draft: JWK, KL; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.
Flow diagram of the patient selection and exclusion process.
jti-2023-0041f1.jpg
Fig. 2.
The Medical Emergency Operation Center under the Korean Armed Forces Medical Command.
jti-2023-0041f2.jpg
Fig. 3.
Field triage protocol in the Korean military.
jti-2023-0041f3.jpg
Fig. 4.
Field triage protocol: ultra-emergency. The Medical Emergency Operation Center evaluates patients’ severity and decides where to direct them. GCS, Glasgow Coma Scale; AVPU, alert, voice, pain, unresponsive; SBP, systolic blood pressure.
jti-2023-0041f4.jpg
Fig. 5.
Field triage protocol: major injury. The Medical Emergency Operation Center (MEOC) evaluates patients’ severity and decides where to direct them. SBP, systolic blood pressure; GCS, Glasgow Coma Scale.
jti-2023-0041f5.jpg
Fig. 6.
The Armed Forces Trauma Center (Seongnam, Korea). (A) Three-story building with a helipad on the roof, which is designated as the shortest line of foot. (B) The ground floor includes two resuscitation rooms in trauma emergency room. (C, D) The second floor includes a trauma operation room and a trauma intensive care unit.
jti-2023-0041f6.jpg
Fig. 7.
Trauma team activation criteria. ROSC, return of spontaneous circulation; GCS, Glasgow Coma Scale.
jti-2023-0041f7.jpg
Fig. 8.
Images of cases 5 and 7. (A–C) Case 5. (A) Injury causing by entrapment by mooring ropes of warship. (B) Fixation during the first surgery. (C) After performing flap surgery. (D–F) Case 7. (D) Leg injury causing by entrapment by mooring ropes of warship. (E) Fixation. (F) After performing flap surgery.
jti-2023-0041f8.jpg
Table 1.
Patients’ transportation processes and characteristics
Case no. Age (yr) Sex Transferred from another hospital Mode of transport Elapsed time (min)
Injury mechanism Injured site Severitya) Associated injury SBP (mmHg) ISS RTS TRISS (%)
From accident site to AFTC ER From ER to OR
1 22 Male No Military ambulance 305 85 Gunshot Foot II None 124 4 7.550 98.40
2 22 Male No Military helicopter 115 80 Landmine explosion Ankle, foot II Multiple lacerations 144 5 7.841 99.58
3 26 Male Military hospital Military helicopter 120 75 Gunshot Foot II None 162 4 7.841 99.28
4 24 Male No Military helicopter 75 35 Grenade explosion Foot, bilateral IIIc Inhalation burn, open facial bone fractures, hemopneumothorax with multiple rib fractures 96 50 7.841 84.74
5 23 Male No Military helicopter 85 40 Landmine explosion Ankle, foot IIIb None 114 4 7.841 99.61
6 21 Male Civilian hospital Military ambulance 405 200 Crushed under vehicle wheel Foot II None 143 4 7.841 99.61
7 25 Male No Public helicopter 135 70 Trapped by mooring ropes Calf (tibiofibular) IIIc Rib fracture, multiple lacerations 83 11 7.108 98.76
8 23 Male Civilian hospital Military ambulance 390 70 Fall Thigh (femur), ankle, foot II Multiple lacerations 115 10 7.841 99.12
9 21 Male Civilian hospital Military ambulance 455 90 Fall Foot II Lumbar spine compression fracture 120 13 7.841 99.19

AFTC, Armed Forces Trauma Center; ER, emergency room; OR, operation room; SBP, systolic blood pressure; ISS, Injury Severity Score; RTS, Revised Trauma Score; TRISS, Trauma and Injury Severity Score.

a) Gustilo-Anderson classification.

Table 2.
Initial laboratory findings in the emergency room
Case no. WBC (103/μL) Hemoglobin (g/dL) Platelet (103/μL) Prothrombin time (INR) Lactate (mmol/L) Creatinine kinase (IU/L)
1 17.59 13.2 261 1.01 1.5 348
2 10.17 12.5 228 1.15 1.8 316
3 6.73 13.5 361 1.00 1.4 99
4 42.99 11.3 295 1.17 9.0 2,836
5 13.29 12.3 167 1.08 4.8 93
6 11.19 15.3 268 1.03 1.1 690
7 9.55 9.6 60 1.32 3.9 572
8 23.33 13.3 247 1.11 3.2 1,039
9 18.11 11.9 215 1.15 1.7 759

WBC, white blood cell; INR, international normalized ratio.

Table 3.
Operative methods
Case Open fractured site Cause of injury Vascular reconstruction External fixation during initial surgery Internal fixation Flap
1 Right foot Gunshot wound No No Yes No
2 Left ankle and foot Landmine explosion No Yes Yes No
3 Left foot Gunshot wound No No Yes No
4 Both feet Grenade explosion Yes (PTA, right) Yes Yes Yes
5 Right ankle and foot Landmine explosion No Yes Yes Yes
6 Left foot Crushed under vehicle wheel No No Yes No
7 Right calf (tibiofibular) Trapped by warship’s mooring ropes Yes (ATA) Yes Yes Yes
8 Left thigh (femur), ankle, and foot Fall No No Yes Yes (foot)
9 Right foot Fall No No Yes No

PTA, posterior tibial artery; ATA, anterior tibial artery.

Table 4.
Hospitalization-related variables
Case no. Length of stay (day)
Results of rehabilitation Reason for psychiatric consultation
Intensive care unit Hospitala)
1 13 216 Able to walk PTSD
2 4 243 Able to walk PTSD
3 4 46 Able to walk Suicide attempt, PTSD
4 169 335 Active assistive joint movement Suicide attempt, PTSD
5 29 >271b) Active joint movement PTSD
6 0 70 Able to walk None
7 13 >181b) Active assistive joint movement PTSD
8 13 >132b) Able to walk Suicide attempts, PTSD
9 11 130 Able to walk Suicide attempts, PTSD

PTSD, posttraumatic stress disorder.

a) Hospital stays were recorded until August 20, 2023.

b Still hospitalized.

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