Publications
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Ramasamy A, Hill AM, Masouros S, et al., 2013, Outcomes of IED foot and ankle blast injuries., J Bone Joint Surg Am, Vol: 95
BACKGROUND: Improvements in protection and medical treatments have resulted in increasing numbers of modern-warfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome. METHODS: U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms. RESULTS: Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors of amputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury, and only nine (14%) of the service members were fit to return to their preinjury duties. CONCLUSIONS: This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rate and frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population.
Durrant JJ, Ramasamy A, Salmon MS, et al., 2013, Pelvic fracture-related urethral and bladder injury, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 159, Pages: 32-39, ISSN: 0035-8665
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- Citations: 14
Ramasamy A, Cooper GA, Sargeant ID, et al., 2013, (i) An overview of the pathophysiology of blast injury with management guidelines, Orthopaedics and Trauma, Vol: 27, Pages: 1-8, ISSN: 1877-1327
Explosive weapons remain the leading cause of death, injury, and disability to combatants in battle. Recent conflicts in Iraq and Afghanistan have seen considerable advances in the surgical knowledge and skills needed to save life and limb of multiply injured casualties. Global terrorism has seen explosive weapons move from battlefield to urban centres, often with devastating effects.Orthopaedic training prepares for the management of general civilian trauma scenarios, but blast injury pathophysiology and management is rarely considered. It is important that future trauma surgeons have a working knowledge of blast injury and how it affects the musculoskeletal system so that they can manage such patients. © 2013 .
Ramasamy A, Hughes A, Carter N, et al., 2013, The effects of explosion on the musculoskeletal system, Trauma, Vol: 15, Pages: 128-139, ISSN: 1460-4086
Explosions remain the leading cause of death and injury to combatants in conflict. The current ‘Global War on Terror’ has resulted in a shift of explosive-related injuries from the battlefield into civilian centres. Despite musculoskeletal injuries being the most common injury witnessed in blast, there remains little research into the effects of blast on this system. In order to develop new treatment regimens and mitigation systems, there is a requirement to have a better understanding of skeletal trauma in this unique environment. The aim of this review article is to deconstruct the complex injury mechanisms witnessed in blast and relate them to its effects on the musculoskeletal system. © 2013, SAGE Publications. All rights reserved.
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- Citations: 6
Ramasamy MA, Hill AM, Phillip R, et al., 2013, FASS is a Better Predictor of Poor Outcome in Lower Limb Blast Injury Than AIS: Implications for Blast Research, JOURNAL OF ORTHOPAEDIC TRAUMA, Vol: 27, Pages: 49-55, ISSN: 0890-5339
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- Citations: 6
Newell N, Masouros SD, Ramasamy A, et al., 2012, Use of cadavers and anthropometric test devices (ATDs) for assessing lower limb injury outcome from under-vehicle explosions, 2012 IRCOBI Conference Proceedings - International Research Council on the Biomechanics of Injury, Pages: 296-303
Lower extremities are particularly susceptible to injury in an under-vehicle explosion. Operational fitness of military vehicles is assessed through anthropometric test devices (ATDs) in full-scale blast tests. The aim of this study was to compare the response between the Hybrid-III ATD, the MiL-Lx ATD and cadavers in our traumatic injury simulator, which is able to replicate the response of the vehicle floor in an under-vehicle explosion. All specimens were fitted with a combat boot and tested on our traumatic injury simulator in a seated position. The load recorded in the ATDs was above the tolerance levels recommended by NATO in all tests; no injuries were observed in any of the 3 cadaveric specimens. The Hybrid-III produced higher peak forces than the MiL-Lx. The time to peak strain in the calcaneus of the cadavers was similar to the time to peak force in the ATDs. Maximum compression of the sole of the combat boot was similar for cadavers and MiL-Lx, but significantly greater for the Hybrid-III. These results suggest that the MiL-Lx has a more biofidelic response to under-vehicle explosive events compared to the Hybrid-III. Therefore, it is recommended that mitigation strategies are assessed using the MiL-Lx surrogate and not the Hybrid-III.
Masouros SD, Newell N, Bonner TJ, et al., 2012, A standing vehicle occupant is likely to sustain a more severe injury than one who has flexed knees in an under-vehicle explosion: A cadaveric study, 2012 IRCOBI Conference Proceedings - International Research Council on the Biomechanics of Injury, Pages: 289-295
The lower limb of military vehicle occupants has been the most injured body part due to undervehicle explosions in recent conflicts. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested 4 different occupant postures (seated, brace, standing, standing with knee locked in hyper-extension) in a simulated under-vehicle explosion (solid blast) using our traumatic injury simulator in the laboratory; we hypothesised that occupant posture would affect injury severity. No skeletal injury was observed in the specimens in seated and braced postures. Severe, impairing injuries were observed in the foot of standing and hyper-extended specimens. These results demonstrate that a vehicle occupant whose posture at the time of the attack incorporates knee flexion is more likely to be protected against severe skeletal injury to the lower leg.
