Soldiers used body protection during World War II

War-surgical injury patterns in modern wars and crisis situations


Medline research (1949 - 2007) (keywords: combat, casualties, war, military, wounded, neurosurgery) and Google searches on the worldwide web. Data analysis of soldiers who died in Afghanistan (OEF / ISAF) (causes of death).


In Iraq / Afghanistan, grenades with high-energy fragmentation effects, gunshot wounds, aircraft accidents and terrorist attacks are important causes of injury. So far, 3,503 soldiers have died in Iraq and 546 soldiers in Afghanistan (as of March 31, 2007). By enemy action (“hostile-related”) 55% and non-hostile-related 45% of the soldiers were killed. In Afghanistan, 18% of all deaths between 2001 and 2007 were directly caused by armed conflict. The main causes of death for killed-in-action (KIA) soldiers are thorax, abdomen (40%) and craniocerebral injuries (35%). In the Iraq war, the case fatality rate is almost half that of the Vietnam war. At 18.7%, the killed-in-action rate in Afghanistan is similar to that in the Vietnam War (20.0%). In contrast, the amputation rate doubled. Approximately 8-15% of fatal injuries appear preventable.


The military surgeon must competently cover a broad field of surgery: life-saving emergency measures, especially in the field of thoracic, visceral and vascular surgery, practical skills in neuro and maxillofacial surgery. It is also crucial that sufficient tactical and strategic MedEVAC be kept available for the wounded. A uniform registration of all injuries based on the DGU trauma register is required. Additional protection for the neck, throat, shoulder, axilla, pelvis and groin needs to be developed.


According to data from media reports and specific case studies, around 80,000 to 110,000 direct war victims have been expected globally since 2003. However, the total number of fatalities in an armed conflict is considerably higher than the number of those killed in the fighting. Indirect deaths resulting from the consequences of armed conflict such as illness and famine far outnumber the direct war deaths. The ratio of the number of direct and indirect war victims depends on the respective theater of war. In some conflicts, most of the victims are caused by violence (Iraq and Kosovo). In sub-Saharan Africa, the situation is reversed. Here the average non-violence death rate is more than twice the expected natural death rate and in some refugee scenarios it may be more than eight times as high. These factors highlight the extent of the long-term effects a conflict can have on an entire population, and particularly on vulnerable groups. However, reports from conflict zones often only contain numerical estimates of the dead and wounded and their injury patterns caused by direct combat. From a military-surgical point of view, exact epidemiological analyzes of these data are of particular interest. Information about the expected professional requirements for the surgical team or for the individual surgeon can be obtained from them, from which the necessary further training concept and the necessary personnel and material infrastructure can be derived objectively. Given the enormous number of civil aid organizations that provide help with surgeons in crisis areas (e.g. ICRC, MSF), these figures also seem to be of interest to the civilian sector. Usable data is available from some countries and population groups. The most recent examples with the best documentation are the military conflicts in Iraq and Afghanistan, of which the number of killed and wounded US and multinational military are precisely recorded and also generally accessible. Against the background of this data, surgically relevant injury patterns and types of the "modern war" will be worked out and the following questions answered:

  1. Has the wounded-in-action soldier's pattern of injuries changed over the past five decades?
  2. Which operational specialist areas are essential for the care of the wounded soldier in a military deployment?
  3. Are there specialist skills that are particularly urgent for the individual surgeon?
  4. Can demands for infrastructural changes be derived?

