Introduction
December 28, 1895 can be considered the official birth of radiology since the book
“Über eine neue Art von Strahlen” (About a New Kind of Rays) by Wilhelm Conrad Röntgen
was published on this day. In the 19th century, both the science and military sectors
experienced rapid growth and development. European armies introduced firearms to their
weaponry. Military surgeons recognized the importance of using a “new type of rays”
to diagnose firearm injuries and published an article in March 1896 about the use
of the X-ray method for detecting bullet wounds. The years 1897–1898 during the territorial
and colonial conflict between the Russian and British Empires are considered to mark
the beginning of military radiology [1]. 123 years have passed since then. Radiology has since become an integral part of
military medicine and plays an important role not only in diagnosis but also in the
healing process.
The structure and severity of combat injuries vary and depend on the type of weapon
and military technology. Modern armies have weapons with high kinetic energy and numerous
effects resulting in an increase in the percentage of combined injuries, e.g., explosions
result in a combination of mechanical and thermal injuries [2]
[3]
[4].
The Russian invasion of Ukraine has resulted in a high percentage of multiple and
combined injuries. This fact greatly complicates the process for treating and evacuating
the wounded, increases the need for complex surgical aid within a relatively short
period of time, and increases the percentage of mistakes in both treatment and organizational
processes [2]
[3]
[5]
[6]
[7]
[8]
[9]. The amount of time it takes for medical aid to be provided affects treatment results.
Collaboration between radiology and clinical medicine allows a better understanding
of pathological processes and shortens the time for the provision of medical aid.
Military radiology is a specific branch of radiology requiring knowledge of the mechanism
of injuries and patterns of high-energy trauma and has been actively being developed
since Russia’s initial invasion of Ukraine in 2014.
Phases of medical care in times of war
Wartime medical care is provided in Ukraine in accordance with the basic principles
of Ukrainian health law using a 4-stage system:
First stage of medical care (0.5–15 km behind the frontline, within the first 10–60 minutes):
This stage includes preclinical and acute initial treatment. It also includes self-help
and support by medics and general practitioners in mobile units. Care is provided
in medical vehicles. Ultrasound and digital radiographs are used at this point.
Second stage of medical care (25–60 km behind the frontline, within 60 minutes): Specialized medical
care is provided at this point. Care is provided at stabilization points and/or mobile
hospitals. Time plays a crucial role in preserving the limbs and lives of the wounded.
Third and fourth stages of medical care (200 km or more behind the frontline, 12–24 hours): These stages
include tertiary, highly specialized medical care at stationary military hospitals
and specialized facilities. Care is provided within 12–24 hours. Rehabilitation and
palliative care systems implement treatment measures with the goal of restoring function
impacted or lost due to injury in order to create optimal conditions for the return
to normal life, work, and military service.
Imaging methods
Ultrasound
Ultrasound is the most commonly used imaging method when treating wounded individuals
during all stages of care [2] ([Fig. 1]). Ultrasound examination is primarily used during the first two stages of care for
identifying life-threatening injuries ([Fig. 2]). The use of fast protocols like FAST (eFAST) and point-of-care ultrasound (POCUS)
has proven to be effective for evaluating blunt abdominal and chest trauma and for
providing clear answers to specific diagnostic questions. The main advantage of fast
protocols is that radiologists are not needed since these protocols can be performed
by physicians as well as emergency medical technicians.
Fig. 1 Portable ultrasound device.
Fig. 2
a Cardiac ultrasound: Bullet wound to the apex of the heart (arrow). b Cardiac ultrasound: Hemopericardium (arrow).
In addition to the use of ultrasound for diagnosis, it is also used for guiding peripheral
regional anesthesia administration both during evacuation and at mobile hospitals/field
support points. The use of the FAST protocol has shortened the duration of the preoperative
diagnostic workup, improved the quality and efficiency of medical triage, and reduced
the number of diagnostic mistakes [1]
[10].
X-ray
Mobile X-ray devices ([Fig. 3]) are used at field support points and mobile hospitals treating the moderately to
severely wounded with the goal of stabilizing acute life-threatening injuries. These
patients are subsequently assessed to determine further care and are transferred to
centers with the necessary equipment. The acquired X-ray images are evaluated directly
on the monitor of the X-ray device by the medical team at the mobile hospital/field
support point.
Fig. 3 Mobile X-ray device at a field support point 15 km from the front line.