Ramasamy A, Evans S, Kendrew JM, et al., 2012, The open blast pelvis THE SIGNIFICANT BURDEN OF MANAGEMENT, JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME, Vol: 94B, Pages: 829-835, ISSN: 0301-620X
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- Citations: 26
Birch R, Misra P, Stewart MPM, et al., 2012, Nerve injuries sustained during warfare: part II: Outcomes., J Bone Joint Surg Br, Vol: 94, Pages: 529-535
The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.
Birch R, Eardley WGP, Ramasamy A, et al., 2012, Nerve injuries sustained during warfare PART I - EPIDEMIOLOGY, JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME, Vol: 94B, Pages: 523-528, ISSN: 0301-620X
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- Citations: 55
Brown KV, Guthrie HC, Ramasamy A, et al., 2012, Modern military surgery LESSONS FROM IRAQ AND AFGHANISTAN, JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME, Vol: 94B, Pages: 536-543, ISSN: 0301-620X
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- Citations: 40
Ramasamy A, 2012, Re: Deck-slap injuries, JOURNAL OF TRAUMA AND ACUTE CARE SURGERY, Vol: 72, Pages: 312-313, ISSN: 2163-0755
Evans S, Ramasamy A, Kendrew J, et al., 2012, The open blast pelvis: The burden of management, International Journal of Surgery, Vol: 10, Pages: S5-S5, ISSN: 1743-9191
Birch R, Misra P, Stewart MP, et al., 2012, Nerve injuries sustained during warfare Part II – Outcomes, Journal of Bone Joint Surgery Br., Pages: 529-535
Ramasamy A, Hill AM, Phillip R, et al., 2011, The Modern "Deck-Slap" Injury-Calcaneal Blast Fractures From Vehicle Explosions, JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE, Vol: 71, Pages: 1694-1698, ISSN: 0022-5282
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- Citations: 45
Ramasamy A, Hill AM, Masouros SD, et al., 2011, Evaluating the effect of vehicle modification in reducing injuries from landmine blasts. An analysis of 2212 incidents and its application for humanitarian purposes, ACCIDENT ANALYSIS AND PREVENTION, Vol: 43, Pages: 1878-1886, ISSN: 0001-4575
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- Citations: 14
Ramasamy A, Hill AM, Masouros S, et al., 2011, Blast-related fracture patterns: a forensic biomechanical approach, JOURNAL OF THE ROYAL SOCIETY INTERFACE, Vol: 8, Pages: 689-698, ISSN: 1742-5689
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- Citations: 54
Ramasamy A, Masouros SD, Newell N, et al., 2011, In-vehicle extremity injuries from improvised explosive devices: current and future foci, PHILOSOPHICAL TRANSACTIONS OF THE ROYAL SOCIETY B-BIOLOGICAL SCIENCES, Vol: 366, Pages: 160-170, ISSN: 0962-8436
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- Citations: 59
Brown K, Bo C, Ramasamy A, et al., 2011, Prospects for studying how high-intensity compression waves cause damage in human blast injuries, 17th Biennial International Conference of the American Physical Society: Topical Group on Shock Compression of Condensed Matter
Ramasamy A, Clasper JC, 2010, Limb Injuries, Oxford Desk Reference: Major Trauma, Editors: Greaves, Porter, Smith, Oxford, Publisher: Oxford University Press, ISBN: 9780199543328
Ramasamy A, Hinsley DE, Edwards DS, et al., 2010, Skill sets and competencies for the modern military surgeon: Lessons from UK military operations in Southern Afghanistan, INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, Vol: 41, Pages: 453-459, ISSN: 0020-1383
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- Citations: 74
Fries A, Ramasamy A, Midwinter M, et al., 2010, Military scrotal trauma: how should it be managed?, Electronic Poster of Distinction in Association-of-Surgeons-of-Great-Britain-and-Ireland-International-Surgical-Congress, Publisher: WILEY-BLACKWELL, Pages: 190-190, ISSN: 0007-1323
Ramasamy A, Hill AM, Hepper AE, et al., 2009, Blast mines: physics, injury mechanisms and vehicle protection, BMJ Military Health, Vol: 155, Pages: 258-264, ISSN: 2633-3767
Since World War II, more vehicles have been lost to land mines than all other threats combined. Anti-vehicular (AV) mines are capable of disabling a heavy vehicle, or completely destroying a lighter vehicle. The most common form of AV mine is the blast mine, which uses a large amount of explosive to directly damage the target. In a conventional military setting, landmines are used as a defensive force-multiplier and to restrict the movements of the opposing force. They are relatively cheap to purchase and easy to acquire, hence landmines are also potent weapons in the insurgents' armamentarium. The stand-offnature of its design has allowed insurgents to cause significant injuries to security forces in current conflicts with little personal risk. As a result, AV mines and improvised explosive devices (IEDs) have become the most common cause of death and injury to Coalition and local security forces operating in Iraq and Afghanistan. Detonation of an AV mine causes an explosive, exothermic reaction which results in the formation of a shockwave followed by a rapid expansion of gases. The shockwave is mainly reflected by the soillair interface and fractures the soil cap overthe mine. The detonation products then vent through the voids in the soil, resulting in a hollow inverse cone which consists of the detonation gases surrounded by the soil ejecta. It is the combination of the detonation products and soil ejecta that interact with the target vehicle and cause injury to the vehicle occupants. A number of different strategies are required to mitigate the blast effects of an explosion. Primary blast effects can be reduced by increasing the standoff distance between the seat of the explosion and the crew compartment. Enhancement of armour on the base of the vehicle, as well as improvements in personal protection can prevent penetration of fragments. Mitigating tertiary effects can be achieved by altering the vehicle geometry and structure, increasing vehicle mass, as well
Ramasamy A, Hill AM, Clasper JC, 2009, Improvised explosive devices: pathophysiology, injury profiles and current medical management., J R Army Med Corps, Vol: 155, Pages: 265-272, ISSN: 0035-8665
The improvised explosive device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range from rudimentary home made explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as roadside explosives and blast mines, explosive formed pojectile (EFP) devices and suicide bombings. Each of these groups causeinjury through a number of different mechanisms and can result in vastly different injury profiles. The "Global War on Terror" has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma care may be required to manage casualties from similar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.