Causes of injuries, wounds, types of weapons

Grenades with a high-energy fragmentation effect, gunshot wounds, air accidents and the consequences of terrorist attacks are of importance. Individual analyzes show that the main cause of injuries in the Iraq war is the relatively widespread 155 mm artillery shell (with anti-material and anti-personnel explosive charges) - partially hidden under the asphalt and triggered by a cell phone. The cargo can be supplemented with steel nuts, nails embedded in human feces to increase the likelihood of secondary infections [4]. It is not uncommon for high explosive shells of this type or mines (IED, improvised explosive device) to be attached to vehicles of various sizes (from taxis to cargo trucks) and combined with propane gas or other "fire accelerators" to increase the burning effect. Conventional anti-tank grenade launchers (rocket propelled grenade launcher, "Panzerfaust") and the 50 caliber sniper rifle are also used [4, 37]. Fragments of high-energy explosive shells cause 50-70% of all wounds - about three times more than rifle shots, which, however, are responsible for up to 60% of all deaths [14]. A prospective analysis by the USMC field hospital in Fallujah / Iraq (March 2004 to February 2005) on 377 patients revealed explosive ammunition (62%) as the cause in 234 cases and gunshot injuries (38%) in 143 cases. The most pronounced mutilating injuries were mainly caused by self-made explosive devices (63 patients = 17%), which were the cause of almost half of all amputations [7]. Military conflict situations in which suicide bombings and attacks with self-made explosive devices (IED) are less important - as in the Kosovo war - show a significantly higher proportion of blunt injuries. Here traffic accidents were responsible for 45.5% of all injuries (72.2% of the blunt injuries, which in turn made up 63.1% of all injuries) and rifle-shot wounds for 20% of all injuries (55% of the penetrating injuries, this 36.9% of all injuries) [29 ].
An increase in the intensity of firefights "unmask" the less protected areas of the body immediately. The change in the military situation in Iraq in April 2004 not only led to a doubling of the wounded, but also to a drastic increase in headshots. The neurosurgeon Poffenbarger from the 31st Combat Support Hospital Baghdhad put it: "We've done more (craniotomies) in eight weeks than the previous neurosurgery team did in eight months" [26]. Street and house-to-house combat situations in turn cause injury patterns that differ significantly from the above. According to a current analysis in 2005, around 65% of those injured in the Israeli army suffered gunshot injuries (Iraq: approx. 20 - 35%). Explosive, high-energy charges were responsible for injuries in 15% (Iraq: approx. 60%), stones and other slingshot charges for approx. 10% (Iraq: 0%). This led to injuries to the skull in 55%, to the extremities in 50% and to the trunk of the body in 25% [17]. How quickly changes in the military situation change the significance of the individual causes of accidents can be seen in two further examples:

  • The changed “warfare” in the Iraq war meant that in 2005 around 70% of all war casualties were caused by the effects of IEDs and other “small” bombs, compared with 26% a year earlier [16].
  • The 274th FST (Forward Surgical Team), the first FST in Afghanistan (from October 14, 2001 to May 8, 2002, Operation Anaconda), cared for nearly 90% of all US war victims. In this first phase, non-combat-related failures were disproportionately often caused by limb injuries (12.5% ​​of all failures) after falls and falls as a result of the stony and uneven ground and 8% of all failures due to altitude sickness [14]. Injuries caused by traffic accidents occurred in only one case.

"Killed in Action"
"The fate of the wounded rests in the hands of the ones who apply the first dressing."

Dr. Nicholas Senn; Spanish American War, 1898 [19]

"In this conflict, there's no such thing as the golden hour; maybe a golden 15 minutes. "
Captain D. C. Covey, MD, Department of Orthopedic Surgery at Naval Medical Center, San Diego, California, Orthopedic consultant to the Surgeon General of the Navy, 2006 [38]

