Injuries from terrorist attacks in the extremities can be caused by penetrating wounds due to hand guns or, rifle bullets or debris fragments from bombs, shells, mines or grenades. If uncomplicated they show a small entry or exit wound with clean soft tissue tracks and little or no devitalization of tissues; other wounds can be associated with open fractures, nerve or vascular injury. Finally other wounds can be the result of the explosive blast; the maximum damage caused by these explosions is by the blast shock wave to the part of the body in which it is in contact. However, blast air pressure can also cause thermal injury, tattooing of tissues and fragment wounds away from the main side of the blast. Multiple injuries in different parts of the body are common but limb injuries predominate.

Traumatic limb amputations by the primary blast injury are rare in survivors because for such a strong mutilating impact, the victim is highly likely to sustain associate injuries that prove fatal, and consequently during triage at the site of the bombing a limb amputation is suggestive of other serious injuries. (1)

Lower limb amputation caused by the explosive blast shows a significant tendency to happen through the upper third of the tibia, in the region of the tibial tuberosity. The main joints are infrequent sites of amputation because the fracture occurs from the resulting axial stresses in the bone, prior to limb flailing from the gas flow over the limb. The gas flow completes the amputation.(2)

Of special interest are the foot injuries caused by anti-personnel mines, which usually affects the calcaneal region. Anti-personnel mines affect the forefoot and/or the heel tending to incapacite rather than kill. Usually we deal with larger tissue loss, both of skin coverage and pedal bone (mostly calcaneus).(3)

A fracture of the calcaneus is used to illustrate this kind of injury. Calcaner fractures are divided into intra-articular (involving the subtalar joint) or extra-articular. The Essex-Lopresti classification of intra-articular fractures has become widely accepted, dividing them into major groups; in both groups the inferiorly protruding lateral process of the talus is jammed into the superiorly displacing calcaneus during impact cracking the calcaneus in a dorsal-plantar direction. The intra-articular fracture Type 5 (involving the subtalar joint with comminution and central depression is the most common fracture in mine injuries).(4)

REFERENCES

1. Calderwood JW: Analysis of fractures treated in the Royal Victoria Hospital, Belfast, In l972, with special reference to gunshot wounds and bomb blast injuries. Injury, l975:6:296-305.

2. Hull JB, Bower GW, Cooper GJ, Crane J: Pattern of Injury in Those Dying from Traumatic Amputation Caused by Bomb Blast, British Journal of Surgery l994, 81, 1132-1135.

3. Wertheimer B, Lovric Z, Candrlic K, et al: Foot Injuries Caused by Anti-Personnel Mines., Military Medicine, 160, 4:177, l995.

4 Essex-Lopresti, P: The Mechanism, Reduction Technique, and Results in Fractures of the Os Calcis, Br. J. Surg., 39:395-419, l952.