Ramasamy A, Midwinter M, Mahoney P, et al., 2009, Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma, INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, Vol: 40, Pages: 1342-1345, ISSN: 0020-1383
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- Citations: 42
Ramasamy A, Harrisson SE, Stewart MPM, et al., 2009, Penetrating missile injuries during the Iraqi insurgency, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 91, Pages: 551-558, ISSN: 0035-8843
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- Citations: 35
Brooks AJ, Ramasamy A, Hinsley D, et al., 2009, Military general surgical training opportunities on operations in Afghanistan, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 91, Pages: 417-419, ISSN: 0035-8843
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- Citations: 20
Ramasamy A, Harrisson S, Lasrado I, et al., 2009, A review of casualties during the Iraqi insurgency 2006 - A British field hospital experience, INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, Vol: 40, Pages: 493-497, ISSN: 0020-1383
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- Citations: 77
Brown KV, Ramasamy A, McLeod J, et al., 2009, Predicting the need for early amputation in ballistic mangled extremity injuries., The Journal of trauma, Vol: 66
BACKGROUND: Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate after high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The aim of this study was to assess the validity of the mangled extremity severity score (MESS), the only verified score, in a population of UK military patients with ballistic mangled extremity injuries. METHODS: We identified from the prospectively kept Joint Theater Trauma Registry all patients who had sustained ballistic lower limb open fractures during the recent conflicts in Iraq and Afghanistan (May 2003-April 2008). Demographics were assessed using both the trauma audit and the hospital notes. Patients were retrospectively evaluated with the MESS system for lower extremity trauma. Those that required an amputation were compared with those that had successful limb salvage. RESULTS: Seventy-seven military patients with 86 limbs who had ballistic mangled extremity injuries were identified, 22 of whom required amputation. The MESS did not help to decide whether or not an amputation was appropriate and in particular, the age was not relevant. A skeletal score of 4, while being associated with a higher amputation rate, was not predictive of its need. Most amputations were performed when an ischemic limb was present, and the general condition of the casualty precluded the lengthy reconstruction required for salvage. CONCLUSIONS: The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have identified important factors in the management, in particular the need for early amputat
Brown KV, Ramasamy A, Tai N, et al., 2009, Complications of extremity vascular injuries in conflict., The Journal of trauma, Vol: 66
INTRODUCTION: The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, secondary amputation, and graft thrombosis). AIM: The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury. METHODS: A prospectively maintained trauma registry was retrospectively reviewed for all UK military casualties with extremity injuries (Abbreviated Injury Score > 1) December 8, 2003 to May 12, 2008. Demographics and the details of their vascular injuries, management, and outcome were documented using the trauma audit and medical notes. RESULTS: Thirty-four patients (34%)--37 limbs (30%)--had sustained a total of 38 vascular injuries. Twenty-eight limbs (22.6%) had an associated fracture, 9 (7.3%) did not. Twenty-nine limbs (23.4%) required immediate revascularization to preserve their limb: 16 limbs (13%) underwent an initial Damage Control procedure, and 13 limbs (10.5%) underwent Definitive Surgery. Overall, there were 25 limbs (20.2%) with complications. Twenty-two were in the 28 limbs with open fractures, 3 were in the 9 limbs without a fracture (p < 0.05). There was no significant difference in the complication rate with respect to upper versus lower limb and damage control versus definitive surgery. CONCLUSION: We have demonstrated that prognosis is worse after military vascular trauma if there is an associated fracture, probably due to higher energy transfer and greater tissue damage.
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