So far, 3,898 soldiers have died in Iraq (39.4% of all deaths from IEDs), 26,558 US soldiers have been wounded (80.9% of which are directly or indirectly through combat ("Hostile injuries"), 54.9% of all wounded return-to-duty within 72 hours; As of July 11, 2007) [41]. So far 628 soldiers have died in Afghanistan. Of this, enemy action ("Hostile-related") 55% and non-hostile-related 45% killed. A total of 3,094 US soldiers have been wounded in Afghanistan so far (as of July 11, 2007) [39, 42].
If only the hostile-related group is evaluated in the analyzes for Afghanistan, it is noticeable that approx. 66% of the deaths did not occur during firefights. Overall, “only” 18% of all deaths between 2001 and 2007 in Afghanistan were caused directly by armed conflict (see Table 1). In the non-hostile-related group, the aircraft crash (airplane / helicopter) is the most important cause (n = 128) and thus the number 1 cause of death in Afghanistan (24.6% of all deaths). The relatively low rate of deaths and injuries from direct combat operations is confirmed by other authors. The analysis of the causes of the injuries of 162 soldiers repatriated from Iraq shows that ultimately around 17% of the injuries were caused by firefights [23].
Approx. 10% of all injuries died in Iraq [4, 14, 30] - a comparatively very low death rate, as shown in a summary of an article in the New England Journal of Medicine, as it can only be seen by comparing the published figures of 30.3% in World War II, 24.1% in the Korean War, 23.6% in the Vietnam War and 23.2% in the First Gulf War (1990–1991; 154 of 664 wounded) results [28]. However, the differentiated calculation allows a more detailed insight. For example, Holcomb et al. the case fatality rate (CFR), the killed-in-action rate (KIA) and the died-of-wound rate (DOW) using the available data on US ground troop soldiers killed [5]. The working group (see Table 2) confirmed the figures published in 2004 that the case fatality rate in the current Iraq war is actually only approximately half as high as in the Vietnam war, but other interesting insights emerged. It was shown that the rate of wounded who only died after receiving first medical treatment (DOW) is higher in Iraq than in the wars before and in Afghanistan more than twice as high as in the Vietnam War. At 18.7%, the KIA rate in Afghanistan is almost as high as in the Vietnam War (20.0%). Further analyzes show that in World War II and the Vietnam War the ratio of the KIA to the DOW rate was 88%: 12%, while in the current wars more soldiers die only after they have received initial medical treatment. In Iraq and Afghanistan, the KIA: DOW ratio is 77%: 23% [5, 35]. A similar ratio was also reported from the Kososvo war (KIA rate: 78.6%) [34].

Injury pattern and body region

The main causes of death for killed inaction soldiers are thorax, abdomen and cranial brain injuries. Analyzes available so far show the following distribution in this group and for those who died from their wounds [1, 3, 6, 9-12, 14, 15, 21]:

35% penetrating craniocerebral trauma
29% injuries to the thorax and abdomen - poorly
11% chest and abdomen injuries - treatable
10% bleeding shock from bleeding from extremity wounds
8% Maiming Blast Trauma
6% tension pneumothorax
1% obstruction of the airways

Died-of-wounds:mostly infections and complications of shock
The anatomical distribution of survived injuries is shown below [3, 5, 10, 14, 15, 18, 25]. For comparison, the relative distribution of penetrating injuries from previous wars is shown as an average in brackets. Analyzes of World War I and II, the Korean War, Vietnam War, Northern Ireland Conflict, Falkland Islands, Gulf War I, Chechnya and Somalia were taken into account.

  • Head (skull, face, eye, ear, throat and neck): 15 - 30% (15%)
  • Body trunk (thorax, back, abdomen, pelvis, groin and buttocks): 10 - 35% (20%)
  • Extremities (shoulder to hand and thigh to foot): 60 - 90% (65%)