Chest X-rays are acquired to rule out pneumothorax and hemothorax ([Fig. 4]) which require immediate care with drainage placement [10]. They are also used to detect bullet fragments in the chest and to evaluate the
distance from major vessels and the heart ([Fig. 4]).
Fig. 4 Chest X-ray a.p. plane: Metal fragment in the mediastinum, left-sided hemopneumothorax.
Images of the pelvis and extremities are used to evaluate fractures ([Fig. 5]), to detect foreign objects and their location ([Fig. 6]), and to triage amputation injuries ([Fig. 7]) [11]
[12].
Fig. 5
a X-ray of the left shoulder, y-view: Multifragmentary fracture of the left humerus.
b Pelvic X-ray a.p.: Fracture of the superior and inferior pubic ramus on the left,
multiple metal fragments in the genital region.
Fig. 6
a Lateral image of the right elbow joint: Comminuted fracture of the radius, bullet
in the soft tissue of the cubital fossa. b Removal of the bullet. c Removal of the bullet. d Removal of the bullet.
Fig. 7 Lateral X-ray of both feet: Traumatic amputation with short midfoot stump.
Computed tomography (CT)
In a hybrid war, i.e., a war causing combined injuries, noninvasive imaging methods
play an important role. When diagnosing gunshot wounds, computed tomography in particular
makes it possible to evaluate the type and scope of injuries and the topography of
postoperative conditions [13]
[14]
[15]
[16]
[17]. CT is the second most commonly used imaging method beginning in the second stage
of medical care.
It has many advantages due to its speed, noninvasiveness, high sensitivity for differentiating
between air, fluid, and blood, as well as high topographical accuracy for the identification
of injuries and foreign objects and for the evaluation of the injury severity and
the wound path. With CT over 50% of additional injuries can be detected compared to
other imaging methods and physical examination alone [18].
When performing imaging of the wounded, that main goal is the timely detection of
life-threatening injuries requiring immediate surgical treatment, the prediction of
the migration of foreign objects ([Fig. 8]), and the diagnosis of injury complications.
Fig. 8
a Coronal CT scan of the skull: Fractures of the left orbital floor, dislocation of
the lateral orbital wall and the left globe of the eye, and prolapse of the fat tissue
into the maxillary sinus. b Coronal CT scan of the skull: Numerous small bone fragments in the soft tissue of
the left orbital cavity. c Transverse CT scan of the skull: Focal encephalomalacia of the left hemisphere resulting
from a hemorrhagic contusion.
Wounded patients are first scanned from the head to the pelvis sometimes including
the extremities since the prediction of the path of a bullet or a fragment is an extremely
complex task in the case of combined injuries [2]
[12]. Wound paths penetrate various parts of the body and can consequently be in a thoracoabdominal,
abdominopelvic, or cardiothoracic location and affect every organ [17].
Bullets and shrapnel can sometimes travel like an embolism along vessels. Angiography
is performed particularly in patients with wounds caused by shrapnel injuries without
an exit wound [10]
[15]
[19].
Postmortem CT examinations are considered the gold standard for the retrospective
evaluation of the diagnosis and treatment of gunshot wounds if it is not possible
to perform an autopsy [18].
Magnetic resonance imaging (MRI)
Magnetic resonance imaging is used as a visualization method to assess the long-term
consequences of combat injuries in the third and fourth phases of medical care and
during rehabilitation. The use of MRI is often limited due to metal fragments in the
body of the injured person. After removal of the fragments, MRI can be safely performed
([Fig. 9]) and makes it possible to evaluate both soft-tissue changes and bone lesions.
Fig. 9
a MRI examination of the thoracic spine of a patient with lower paraparesis: Condition
after surgery to treat a bullet wound in the thoracic region of the spine, post-traumatic
myelomalacia of the spinal cord. b MRI examination of the thoracic spine of a patient with lower paraparesis: Metal
artifact (arrow) caused by a small foreign object.
Head
In modern armed conflicts, deaths with a neurosurgical profile are 50% soft-tissue
damage to the head, 28% penetrating head trauma, and 17% non-penetrating injuries.
The percentage of explosion and blast injuries is increasing and comprises 70% of
combat wounds. Combined injuries occur in approximately 30% of cases and multiple
injuries in 7% of those affected [20]
[21].