4 - 7% of the resulting wounds are associated with injuries relevant to vascular surgery [8, 20, 24, 25]. As a 10-year overview by Serbian colleagues (1992 - 2001) and the analysis of current data by the group of vascular surgeons at the Walter Reed Army Medical Center show, it is predominantly peripheral arterial vessels close to the trunk (Aa. femoralis comm / sup / prof approx. 30%; Aa . axillary / brachialis approx. 25%), more rarely the aa further distal. radialis / ulnaris in approx. 25%, the popliteal artery in 10-20% and the crural arteries (approx. 4%). Central vessels such as the carotid artery (approx. 4%), the temporal artery and inf epigastric artery were affected much less often. (2% each) [20, 22, 33]. The injury-related amputation rate is given as 10–20% [20, 22, 24, 33], and mortality as around 3–5% [22, 24, 33]. Ultimately, 6% of US soldiers wounded in Iraq lost an extremity, doubling the amputation rate compared to previous wars. One reason for this development is the improved protection of body cavities, which means that previously fatal injuries from IEDs or other explosive weapons can now be survived by restricting them to mutilating limb injuries [13]. Another reason is the changed quality of the injury caused by explosive charges, some of which were improvised. They cause far more serious soft tissue injuries and more often primarily massively contaminated wounds [7]. The modern fragmentation vests contain inlays made of Kevlar and ceramic, weigh 7 - 8 kg, cost about 1500 US $, can stop the high velocity bullet of an AK-47 and seem to cut the number of thoracic and abdominal injuries in half. According to the experience of the 31st Combat Support Hospital in Baghdad, the trunk injury rate is 14% (of 598 soldiers), while a rate of 27% was observed for injured Iraqi soldiers over the same period. Penetrating wounds in the unprotected areas of the face, groin and pelvis continue to contribute significantly to the mortality rate.

"... the nature of war injuries is different in every war ..."

Col. David C. Polly, Jr., MD; 2003
Chief Department of Orthopedic Surgery and Rehabilitation
WALTER REED Army Medical Center [40]

 WW IIVietnamTotal Iraq / AFGAfghanistanIraq

WW II: World War 2
AFG: Afghanistan
KIA: killed in action
DOW: died of wounds (! The denominator of DOW and KIA is not identical, therefore no sum can be formed)
CFR: case fatality rate
*: p <0.05 Afghanistan versus Iraq


The present analysis was intended to show the causes of injury / death and injury patterns in current military conflict situations. It turns out that explosive shells (especially IEDs) and rifle shots are the most important causes. 80-90% of all fallen soldiers died before reaching a medical facility, approx. 70% from skull, thorax and abdominal injuries. These data and the background information provided provide a basic understanding of what can be done to prevent fatal injuries in the future and to ensure a more realistic level of expectations regarding medical care. Nevertheless, these data, which come from scientific publications or other sources, must be viewed critically. Ultimately, there is hardly any structured prospective analysis of all injuries and all deaths. Rather, subsets of the population “combat casualties” are considered, the evaluation results of which depend on a variety of factors. The level of care alone (rescue center / deployment hospital / home hospital) produces considerable differences in the results.Analyzes at the level of a Combat Support Hospital in Baghdad showed injury rates for the trunk of about 13%, while authors from the Walter Reed Army Medical Center in Washington calculated almost two to three times the rate [15]. Specifying injury patterns without considering the background can also give completely false insights. For example, on the surface, the number of limb injuries in the current Iraq war is curiously identical to that of the American War of Independence (1861-1865). For the Iraq war the figures vary between 58 and 75%, for the Civil War between 65 and 71%. So has nothing changed in the 140 years in between? In the American Revolutionary War, hardly any soldier survived a trunk injury. Approx. 94% of all soldiers in the Union Army died of injuries to the head, neck or neck area or from thoraco-abdominal wounds. Most of the survivors had limb injuries. Today, former fatal torso injuries as a result of body protection are survived and injuries to extremities are "experienced". As a restriction, it must also be stated that the aforementioned number of injuries apply above all to ground troops and therefore naturally no analogy to other operational groups (e.g. jet pilots, combat swimmers, naval operations) may be drawn. It must also be emphasized that the named causes of injuries and the pattern of injuries caused by them apply only to the local area analyzed and only for a certain period of time. Even for a homogeneous task force, changes in the military situation can quickly lead to changes in the injury pattern. When IEDs hidden at the roadside are predominantly used, splinters and dirt are explosively driven into the face from below, which reduces the protective effect of the Kevlar helmet, which in turn results in a considerable increase in eye and other facial injuries. Increased terrorist attacks result in more severe and more complex injuries to a higher number of affected body regions, a higher number of necessary surgical interventions, longer intensive stays and a comparatively higher mortality, as a study of n = 906 victims of terrorism compared to 55,033 other trauma victims in Israel showed [27 ]. Finally, it should also be mentioned that the deployed military surgeons also regularly take care of the less well-protected, wounded “opponents” and civilians of all ages. In the latter case, it is not uncommon for war-independent diseases (e.g. goiter, hernias, tumors, cholecystolithiasis), injuries (especially burns from domestic accidents in children) and chronic consequences of war-related injuries (scarring after burns, splinters in soft tissues) for their therapy the military surgeon is visited and will help within the framework of free capacities [31]. Civilians who have been injured by mines (approx. 100,000 mine victims in the last 25 years in Afghanistan alone) and the consequences of armed conflicts must also be treated.