Skull and brain injuries are classified as closed or open depending on the type of
tissue damage. In the case of closed injuries to the brain and skull, only the skin
is damaged while the soft tissue of the head as well as the epicranial aponeurosis
remain intact. An injury to the brain and skull is considered open when the integrity
of both the skin and aponeurosis is damaged. This category also includes fractures
at the base of the skull [22]
[23].
Open head and brain injuries are categorized as penetrating and non-penetrating. Open
non-penetrating injuries are characterized by the integrity of the dura mater which
protects the subarachnoid space and the brain tissue from possible infection.
In the case of open penetrating skull injuries, the dura mater is usually damaged,
often resulting in infection. Therefore, it is important for the further planning
of surgical interventions and the prognosis of possible complications for radiology
to clearly identify the type of injury to the skull and brain.
Skull fractures are categorized as linear, competing, fragmented, puncture, and splintered
fractures. The location of the skull fracture and its connection to the base of the
skull and the top of the skull are taken into consideration. A basilar skull fracture
is considered an open penetrating skull injury since it is normally associated with
a tear of the dura mater.
When radiologists are evaluating head injuries, it is important to determine the exact
location of bone fragments ([Fig. 10]
a, e), the presence of foreign objects, and their relationship to the main blood vessels,
as this information plays an important role in the further planning of the scope of
surgical interventions and often determines the patient’s prognosis.
Fig. 10
a Transverse CT scan of the skull: Image of a multifragmentary fracture of the right
maxilla two months after the trauma. b/c Transverse MRI scan of the head: Diffuse axonal damage (grade 1 according to Adams)
on SWI. d Transverse CT scan of the skull: Chronic epidural hematomas on the right frontal
side. e Transverse CT scan of the skull: Fractures of the right frontal bone and multiple
foreign objects in the subcutaneous soft tissue.
Gunshot wounds to the head include the elements of injury described above but also
have their own special features. They are classified as injuries caused by a projectile,
shrapnel, or a bullet. Depending on the type of injury canal, a differentiation is
made between simple, penetrating, perforating, and graze injuries. Brain injury locations
include the forehead, temples, top of the head, and back of the head as well as parabasal
injuries.
In the case of head injuries, it is important to detect brain contusions, diffuse
axonal damage, intracerebral and intracranial hematomas, and brain compression.
Brain contusions are characterized by macroscopic damage to the brain tissue and are
clearly seen on CT ([Fig. 10]d) and MRI. Swelling as well as hemorrhages of the brain tissue, which are usually
associated with fractures in the top of the skull or the base of the skull, and significant
subarachnoid bleeding are seen on CT.
Diffuse axonal damage to the brain is a separate form of craniocerebral trauma that
is considered severe. This is seen on CT and MRI in the form of parenchymal swelling,
compression of the ventricles and subarachnoid spaces, and small focal hemorrhages
in the white matter ([Fig. 10]
b, c), the corpus callosum, the subcortical brain structures, and the structures of the
brainstem.
Brain compression presents as qualitative impaired consciousness, vegetative disorders,
amnesia, epileptic seizures, and the occurrence and progression of focal neurological
deficits. Brain compression is caused by the development of an intracranial hemorrhage
resulting in the compression of brain structures, the displacement of bone fragments
into the cranial cavity, the development of acute hydrocephalus, pneumocephalus, or
the quick progression of secondary cerebral edema. CT is the most important imaging
method for diagnosing intracranial hematomas.
Thorax
Trauma involving the organs in the chest cavity comprises approximately 7–12% of combat
surgeries [16]. The severity of these injuries is the result of the combination of lung injuries,
vascular damage ([Fig. 11]), and trauma to the pericardium, heart, and esophagus [24]. Chest trauma can be divided into two types: penetrating and blunt. There are also
“regional injuries” that can be both blunt and penetrating. Penetrating wounds are
caused by the direct effect of a wounding agent (bullet, shrapnel, body armor, etc.)
that compromises the integrity of tissues. A special characteristic of blunt trauma
is that organ damage occurs without visible signs on the surface [14]. The large majority of combat chest injuries are shrapnel wounds (up to 72%) [24]. The characteristics, shape, and size of an injury canal depend on the kinetic energy
and the physical properties of the wounding agent. In the case of perforating gunshot
wounds, significant external bleeding is typically seen. The injury canal is identified
on CT by a hole in the parenchyma ([Fig. 12]) surrounded by a zone of lung parenchymal damage and containing blood, air bubbles,
fragments of damaged tissue, and foreign objects. A pulmonary contusion, which occurs
in both penetrating and blunt trauma, is usually seen on CT as diffuse areas with
increased density in the lung tissue that can indicate bleeding, edema, or inflammation.
Fig. 11
a Projectile (arrow) in the mediastinum (intraoperative images). b Projectile (arrow) in the mediastinum (intraoperative images).
Fig. 12
a Coronal thoracic CT scan: Projectile in the left mediastinum lateral to the aortic
arch. Clearly visible projectile path in the left lung. b Transverse thoracic CT scan: Projectile in the left mediastinum lateral to the aortic
arch.
Blast injuries can result in lung rupture with bleeding, bilateral pulmonary contusions,
skeletal damage, and damage to the soft tissue of the chest wall [2]. In the case of penetrating chest trauma, vascular damage with massive bleeding
in the pleural cavity and the formation of a tension pneumothorax can be the main
causes of death. Perforating wounds of the mediastinum are diagnosed in only 1–3%
of cases since this type of trauma results in immediate death in 97–99% of cases [16].
Abdomen and pelvis
Abdominal and pelvic injuries are the most severe modern combat injuries and due to
hybrid warfare they present a challenge with respect to selecting suitable surgical
approaches and effective medical imaging methods [13]
[25]
[26]
[27]. Closed abdominal trauma in combination with gunshot wounds comprise approximately
20% of all medical losses.
Abdominal and pelvic gunshot wounds are the most complex cases in military radiology
[10]
[11] and military surgery [26].
Abdominal gunshot wounds are penetrating in 33% of cases and non-penetrating in 67%.
Shrapnel and blast wounds are the most common type of abdominal injury (62%) while
only 1% of injuries are pelvic injuries [25, 17].
Depending on the type of tissue damage and organ trauma in the abdomen and pelvis,
a differentiation is made between non-penetrating and penetrating injuries as well
as closed abdominal trauma ([Fig. 13]). Pelvic fractures are quite common and require a detailed description of the displacement
of bone fragments ([Fig. 14]) and determination of the topography in relation to large vessels and nerve bundles.
Fig. 13
a Transverse CT scan of the abdomen: Penetrating injury to the abdominal cavity with
metal fragments (arrow) in the left psoas muscle. b Transverse CT scan of the abdomen: Penetrating injury to the abdominal cavity with
fragments (arrow) in the large intestine.
Fig. 14
a/b Transverse CT scan of the pelvis: Multifragmentary dislocated fractures of the pelvis
a and of the left femur.
Thoracoabdominal injuries are one of the most complex combined injuries caused by
simultaneous injury of the ribcage and the abdomen with damage to the diaphragm.
Extremities
Trauma to the extremities is one of the most common causes of surgical death in wars
and military conflicts and comprises approximately 54–70% of all deaths. In most cases,
this type of trauma is part of a polytrauma. Extremity fractures are associated with
severe soft-tissue damage in one third of cases. Tibial fractures comprise 42.1% of
cases and are usually caused by bullet wounds. Femoral fractures occur in 23.8% of
cases, humerus fractures in 22.3%, and forearm fractures in 11.8%. These fractures
are typically shaft fractures. Intraarticular fractures are diagnosed in 17.1% of
cases. Of the 76.4% of bullet wounds caused by modern weapons, 35.1% are comminuted
fractures and 41.3% are splintered fractures. Primary bone injuries comprise 7.1%
of injuries, with 79.3% of long bone injuries having defects of 3 cm or more [12].
In the case of trauma to the extremities, it is important for radiologists to characterize
injuries to soft tissue, bones, and joints. Depending on the number and location of
the injuries, they should be classified as isolated, multiple, and combined injuries.
If possible, the description of a bullet wound should include the type of projectile
(bullet, shrapnel, explosive projectile, etc.), the type of injury (perforating, penetrating,
graze), the type of fracture (complete, incomplete) ([Fig. 15]), the size of bone defects ([Fig. 16]), the nature of the fracture line (transverse, oblique, etc.), the location, accompanying
injuries to soft tissue, main vessels and nerves, and joints and their structures,
as well as the location of injuries in multiple, combined, and complex trauma. Complications
should also be documented.
Fig. 15 Coronal a and transverse b CT scan of the lower leg: Multifragmentary fracture of the tibia with external fixation
a. Soft-tissue damage to the lower leg b.
Fig. 16
a/b Coronal MRI scan of the knee joint: Condition after removal of a metal fragment.
Bone defect of the distal femur.