Head, face, neck - soft tissue surgery535,4%
"Damage control" laparotomies12112,3%
Debridement on the trunk10610,8%
Major amputation262,7%
Large vessels (ligature, reconstruction)626,3%
Fasciotomy, escharotomy474,8
External fixator545,5%
Finger amputation131,3%
Debidement with plaster restraint16016,3%
Debridement with bandage26126,6%

These operations were performed by three general and visceral surgeons and an orthopedic surgeon [9].


As an explanation for the relatively high survival rate in the Iraq war, the regular wearing of effective, lightweight protective vests, a considerably improved battlefield medicine (training for all soldiers, ATLS principles, standardized care protocols, establishment of the so-called "Forward Surgical Teams" with the earliest possible surgery directly after trauma (sometimes 15 minutes later), the availability of a CT, especially for neuro- and abdomino-thoracic trauma, as well as advances in anesthesia technology, intensive care and critical care air transport to Landstuhl or the USA) and the lack of one Iraqi artillery viewed [2].

Why the rate of US ground troop soldiers who died before reaching the first medical facility (killed-in-action) is comparatively high in the current Afghan conflict (significantly higher than in Iraq, 18.7% versus 13.5%, almost as high as in the Vietnam War 20.0% ) remains unclear. Conceivable reasons for this difference are the different numbers of dead, each of which differs by a power of ten, unclear and precise calculations of the KIA rates, but presumably also different injury mechanisms, acting at great heights and, as a result, longer medical evacuation routes. The significantly higher deaths of wound compared to the figures from Iraq (6.7% versus 4.7%) can be explained by the fact that the soldiers who were ultimately successfully evacuated nevertheless died as a result of complications. Overall, only the constellation of Iraq with a significantly lower KIA and DOW rate compared to the wars of the past speaks for an improvement in the survival rate of wounded soldiers, which is also shown in a case fatality rate of 9.1% (for comparison: Afghanistan 16.4%, Vietnam 15.8%). The high DOW rate - both in Afghanistan and Iraq - is a clear indication that in this variant of a current war, increasing numbers of critically injured patients are arriving in the first medical facilities. Unfortunately, there is no analysis of the clinical course of these DOW patients from Afghanistan or Iraq, in which their causes of death were investigated, and from which the need for future organizational / infrastructural changes could be derived. Much effort is being made to improve first medical aid training during combat. Even if in many countries the familiarization of ATLS principles is already a matter of course for those affected, the deficits of this training are still cited: Requirement of the usual diagnostic and therapeutic equipment of the home hospital, no consideration of the tactical-military framework conditions, no work under combat conditions, Possibly darkness and other unfavorable environmental factors (cold, snow, sandstorm, ...), evacuation problems with delays in temporary or permanent care. Against this background, training programs are currently being created (tactical combat casualty care, TCCC), especially in the USA, partly on the basis of experience in the Israeli military, with which the combat troops themselves are addressed and, for example, the use of the tourniquet (Combat Application Tourniquet). to avoid hemorrhagic shock [32, 36]. In addition, research programs aim to develop hemostatic dressings or substances (e.g. QuickClot®), more practicable pain reliever applicators (ketamine nasal spray, morphine autoinjectors, transmucosally acting fentanyl sticks).

Summary - Conclusion for practice

Injury Pattern

Reliable current data is only available for the Iraq war and the military actions in Afghanistan. However, every military conflict has its own character with regard to the cause and pattern of injuries, which can change very quickly. Grenades (especially roadside bombs, IEDs) with high-energy fragmentation, gunshot wounds, aircraft accidents and the consequences of terrorist attacks are of particular numerical importance as the cause of injury for Iraq / Afghanistan. Around 50% of all deaths are not caused by enemy action. Only about 20% of all deaths occurred in a firefight. The main causes of death are thoracic, abdomen, and cranial brain injuries. According to estimates, around 10% of fatal courses can be avoided (especially bleeding shock from bleeding from extremity wounds, tension pneumothorax). The lethality of an injury is around 10%, which is halved compared to previous wars. It is noticeable that under optimal MedEvac conditions the rate of soldiers still dying on the battlefield can be reduced considerably. The evaluation of the available data shows very clearly how unfavorable geographical situations increase the rate of KIA and DOW by making the MedEvac more difficult. In such situations, it becomes essential to take particularly complex measures in good time to ensure medical evacuation, if one does not (then consciously) want to accept a certain proportion of avoidable victims, and the simultaneous gigantic effort for the inpatient part of the treatment chain ad absurdum leads. In the overall view of all injuries, the pattern of injuries has changed compared to the wars of the 2nd half of the 20th century, mainly in that the head injury rate has increased significantly. Wearing the protective vest almost halved the rate of thoracoabdominal trauma in hostile-related injuries. Due to the ballistic protection of the trunk and the frequent use of IEDs with a devastating effect on the soft tissue of the extremities, the amputation rate has doubled compared to previous wars.

Essential surgical specialties

The range of operations mainly includes emergency laparotomies and debridement measures on the trunk and extremities. In addition, interventions in the head area, on large vessels, thoracotomies and fixator systems are carried out. From the overview it follows that a very broad field of surgery has to be competently covered in today's modern medical facility. The surgeon must be able to be trusted to master all life-saving emergency measures, especially in the field of thoracic, visceral and vascular surgery.

Necessary expertise in action

For this purpose, a further training path is pursued in which the young surgeon, rotating between the various surgical disciplines, first becomes a specialist in general surgery and only then acquires further specialist expertise. By continuing the rotation, the maintenance of the broad emergency competence can be guaranteed. In the area of ​​extremity surgery, debridement is the focus of hostiler-related injuries. In addition, practical skills in neurotraumatology and oral and maxillofacial surgery are required. In the event of a high intensity of fighting, neurotraumatological expertise must urgently be kept available on site. For this purpose, the surgeon is required to complete an internally oriented neurotraumatology course as well as internships with the practical implementation of craniotomies. If necessary, a requirement of this type must also be extended to the area of ​​oral and maxillofacial surgery. Infrastructural requirements Surgical expertise can only be effective, however, if infrastructural changes are sought beyond the acquired professional competence. The wounded soldier must be evacuated from the battlefield in good time. Professional implementation and adequate provision of tactical and strategic MedEVAC are essential for the subsequent quality of the results of the treatment. For this purpose, MedEVAC operations of helicopters must be possible in today's crisis areas for the transport of injured persons and the bringing in of medical personnel in sufficient numbers and adapted to the climatic and geographical conditions. A prospective, uniform registration of all injuries based on the tried and tested trauma register of the German Society for Surgery is also required. Work needs to be done to develop additional protection for the neck, throat, shoulder, axilla, pelvis and groin.

Bibliography from the author or the publisher.

Date: 01.10.2008